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SURGICAL

AFTER -TREATMENT

A MANUAL OF

THE CONDUCT OF SURGICAL CONVALESCENCE

L R. G. CRANDON, A. M., M. D.

ASSISTANT IN SURGERY AT HARVARD MEDICAL SCHOOL; ASSISTANT VISITING SURGEON
TO THE BOSTON CITY HOSPITAL; CONSULTING SURGEON TO FROST GENERAL
HOSPITAL AND TO WOONSOCKET HOSPITAL

AND

ALBERT EHRENFRIED, A. B.. M. D.

ASSISTANT IN ANATOMY AT HARVARD MEDICAL SCHOOL; SURGEON TO MT. SINAI HOS-
PITAL; SURGEON TO BOSTON CONSUMPTIVES* HOSPITAL, ETC.

SECOND EDITION, THOROUGHLY REVISED

WITH 265 ORIGINAL ILLUSTRATIONS

PHILADELPHIA AND LONDON

W. B. SAUNDERS COMPANY

1912

This On

CRW6-Y19-ZN9W

reprinted, and recopy righted April, 1912

^RINTCO IN AMKftiCA

^RKSS OP
■ . BAUNOCRS COMPAMV
^HlkADCkPHIA

PREFACE TO THE SECOND EDITION

The gratifying reception which has been accorded this book has
encouraged us to undertake its revision. We have attempted to
modify and add to the presentation of each subject as the shift of
medical opinion and the advance of surgical knowledge have required.
As a result, the volume has been largely recast; some chapters have
been entirely rewritten and others nearly so; several illustrations
have been replaced by better ones, and many new ones have been
added.

We have received great help from the kindly criticisms of our
friends, and we believe that we here present a book which may be
taken, as it were, to the bedside with full confidence in the assist-
ance it will afford in the recognition of the complications of the
postoperative period, and reliance on the specific directions as to
treatment which it offers.

We wish to thank Dr. Lewis P. Felch, of Boston, for assistance
in compiling the chapter on Massage. For other assistance, intelli-
gent and tireless, in the work of revision, we have to thank Miss
Mary Clancy.

L. R. G. Crandon,
Albert Ehrenfried.

Boston, Massachusetts,
April, 1912.

PREFACE TO THE FIRST EDITION

These suggestions for After-treatment of Surgical Cases are written
for two classes of practitioners: house surgeons in hospitals and general
practitioners in communities which are not surgical centers.

Hospitals develop traditions of treatment; the graduating house
surgeon is an oracle to the beginning junior oflBcer; the visiting surgeon
leaves most of the postoperative detail to the house surgeon, and if the
latter has good sense in addition to his academic knowledge, he is able to
use the traditions of treatment which he has inherited from his prede-
cessor in office wisely, and matters of after-treatment in the wards go
on serenely. Traditions and customs, however, may be bad, and it
seems unnecessary, if it is avoidable, that each succeeding house officer
should have to learn all details of after-treatment empirically and at the
patient's expense. It must be admitted that the danger of an arbitrary
printed page may be greater than that of a verbal tradition of treatment,
but if these pages can serve to show that successful after-treatment, like
successful primary treatment, depends first on common sense, that each
case should suggest its own after-treatment to some degree, that an
arbitrary rule is dangerous, the book will have served its purpose.

When the metropolitan surgeon operates in the smaller towns, he
leaves the, case after operation in the hands of his consultant, who may
not be a man of recent hospital experience. For such a man a manual
of elastic but detailed tlirections should be of value.

Every procedure herein advised has stood the test of practice and
will safely do for the reader until, from his own experience, he develops
his own methods. The fact that each surgeon eventually grows into a
technique peculiar to himself, and that many differing ways are suc-
cessful, should make us liberal in spirit and constantly alert for new
truth. No surgical life is so brief but that it has seen new methods ap-
pear, vaunted as perfect, pursued for a time, only to fade away.

Statistics are given little place, therefore, in this work. It is little
comfort to a patient that ninety out of a hundred with his malady get
well. Such a statement contains no assurance that he is not of the ten.
Furthermore, we must acknowledge some truth in Christopher Heath's
remarks (Brit. Med. Jour., 1892, i, 1243): "Of course, we hear of one
case that did recover, but do not hear of the ninety and nine cases that

8 PREFACE

did not. When a man has a case of that kind which gets well, he puflFs
it tremendously, and you always hear of it; but those who have unsuc-
cessful cases are content to leave them alone and keep them out of the
Journal; therefore, you must not believe too much in statistics. As
soon as a gentleman begins to work up his statistics, his moral faculty
appears to become relaxed."

Finally, I wish to quote from an admirable letter written by Gustavus
Richard Brown, January 2, 1800, to Dr. Craik, concerning the last
illness and death of General Washington:

"We were governed by the best light we had; we thought we were
right, so we are justified.

"Dr. Rich is a most sensible man. He uses his common sense in-
stead of the books as his guide in his profession, and he is no bigot. He
says our professional practice needs great reform, and that can be brought
about only by each individual becoming a practical reformer himself.
He is disposed to put up his lancet forever and turn nurse instead of
doctor, for he says one good nurse is more likely to assist nature in
making the cure than ten doctors will by their pills and lancet." (Loss-
ing's Hist. Rec, ii, 501.)

I wish here to thank Dr. Albert Ehrenfried, of Boston, for continuous
and enthusiastic assistance in the preparation of this manual — assistance
which has amoimted to collaboration.

Dr. George P. Sanborn, of Boston, a leading disciple of Sir Almroth
E. Wright in America, has written the chapter on Vaccine Therapy, a con-
tribution I was very fortunate to get. He also prepared the section on
Intubation, based on an experience of three hundred cases.

Dr. Frank B. Granger, of Boston, has contributed the section on
Electrotherapeutic Technique, to my great satisfaction.

Such a manual as this must be, to a degree, a compilation. I have
used the literature freely, meaning in each instance to give full credit and
exact reference.

Thanks are due, and are herewith gladly given, to Doctors John
H. McCoUom, John Bapst Blake, Frederick J. Cotton, John H. Blodgett,
Nathaniel R. Mason, Allen G. Rice, John T. Williams, Walter M.
Boothby, and Miss Mabel R. Harris, for suggestions, criticism, and
other material assistance.

L. R. G. CRANDON.

Boston, Massachusetts,

366 Commonwealth Avenue.

CONTENTS

PART I

CHAPTER I PAGE

Sick-room, Nurse's Chart, Posture 17

Sick-room 17

Nurse's Chart 21

Posture 24

CHAPTER II

After the Anesthetic: Nausea and Vomiting, Hematemesis, Restlessness,

Sweating 28

After the Anesthetic 31

Nausea and Vomiting 35

Hematemesis 40

Restlessness 42

Sweating 43

CHAPTER III

Thirst, Its Significance and Relief 44

Proctoclysis 45

Hypodermoclysis 49

CHAPTER IV

Pain and Sleep 51

Headache 56

CHAPTER V

Pulse, Temperature, and Respiration 59

Pulse 59

Temperature 65

Respiration 70

CHAPTER VI

Postoperative Hemorrhage: Primary, Delayed, Secondary; Transfusion... 71

Primary Hemorrhage 71

Delayed Hemorrhage 71

Secondary Hemorrhage 74

Transfusion 78

CHAPTER VII

Shock 91

Causes 92

Symptoms 94

Treatment 95

Intravenous Infusion 100

Massage of the Heart 103

CHAPTER VIII

Coma: Diabetic, Uremic; Collapse; Sudden Death 106

Diabetic Coma 107

Uremic Coma 107

Collapse 109

Sudden Death no

lO CONTENTS

CHAPTER IX p^QB

THROBfBOPHLEBinS; PULMONARY EmBOLISM; PYLEPHLEBITIS; SUBDIAPHRAGMATIC

Abscess u^

Thrombophlebitis 114

Puhnonary Embolism 118

Heart-clot 122

Fat Embolism 123

Air Embolism 1 24

Pylephlebitis 1 24

Subdiaphragmatic Abscess 125

CHAPTER X
ARTiFiaAL Respiration; Oxygen; Electricity 127

CHAPTER XI
Diet After Operation 133

CHAPTER Xn
Rectal Feeding 140

Rectal Suppositories 145

Formulas for Nutrient Enemas 146

CHAPTER Xm
Gavage and Other Forms of Artificial Feeding 148

Nasal Feeding 150

Subcutaneous Feeding 151

Feeding in Gastric Fistula 152

After Laryngeal Operations 153

CHAPTER XIV

Catheterization; Cystitis; Catheter Fever 154

Catheterization 154

Cystitis 157

Catheter Fever 161

CHAPTER XV
Care of the Bowels: Cathartics, Enemas, Distention, Fomentations 165

Cathartics 167

Enemas :: 171

Distention 174

CHAPTER XVI
Acute Intestinal Obstruction; Acute Gastric Dilatation 180

Acute Intestinal Obstruction 180

Acute Gastric Dilatation 183

CHAPTER XVn
Bursting of the Abdominal Wound 189

CHAPTER XVm
Sequeub of the Anesthesia: CoNjuNcrivrns, etc., Pneumonia, Nephritis... 192

Sore Jaw 192

Sore Tongue 192

Sore Chest 192

Paralysis i93

Bums 193

Conjunctivitis i93

Pneumonia i94

Nephritis 198

CONTENTS 1 1

CHAPTER XIX PACE

Acetonemia; Acid Intoxication; Delayed Chloroform Poisoning; Fatty

Degeneration of the Liver 201

CHAPTER XX
Hiccough: Causes and Treatment 209

CHAPTER XXI
The Tongue: Its Significance 212

CHAPTER XXII
Bandaging 216

CHAPTER XXIII

Treatment of the Operative Wound: Dressing, Stitches, Drainage, and

Stitch-abscess 241

Time for Dressing 241

Aseptic Wounds 242

Stitches 242

Drainage 246

Stitch-abscess 253

CHAPTER XXIV

Treatment of Septic Wounds: Soaks, Poultices; Hyperemia, Passive and

Active 257

Heat 258

Poultices 260

Bier Hyperemic Treatment 263

CHAPTER XXV

Sinuses and FistuljE: Lymphatic Fistula, Fecal Fistula, and Artificial

Anus 273

Sinuses and Fistulae 273

Lymphatic Fistula 279

Fecal Fistula 280

Artificial Anus 282

CHAPTER XXVI
Septicopyemia 284

CHAPTER XXVII

Cutaneous Rashes: Ether Rash, Septic Rash, Erysipelas, Surgical Scarla-
tina, Drug Poisoning 287

Ether Rash 287

• Septic Rash 287

Erysipelas 288

Surgical Scarlatina 289

Drug Poisoning 290

CHAPTER XXVIII

Rare Complications: Tetanus, Malignant Edema, Parotitis, Status Lym-

PHATicus, Hemophilia 293

Postoperative Tetanus 293

Malignant Edema: Gas-bacillus Infection 297

Parotitis 298

Status Lymphaticus 301

Hemophilia 303

1 2 CONTENTS

CHAPTER XXIX page

Habits and Their Relation to Surgical Conditions: Alcohol, Morphin,

CocAiN, Tea, Tobacco, Snuff 307

Alcohol 307

Morphin 308

Cocain 308

Tea and Coffee 309

Tobacco and Snuff 309

CHAPTER XXX

Postoperative Psychoses: Delirium Tremens, Insanity, Menopause 310

Delirium Tremens 310

Postoperative Insanity 313

Menopause 316

CHAPTER XXXI

General Treatment in Convalescence 317

CHAPTER XXXII

Bed-sores: Causes; Prevention; Treatment 320

CHAPTER XXXIII

Foreign Bodies Left in the Abdominal Cavity 323

CHAPTER XXXIV

Postoperative Hernia; Adhesions 328

Postoperative Hernia 328

Adhesions 332

CHAPTER XXXV

Abdominal Swathes: Their Use and Abuse 341

CHAPTER XXXVI

Artificial Limbs; Postoperative Flat-foot 347

Artificial Limbs 347

Postoperative Flat-foot 352

CHAPTER XXXVII

Massage: Friction, Percussion, Kneading, and Remedial Movements 356

Friction 357

Percussion 357

Kneading 360

Remedial Movements 362

CHAPTER XXXVIII

Electrotherapy; X-ray Therapy; Radium 367

Indications 368

Electrotherapeutic Technique 374

Carbon-dioxid Snow 381

CHAPTER XXXIX

Preparation of the Patient 383

Catharsis 384

Diet 385

Geraghty Test 386

Field of Operation 389

Preparation of Special Areas 394

CONTENTS 13

PART II

CHAPTER XL page

Operations on the Head and Face 398

Scalp Wounds 398

Trephining and Brain Operations 398

Removal of the Gasserian Ganglion and Other Nerve Resections 400

Excision of the Upper and Lower Jaw 400

Tumors of the Parotid 401

Enucleation of the Eye 402

Cancer of Lip 402

Other Plastic Operations on the Face 403

CHAPTER XLI

Operations on the Mouth, Nose, and Pharynx 405

Hare-lip 405

Cleft-palate 406

Excision of the Tongue, Partial or Complete 408

Ranula 409

Alveolar Abscess 410

Parafl^ Prosthesis for Deformity of the Nose and Other Parts 411

Nasal Polypi and Spurs 412

Antrum of Highmore 413

Frontal Sinus 414

Removal of Adenoids 414

Removal of Tonsils 416

Tumors of the Tonsil 417

Peritonsillar Abscess 418

Retropharyngeal Abscess 418

CHAPTER XLU

Operations on the Neck 420

Tracheotomy 420

Laryngotomy 423

Intubation 424

Esophagotomy 432

Esophageal Diverticula 432

Partial Thyroidectomy 433

Excision of Lymph-nodes of the Neck 441

Incision and Excision of Carbuncle of the Neck 442

Branchial Cysts and Sinus 443

Mastoiditis 443

CHAPTER XLIII

Operations on the Thorax 446

Amputation of the Breast 446

Excision of Benign Tumors of the Breast 447

Abscess of the Breast 448

Empyema 449

Abscess of the Lung 454

Thoracoplasty (Estlander's Operation; Schede's Operation) 454

Operations on the Pericardium 454

Gunshot and Stab- wounds of the Chest 454

CHAPTER XLIV

Operations on the Abdomen 457

Omphalitis 457

Gastro-enterostomy 457

Gastrostomy 460

Gastrectomy 462

Pyloroplasty 463

Gastroplication 465

Pylorectomy 465

Perforated Gastric Ulcer 465

14 CONTENTS

PAGE

Operations on the Abdomen— Perforated Duodenal Ulcer 468

Colostomy ^58

Jejunostomy 474

Intestinal End-to-end Anastomosis, or Circular Enterorrhaphy 474

Abscess of Liver 47^

Hydatid Cyst of Liver 476

Gall-bladder and Biliary Passages 477

Cholecystotomy 478

Cholecystenterostomy 480

Cholecystgastrostomy 481

Choledochotomy 482

Choledochostomy 482

Choledocho-enterostomy , Choledochectomy 483

Choledochoduodenostomy 483

Duodenocholedochotomy 483

Hepaticodochotomy 483

Hepaticodochostomy 484

Hepaticodocholithotripsy 484

Gunshot and Other Injuries of the Abdomen 484

CHAPTER XLV

Operations on the Abdomen (Continued) 486

The Radical Cure of Hernia 486

Large Incarcerated Hernia 492

Strangulated Hernia (Inguinal or Femoral) 494

Operations on the Pancreas 496

Splenectomy 499

Appendicostomy 500

Appendicitis and Its Complications 502

General Peritonitis 517

Tuberculous Peritcmitis 520

CHAPTER XL VI

Operations on the Vagina, Uterus, and Adnexa 522

Incomplete Perine<MThaphy and the Repair of Rectocele 522

Complete Perineorrhaphy 524

Repair of Cystocelc 525

Vesicovaginal Fistula 526

Rectovaginal Fistula 527

Excision of the Vulva 527

Excision of the Urethral Caruncle 528

Vulvovaginal Abscess 528

Cyst of Bartholin's Gland 529

Vaginal Section (Colpotomy) for Drainage of Pelvic Abscess 529

Vaginal Section for Removal of the Appendages 531

Vaginal Hysterectomy 532

Operations on the Cervix Uteri 534

Curettage for Abortion and Miscarriage 535

Hydatiform Mole 540

Curettage for Endometritis or Anteflexion 541

S)anphysiotomy 541

Pubiotomy 543

Operations for Retroversion and Lesser Operations on the Appendages 544

Ovariotomy 545

Salpingo-obphorectomy for Salpingitis and Ovarian Abscess 546

Tuberculous Salpingitis 549

Abdominal Hysterectomy 550

Inoperable Malignant Disease of Pelvis 553

Celiotomy for Extra-uterine Pregnancy 555

Cesarean Section 556

Extraperitoneal Cesarean Section 559

Vaginal Cesarean Section 561

Other Operations 562

Eclampsia 562

Early Rising After Labor 565

CONTENTS 1 5

CHAPTER XLVn page

Operations on the Penis, Scrotum, Urethra, and Prostate 566

General Considerations 566

Circumcision 570

Meatotomy 57i

Hypospadias 57i

Epispadias 572

Hydrocele 572

Varicocele 573

Undescended Testis 574

Castration 574

Internal Urethrotomy 574

External Urethrotomy 575

Ruptured Urethra 5^4

Perineal Prostatectomy 584

Suprapubic Prostatectomy 587

Prostatotomy for Prostatic Abscess 589

CHAPTER XL VIII

Operations on Kidney, Ureter, and Bladder 590

Nephrotomy 590

Nephrectomy 597

Nephrorrhaphy 599

Operations Upon the Ureter 600

Suprapubic Cystotomy 600

Lateral Cystotomy 603

Median Perineal Lithotomy 603

Vaginal Cystotomy 604

Exstrophy of the Bladder 605

CHAPTER XLIX

Operations on Anus and Rectum 607

Fissure in Ano 607

Fistula in Ano 607

Pilonidal Sinus; Cyst of Coccyx 608

Imperforate Anus; Imperforate Rectum 608

Ischiorectal Abscess 609

Hemorrhoids 609

Prolapse of Rectum 612

Kraske's Operation for Cancer of the Rectum 613

Weir's Combined Operation for Cancer of the Rectum 615

Vaginal Proctectomy 616

CHAPTER L

Operations on the Extremities 617

Amputations 617

Ligation of the Innominate Artery 619

Ligation of the Carotid Artery 620

Ligation of the Subclavian Artery 620

Ligation of the External Iliac or Femoral Artery 621

Arterial Suture 621

Matas' Operation for Aneurysm 623

Varicose Veins of Lower Extremity 624

Subacromial Bursitis 625

Olecranon Bursitis 625

Suture of Tendon and Muscle 625

Tendon Transplantation 627

Nerve Suture 627

Suture of the Brachial Plexus 628

Nerve Anastomosis 628

Psoas Abscess 630

Inguinal Bubo (Abscess of the Groin) 631

Paronychia and Perionychia 631

1 6 CONTENTS

PAGB

Operations on the Extremities — Ingrowing Toe-nail 631

Palmar Ganglion; Tuberculous Tenosynovitis 631

Dupuytren's Contraction 632

Skin-grafts 633

CHAPTER LI

Operations on Bones and Joints 635

Excision of Elbow 635

Excision of Shoulder-ioint 635

Excision of Wrist 636

Excision of Hip 636

Excision of Knee 636

Open (or "Compound") Fractures 637

Operative Fixation of Fractures 646

Operations on the Knee: Dislocated Cartilage, Synovial Fringe 650

Operation for Recurrent Dislocation of the Shoulder 651

Operation for Purulent Arthritis 652

Osteomyelitis 652

Operations for Bow-legs, Knock-knees, and Coxa Vara 654

Club-foot (Congenital Equinovarus) 655

Hallux Valgus 650

Operation for Spina Bifida 660

Laminectomy 661

CHAPTER LII

Therapeutic Immunization and Vacx:ine Therapy 663

Principles of Immunization 663

Immunization Against the Bacterial Cell 665

Antitropins: Ag^utinins, Bactericidins, and Bacteriolysins 665

Opsonin and Phagocytosis 665

Determination of the Op)sonic Index 669

Therapeutic Inoculation 674

Preparation of Bacterial Vaccine 716

Laboratory Technique 717

The Tuberculins 730

The Sterilization of Vaccines 732

New Methods of Killing Bacteria for Vaccines 732

Clinical Practice 734

Acute Fulminating Infections 734

Generalized Infections 74©

Infectious Arthritis 745

Localized Staphylococcic Infections 753

Localized Tuberculosis 768

Genito-urinary Tuberculosis 783

Tuberculin Treatment 792

Dosage Table 794

CHAPTER LHI

COLEY SERtTM FOR MALIGNANT TUMORS 797

APPENDIX

Some Invalid and Convalescent Food Recipes 800

Index of Authors 809

Index 817

SURGICAL AFTER-TREATMENT

PART I

CHAPTER I

SICK ROOM, NURSPS CHART, POSTURE

As a rule, the end of the operation marks the beginning of the sur-
geon's care and anxiety. In operating, the surgeon consumes from
fifteen minutes to one hour — rarely longer — in performing a piece of
surgical technique with which he presumably feels quite at home. When
the patient leaves the table, however, he goes over into strange hands
for an indefinite period of convalescence, with all its discomforts and all
the possibility for mishap. The surgeon must now depend, in a large
measure, upon others to carry out his plans for after-treatment and to
keep him informed of the changes that may develop from hour to hour
and the emergencies that may arise. For the time being, he must relegate
a portion of his authority and responsibility to the person in charge —
the nurse in a private family, or the house officer in a hospital. Skilful
after-treatment has pulled through many a forlorn hope, while neglect
in the after-care will negative the skilful eflfort of the best surgeon.
Success in after-treatment means the successful mastery of a mass of
details.

SICK ROOM

The room in which the patient is to pass his convalescence should
be large, airy, well ventilated, and capable of being adequately heated.
If in a private house, it should be situated apart from the living rooms
and cooking, and near to a bath-room. The walls should be painted
with washable paint in plain colors, without figures. The floor should
be of polished wood, linoleum, or concrete, and without carpets.

The bed should be light, easily movable, with low head- and foot-
pieces, best made of enameled iron, so that it may be readily and thor-
oughly cleansed. It should be narrow, and stand so high above the

2 17

SICE ROOM, nurse's CHART, POSTURE

floor that the patient can be easily dressed and attended. It should be
so placed that the nurse can readily get around all sides of it, and so
situated that the patient does not have to look directly at a window or
have the sun strike his face. It is well to have blocks, which may be
placed under the head or foot casters of the bed, and to have boards to
be placed across the middle of the frame to support the spring if it sags
and gives the patient a backache.

Two small and rather hard feather pillows will suffice. One may
be encased in rubber for use if the patient vomits. Sometimes several
pillows of different sizes are handy to place under the small of the back
or under the knees of the patient, as after an inguinal hernia operation,
or to place against the foot of the bed for the patient to brace his feet
against, in case the head of the bed is elevated.

A small enamel or wooden table may be useful, placed at the right
side at the head of the bed. Otherwise, sa\'e for a chair or two, there
should be no furnishings in the room. Ornaments, pictures, hangings,
and bric-a-brac are out of place. There should be a convenient hook
or nail to be used in hanging up a fountain syringe.

The bed should be provided with a firm, level, horsehair mattress.
A water-bed may be employed in case the patient is paralyzed, en-
feebled, or emaciated, to prevent bed-sores; its use should be restricted,
for it sometimes imparts a sensation akin to sea-sickness. Over the
mattress comes the sheet; a narrow rubber "draw-sheet" is placed
across the middle of the bed to protect the mattress. A full-sized

SICK ROOM

sheet, once folded end-to-end, is also placed across the bed to cover
the rubber sheet. This is of great convenience, because it can be

PatieDt wrapped

readily changed when soiled by discharges, dressings, irrigations, or
the bed-pan, without disturbing the under sheet.

In changing the draw-sheet a nurse stands on each side of the bed.
One nurse gently turns the patient toward the side nearest her, while
the other rolls up the soiled sheet, wipes off the rubber draw-sheet, and

SICK ROOM, NUKSES CHART, POSTURE

lays on the clean sheet, which has been folded and rolled up. and tucks
her end in under the mattress. Then the patient is allowed to turn on

his back and is gently rolled on the other side, while the other nurse
pulls out the soiled sheet, wipes off the rubber sheet on her side, unrolls

the clean draw-sheet from under the patient, and tucks her end in,
taking care that it is tightly stretched and smooth. This procedure

nurse's chart 21

may be easily carried through by a single nurse, provided the patient
can be turned without danger.

The under sheet may be changed in the same way. The under
sheet should be changed every morning and the draw-sheet as often as
necessary. The bed should be kept free from crumbs and food par-
ticles, which will cause irritation of the skin or may even lead to bed-
Over the patient all that is necessary is a sheet, a blanket, and a
coverlet; extra blankets may be added when necessary.

The nurse should see that she has at hand a 4-quart fountain syringe
and connections, hot -water bags, a rectal tube and glass female catheter,

a hard-rubber oil enema syringe, bed-pan, towels and bed linen, toilet-
paper, basins, hypodermic syringe with strychnin, morphin, and
atropin, feeding-glass, feeding-tube, thermometers, and temperature
charts. In private practice she can depend upon the surgeon to
supply or order the other instruments and drugs necessary.

NURSFS CHART
A surgeon at his visits will rely largely upon the nurse's chart.
This should be accurate and explicit. It should record the tempera-
ture, taken twice daily (10 a. m. and 4 p. m.) or every four hours, as
the case demands, and at the same time the pulse, and the respiration
if the surgeon wants it. The frequency and nature of bowel move-
ments should be stated, as well as the occurrence and the quantity of

SICK ROOM, nurse's CHART, POSTURE

urination. For the first few days after operation, especially in stom-
ach and other abdominal cases, it is well to keep a detailed diet-chart
(Fig. 7), recording the occurrence of vomiting and the stimulation,

THE BOOTHBY SURGICAL HOSPITAL

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ikat

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Flo. 7.— A Convenient T«pe op Detailed Chart. (Reduced one-half)

nourishment, enemas and their retention, catheterization, sleep, etc.
It is valuable also for future record to enter briefly on the temperature
chart such items as the date of operation, wicks out, stitches out, the
date of sitting up, and final discharge.

Name.

Resioencc.

Birthplace.
Occupation-

Date OF Adm..

Transfer — See .

Rs-Entrv See.

Servicx of. Dr.-

DtACNOSIS

CoMPUCATtONS.

nurse's chart

Ho«r. No.

.0. P. D. No..

Ace.

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Patient's Physician.
Address

.Whits or Colored

.Ward.

. Path.. No. .

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DATE.

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imt.

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TNIE.

Fig. 8. — BEDsroE Chart Used at the Massachusetts General Hospital (reduced).

With the exception of "Diagnods" and " G>mplications, " which are filled out only after discharge, this chart

contains no data undearable for the patient and his friends to read.

SICK ROOM, NUKSE S CHART, POSTURE

The nurse is expected to be fully informed as to the pulse and tem-
perature, state of the bowels and bladder, distention, vomiting, pain,
delirium, sleep, amount of discharge or hemorrhage if it soaks through
the dressing, and the occurrence of menstruation or vaginal discharge,
A nurse of experience can be of help in other ways, but these things
she must know. Moreover, she must have sufficient judgment to
be able to decide whether to summon the surgeon and when to do so.
Upon her devolves the responsibility of informing the surgeon of any
change or emergency, otherwise it is a matter of waiting upon the
patient and of following explicitly the orders of the surgeon in charge.

POSTURE

The patient should be allowed to assume in bed the position of
greatest ease and comfort, provided this position is not harmful.
Comfort and sleep are important after a serious operation, and any-

thing which will tend to induce them — avoiding opiates — is to be
diligently sought after and practised. It has been generally held
that the only proper posture for a patient after an operation of any
severity is the supine, with the patient flat on his back, and some-
times, in spite of increasing discomfort, he will not be allowed to turn
for some days. The cases where this rule need be enforced are few,
and ordinarily, in celiotomies which have been sewed up tight and
wear a firm swathe, there is no reason why a position of greater comfort
may not be allowed. In the supine posture backache is frequent,

though this may be relieved by flexing the knees at 45 degrees on pil-
lows, or by placing a small pillow under the hollow of the back (Fig. 9).
Few persons sleep on their backs, and turning the patient gently on his
side in the natural resting position, supporting his back with a pillow,
may often induce sleep.

Many women are unable to empty the bladder lying upon the
back, and residual urine collects and may develop into a troublesome
cystitis, which could have been obviated by turning the patient on her
side to micturate. Some patients appreciate being turned face down-
ward in bed, and drainage from an abdominal wound may often be

appreciably assisted by this position. Others will take comfort in
being allowed to assume the semiprone posture.

It is frequently advisable so to prop up the upper half of the mat-
tress that the patient is in a semireclining posture — for instance, in
elderly persons, in cases of cardiac asthma, bronchitis, hypostatic
pneumonia, and after thoracic and gastric operations. The sitting
posture is of distinct value in preventing postoperative pulmonary
complications, especially in fat patients, after celiotomies for condi-
tions such as gall-stone disease, gastric troubles, or umbilical hernia.
It is a good practice in patients who are old or feeble, or who have pul-
monary emphysema or bronchitis, to set them up soon after they have
recovered from the anesthetic. Hypostatic congestion of the bases of
the lungs is not then likely to occur, and the liability of pneumonia
is lessened. If the patient is held upright without any effort on his
part, there is no increased strain on the abdominal wound. As

26 SICK ROOM, NURSE^S CHART, POSTURE

this position takes the pressure oflf the bony prominences of the back,
patients are in less danger of bed-sores. In distention this position is
advantageous, in the first place, because the diaphragm and ab-
dominal muscles compress the viscera more powerfully, and, in the
second place, because in this position the action of the heart is less
impeded by upward pressure of the distended intestines. Sitting up
a distended patient always causes an improvement in the pulse. When
sitting up such patients can breathe better, they take food and liquids
better, the tone of vascular system is better preserved, and they are not
so Uable to dizziness and swelling of the feet when they finally walk.

R. H. Fowler,^ analyzing 69 cases of diflfuse septic peritonitis
operated upon in St. Luke's Hospital in ten years, refers to the article
by G. R. Fowler* on the advantages of the elevated head and trunk
position. He concludes as follows: /* Early institution of postural
drainage is of great aid in preventing septic material from reaching
the diaphragmatic peritoneum. The manner of instituting postural
drainage matters but little, provided that the pelvis is sufiiciently
low for gravitation to take place and the patient is comfortable. A
wooden frame may be used with a folded pillow beneath the knees
to prevent the patient from slipping."

This posture has been universally adopted in the treatment of
general i>eritonitis. Experimentally, H. T. Buxton^ has shown that
there is an almost instantaneous rush of bacteria into the lymphatics
of the diaphragm whenever infectious material comes in contact
with it. If the head and trunk are sufficiently elevated, septic matters
drain into the pelvis, where absorption is much slower. R. C. Coffey,*
by means of an ingenious cast of the peritoneal cavity, has shown that
it is necessary to elevate a person's body as high as 45 to 50 degrees
to insure drainage of the Imnbar depressions of the abdomen. The
Fowler position, to be at all effective, must be maintained all the time.

Many devices have been described for maintaining a position
upright in bed. Elevating the head of the bed and placing a pillow
under the knees is ineflfectual because the support is too yielding.
J. F. Baldwin^ advises the use of an ordinary rocking-chair; J. E.
Allaben' describes a back rest on the principle of a double-inclined

* Ann. Surg., 1908, xlviii, 828.
*Med. Rec., 1900, Iviii, 617.

'Jour. Med. Research, 1907, 17, 25, 251.

* Jour. Am. Med. Assoc., 1907, xlviii, 937.
' Ibid., 1907, xlix, 1043-

* Ibid., 554.

POSTURE 27

plane; and D. T. Gilliam^ advocates the use of a steamer chair. S.
McGuire^ elevates the head of the bed and uses an adjustable seat to
keep the patient from sUppmg downward. W. D. Gatch^ describes an
apparatus consisting of an oblong frame of stout boards, to the upper
surface of which are hinged three movable flaps, which can be arranged
so as to give a sitting posture. An efficient way to maintain Fowler's
position is shown in Figs. 169, 170, and 171, pages 518 and 519.

* Jour. Am. Med. Assoc., 1908, li, 1133.

^ Ibid., 1, 1019.

^ Ann. Surg., 1909, xlix, 410

CHAPTER II

AFTER THE ANESTHETIC: NAUSEA AND VOMITING,
HEMATEMESIS^ RESTLESSNESS, SWEATING

In the ordinary operation of election, the major incident, so far
as the patient is concerned, is the anesthesia. With no well-defined
appreciation of the so-called horrors of the operating-room, but with
an innate dread against resigning himself to the fumes of an over-
powering drug, sharpened by the harrowing recitals of acquaintances
who have been through it, the patient usually goes to the table in a
state of anxiety and suppressed excitement which has an important
bearing upon the course of the anesthesia and the recovery therefrom.
If such a patient is unskilfully handled, he will come out of the ether in a
state of collapse, he will be distressed for hours by nausea and vomiting,
the operative recovery will be retarded, and the whole incident will
constitute a nightmare which he will carry through life, with the lead-
ing part taken by a professional person who is throttling him noncha-
lantly, and is bellowing in his ear, *' Now take a long breath,'^ with, as
support, a grim surgeon in a white gown, who hisses through his
teeth, "Get him under '^ or *'Give it to him/*

The surgeon does wrong to himself as well as to his patient if
he neglects the anesthetic. A considerate, even etherization, com-
petently conducted, will see the patient to bed almost recovered, with
the minimum of shock, and with little or no gastric disturbance. The
experience has not been disagreeable to the patient, and he starts his
convalescence with a better spirit and a higher resistance than the
person who has been fagged out and distressed by an irregular or
hurried anesthesia, and its subsequent nausea and vomiting.

If an expert anesthetist can be obtained, this should be done.
A well-trained nurse who specializes in this field is as satisfactory as
most male anesthetists, and is distinctly safer and better than the
average doctor. As has been said elsewhere,^ a perfect solution of
the problem of giving anesthetics would be a medical man of high
grade of intelligence, with a well-grounded medical and surgical
education, and especial education in anesthetics, supplemented by a
natural inclination in this direction as against any other. Are the

* J. M. Baldy, Boston Med. and Surg. Jour., 1909, clxi, 262.

AFTER THE ANESTHETIC 29

attractions of anesthesia sufficient to overcome the disadvantage of
the scientific narrowness and lack of opportunty for distinction and
income to hold a sufficient number of men of this type, or even of
great worth, in this field? The answer seems apparent. To the
nurse, anesthesia would prove a stepping-stone to something better
than she had originally chosen, a higher and more dignified position,
and appeal in its own way to her ambition and pride, just as does the
superintendency of a training-school. With the nurse anesthetist
is eliminated the inattention to the anesthetic, with its attendant an-
noyances and dangers, there being no desire for, or chance of, an assist-
antship or future chiefship.

An element in humane and successful anesthesia, where time and
other conditions permit, is for the personal physician, if he be at all
competent, or the surgeon himself, to start the anesthesia. By this
means no new individual is introduced to the patient at the last
moment, with a possible unpleasant psychic effect.

Most important, first of all, is that the anesthetist should, by pre-
liminary conversation with the patient, by air of self-confidence, dehb-
eration with no suggestion of hurry, by constant spoken reassurance as
the anesthesia proceeds, gain and keep the entire confidence of the
patient. If at first the patient asks for a little more air, he should
have it. Unless the patient is likely to harm himself by his struggling,
no one should touch any part of the patient as he goes under. In the
midst of the weird dreams of ether intoxication the mere restraining
hand of a bystander on the patient may convert a fantasy into a wild
delirium, a quiet patient into a temporary maniac. Successful ether-
izing is half hypnotic in its method.

In the hands of the slightly skilled or the average anesthetist, as
well as the expert, the drop method of giving ether is the safest and
best. Twelve to twenty layers of gauze, cut rectangular in shape,
7 by 9 inches, are laid over nose and mouth and tucked under chin.
The patient gets used to breathing through the gauze, and then, so
slowly that he may get used to the smell, ether is played over nose-
and mouth-area of gauze from a single pin-puncture in the top of a
250-gm. tin ether can. The patient thus gets constantly ether-laden
air, which is at the same time always fresh.

Certain advantages are claimed for various methods of inducing
anesthesia. Nitrous oxid gas, anesthol, ethyl chlorid, and chloroform
are all less unpleasant to most patients for beginning anesthesia than
ether; they go under more rapidly and quietly, there is less swallowing
of ether-laden mucus, and as a result the after-effects are far less dis-

30 AFTER THE ANESTHETIC

agreeable, as a rule. But all these methods complicate the problem
of anesthesia, and they must be used with care and discretion. Nitrous
oxid gas, the safest of those mentioned, requires a special apparatus
and a trained administrator, and it should not be used in patients
with valvular disease or myocardial degeneration. Chloroform,
ethyl chlorid, and anesthol are dangerous in increasing ratio: death
from the two latter is extremely sudden, and in the majority of cases
occurs within five minutes of the beginning of inhalation. ^ These
agents will give good results only in the hands of trained anesthetists
of wide experience in their use, and with cognizance of their dis-
advantages.

Similarly, some surgeons employ as a routine, preliminary to ether
or chloroform, morphin (gr. J to \) and atropin (gr. y^^ to y^^), or
morphin and scopolamin (gr. y^ to y^^), by subcutaneous injection
or by mouth, a half-hour or one hour before the anesthetic is started.
The advantages of this procedure are, a smoother anesthesia, more
readily induced, with decreased salivation, economy of the anesthetic,
and lessened nausea and vomiting. On the other hand, their action
is variable with individuals and they sometimes fail to act, they are
likely to be followed by dryness of the mouth and thirst, and by
prolonged sleep, and they depress circulation and respiration, and
may cause death. The routine use of these combinations should be
deprecated; they should not be employed in severe cardiac conditions
or in operations about the mouth and throat on account of the inter-
ference with expectoration.2 Their use is sometimes indicated in
the case of alcoholics, dyspeptics, and the nervously unstable. Nitrous
oxid with oxygen, which has been gradually growing in favor in major
surgery in this country within the last five years, is noted for the mild-
ness of its after-effects. Crile^ reports only 139 cases of nausea (of
which 9 were severe) after 1000 major operations in which gas and
oxygen were used. The effects on the kidneys and liver are equally
mild, as compared with ether, and particularly chloroform. When
ether vapor is added to the combination, as it frequently has to be to
overcome spasm of the abdominal muscles and rigidity of the legs
when the lithotomy position is used, these beneficial effects are more

1 H. C. Wood, The Comparative Danger of Ethyl Chlorid as an Anesthetic, Jour. Am.
Med. Assoc., 1910, Iv, 2229.

2 R. A. Hatcher, Scopolamin and Morphin in Narcosis and Childbirth, Jour. Am.
Med. Assoc., 1910, liv, 446; C. V. Collins, Scopolamin and Morphin as a Preliminary
to General Anesthesia, Jour. Am. Med. Assoc, 1910, liv, 1051.

' Jour. Am. Med. Assoc., 1910, liv, 1907.

APTER THE ANESTHETIC 3 1

or less neutralized, however. This form of anesthesia is as expensive
as regards materials, it requires special and complicated apparatus,
and a professional anesthetist.

AFTER THE ANESTHETIC

Immediately after the operation the patient is wiped dry, the
dressing or bandage is adjusted, wet clothes changed for dry, and he
is wrapped in blankets and transferred to a warm bed, to be carefully
watched during his recovery from the anesthetic. In hospitals there
is usually set apart a special room called a recovery room. This
should be high-posted and airy, maintained at a constant tempera-
ture of about 70** F. It should be quiet, with a subdued light, and so
isolated from the general wards that any disturbance or loud retching
may not upset other patients in a critical condition. The room should
be barely furnished, the walls painted in a plain color, and windows
should be barred. In a private house these conditions should be ap-
proximated as closely as may be.

During the recovery the patient should have the imdivided atten-
tion of the nurse detailed for the purpose. Vigilance is necessary, not
only to prevent the imconscious patient from swallowing his tongue or
choking in mucus or vomitus, but also from injuring himself in delirium,
or from removing or displacing his dressing. Rarely there may be ne-
cessity for restraining a patient by means of a folded sheet passed
across the body and made fast to the bed-frame on either side (Fig. 1 1),
as, for instance, when a delirious, muscular man is in the care of a little
nurse who is alone. But usually, with the patient in a semiconscious
state, restraint of any kind has a tendency to cause him to struggle
and to increase the violence of the delirium. It is only rarely that
delirium goes farther than random or irresponsible talk or an attempt
to sit up, and it lasts, as a rule, not longer than ten minutes, so that
a competent attendant will not often find use for restraint. Extra
heaters and hot-water bottles, well covered beyond the possibility
of burning the patient, should be at hand to distribute about the
patient as necessary.

Recovery from anesthesia occurs, roughly speaking, with a rapidity
in inverse proportion to the length of narcosis and the amoimt of anes-
thetic employed. Other facts enter into the matter, however. Re-
covery from chloroform is more rapid than from ether. The recovery
will be shorter if the administration has been even; if a good quality
of ether has been used; if the patient has been at all times allowed
sufficient oxygen; if the air-passages have not been plugged with mu-

AFTER THE ANESTHETIC

cus; if the circulation has been well maintained during the anesthesia;
if the patient has not vomited during the administration, or any

0 ig'A

emergency has arisen necessitating the use of tongue-forceps or of
artificial respiration. A skilful anesthetist will at the end, have his

subject so lightly under the influence of the anesthetic that signs of
recovery appear immediately upon transference from table to bed.
Some operators, indeed, demand of their etherizers that the patient

AFTER THE /VNESTHETIC 33

vomit before he leaves the table; this is of particular advantage in
private-house operations, where the surgeon is usually loathe to leave
until he is assured that recovery is well under way.

The anesthetist should in every case see the patient to bed, and
stay by him until distinct signs of recovery are evident— until the
patient is able to dispose of his vomitus. He should remain until
some semivoluntary action takes place— until the patient turns his
head, opens his eyes, moans, or talks. In certain types of cases tcm-
porarv obstruction of respiration is likely to occur, and there must be
some one at hand who is competent to use the mouth-gag and tongue-

forceps in an emergency, who will hold forward the jaw, wipe away
the frothy mucus, and clear the mouth of vomitus if necessary. Neg-
lect of this precaution may be serious, either as regards inmiediate
strangulation or subsequent pneumonia. When a patient responds
in any way to the question "Feeling better?" he may be safely left
with a nurse.

If a patient who has not had preliminary morphin or scopolamin
remains for a long time after the operation in a state of deep narcosis.
it means that an unnecessarily large amount of anesthetic has been
used. Accompanying this prolonged stupor there will be a deteriora-
tion in the pulse and duskiness of the face and lips. Sometimes, how-

AFTER THE ANESTHETIC

ever, even if an excessive quantity of the anesthetic has not been used,
there will appear a slighter degree of duskiness and some flagging of
the pulse, independent of length or seriousness of operation, which
is probably due to the presence of mucus in the air-passages and to
the deprivation of the stimulating action of the anesthetic'

Both chloroform and ether act as cardiac stimulants in feeble sub-
jects, and as soon as their administration is stopped the circulation will
flag. During the interval of lowered vitality the patient should be kept
dry and warm. As soon as retching and vomiting occur and the air-
passages have cleared themselves of their accumulations, the normal

color will come back to the face and lips and the pulse will be restored
to its former strength.

The best position for a speedy and satisfactory recovery is with
the patient on his side. When conditions allow this — and the excep-
tions are rare— it will be found that the tongue gravitates to the side
of the mouth, a free air-way is established, stertor disappears, mucus
and saliva will find their way out without being sucked into the air-pas-
sages, and coughing ceases; if there is vomiting, the vomitus will escape
freely. The patient, having no pillow under his head, may be bolstered

' J. B. Blake (Boston Med. and Surg. Jour., i8g6, txxsv. 492): "Oxygen shortens the
time of returning consciousness and diminishes unpleasant after-effects of ether. It is a
Riiod cardiac and respiratory stimulant, and is indicated in threatened collapse. Insert a
soft -rubber catheter K*ntly through the nares until the eye is iipproximately opposite the
opening in the trachea."

NAUSEA AND VOMITING 35

up if turned on his right side by putting a doubled pillow behind his
left shoulder, taking the precaution of making sure that he is not lying
upon his right arm. When the patient cannot be turned, his head should
be held to the right.

NAUSEA AND VOMITING

The occurrence of nausea, retching, or vomiting in some degree is
characteristic of the after-effects of ether. It comes on suddenly, and
for the time being it may be violent, but subsides rapidly and leaves
the patient half awakened to clear-headed consciousness, or is suc-
ceeded by quiet, normal sleep. Vomiting after ether practically always
is temporary ; as a rule, it occurs while the patient is unconscious, and
has spent itself before the patient has been brought to a state of reali-
zation of his distress. It may, however, recur in repeated attacks,
and this depends on certain factors which should be mentioned.

If solids or liquids are present in the stomach at the beginning of
the administration, there will not only be difi&culty in maintaining a
deep, even, quiet anesthesia, but the after-symptoms may be severe.
The quality of ether used is important — it should be made from pure
grain alcohol, free from methylic ether, sulphuric acid, alcohol, or
water; it should be freshly opened, for ether exposed to the air develops
acetic acid.

If during the operation much blood, mucus, or saliva passes into the
stomach, it will be bound to find its way up in the post-anesthetic stage.
The after-symptoms are likely to be more severe in constipated persons,
after handling of the stomach or intestines, if the anesthesia is pro-
tracted, or if the patient is jolted about during recovery. Some surgeons
make it a practice to wash out the stomach after the operation is over
while the patient is still on the table; this often is advantageous, espe-
cially in cases where proper preparation has not been possible, in that
it forestalls what may prove to be an uncomfortable period for the
patient. As a routine its employment is unnecessary.*

* Ochsner (Clin. Surg., 1902, 108 et seq.) : " The fact that the patient is suffering from
nausea or vomiting is the strongest indication for the use of gastric lavage, because the
nausea is caused by the presence of decomposing material in the stomach, and its re-
moval must result in the greatest benefit to the patient. It frequently happens that
these patients lose their anxious expression and restlessness, which we have observed in this
case, and that the skin becomes warm and moist, and they begin to sleep directly after the
gastric lavage has been practised. . . .

"It is possible that there may be more material of the same character in the small intes-
tines, but, if so, it will soon regurgitate into the stomach and make its presence known by
the recurrence of nausea. Should this occur, the gastric lavage will be repeated at once.
If no food is given by mouth, I have never been compelled to irrigate the stomach more
than two or three times in the same patient, and usually one careful, thorough irrigation

36 AFTER THE ANESTHETIC

Chloroform in this respect acts diflferently from ether. The transient
nausea, with retching, ending in the expulsion of a small quantity of
whitish or yellowish stringy fluid, rarely occurs, owing chiefly, perhaps,
to the smaller quantities of mucus w^hich are secreted under the stim-
ulation of chloroform. If the chloroform anesthesia has been main-
tained evenly and deeply the recover}', as a rule, is rapid and satis-
factory— a single cough or act of retching will suffice to clear the larynx
of any mucus-plug, the dusky hue will depart from face and lips, the
pulse will rapidly restore itself, and the patient, if not disturbed, will
usual! pass off into a quiet sleep. When, however, vomiting does
come on after chloroform it is much more likely to prove distressing to
the patient and intractable to treatment; indeed, fatal cases have been
reported. It is apt to occur at intervals for hours and sometimes days,

will suflfice. It will be wise to direct attention to the method employed in such cases. The
patient is turned upon the right side in order to add the weight of the intestines to the
support of any adhesions which may exist in the vicinity of the appendix. The head and
shoulders are slightly elevated by means of pillows or a head-rest, then the pharynx is
sprayed with a 4 per cent, solution of cocain in order to prevent gagging when the stomach-
tube is passed, because this might disturb the adhesions in the vicinity of the appendix.
It is well to spray the pharynx repeatedly for a period of about five minutes, permitting the
patient to swallow a little of the saliva mixed with cocain in order to anesthetize the esopha-
gus to some extent at the same time. After holding the cocain in the pharvnx a minute
it is expectorated with the saliva which has accumulated and a fresh spray is applied. As
most of the cocain is thus throw^n out, there is no danger from poisoning. After about
five minutes a fairly large stomach -tube is inserted and the contents of the stomach siphoned
out. The stomach-tube should have one or two lateral openings aside from the opening at
its end. These openings should be vvithin i to 2 inches from the end which is inserted in
the stomach. This will prevent the end of the tube from becoming closed by drawing
into it a portion of the mucous lining of the stomach.

^'Whenever there is any interruption in the flow, this may be overcome by pouring a
little water into the tube and thus dislodging any substance which may have become
fixed therein.

''After the accumulation which is present in the stomach has been siphoned out it is
well to introduce into the stomach i pint of normal salt solution at 100° F. and then
siphon it out. This may be repeated until the fluid returns clear.

"The patient will now be placed in bed, with the shoulders somewhat elevated, so as
to favor gravitation toward the pelvis. She will receive absolutely no food and no cathar-
tics by mouth. Every four hours she will receive an enema of i ounce of one of the con-
centrated predigested foods dissolved in 3 ounces of normal salt solution. I am confident
that she will not require any anodyne, her pain will disappear spontaneously, since we have
removed the cause of irritation by performing gastric lavage. . . .

"There are two classes of patients in whom this form of treatment is not so satisfactory
as it is in all other classes — namely, the very old and the very young. Very old patients
do not bear confinement in bed well, no matter what their condition may be, and they
do not prosper generally on rectal feeding. In these cases one is compelled to choose
between two evils, and whichever is chosen, one usually wishes it had been the other.

"In children it is difficult to perform gastric lavage; they are likely to struggle and injure
themselves while this is being accomplished."

NAUSEA AND VOMITING 37

even after the stomach has emptied itself beyond any possibility of
doubt, which leads to the inference that it is due to some not clearly
evident reflex mechanism, or, in severe cases, to derangement of the
general metabolism, from the effects of the anesthetic upon the liver.
As against the brisk but transient gastric disturbance of ether, the
more rare but persistent retching of chloroform is far worse.^

It must not be overlooked that the vomiting following operation
may have a significance of its own, apart from the anesth^ic. It may
be a symptom of intestinal obstruction or peritonitis, in which case its
character and appearance are of importance; it may be an early mani-
festation of pneumonia or uremia, or represent an acetonemia. Some-
times vomiting will apparently be continued as a reflex from the pres-
sure of gauze drainage or of a glass or rubber tube, and will cease with
its removal; sometimes it will be kept up by improper food supplied by
injudicious friends. After anesthesia, if the vomiting is protracted
or violent and there is danger of the slipping of a ligature or of too
much strain being placed on a long abdominal wound, it is advisable,
if none has been given for three or four hours, to administer a suitable
dose of morphin hypodermically.

Recovery Room. — To aid an unconscious person to vomit the
head should not merely be turned over, but the patient should be
lifted by the shoulder over on the side until the thorax is well turned.
If, then, with the chin pulled forward, reflex expulsive effort is not
suflScient to drive the vomitus out of the pharynx and mouth, inspira-
tion involuntarily foUows, and the vomited matter is pulled back
toward the trachea. The first danger from vomiting after ether is
that the vomitus shall enter the trachea and acutely interfere with
respiration — in short, choke the patient. Should a patient, therefore,
be seen to make a vomiting effort, little or nothing come out of the
mouth, and cessation of breathing with cyanosis appear, the air-pas-
sages above the larynx must be cleared at once by the deep-reaching

^ Blanlaret (Presse Med., 1909, xvii, 481, " Vomissements Chloroformiques ") •
" Vomiting from chloroform is annoying, threatens the solidity of the suture, weakens
the patient, and by inhalation of solid or fluid particles causes postoperative pneumo-
nia and bronchitis. The patient should be kept under the influence of the anesthetic
until he is safely returned to bed, because movement of the body, especially when the
anesthesia is not complete, increases the tendency to vomiting. Of equal importance
is the maintenance of an even temperature of the body and the removal of the patient
from an atmosphere charged with chloroform. Lavage of the stomach before the
patient regains consciousness may be advisable if there has been much secretion and
swaUowing of saliva. If vomiting occurs, cold applications to the stomach or injections
of ergot or of picrotoxin, i cc. of a 2 per cent, solution, are indicated."

38 AFTER THE ANESTHETIC

finger or swab. Obstruction may be due to the tongue being sucked
backward into the pharynx — a matter quickly remedied.

If the vomited matter has been inspired deeper than the larynx, and
the reflex coughing is not sufl&cient to clear the trachea, tracheotomy
must be done at once.

As a rule, a patient vomits most easily with head low, that is to say,
without a pillow. It is said that lying on the right side diminishes the
tendency to vomit, as the contents of the stomach move over toward
the right orifice and will not so easily be ejected. It should not be
forgotten, however, that during anesthesia ether is excreted by the
stomach, and hence the stomach-contents must contain a certain
amount of irritative ether.^ Some vomiting, therefore, is desirable.

The treatment of protracted vomiting is sometimes imsatisfactory,
but ordinarily after ether comparatively simple measures will give
relief. It is fair to say that a patient adequately prepared for opera-
tion by rest in bed and thorough emptying of the alimentary tract
vomits the least after ether, but it should not be forgotten that ex-
cessive nausea after ether may be an individual peculiarity that no
amount of preparation will counteract in a given case. Frequent
rinsing of the mouth with cold water should be tried, but ice increases
the tendency to vomiting. Five to 15 minims of cocain hydrochlorid,
2 per cent, solution, in i dram of hot water every half-hour for three
or four doses, will sometimes allay a most persistent case.

By far the best and simplest procedure is to give the patient,
three or four hours after operation, or as soon as he asks for it, a glass-
ful of hot water (^ pint). This will promptly make him sick, and
he will vomit it, together with the mucus and saliva and the ether
which he has swallowed as vapor, or which has been reexcreted by the
gastric mucous membrane. This is, in short, an effectual form of
gastric lavage; the stomach, which has been ineffectually retching in
an effort to bring up a small quantity of thick, slimy, irritating material,
now successfully exerts itself in getting rid of a larger bulk of more
dilute fluid. Later another drink may be given, and it will usually be
retained. This procedure is contraincficated only in certain opera-
tions involving the stomach and duodenum.

If the vomiting is still persistent and prolonged — that is, after

1 A. Graham (Jour. Am. Med. Assoc, 1909, liii, 2094) recommends the administra-
tion of I ounce of pure olive oil just as soon as the patient can swallow. He reports that in
29 out of 30 cases there was no vomiting after this procedure. The oil is supposed to
dissolve the ether within the stomach. The oil may be poured into the stomach through
a tube before the patient leaves the operating-table.

NAUSEA AND VOMITING 39

five or SIX hours, and is not then definitely becoming less frequent —
the stomach should be washed out with hot water containing sodium
bicarbonate, 2 drams to the quart. This lavage may be repeated
every four hours if vomiting persists. Although an uncomfortable
procedure for the patient, it is brief and most efficiently relieves the
symptoms. The tube should be passed rapidly well into the stomach,
and as much sodium bicarbonate solution as the stomach will com-
fortably hold is passed in. This is forthwith siphoned out, and the
stomach is so filled and emptied three times. Just before the tube is
withdrawn a small amount of the alkaUne solution is left in. This
method is better than any of the medical remedies.^

Charged waters and champagne seem to exert a quieting effect
upon the stomach. Essence of peppermint, 5 to 10 drops on a lump of
sugar or in water, may often be of benefit, as well as tincture of capsi-
cum or tincture of iodin, 2 or 3 drops in water. Hot fomentations or,
much less conmionly, the ice-bag over the epigastrium may relieve
the stomach spasm. The inhalation of vinegar is said to have a seda-
tive effect in vomiting after ether.

If the vomiting does not yield to these milder measures after a
reasonable time, it is likely to prove troublesome. The patient should
be kept in a quiet, darkened room, propped up in a sitting posture in
bed (to reduce the sensation of nausea), and all food and drink by
mouth stopped. Any residue in the stomach should be gotten rid of
by means of gastric lavage. Thirst should be satisfied by saline ene-
mata, and nourishment should be administered only by way of rectum.
Hot poultices or a mustard plaster should be applied to the epigas-
trium, or a hot- water bag should be applied and frequently renewed.
Morphin will be of service, or a cup of black coffee to which 10 gr. of
sodium bromid has been added may be given, or an enema of bromid
and chloral, if there is violent retching. Milk of bismuth in ounce
doses may be repeated frequently. Cocain, gr. yV (s minims of a 2
per cent, solution), may be given every half-hour. Cerium oxalate
gr. 5 to 10; chloroform, i minim in a teaspoonful of water; dilute
hydrocyanic acid, i or 2 minims in water, have all been recommended.
The urine should be examined for albumin and acetone.

Emergency tracheotomy must be performed rapidly to be
successful. The head is dropped into the Rose position — that is to
say, backward over the edge of the bed or table. Standing on the
patient's right the surgeon, with the left thumb and forefinger, grasps
the cricoid and upper trachea, holding it firm in the middle line. With

^ For the technic of gastric lavage, see page 148.

40 AFTER THE ANESTHETIC

the right hand an incision is made with a pocket-knife or any cutting
instrument which it is possible to get, from just below the cricoid,
I to I J inches downward, if possible at once to the depth of the trachea
itself. Bleeding is absolutely disregarded. The knife, now turned
edge toward the patient^s chin, slipped into the trachea at the bottom
of the wound, cuts upward about three tracheal rings. The knife
turned at right angles will hold open the tracheal wound while artificial
respiration helps the patient to breathe.

When this operation is started, some bystander should at once go
for the tracheal dilator and two or three tracheal cannulas, and when
they arrive, one of the tubes may be inserted, a tube sufficiently long to
well enter the trachea, but not long enough to cause pressure deep in
the trachea where it is in relation to the arch of the aorta. The tube
at first rapidly fills with blood or mucus. This is best cleared by rotat-
ing a hen's feather down through the tube. The head should be
kept low until all bleeding has ceased, so as to allow the blood to run
from the mouth. If a tracheotomy tube is not at hand, a piece of
bent wire or rubber tubing may be used temporarily to hold the edges
of the trachea apart. When respiration is well established, any part
of the wound extending above and below the tube may be closed with

sutures.

HEMATEMESIS

The vomiting of blood after operation, where no lesion in the
gastro-intestinal tract exists to explain its occurrence, was first noted
forty years ago,^ and it has never yet been satisfactorily explained.
Cases are not frequent in the literature, but they have been recorded
by A. V. Eiselsberg,2 C. W. Mansell-Moullin,^ A. W. Mayo-Robson,^
J. H. Croom,* W. E. Lee,' G. E. Potter,^ and others. Busse recorded
96 cases occurring up to 1905.

Hematemesis occurs practically only after celiotomy. The opera-
tion need not have been performed on the gastro-intestinal tract, for it
has followed cases of ovariotomy, hernia, pelvic abscess, peritonitis,
and cholecystotomy. General anesthesia is not a necessary ante-
cedent, nor does the presence or absence of frank sepsis seem to have
any bearing upon the etiology.

* Fox, Diseases of the Stomach, 1872, p. 205, quoted by McKay.

2 Archiv. f. klin. Chir., 1899, lix, 832.

' Lancet, 1900, ii, 1 1 25.

<Ibid., 1901, i, 375.

^ Brit. Gyn. Jour., 1902, xviii, 59.

® Ann. Surg., 1908, xlviii, 632.

' Jour. Am. Med. Assoc., 1910, liv, 872.

HEMATEMESIS 4 1

Von Eiselsberg considered that the condition was the result of
torsion or ligature of the omentum, causing multiple gastric hemor-
rhages. McKay suggests that a common factor in all cases is shock,
and that shock may produce portal engorgement, and, secondarily,
venous congestion of the walls of the stomach, and that diapedesis or
even rupture of the capillaries may result. Others have suggested
that the hemorrhage is the result of operative trauma to the gastro-
intestinal tract, that it is caused by thrombosis,^ or that it is the result
of multiple infective emboli from any source of infection, such as the
appendix or gall-bladder, set free by the manipulation attending opera-
tive procedure and distributed by the blood-stream. Winiwarter,^
who studied 30 cases occurring in von Eiselsberg's clinic within five
years, asserts that there are two important etiologic factors: retro-
grade embolism in the vessels of the stomach-wall caused by detached
thrombi from ligated veins in omentum or mesentery, or by direct
extension of thrombosis, and, second, paralysis of the vessels from
toxins set free in the blood after major operations on any part of the
body, and in the formation of which the anesthetic, vomiting, and
predisposition may be factors.

Autopsy on fatal cases is likely to show the stomach filled with
thin, chocolate-colored fluid, with its vessels engorged, and its mucous
coat exhibiting occasional minute extravasations and frequent small
shallow ulcers scattered over its entire surface. Sometimes evidence
will be foimd of retrograde embolism or extending thrombosis from
ligated veins in the neighborhood of the stomach.

It is not uncommon to note that a patient who has just undergone a
severe operation, particularly one who has taken his ether badly, while
coming out will vomit a small amoimt of brownish, frothy fluid. This
is always transient, and it represents the small amount of blood which
is swallowed during the operation and digested in the stomach. Post-
operative hematemesis may come on a few hours after the patient has
recovered from the anesthetic, or its onset may be postponed a day or
two. The blood may be bright red in color, but it is more likely to
present some degree of decomposition, varying in shade from light
brown to black, and it tastes intensely bitter. The fluid contains
brown, flocculent masses, resembling coffee-grounds, and responds to
the tests for the recognition of blood. The vomitus is, as a rule, small
in quantity, and occurs at intervals of an hour or two; the patient may

^ Schwellbach, Postoperative Gastro-intestinal Hemorrhage After Appendix Opera-
tions, Deutsch. 2^it. f. Chir., 1908, xcv, 141.

Magen-Darmblutungen nach Operationen, Archiv. f. klin. Chir., 191 1, xcv, No. i.

42 AFTER THE ANESTHETIC

vomit but once or twice in considerable quantity — from a pint to a
quart at a time. Sometimes the vomiting is accompanied by the
passage of blood per rectum. The general condition resembles that
of profound collapse. The pulse is small and rapid, the skin becomes
cold and clammy, and the temperature may be subnormal.

The prognosis in all cases is poor. As stated by Lee {loc, cit.), the
mortality has been placed at 55 and 72 J per cent. If the hemorrhage
is in small quantity and digested, rather than in larger quantity of
fresh blood, the pulse is more likely to maintain its tone and collapse
is less to be feared.

Treatment promises little. Morphin should be administered to
keep the patient, and particularly his gastro-intestinal tract, quiet,
and an ice-bag should be applied to the epigastrium. Nothing
should be given by mouth. Saline solution and a nutrient enema when
indicated should be given by rectum. Saline with adrenalin should
also be given subcutaneously if there are signs of collapse. Hot gastric
lavage has been recommended; saline solution or 2 per cent, sodium
bicarbonate at a temperature of 115° F. should be used. After this
comes back clear, 15 minims of adrenalin in i pint of normal salt solu-
tion can be poured in and left. Winiwarter recommends washing
out the stomach with silver nitrate solution.

RESTLESSNESS

Restlessness is due most often to the mild delirium from ether and
to petty discomforts; next, to pain. It is always present after serious
loss of blood and is frequently present in shock. The restlessness of
hemorrhage and shock is considered elsewhere; that due to pain will
be discussed later.

The restlessness due to ether is usually mild and soon passes off.
It may occasionally closely resemble a delirium; the patient acts
wildly, is very talkative, sometimes screaming and thrashing about
violently. If his attention can once be secured, he becomes quiet,
and often confesses to acting queerly without cause. As a rule, this
foretells the end of the delirium, but frequently it is necessary to hold
the attention for a few moments. Sometimes he relapses into de-
lirium, but is readily made rational by the same means.

The petty discomforts causing restlessness are numerous. Often
the worry and anxiety incident to the operation are the cause. What-
ever the result of the operation may be, assure the patient for the time
being that everything is as favorable as could be expected; tactfully
allay his suspicions and anxieties and encourage him not to talk.

SWEATING 43

The relief of nausea and thirst is generally followed by satisfaction
of mind and body. A sUght change in posture ; a pillow under the small
of the back or imder the knees; a blanket less or a blanket more; the
loosening of a tight binder, or the granting of a harmless whim, will
often allay the restlessness. Not rarely a heater has caused a burn,
slight but nevertheless irritating, proper attention to which is gratify-
ing and restful to the patient. See that the patient is dry throughout,
and that his wound is free from unnecessary pressure and strain. If
the patient has recovered from his ether, and the simple measures
described above have failed to quiet him, the cause of his restlessness is
probably more serious, and should be found and treated accordingly.

SWEATING

In most cases ether, by dilating the superficial capillaries, induces
sweating. This commonly occurs early in anesthesia, and ceases as
the circulation regains its equilibrium. In strong, healthy patients it
rarely has any untoward significance. This sweating may be called
physiologic, in that it is eliminative and harmless, provided the body
surface is guarded from sudden chilhng. Therefore, in the recovery
room even profuse sweating in itself need cause no alarm in the case
of a vigorous person, or in cases where the operation has been short.
Toward the end of a long operation, or when the patient has been some
little time in the recovery room, sweating occasionally appears. This
is a cold, rather scanty, and clammy sweat, of far different aspect and
graver significance than the other variety. It is a sign of weakness,
and should call attention at once to the patient's general condition.
Shock and hemorrhage are both to be looked for, and measures taken
at once to support the patient. It is an early danger-signal of con-
siderable value, and while it may not be followed by a serious condi-
tion, it is by no means to be disregarded.

CHAPTER III

THIRST, ITS SIGNMCANCE AND RELIEF

The sensation of thirst which is commonly complained of after
operations, especially laparotomies, sometimes assumes troublesome
proportions. Thirst is partly symptomatic; the inhalation of ether or
chloroform seems to exert a postanesthetic inhibitory action on the
secretion of the mucous glands of the mouth and throat, and anesthesia,
especially if there is any manipulation of the stomach and intestines,
seems to be followed by a reflex decrease in the secretion of saliva, so
that, as a result, the patient suffers from a dryness of the mouth and
fauces and begs for water. This same condition, moreover, may be due
in part or chiefly to the action of morphin or atropin administered before,
during, or after the operation. Thirst may, without doubt, result
also from an actual loss of body fluids — by a purge before operation,
by increased secretion of mucus and saliva under the anesthetic, and
by vomiting, sweating, or hemorrhage during or after the operation.

Operations involving the peritoneum are practically always followed
by the symptom thirst, due to loss of body fluids, as shown by an increase
(which has been demonstrated experimentally) in the specific gravity
of the blood; intense thirst usually also characterizes the condition of
shock, and occurs generally in peritonitis and to a less degree in febrile
temperature from any cause. Thirst ceases as soon as the body tissues
have been provided with their proper complement of fluid.

The condition of thirst may be met by the use of drinks, washing
of the mouth, by enemas, by leaving water in the abdomen before sewing
up after celiotomy, and by the use of water subcutaneously.

By mouth, as already stated, there is very rarely any contra-indication
to giving water in considerable quantities. If the patient is nauseated
after the anesthetic, and water in copious draughts seems temporarily to
increase his vomiting, it must be borne in mind that the water is serving
to wash out the stomach and to help it relieve itself of an irritating sub-
stance. If the patient is vomiting from any other cause, and it becomes
important to supply fluids to the body, it will be found usually that the
water is retained suflSciently long to allow a considerable portion of it to
be absorbed. In either case the giving of small sips of water, frequently

PROCTOCLYSIS 45

repeated, is to be condemned, for such a method is apt to provoke vomit-
ing where it does not already exist, and is ineffectual either in relieving
thirst or in diluting the contents of the stomach and so assisting in their
expulsion. Hot water is better than cold, and drinks should not be
repeated oftener than every fifteen minutes. Ice, for the purpose
of slaking thirst, as well as ice-water, should be banished from the sick
room. It does nothing toward reducing temperature which ice applied
externally will not do. If it momentarily decreases the sensation of
thirst, it in reality increases and stimulates it by causing a hyperemia of
the mucous membranes of the mouth and throat.

Sometimes a patient will appreciate a drink of hot weak tea, the
flavor giving a satisfaction which does not exist in plain water. In
the same way, champagne or siphon soda may be used, or raisin tea,
or a drink made up of the juice of a lemon, i ounce of glycerin, added
to a pint- of water. If the patient has lost blood, or is still oozing,
there will be advantage in giving dilute gelatin solution, with lemon
added for flavor. If a patient complains of thirst, and it is not desired
to give water by mouth, much satisfaction will be afforded by allowing
the patient to suck the end of a towel moistened in water or to chew
gum.

Washing of the mouth is always appreciated by a patient after anes-
thesia. It removes the disagreeable sensation of dryness and stickiness,
the foul taste following vomiting, and bits of vomitus themselves. If
Dobell's solution is used, or glycerin and rose-water equal parts, there
is substituted a pleasant taste and an agreeable sense of cleanliness and
coolness. Patients are rarely too weak to rinse out their mouths. If
this condition arises, the nurse can wash out the mouth and scrub the
furred tongue with her forefinger wrapped in absorbent cotton and dipped
in the solution. For this purpose glycerin with a few drops of lemon-
juice added is good.

Proctoclysis. — In serious conditions, where water in sufficient
amount by mouth is impracticable, the simplest method for its adminis-
tration is by means of enema. If the need is anticipated before the
operation is over, an enema of normal saline solution (a teaspoonful of
salt to a pint of warm water) may be given while the patient is still
under the influence of the anesthetic, otherwise the enema may be started
as soon as the patient has been put to bed, and a quart may be given
and repeated in two hours if necessary. As in giving fluids by rectum
in bulk there is a likelihood of a considerable proportion not being re-
tained and absorbed, especially with a patient not fully recovered
from the anesthetic or weakened by hemorrhage or shock, it is often of

THIRST, ITS SIGNIFICANCE AND RELIEF

advantage to administer saline solution by the drop or Murphy
method.' For this purpose the fountain syringe is hung at a moder-
ate distance above the bed (page 519), in a position where it or the
tube will not be disturbed by the patient. On the tube a clamp or
hemostat is adjusted, so that the water comes away drop by drop at
the rate of about a drop a second (which is equivalent approximately
to 16 ounces per hour). To the end of the tube is attached a small-
caliber soft-rubber catheter, which is introduced 6 inches into the rec-
tum, or a small-sized vaginal hard-rubber syringe tip may be employed.
The water in the syringe should be hot, so as to allow for cooling in the
tube. If the instillation is accurately regulated, the question of
maintenance of heat in the reservoir is relatively unimportant, be-
cause the amount of heat ab-
stracted from the rectum dur-
ing so slow an introduction
is practically negligible. If
the flow becomes too rapid,
the fluid docs not absorb as
fast as it comes in, the rectum
becomes flooded, and the tem-
perature falls. Instead of
saline solution, Ringer's so-
lution (see p. 50) has been
recommended,^ as well as
Trunecek's serum, ^ and
Brunings* suggests from per-
sonal experience the advan-
tage of the occasional sub-
stitution of coffee, diluted to half strength, and without sugar, for
stimulation as well as the relief of thirst.

Se\'eral forms of special apparatus have been recently devised to
keep the supply-tank warm during the long administration, and to
allow for the expulsion of flatus. Thus, G. J. Saxon" describes an

'Jour. Am. Med. Assoc., IQ09, Mi. 1248.

' Rosenstem (Deutsch. med. VVoth., igii, ixivi, 54) employed Ringer's solution
(see p. 50) in 4 cases of pyloric spasm, and Found that it induced relaxation of the
pyloric sphincter, as evidenced by cessation of vomiting.

'd'Amico (Gaz. degli Osped.. iqio. xxxi, no. 1J2) has seen remarkable results in loo
cases of uncontrollable vomiting follow the injection of diluted Trunecek's serum (sec p.
SO for formula).

'Munch, med, Woch., ifjn, Iviii, no. 24.

^ Ann. Surg.. iQog. ilix. 404.

PROCTOCLYSIS

! V

apparatus which maintains the temperature of the solution to be
given by rectum, and which controls the flow in a manner which will
not interfere with the quick passage of flatus or the sudden expulsion
of salt solution back through the tube. The fluid enters the rectum
at a temperature ranging from ioo° to 115^ F. He
uses a cc^per bucket with legs, handle, and lid; in-
side of this is placed a glass percolator, to be used
as a reservoir, and about this is placed a warming
fluid (Fig. 15). The technique in the application
of the Murphy treatment is so perfected by Dr.
Saxon's apparatus that the solution can be kept at
a temperature of from 105° to 115° F. without any
interference for a period of two hours or longer; it is
easily renewed for prolonged application; rapidity
of flow is under accurate control; a thermometer
interposed near distal end permits easy reading of
temperature near the exit.

W. A. Dewitt^ describes a simple and efficient
means of estimating the rapidity of flow and of
allowing for expulsion of flatus (Fig. 16). He re-
moves the plunger from a large glass irrigating
syringe with a metal cap, and punches three or four
holes in the cap. Through the hole for the plunger
he inserts the glass tube of a medicine-dropper.
The upper end of the dropper is connected with
the reservoir, which may be an ordinary fountain
syringe, by a short length of rubber tubing, carry-
ing a screw clamp. The tip of the glass syringe is
connected with the rectal tube. By this means one
can watch the rapidity of flow, and an outlet is provided for flatus.^

Some surgeons make it a practice in celiotomies, when the patient

* An Efl5cient Inexpensive Enteroclysis Apparatus, Surg., Gyn., and Obstet., 191 1, xiJ,
166.

2 Other references on this subject are: D. N. Eisendrath, Jour. Am. Med. Assoc,
1908, li, 406.

S. E. Newman, Jour. Am. Med. Assoc., 1909, lii, 1250, Continuous Enteroclysis.

B. B. Wechsler, Jour. Am. Med. Assoc., 1909, lii, 1251, An Apparatus to Keep Entero-
clysis Solutions Hot.

J. B. Murphy, Jour. Am. Med. Assoc., 1909. lii, 1248, Proctoclysis in the Treatment
of Peritonitis. Shows apparatus for maintaining the heat of the solution by electricity,
gas, or alcohol flame.

Kemp, New York Med. Jour., 1909, xl, 298, A New Container for the Preservation
of a Constant Temperature of Saline Solution for Rectal Irrigation or Infusion. An

Fig. 16, — Modifica-
tion OF Dewttt's Appli-
ance FOR Regulating
Flow, and Allowing
Escape of Flatus.

48 THIRST, ITS SIGNIFICANCE AND RELIEF

is in a serious condition from shock, or when the operation is being
done on a patient in extremis, say, from intussusception or strangulated
hernia, to leave a quart or so of hot normal salt solution in the perito-
neal cavity on sewing up. This maneuver takes no time and some-
times acts effectually in forestalling shock and thirst. In localized
septic conditions, as appendix abscess, pyosalpjnx, or localized perito-
nitis, its employment is. of course, contraindicated, as the fluid tends
to disseminate the infection. In diffuse peritonitis, where the infec-

tion is already widespread, and in such conditions as bullet wounds
of the intestine or rupture of a gastric or duodenal ulcer, operated on
immediately, where material which is presumably strongly infective

application a( the vacuum bottle to proctoclysis, enteroclysis. hypodermoclysis, and
infusion.

E. A. Babler. Jour. .\m. Med. .\ssoc., igio. liv. 870. \ Satisfactory. Inexpensive, and
Portable Proctoclysis Apparatus,

A. McLean, Jour. Am. Med. .\ssoc.. 1910. liv, 1134, .A New .Apparatus for Proctoclysis.

E. C. Hill, Jour. .\m. Med. .^ssoc., 1910. Iv, 2233. A Simple Method of Rectal Feeding
or Proctoclysis.

W. S, Sutton. Surg.. Gyn., and Obstet., ;gii,xii. i65, A Speedometer for Proctoclysis
Apparatus.

SALINE INFUSION 49

is spread about generally through the abdomen, the water which is
allowed to remain after washing out the peritoneal cavity acts bene-
ficially in diluting the infective material and in exciting a secretion of
bactericidal serum from the peritoneum.

Saline Infusion. — Finally, the method for supplying fluid to the
body, which, of all the artificial means, is probably the most com-
monly employed, is the administering of sterile salt solution by sub-
cutaneous injection (hypodermoclysis). For this purpose a thora-
centesis or salt infusion needle of medium size is used. It should be
sterile and attached to a sterile rubber tube, which in turn may be
connected with the nozzle of the container of the salt solution. In
the technique of administering a subcutaneous injection all care with
regard to asepsis of the operator, the field, the instruments, and the
solution should be exercised in order that the danger of submammary
or other abscess be reduced to a minimum. The field usually chosen
is the breast, the injection is made (with the needle full of water and
the tube pinched) in the outer lower quadrant, upward and inward
under the mammary tissue, or upward under the pectorals and into
the axilla. Sometimes the injection is made into the inner aspect of
the thigh or in the loin.

The needle should be inserted its full length, and as the tissue begins
to bulge with fluid, the unengaged hand of the operator, anointed with
sterile oil, should massage the parts, to assist the tissues in taking up
the solution. As the fluid runs in and the parts become white and
tense, the needle may be gradually withdrawn, or its point shifted from
time to time in various directions, to open up new avenues of absorp-
tion. A quart of fluid is the ordinary limit in one place. If more is
to be given, it is better to give a quart imder each breast. Undoubt-
edly in men the best site of injection is upward under the pectorals,
for here there is all the loose tissue of the axillary space to take up the
fluid rapidly. After the injection, the needle is quickly withdrawn,
a finger placed over the puncture to prevent oozing, the surrounding
skin wiped dry, and a small wad of sterile absorbent cotton is applied
and held in place by collodion. The dangers to be avoided, after
sepsis, are puncture of a vein, injection of air, puncture of the pleura.
The salt has no injurious effect, as shown by the experiments of
Henkel,^ and it may be given unreservedly even in cases with edema,
heart affections, or nephritis.

The intravenous in fusion of salt solution (see p. loo) is reserved for
cases of shock or hemorrhage, where immediate relief to the vascular

* Einfluss der Kochsalzinfusion, Miinch. med. Woch., 1910, Ivii, 2505.
4

50 THIRST, ITS SIGNIFICANCE AND RELIEF

system is necessary, and where absorption from beneath the skin
would be too slow.

Ringer's solution has the following composition (Jour, of Phys., London, 1885, vi, 361) :

^ ■ NaCl 0.07 per cent.

KCl 0.03 per cent.

CaClj 0.026 per cent, (crystals).

Locke's solution is made up as follows (Jour, of Phys., London, 1895, xviii, 332):

^. CaClj 0.024 per cent, (crystals).

KCl 0.042 per cent.

NaHCOg 0.03 per cent.

NaCl o.g per cent.

Dextrose o.i per cent.

The formula for Trunecek's serum is as follows (d'.\mico, Gaz. degli Osped., 1910,
xxxi, 1393):

1\. Sodium sulphate 0.44 gm.

Sodium chlorid 4.92 gm.

Sodium phosphate 0.15 gm.

Sodium carbonate 0.21 gm.

Potassium sulphate 0.40 gm.

Distilled water to 1000.00 gm.

CHAPTER IV

PAIN AND SLEEP

The amount of postoperative pain seems to bear no relation to the
seriousness of the operation. Some patients after minor procedures
will suffer agony, while others, who have endured a serious or pro-
tracted abdominal operation, make no complaint except perhaps of a
backache. The personal element seems of much importance here, for
the better the mental control, or the deeper the faith in the surgeon,
the less is the likelihood of the patient's magnifying discomfort into
pain.

If in a celiotomy there have been found extensive adhesions, or if the
occasion has made necessary much handling of the intestines, pain is
pretty sure to follow. The most conunon cause of pain in abdominal
cases is distention of the bowel. From one cause or another there is
induced a paresis of the intestines, then distention with gas, and the
patient, unable to pass it himself, suffers from colicky pains, which
are the more trying because the relief ordinarily afforded by pressure and
movement in bed is not at his disposal. In this case the relief of the
distention by measures to be discussed later is to be sought.

Another cause of postoperative pain is pressure from packing or
from drainage, either by gauze wicks or glass or rubber tubing. Wounds
are packed for different purposes, such as to control hemorrhage, or to
absorb pus or serous fluid. To accomplish these purposes it may be
essential that the packing should be tight, and any pain which results
must accordingly be endured if it cannot be relieved by some other means.
The most that can be done is to make certain that the packing is rightly
placed and is no tighter than is necessary to serv^e its purpose. It
usually becomes unnecessary after twenty-four hours. Relief can be
obtained at the time of redressing. Gauze wicks rarely exert enough
pressure to cause trouble. Rubber tubing, however, and glass tubing
may exert considerable pressure on the intestine or rectum, and, if
disturbed by the restlessness of the patient, may even slip through the
wound into the abdomen. In placing rubber or glass drainage-tubes one
should be sure that their edges are well protected, that they are so placed
that they exert no pressure upon the gut, and that they are so long that
there is no danger of their slipping into the abdominal cavity. Until the

52 PAIN AND SLEEP

proper time for their removal any pain which they cause must be
treated by means of morphin.

Pain developing some hours after operation is not to be dismissed
with the administration of an anodyne, but its cause should be care-
fully sought and removed. Often a simple change of posture, the
cutting of a tight bandage, the removal of pressure on some bony
prominence, straightening out the clothing, and such little attentions
will give relief. A safety-pin passed through the patient's skin in fix-
ing the bandage may cause the trouble.

Another common cause of the complaint of pain is splints. As
usually constructed, splints are rigid and unyielding. Whenever they
are applied to imconscious patients, one can never be sure, no matter
how generously they are padded and how carefully they are put on,
that some point is not unduly pressed upon. As soon as conscious-
ness is regained, every splint should be subjected to detailed inspec-
tion and careful readjustment. No complaint on the part of the
patient referred to the spUnted limb, however trivial it may seem, is to
be neglected; particularly is it important to see that the circulation
and the sensation of the part is not interfered with; coldness, blueness,
edema, or numbness of the finger-tips, for instance, must be instantly
relieved by loosening the splints. In applying splints, one must
remember that a certain degree of swelling follows every trauma, and
that due allowance must be made for this. Plaster bandages make
the best-fitting and most effective splints, but they can easily cause a
great deal of discomfort and serious damage on account of their
unyielding nature and their intensive pressure as swelling takes place.
Instant relief is obtained and all danger averted, without sacrificing
efficient fixation, simply by splitting the bandage itself full length
down one or both sides. Operations involving bones and joints are
peculiarly Uable to give rise to pain; still, morphin should never be
given to a patient wearing a splint until it is certain that the splint
itself is not at fault.

Every wound is surrounded by localized muscular spasm. This
is nature's method of maintaining the part at rest. It is most apparent
in fractures. If the muscles become tired and relax, pain then occurs
from the fatigued muscles and from the wound, which is no longer kept
at rest; spasm then becomes noticeable because it is painful. The
way to prevent painful spasm, or to treat it if present, is to immobilize
the wounded part. A firmly applied bandage is often sufficient. If
the wound is near a joint, a properly fitted splint to fix the joint is

CAUSES OF PAIN

essential. Wounds of the trunk are readily immobilized by adhesive
plaster strapping or tight swathes.

It is only a poorly applied bandage that causes pain. A bandage
serves two purposes — it keeps the dressing in place and gives firm,
even pressure. Several layers of sheet wadding beneath a bandage
give the whole dressing elasticity and help to distribute the pressure
evenly. A bulky dressing gives the most comfort. Every bandage
should be applied from an extremity toward the trunk, steadily lessen-
ing the pressure while advancing. Too tight a bandage causes pain
from congestion ; too loose a bandage causes discomfort and even pain
by allowing the dressing to slip about. One should watch particu-
larly the limits of the bandage, for it is here that painful chafing
readily occurs.

If properly applied, the dressing itself is rarely a source of pain or
discomfort for the first twenty-four hours. However, there are two
evils which may be due to the dressing in this early period, therefore
it is unwise not to investigate complaints. The dressing may have

Fig. I 8.

slipped, owing to its insecure retention or to the patient's movements,
leaving the wound partially or wholly uncovered; or the sharp end of a
suture may be pricking the skin. Relief is easily obtained. After
twenty-four hours the dressing becomes hard and caked from the
dried secretions. This serves as a splint and rarely causes distress.
The removal of the dried gauze is all that is necessary if there is real
discomfort.

Pain from stitches is due — (i) to tying the suture too tightly, thus
putting the parts under too great tension; (2) to imperfect immobiliza-
tion of the wound; and (3) to sharp ends of the sutures pricking the
skin. The last has already been spoken of and its treatment indi-
cated. If the wound is immobilized, as described above, the stitches
in themselves cause very little discomfort. Even if the sutures have
been too tightly tied, one dislikes to cut them at the risk of having the
woimd gape open. Relief can be obtained by the use of adhesive
straps, so applied that the tension on the stitches is lessened. The
method is as follows: Cut two pieces of adhesive plaster, shaped as in
Fig. 18, and fasten the broad ends, a, a, on opposite sides of, and at

54 PAIN AND SLEEP

some distance from, the wound, so that the narrow ends cross the
wound, the tongue, b, lying in the space c. While an assistant presses
the sides of the wound together, the narrow ends are drawn taut and
stuck fast to the skin. If the tension is still painful, the stitches are
probably cutting their way out. Only when this is actually seen to be
the case is it advisable to cut the sutures and trust to the strapping to
hold the wound together.

Every septic process is accompanied by pain, varying all the way
from the nagging discomfort of a furuncle to the intense throbbing,
excruciating pain of bone infection. Incision and drainage, by reduc-
ing tension, generally aflford immediate relief to such an extent that
opiates are not required. If, however, sufficient relief is not ob-
tained by satisfactory incision and drainage, it is far better to give
morphin than to let the patient lower his powers of resistance through
suffering.

Rest and sleep are not compatible with pain. As rest and sleep
are requisite elements of a safe and speedy convalescence, they should
be encouraged after operation by .all safe means. Most often the
occurrence of pain can be estimated in advance, and, if no contra-
indication exists, the patient's comfort can be assured, after setting or
wiring the fracture, after amputation, after a dilatation and curettage,
by injecting subcutaneously a dose of morphin before the patient has
recovered from the anesthetic. After operations about the anus or
male urethra morphin may be administered similarly, in the form of
suppositories. Giving morphin in this fashion before coming out of
ether often works strikingly; the patient awakens from a quiet sleep,
two or more hours after the operation is over, with a sense of well-
being and no memory of the discomforts of nausea or vomiting. As
many patients dread the postoperative pain more than the idea of the
operation itself, this relief will assure the surgeon of their gratitude.

In operations upon the abdomen surgeons are of two minds as to
the propriety of employing morphin at all. Lawson Tait was the first
to argue strongly against its use after celiotomies, on account of its
effect in decreasing intestinal peristalsis, and its action, accordingly, in
favoring the production of distention. It is known that distention
and intestinal paresis favor the occurrence of peritonitis, especially
after operations involving infected matter, such as for salpingitis and
appendicitis. Over against these theoretic considerations other men
have placed the comfort and quiet which come from morphin properly
used, and have favored the use of morphin after celiotomies as a rou-
tine.

RELIEF OF PAIN $$

Gibbon' says: "Abdominal operation produces more pain than
others because of the aggravation and discomfort caused by the move-
ment of the diaphragm, especially such excessive actions of this muscle
as take place in retching and coughing. It is a good rule always to
administer a hypodermic of morphin and atropin before the patient
has recovered consciousness. The patient passes from the sleep of the
anesthesia to the morphin sleep, gets comfortably over the most dis-
tressing hours after operation, and never knows the morphin has been
given. It is seldom that a second dose is necessary, and postoperative
vomiting is infrequent."

Perhaps the safest rule to follow in this regard is to use morphin
after celiotomies where much pain is anticipated, provided there has

been no infected material let loose into the abdomen. In cases of
peritonitis, or where peritonitis is imminent, it will be wise not to
allow one's self to use morphin until the bowels have moved for the
first time after operation.

Sometimes it will be found that heat in the form of fomentations,
stupes, or poultices, applied locally, will be efficacious in relieving
pain of local origin. In the same way cold may be employed ad-
vantageously, especially after operations upon joints. As the weight
of a heavy ice-bag or hot-water bag might in itself cause considerable
pain, it is well to have such a bag slung from a cradle, or in some other
way suspeoded so as to take the weight off the wound. It will easily

' Postoperative Treatment, Ann. Surg., 19Q7, sivi, 208.

56 PAIN AND SLEEP

be found that if pain is relieved by one or the other of the methods
which we have suggested, sleep will naturally follow. When it be-
comes necessary to resort to drugs, morphin is by far the most reliable
where no contraindication exists. Sometimes trional, paraldehyd,
hyoscin, or codein will be found to work equally satisfactorily. If
the patient is kept awake by pure nervousness, rectal enemata of
sodium bromid (gr. 50 to 80) or chloralamid (gr. 30) act advantage-
ously. By whatever means effected, sleep must be induced as essen-
tial to the patient's well-being.

Headache. — Headache is a symptom which the surgeon is fre-
quently called upon to treat in the course of convalescence from
operations. It is just as bad practice to order drugs to relieve pain
without looking into the underlying cause during this period as at
any other time.

In general the treatment of headache may be outlined as follows :

1. Discover and remove the cause.

2. Local applications: heat, cold, menthol, wintergreen, etc.

3. Drugs: aspirin, bromids, acetphenetidin, morphin.

The two last named drugs are to be used only after everything
else has failed, and morphin only in acute cases.

Causes of Headache, — According to R. C. Cabot^ the position and
character of the headache have little significance. Exceptions to
this are pain due to inflammation of the antrum or frontal sinus,
migraine, trigeminal neuralgia, and periostitis.

A. D. Wilmoth^ divides headaches into two classes with regard to
cause :

1. Those secondary to conditions not located in the head.

2. Those in which there is a definite pathologic process at the
site of the headache.

Under Group i: Under Group 2:

Ether. Periostitis.

Constipation and indigestion. Sinusitis.

Excitement and fatigue. Trigeminal neuralgia.

Elevation of temperature. Migraine.

Menstruation. Meningitis.

Eye strain. Brain tumor.

Alcoholism.

Nephritis.

Toxemias (as eclampsia).

Psychoneurosis.

* Differential Diagnosis, 191 1, p. 35.

* Kentucky Med. Jour., 1910, viii, 2022.

HEADACHE 57

Sometimes the diagnosis will be obvious. A headache on the
afternoon after operation is usually due to ether, or when the bowels
have not moved for several days it may be predicted with a fair amount
of certainty that the headache is due to constipation. If the patient
complains of headache and the face appears flushed, the temperature
should be taken at once, even though it has been taken a few hours
previously and found normal. In such instances the headache is due
to elevation of temperature which may be due to some local cause, as
suppuration of the wound, or to a general cause, as the supervention
of an acute disease — influenza, pneumonia, typhoid, etc. Excitement
and fatigue, perhaps from receiving too many visitors, may cause
headache. In this instance there is likely to be also a slight elevation
of temperature and an increase in the pulse rate. Menstruation
should be inquired about in any obscure case in a woman, and eye
strain from too much reading in the latter part of the convalescence.
Alcohol is rather rare as a cause of headache following a surgical opera-
tion. A high-tension pulse and enlargement of the heart should sug-
gest nephritis and call for an examination of the urine. In the preg-
nant or parturient woman headache demands an immediate examina-
tion of the urine, whether there are other signs and symptoms of
toxemia — headache, edema, disturbance of vision — or not. The di-
agnosis of nervous headaches will depend largely on previous history
and the exclusion of other causes.

Periostitis is to be suspected whenever there is syphilis, and when-
ever there is severe local tenderness not situated over an accessory
cavity of the nose or a branch of the trigeminal nerve. Potassium
iodid is the best analgesic in this condition. Pain from a frontal
sinus or an antrum is to be diagnosticated from its location, espe-
cially if there is tenderness over the cavity and an unnatural nasal
discharge. The diagnosis of trigeminal neuralgia or migraine is
usually easy, however. As Cabot has pointed out, headache from
nephritis, infection, brain tumor, and other causes may be unilateral.
In severe headache of acute onset, with elevation of temperature and
pulse, stiff neck, Kernig's sign, squints or other paralyses, meningitis
should be suspected. In more chronic headache with vomiting
the eye fundus should be examined upon the possibility of brain
tumor.

Finally, in any puzzling case the following tests laid down by R. C.
Cabot^ should be made:

* Differential Diagnosis, 191 1, p. 37.

3
0

S8 PAIN AND SLEEP

"i. Thorough examination of the eyes (including retinoscopy),
the pupils, and the testing of the intraocular tension (glaucoma).

"2. Temperature record (infections).

''3. Blood-pressure measurement (nephritis, tumor).

''4. Urinalysis (albumin, sugar, acetone).

''5. Palpation of the insertion of the nape muscles at the oc-
ciput.

6. Examination of the nose and its accessory sinuses."

CHAPTER V

PULSE, TEMPERATURE, AND RESPIRATION

The temperature chart may be considered the barometer of the
patient's condition. It is one of the few means of accurate observation
which we have at our disposal, and should never be neglected. Some
surgeons of wide experience will sometimes studiously ignore the chart
and pass their judgment of a patient's condition upon his general aspect,
his posture, the appearance of his tongue, and all these aided by intuition.
Their deductions may often appear brilliant, but their example is a
dangerous one for the younger man to follow.

When one has studied many charts representing the same condition,
he is usually able to prognosticate with some degree of accuracy in the
case of any individual patient. If one considers the pulse alone, how-
ever, or the temperature alone, he is likely to be led astray. The firmest
conclusions can be drawn only from a study of the pulse and the tem-
perature and the respirations and their relation to each other. For
instance, a falling temperature in itself is usually of good omen; when
combined with a rising pulse, it may mean serious trouble. A surgeon
may argue that a patient cannot be badly off when his pulse and tem-
perature are both normal, but a normal pulse and temperature after a
celiotomy, combined with an increased respiratory rate, is very likely to
mean peritonitis.

PULSE

The most importance is usually, and properly, placed upon the ob-
servation of the pulse. Although the rate is the only quality which is
usually recorded upon the chart, the surgeon should also take into con-
sideration the rhythm, volume, and tension. Moreover, if he would save
himself the possibility of some needless anxiety later, the surgeon should
have become familiar with any peculiarity of the patient's pulse before
operation, as, for instance, the irregular rhythm and the constantly in-
creased or diminished pulse-rate which one sometimes comes across in
otherwise normal young individuals, which apparently have no pathologic
significance. In this study of the pulse, from the point of view of the
surgeon, we will confine ourselves to a consideration of the variations
dependent upon and following surgical procedure, it being understood

6o PULSE, TEMPERATURE, AND RESPIRATION

that cardiac lesions, angina, and arteriosclerosis have been ruled out by
a previous examination, or that due allowance is made when they exist.

The normal pulse-rate may be considered to be 72 beats per minute.
The excitement preceding an operation and attending the administra-
tion of the anesthetic usually increases this rate, except in the most
phlegmatic, about 20 beats. If the operation is short and involves
little loss of blood, and the anesthesia is well conducted, the pulse recovers
somewhat from this preliminary rise as soon as the patient has cleared
himself of mucus. During the recovery the rate will probably drop still
farther and its normal quality will be restored, to continue normal, un-
less complications arise, throughout the convalescence. After any pro-
longed or serious operation, or one attended by a loss of blood, the
patient may be put to bed with the pulse-rate increased anywhere from
25 to 40 beats.

Most celiotomies show a rise of 10 to 20 beats after the patient has
fully recovered from ether. This rate gradually drops off, unless com-
plications arise, to reach normal on the second or third day. If the
pulse-rate rises suddenly on the third or fourth day, we have to con-
sider the onset of peritonitis or some intercurrent affection, as bron-
chitis, pneumonia, la grippe, tonsillitis, malaria, or an acute exanthem.
Distention alone is apt to send up the pulse-rate, and is likely, also, to
cause it to become irregular. If the pulse goes up for the first time at
the end of a week after operation, there is likelihood of a stitch-abscess
or pelvic abscess. A sudden and rapid increase in pulse-rate at any
time, coupled with dyspnea, usually means pulmonary embolism.

After hemorrhage the increase in frequency will depend not so much
upon the amount itself, as upon the rapidity with which a considerable
amount is lost; for instance, the loss of blood during 4 or 5 beats from a
medium-sized trunk seems to send up the pulse-rate much more effec-
tually than the loss of the same amount of blood from a small vessel.
It may be considered that in the former case the heart is wearing itself
out by pumping against a suddenly and enormously decreased peripheral
resistance — to be compared to a fighter who puts his whole force in a
blow, fails to meet his object, and exerts his energy on empty air. Unless
the hemorrhage is checked, the rate rapidly and progressively rises, the
pulse finally becomes uncountable, and the patient dies.

Intense pain will frequently send up the pulse-rate from 10 to 20
beats, and sometimes in nervous women the pulse will suddenly increase
to 120 or over without apparent cause. In the former case a subcutan-
eous injection of morphin will relieve the pain and restore the pulse to
normal. The nervous crises are probably related to pseudo-anginal

PULSE

attacks which the patient has had when in her normal state. The use of
bromids by rectum is indicated as soon as the diagnosis is made sure.

Rarely the pulse-rate will fall below^ normal. The slow full pulse
is the accompaniment of increased intracranial pressure from hemorrhage,
clot, abscess, or tumor. The pulse-rate is usually restored to normal
within a few seconds after decompression has been practised. Elderly
persons with good heart muscle and more or less thickened vessels
are apt to exhibit ordinarily a slow pulse. The pulse is commonly

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slowed during convalescence from erysipelas, pneumonia, or typhoid.
If the chart records a slow pulse where it is not readily accounted for,
one must not be satisfied until he listens at the apex, for, in conditions
of marked debility, it will sometimes be found that, on account of the
weakness of the stimuli, the arterial contraction-wave expends itself
before it reaches the peripheral arteries, and the radial pulse records
only every second or third beat — thus an entry of 6o on the record may
have to be corrected to 120.

The pulse may be irregular in force and rhythm. If irregular in

PULSE, TEMPERATURE, AND RESPIRATION

rhythm alone, and of well-sustained force, and the radial pulse registers
every contraction of the heart, the condition is apt to represent a tem-
porary vasomotor derangement, such as may occur in persons of a high-
strung or hysteric disposition. In other words, the heart (from excite-
ment) is skipping an occasional beat. Such a condition, other things
being favorable, is sure to disappear as soon as the patient is restored to
her normal state of nervous equilibrium.

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Po8toperati\'e rise in tcmpcratiire and pulse simulating sepsis, but due, in fact, to absorption from lacerated

soft parts. Primary healing.

If, on the other hand, the irregularity of the pulse means that a certain
proportion of the cardiac contractions are lost before reaching the periph-
eral arteries — even if the cardiac rhythm itself is normal — or if irreg-
ularity in the force of the beat exists, or if the pulse is irregular both
in force and in rhythm, we have a condition of the gravest significance,
which can result only from a played-out, overworked heart-muscle.
A pulse may be ever so weak or so rapid, but so long as it is regular in
force and rhythm there is hope; the heart in such a case preserves its
power to recuperate, to respond to stimulation and the treatment of the

PULSE

underlying condition. If, now, such a pulse suddenly becomes irregular
in force and rhythm, it may be considered that the nervous and muscular
mechanism of the heart are wearing themselves out under the strain — that
is to say, that the heart is going to pieces.

Irregular pulse occurs in shock, hemorrhage, and overwhelming
septic intoxication or other forms of toxemia, such as thyrotoxicosis.

The volume of the pulse represents the quantity of blood which

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On the eighth day drainage became inefficient, and a week later a second operation was done, after which

temperature, pulse, and respiration again fell to normal.

passes under one's finger; that is, the arterial content. The volume
is small after loss of blood from hemorrhage and in conditions where the
systemic tissues have been depleted of fluids from any cause. Thus,
volume decreases with increasing hemorrhage or progressing septic
infections.

Volume is closely associated with tension. Tension represents the
pressure w^ithin the artery; it expresses the degree of blood-pressure.
It is measured by the amount of compression which must be exerted to

PULSE, TEMPERATURE, AND RESPIRATION

shut off the transmission of the pulse-wave. A reliable appreciation
of arterial pressure, apart from volume, can be acquired only after con-
siderable education of the finger-tips. In making the observation one
must not be led astray by the resistance offered by the thickened walls
in arteriosclerosis. The use of blood-pressure apparatus generally
after operation has not yet demonstrated its necessity.

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Rise in pulse and drop in temperature, the so-called Gradual development of distention such as

"closing of the jaws of death." appears in a diflfuse dry peritonitis. The graphic

record in no way suggests the actual serious condi-
tion of the patient. Old people react less mark-
edly and the chart is of less value as a criterion.

Changes in volume are not necessarily related to changes in tension,
but the two qualities are often characteristically associated. Thus,
the full volume and high tension give a large, hard, bounding pulse;
with the low tension, a full, soft, flabby pulse; low volume with high
tension gives the small, hard, wiry, cord-like pulse, and with low^ tension
the flickering, thready pulse— all of which have important clinical sig-
nificance.

TEMPERATURE

Variations in temperature may be considered as due to the normal
reaction after simple aseptic operations; to shock after prolonged opera-
tions or those attended by much manipulation of the abdominal contents
or from loss of blood; to septic causes, in cases febrile at the time of oper-
ation, or those developing peritonitis, or pelvic or stitch-abscess; and,
finally, to accidental and intercurrent conditions, such as thrombosis,
phlebitis, or pneumonia.

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Fig. 25. — Childbed.
Rise of temperature and pulse on fourth day, aseptic
absorption from retained membranes.

Fig. 26.— Perineal Prostatectomy (weight of
prostate, 12 ounces).
Marked shock shown by drop in tempera-
ture and rise in pulse; then temperatiu-e, pulse, and
respirations all rise till the end.

Most uncomplicated aseptic procedures show a reactionary rise in
temperature which reaches its maximum, about ioo° F., tw^enty-four
hours after operation, and strikes normal on the evening of the second
day after operation. Sometimes there will be a lesser rebound of the
temperature-curve on the third day (Fig. 20). Thepulse, without altering
its character, accelerates its rate simultaneously with and in proportion

PULSE, TEMPERATURE, AND RESPIRATION

to the rise in temperature, usually reaching 90° or 100° F. In children
and young persons, or after operations on bones, or about the anus, the
pyrexia may go to 102° F. or higher. This rise in temperature, some-
times called aseptic fever, is usually to be expected, and, in so far as it
represents the normal reaction in persons in good health at the time of
the operation, it is a good sign and should not be confused with sepsis.
There has been much theorizing concerning the mechanism of its pro-
duction. It may intelligendy be considered as due to absorption of

J6^

JHagnosii Kxclsion Of Cartilage of Knee- |

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Fig. 27.— ExCTsioN of Cartilage of Knee.
Sustained rostoperativc reaction in a neurotic individual. Typical rise of temperature on first day out of bed.

decomposition products, of liberated blood, and of matters set free by
destruction of tissues.

After hemorrhage or in shock this reaction is delayed. The first
effect on the temperature, if the shock is considerable, is a notable falL
The temperature often becomes almost immediately normal or sub-
normal, even in cases febrile before operation, and the pulse rises
sharply to 130 or more. A falling temperature with rising pulse in the
early hours after operation must always make us fearful of collapse and

TEMPERATURE

death. If the patient is successful in combatting the condition, a late
reaction will occur; the temperature goes up to a degree proportionate
to the pulse, and then pulse and temperature gradually subside, to reach
normal some days later.

Sometimes there will be a condition of continued shock, immediately
following operation, which lasts for twenty-four to forty-eight hours
before it changes for better or worse. Then there is the condition of
late shock, which puts in a rather unexpected appearance twenty-four

lAr^

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JHae-noiis Appendicitis*

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Fig. 28. — Immediate Drop in Temperature and Pulse After Relief of Tension in Sepsis.

hours after the operation, the patient having apparently recovered
normally from the operation. Often there is a low fever, about 101° F.,
and a pulse of no, where no symptoms of shock are apparent in cases that
have endured a long and severe operation. This condition is apt to be
maintained for four to eight days, gradually working down to normal.
It may be taken to represent not so much shock as a condition of ex-
haustion and a poor or delayed operative reaction. If pulse and tem-
perature are approximately normal, or if the normal pulse-temperature
ratio is maintained, it is rarely that death occurs from shock.

PULSE, TEMPERATURE, AND RESPIRATION

The onset of sepsis is usually marked by an immediate rise in pulse
and temperature, unless the patient is septic at the time of operation.
The only exception to this rule is the occurrence of sepsis in persons
who have lost their powers of resistance through exhaustion; a patient
may die, for instance, of peritonitis, with a normal pulse and temperature.
If the patient is febrile from retained pus, and the operation consists
in liberating this, the temperature chart is apt to show a short, sharp

. G.

Dt'dpnosts Hernia.

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Diagnosis Appendicitis.

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Fig. 29. — Herniotomy.

Rising temperature; wound inspected on the
axth day, stitch-abscess found and relieved, imme-
diate drop to normal.

Fig. 30. — Appendix Abscess.

Usual drop after drainage, sudden rise of temper-
ature on the fourth day, due to backing up of pus,
drop to normal when drainage is again made efficient.

reaction, and then a sure and progressive decline as the drainage effec-
tively acts (Fig. 28). If the patient's temperature is about normal,
and the operation discloses an abscess and some pus is set free in removal
or drainage, there will be the regular reactionary rise in temperature,
and the height of the curve will be maintained, with a tendency to morning
remissions, until the system has successfully combatted the infection.
On general principles, in an aseptic operation a rise in temperature,

TEMPERATURE

occurring on or after the third day after operation, should be considered,
until proved otherwise, as due to sepsis— from infection of the wound,
peritonitis, decomposition of retained blood-clot. In a septic condition
it means blocked drainage, residual abscess, peritonitis, septicemia.
A late rise — after the fifth day — frequently means stitch-abscess (Fig. 29).
One should look for sepsis, then, whenever the reactionary rise '\n tem-

M. P-

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Fig. 31. — Phlebitis on the Eighth Day.
Sharp reaction in temperature and pulse.

Fig. 32.— General Peritonitis
OF Sltbdiaphracmatic Origin.

Temperature and pulse not so
sgnificant as the practically con-
tinuous rise oi respirations.

perature fails to drop, whenever the temperature rises on the third day
or later.

It must not be forgotten that complications may arise during con-
valescence which will affect the appearance of the chart without any
respect for the arbitrary rules which we have laid down above. Common
among these are tympanites, menstruation, tonsillitis, erysipelas, the
acute exanthems, pneumonia. Less common, but not to be overlooked
when other causes fail, are malaria, la grippe, tapeworm, phlebitis

70 PULSE, TEMPERATURE, AND RESPIRATION

(Fig. 31), pylephlebitis, thrombosis, and embolism. When the tem-
perature rises from these so-to-speak accidental causes, one should
make his diagnosis with extreme care. They will be considered in

detail later.

RESPIRATION

The record of the respiratory rate is apt to be neglected. A good
working rule is to take the respirations whenever the patient is doing
poorly, or whenever the diagnosis of his condition is in doubt.

In i>eritonitis the respirations are practically always increased and
may run up to 48 per minute (Fig. 32). The abdomen is kept tense in
an effort to guard and *^ splint^' the inflamed and acutely painful areas;
there is no longer the normal rhythmic rise and fall of the abdominal
wall. In advanced cases the movements of the diaphragm even are
inhibited and the respiration becomes entirely thoracic.

In tympanites, without peritonitis, these same phenomena are to be
noted to a lesser degree. The advantage of having a record of respira-
tions in case there is question of the onset of pneumonia goes without
saying.

In severe hemorrhage the respiration is quickened and sighing, the
chin is elevated, the nostrils dilated, and the arms thrown over the
head. In pulmonary embolism the respirations are rapid, shallow,
and gasping, the mouth is held open, and the patient tries to sit up in
bed.

CHAPTER VI

POSTOPERATIVE HEMORRHAGE: PRIMARY, DELAYED,

SECONDARY; TRANSFUSION

Postoperative hemorrhage may be defined as primary, delayed,
and secondary.

PRIMARY HEMORRHAGE

Primary hemorrhage is that form which comes on during an operation.
The indication in this form of hemorrhage is, clearly, to find the bleeding
point and secure it. The after-treatment may be considered the same
as that for shock. This condition is one of the best indications for the
use of salt solution subcutaneously and the employment of transfusion
if necessary. These are dwelt upon in detail elsewhere.

DELAYED HEMORRHAGE

Delayed hemorrhage may be taken to be that form of hemorrhage
which comes on after the patient has recovered from the anesthetic
after the lapse of anywhere from a few hours to six days.

Causes. — (i) A wound may be left apparently dry — on account
of feeble circulation and the consequent low blood-pressure no bleeding
may be apparent from some smaller cut vessels or from torn tissues or
omentum. Later, after the operative depression passes ofT, blood-
pressure mcreases as the circulation improves, and hemorrhage results.

(2) Small vessels may occlude by clot; as pressure increases or the
patient moves about, the clot may be displaced and bleeding ensues.

(3) Trifling bleeding may not be noticed, but reliance may be placed
on pressure from the dressings. A small vessel may be cut by the needle
in sewing up. This forms a hematoma, which increases, especially in
soft tissues, as about the scrotum and lower abdomen, by stripping up
skin or fascia.

(4) Catgut ligatures may soften or absorb. If the vessel the ligature
IS holding is near a main trunk, the pressure behind the thrombus may
be so great as to force it out of the stump, and so cause late hemorrhage.

(5) The untied distal end of an artery may bleed when collateral
circulation has been established.

72 POSTOPERATIVE HEMORRHAGE

•

(6) A ligature may slip if it is not tied tight enough; if the knot is
poorly done; if the distal tissues have been severed too closely to the
ligature. If in the removal of a pedunculated tumor of any sort the
ligature is applied with the pedicle on the stretch, and this is then cut
off close to the ligature, the traction on the elastic arteries being relaxed
they have a tendency to retract behind the Ugature, whereupon they
may give rise to serious bleeding. Hemorrhage may occur as a result
of the gradual shrinkage of the tissues which a ligature surrounds and
the consequent loosening of the ligature, as in the uterus after Cesa-
rean section or a fibroid enucleation.

(7) If the vessels are thin- walled and delicate, as the veins of the
omentum, or if the tissues are soft and friable from inflammation, as
about a pus-tube, a ligature tied tightly may cut through the vessel.
Also, if the arteries are atheromatous, as in the amputation of an arterio-
sclerotic uterus, a ligature, especially of silk, may cut through them.

The sjrmptoms of internal concealed hemorrhage vary with the
amount of blood lost and the rapidity. It is not the loss of blood alone
which causes trouble; there is an element of shock in the dynamic
insult to the heart-muscle of pumping against much decreased pe-
ripheral resistance. It is said that a loss of from 4 to 10 ounces will
suffice to bring about the typical picture of hemorrhage.

The onset may be fulminating in character. If a ligature slips from
a large artery, the patient will start up suddenly, cry out from pain as the
blood rushes into her peritoneal cavity; the pulse rises in a moment to
130, temperature drops to subnormal, respiration becomes hurried and
gasping, the face becomes pinched and ashy pale, and death ensues in-
side of half an hour.

Usually the story is longer, but no less typical. The patient, apparently
doing well, at ten to thirty hours after operation begins to show a slight
increase in the pulse-rate. At the same time, she becomes nervously
aware that all is not well, she can feel her heart beat, and she has harder
work in breathing. She calls for a glass of water, and asks to be fanned
or to have the windows opened. Then she has a sensation of pain
referred to the abdomen from the presence of blood. The symptoms
increase at the end of an hour. The pulse has reached 100 and the
respiration 26. A yellowish pallor is spreading o\'er her face and her
lips are blanched; the pupils are somewhat dilated; the hands and feet
become cold and clammy, and a cold sweat appears on her forehead.
By the end of the second hour the pain and anxiety increase, she becomes
restless, tosses about in bed, and throws her arms over her head to help
her now labored respiration. Her temperature is subnormal. Her pulse

TREATMENT 73

by this time has reached 140 and the respirations are 30. She begs
constantly for water and tries to get relief in sitting up, but this makes
her head swim round uncomfortably. Soon, exhausted by her struggle,
cold, with dilated pupils, an uncountable, thready pulse and rapid, em-
barrassed respiration, she dies.

Although shock is an important element in the cause of death from
hemorrhage, the two conditions of shock and hemorrhage are distinct
clinical entities and should rarely be confounded. The patient suffering
from protracted shock, or delayed shock, often is apparently most phleg-
matic, lying quiet and motionless in bed, stupidly comfortable, taking a
patronizing interest in what is being done for him. The patient
with hemorrhage, on the other hand, is nervous and restless, panting
for air.

The diagnosis of abdominal hemorrhage is always made cer-
tain by signs of free blood in the peritoneal cavity. If it remains
fluid, there will be dulness in the flanks, shifting as the patient turns
upon one side and the other. If it clots, it presents the sensation of
boggy fullness and resistance and dulness which does not change. If
blood accumulates in the pouch of Douglas, it may be felt through the
vagina. If the hemorrhage is between the folds of the broad ligament —
that is to say, extraperitoneal — a definite mass may be made out per
vaginaniy pushing the uterus forward and to the other side of the pelvis.
An examination of the wound dressings should never be neglected. If
the wound is sutured tight, there may be no blood upon the dressings.
If the wound has been drained, the gauze of the dressings is apt to be
saturated, and a slight loosening of the drain is apt to be followed by a
flow of blood.

Operative Treatment of Superficial Hemorrhage.— Ether-
ize, reopen the wound, clear out the clot, and snap and tie the bleeding
vessel. If the patient is in extremisj the wound should be opened im-
mediately without anesthesia, a hemostat or clamp applied and left
in situ, and steps taken to restore the patient. If the bleeding has
ceased when the surgeon arrives on the scene, and a large subcutaneous
clot is in evidence, the wound should be opened, unless the patient's con-
dition contraindicates, and the clot evacuated, because there is danger of
renewed bleeding as soon as the patient recuperates, and the presence of
a mass of blood-clot will materially delay repair and interfere with first
intention healing, if it does not serve as the nidus for secondary infection.
If the bleeding is venous and occurs in a limb, care should be taken that
it is not maintained by congestion dependent upon tight bandage or
dressings proximal to the wound.

74 POSTOPERATIVE HEMORRHAGE

Operative Treatment of Internal Hemorrhage.— If, after

due consideration, it has been decided that operation is necessary, or if, in
cases of collapse, the patient has revived suflBciently to make etherization
feasible, the abdominal wound is reopened and a search instituted for
the source of hemorrhage. Some surgeons make it a rule not to open up
the entire wound at once, but remove only a few of the stitches at one
end, and through these enter the peritoneal cavity. If the procedure is
followed by a gush of blood, then the entire wound is immediately thrown
open. If no blood follows, a large, soft-rubber catheter is introduced
and a glass syringe attached, to be used as a sucker. If there is any free
blood, this apparatus is sure to locate it. If none is found, it is decided
that there is an error in diagnosis, or that the bleeding has arrested itself,
and the patient is sewed up again.

Most men, however, after having made a definite diagnosis of hemor-
rhage, open the wound from end to end, and if this does not give enough
room, may enlarge the old incision. The free blood and clots are now
rapidly scooped out, and, if the bleeding point does not present at once,
a search is made over the field of operation. Sometimes the wound of an
artery may be accidental, and is found at some distance from the opera-
tive site. The bleeding vessel once found is tied off, the abdomen
washed free of clots with sterile salt solution, some of which may be left
in the abdomen, and the abdomen sewed up. If the patient is in a critical
condition and time is an object, a long-handled clamp may be applied to
the artery and its handle left projecting through the wound, to be removed
at the end of forty-eight hours. If the bleeding is of such nature that it
cannot be controlled by ligature or suture, the region can be packed firmly
with gauze strips, the ends of which are left hanging through the wound.
Oozing from a denuded surface will sometimes respond to hot water.

SECONDARY HEMORRHAGE

The term secondary hemorrhage is applied to that form of hemor-
rhage which makes its appearance some days after the operation, and is
dependent upon erosion of a vessel by the extension of a septic process.
This condition is less frequently met than in the old days when sepsis
was the rule, and when a rubber tourniquet was hung over every bed and
the ninth day awaited with trepidation. It is to be feared now in wide-
spread and deep sepsis of a limb treated without amputation.

Secondary hemorrhage may occur through the ulceration of an
artery from pressure of a drainage-tube. Caraven and Bassett^
report a case of ulceration of the external iliac artery from pressure

^ Rev. de Chir., 1910, xxx, No. 12.

SECONDARY HEMORRHAGE 75

of a drain in appendix abscess, and refer to 4 similar cases, and
Moschcowitz^ reports secondary hemorrhage from ulceration of both
external iUacs caused by pressure from rubber drainage-tubes in a case
of bilateral ureterolithotomy, following removal of the tubes, which
necessitated the liagation of both external iUac arteries.

Secondary hemorrhage, when it occurs, comes furiously and
practically without forewarning. In the older hospitals there are
still traditions of patients being left for a few moments, to be found
exsanguinated in a pool of blood.

A man of twenty-six sufTered a homicidal large-caliber bullet wound of the
abdomen. At the operation it was found that the bullet had entered at the
left of the navel from above, had made seventeen wounds of intestine, and had
then buried itself in the region of the right psoas muscle. Blood and intestinal
contents were free in the abdominal cavity. Several wounds of intestine were
sewed and two resections were made. All mesenteric hemorrhage was stopped
by ligature. The cavity was washed out, drains were left in, and the patient
was put to bed. Convalescence was uninterrupted. Some mild suppuration
persisted, however, from the region of the pehis, into which the bullet had
apparently disappeared. A wick was in this sinus.

On the twenty-third day, at 6 A. m., the patient called the nurse and asked
to be fanned. One glance showed the patient to be deathly pale; the bed-
clothes were pulled down, and the patient was discovered to be lying in a bed
literally full of blood. He died in twenty minutes, and autopsy revealed a
suppurative process which had eroded the right common iliac vein.

Any treatment to be efficacious must be immediate, and here the
tourniquet and digital pressure proximal to the wound are to be relied
upon until the vessel can be found and tied or clamped. If the sloughy
nature of the wound makes this difficult or impossible, the wound may
be packed, or the old-fashioned methods of the actual cautery, acu-
pressure, or tying the vessel through the skin by using a curved needle
some distance above the wound, must be practised.

Sometimes the condition of recurrent hemorrhage is complicated by the
presence of one or another constitutional diathesis, as hemophilia,
leukocythemia, jaundice. In this case the bleeding does not come from
a single vessel which can be tied off, but is in the form of a general ooze,
and the above rules do not apply. This form of bleeding may occur
from the moment of the operation, or may not come on for some days
aftenvard; it may continue interruptedly, or it may stop for some hours
and then start afresh. The flow of blood is not copious, but the amount
lost is often considerable, and the patient may soon be reduced to a

^ Ann. Surg., 191 1, liii, 547.

76 POSTOPERATIVE HEMORRHAGE

dangerous condition. Such hemorrhage is not readily amenable to
treatment, and, on the whole, when it occurs, is one of the most try-
ing of all complications which the surgeon has to face.

If the diagnosis of any of these conditions is made before opera-
tion, and the operation cannot be postponed, the patient should be
given the benefit of the administration of large doses of calcium lac-
tate for a few days before as well as after the operation, in order to
increase the coagulability of the blood.

Calcium lactate occurs in white, granular masses, powder, or in crystals, is odorless,
and has scarcely any taste. It is soluble in water (i: 15), less so in hot water, slightly
soluble in alcohol, and insoluble in ether. The solubility of different specimens of calcium
lactate varies considerably and is affected by age. Calcium lactate is given before opera-
tions in doses of i or 2 gm. (15 or 30 gr.). The ordinary dose is 0.5 to 4 gm. (10 to 60
gr.). It is much less irritant than calcium chlorid, and may be injected subcutaneously.
The large doses now given may be suspended in water, or, as this salt is permanent in the
air, dispensed in powders or in cachets. Calcium lactate should be fresh, that is, it should
form a clear or nearly clear solution in water. If there is a white precipitate, it should not
be used. It may be given as follows:

I^. Calci. lact lo.o

Tinct. capsici 0.3

Aquae chloroformis ad. 150.0. — M.

Sig. — Tablespoonful in water three times a day, one hour before meals.

The lactate should be given on an empty stomach, otherwise it is likely to be precipitated
by the phosphates of the food. Saline aperients are contraindicated for the same reason,
and to relieve the constipation which the calcium salts usually induce other cathartics
should be employed.

The intravenous infusion of concentrated salt solution is known to
be followed by a temporary increase in the coagulating power of the
blood. As a means of prophylaxis in operative cases where paren-
chymatous hemorrhage is expected, or where the blood coagulates
more slowly than normal, von den Velden^ accordingly advises the
injection of 3 to 5 cc. of a 5 per cent, salt solution into a vein before
operation, to be repeated, if indicated, every half-hour.

The use of animal sera before as well as after operation has been
followed by good results. For the technique of their administration
see Hemophilia (Chapter XXVIII).

Locally, the wound, if it can be reached, may be packed with gauze
soaked in adrenalin, and this packing renewed frequently. Other
styptics, such as MonselPs solution, may be used in the same way. A
styptic is useful only when applied while the bleeding is temporarily

* Centralblatt filr Chir., 1910, xxxvii. No. 21.

SECONDARY HEMORRHAGE 77

arrested. The clot formed by the styptic must be actually in the
mouth of the vessel and not on the surface of the wound. Pressure
alone is rarely of much assistance, but long-continued digital pressure
on the artery or arteries supplying the part, or even Ugation of these
arteries, when feasible, has been practised with success. The patient
should be kept quiet by opiates, he should be given gelatin lemonade
and ice to drink, and stimulation by brandy or digitaUs administered
as necessary\ Vasodilators and salt solution should not be given.

Gelatin when injected subcutaneously has long been known to
exercise a beneficial effect in promoting coagulation of the blood.
It has frequently been a source of tetanus infection (see p. 293);
sterilization is difficult, and overheating is said to destroy its thera-
peutic property. Given by mouth or rectum it is considerably less
active. Ciuffini* has noticed effectual results from a combined treat-
ment with gelatin and ferric chlorid. The non-sterilized gelatin is
given by mouth or rectum, and ferric chlorid mixed with a concen-
trated solution of acacia (both previously sterilized) is injected sub-
cutaneously. His investigations show that by this method coagula-
tion is notably increased, and the effect persists for twenty-four hours
or longer.

Constitutional Treatment. — The treatment of these condi-
tions after the hemorrhage has been securely stopped is mainly that of
shock, but before it is certain that there is no chance of further bleed-
ing, great care must be taken that the arterial tension is not increased
either by the use of vasoconstrictors or of much fluid by mouth, by
rectum, subcutaneously, or by transfusion. The use of vasodilators
is clearly contraindicated. Sometimes the patient is too low to
allow of operation for the control of bleeding. The condition of col-
lapse, with its state of lowered tension, favors clot formation, and dur-
ing collapse hemorrhage may be stayed; thus the expectant is some-
times the best treatment in slow forms of internal hemorrhage with
the patient in collapse.

When this course is decided upon, the patient should be given J gr.
morphin, to be followed by yV gr- every half-hour, and nothing else.
If the loss of blood is overwhelming, and the surgeon has no question
but that it comes from a large radical and interference will be necessary,
a patient in collapse may be stimulated temporarily by the use of
adrenalin subcutaneously, by brandy, strychnin, strophanthin,
digitalis, or camphor, to a state where she can stand ether and a hur-
ried operation. It is to be remembered that in collapse ether inhaled

^ Policlinico, 1910, xvi, Medical Section, p. 525.

78 POSTOPERATIVE HEMORRHAGE

acts as a temporary stimulant within certain limitations, and also that
in collapse but little vapor in proportion to air is necessary to keep
the patient anesthetized. Ether should not be started, however,
until all is ready for the operation Chloroform should not be used.
The surgeon should plan out his course of action before he starts.
He should work rapidly and, if time is precious, should not hesitate
to leave in gauze packing or a clamp. After the operation is finished,
treatment for shock should be instituted (Chapter VII, page 91).

In general, the following directions apply to all forms of hemor-
rhage :

(i) Lift the foot of the bed by means of bed-blocks or a chair.
This determines the flow of blood to the medulla, where resides the
vasomotor center.

(2) Open the windows and allow a free current of air to aid in the
ready oxygenation of the blood.

(3) Apply heaters to the extremities and blankets to the body to
aid in the maintenance of body heat.

(4) Apply ice locally — the coldness decreases pain and constricts
the capillaries.

(5) Give morphin if necessary to keep the patient quiet in bed.

(6) Give normal salt solution intravenously or subcutaneously, or
normal salt solution with adrenalin, or employ transfusion of blood
from another individual after the bleeding has ceased.

(7) Stimulate by meems of enemas, which may be composed of
black coffee and contain ammonium carbonate, brandy, or strophan-
thin.

(8) Stimulate by means of subcutaneous injections of strychnin,
ether, adrenalin, strophanthin.

TRANSFUSION

The transfusion of blood has recently come into prominence in
I the treatment of hemorrhage. It is indicated in acute hemorrhage

\ from any cause. Cases which have been exsanguinated, so that the

j infusion of salt solution to increase the blood volume does not suffice

to maintain life, may be saved by transfusion. This not only makes
up for loss of fluid, but provides red blood-corpuscles, which can serve
temporarily as oxygen carriers. It is of the greatest value in internal
hemorrhage preceding operation (as in extra-uterine pregnancy),
postoperative hemorrhage, hemorrhagic disease of the newborn^
hemophilia, and illuminating gas poisoning.

TRANSFUSION 79

Transfusion is of interesting and ancient origin.^ It was known to
the Egyptians of old and is referred to in the works of the Romans.
The earliest known authentic case is that of Pope Innocent VIII, who
was operated upon in 1492 by his Jewish physician, whose name has
not come down. The blood of three boys was passed into the veins
of the prelate, but without marked benefit. The discovery of the cir-
culation by Harvey gave a new impetus to the discussion of the sub-
ject, and research was instituted upon animals. Lower, in 1666, wrote
the first detailed account we have of the method of performing trans-
fusion, and in the same year Jean Denys, in France, carried on similar
experiments. He also performed the operation three times success-
fully upon human beings. Following his report, transfusion was car-
ried on extensively, sometimes from animal to man, and sometimes
from man to man, either by direct communication of vessel to vessel
or through the mediation of a quill or cannula of silver or of bone, or
indirectly by a syringe or pump. Other successes were reported, but
the method aroused fierce opposition, and, as a result, in France the
procedure was forbidden (1668) except by express permit of the
Faculte of Paris.

For a while the procedure fell into disuse, to be revived from time
to time only in discussion, until about the year 1800, when it was
again revived and given an important position in experimental
physiology. Blundell,^ in England, did important research upon the
subject. About this time also it was first noted that the blood of an
unlike species would be liable to cause distressing and even fatal
symptoms in the person in whom it was injected. About 1835 ^^^'
chofif experimented with defibrinated blood, and the use of this became
an established procedure up to about the middle of the century.*
In 1863 Blasius'* collected 116 cases of transfusion which had been
performed during the preceding forty years, and found that there
had been 56 successful results. All these cases were cases of indirect
transfusion, and in 2 the source of the serum was an animal.

From this time on a great deal of attention was paid to trans-
fusion, and claims of a highly exaggerated nature were advanced

* See Landois, Transfusion des Blutes, Leipzig, 1875; Or^, 1876, quoted by Crile,
Hemorrhage and Transfusion, 1909, 151.

2 Medico-Chirurgical Transactions, 1818, ix, 56.

* Cheever, of Boston, in his interesting reminiscences (Boston Med. and Surg. Jour.,
191 1, clxv, 485), says: " I did it, in old times, drawing blood by venesection, whipping
out the clot, warming and infusing it into a vein through a funnel and glass-tube.
The entrance of clots, or of air, was the peril."

* Deut. Klinik.

POSTOPERATIVE HEMORRHAGE

and new and complicated methods originated. The transfusion
from animals to man was reintroduced, but after Landois' discovery
that the serum of one animal may have the property of destroying the
red corpuscles of another, the use of heterogeneous blood was given
up. It was found also that defibrination of the blood createtl a source
of danger, inasmuch as it contained a fibrin ferment which might
cause intravascular coagulation. These limitations, together with
the general introduction of intravenous injection of normal saline
solution, about 1S75. brouglil llIiouI .1 'jrLidu.iI dl^u^c of IraiL^u^ion.

which lasted until some time in the 8o's, when it was taken up with
renewed enthusiasm.

There were three methods of transfusion ordinarily emploj-ed —
the intravascular, the intraperitoneal, and the subcutaneous. The
work of Carrel and Guthrie was the foundation for a great advance-
ment in the use of the intravascular method. As a result of their
experiments a practical method of end-to-end suture of vessels was
perfected. Crile' simpHfied this technique by the use of a cannula
' Hemorrhage and Transiusicin, New York. 1909.

TRANSFUSION 8 1

adapted from that which had already been introduced by Queirolo and
Payr. Modifications of the Crile cannula have recently been intro-
duced by Elsberg/ Bemheim,^ Curtis and David,^ and Janeway.'*

For a complete exposition of the subject of transfusion, both ex-
perimental and clinical, as well as his own technique, the reader is
referred to Crile's book; from it we quote freely, with Dr. Crile's kind
permission.

Technique/ — " The following instruments (Fig. 33) and materials
have been found to be most helpful: (i) Scalpel; (2) blunt dissector;
(3) small, sharp-pointed straight scissors for dividing the vessels, snip-
ping off fragments of the adventitia, and so forth; (4) ordinary dis-
secting forceps; (5) minute tissue-forceps, with exact approximation
at the points (those used by the watchmakers have been found to be
useful); (6) half a dozen mosquito hemostats, to use in securing the
minute branches of the radial artery and the small venous branches;
(7) a pair of small "Crile'* artery clamps; (8) a set of "Crile" can-
nulcT; (9) sterilized vaselin; (10) the ordinary means of closing a wound,
and dressings.

"The vessels to be anastomosed are exposed (the details will be
described later), and, after selection of a cannula of size suitable to
the size of the vessels, the end of the vein is either pushed through the
needle 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 (the fingers are too clumsy) (Fig. 33), three mos-
quito hemostats or small fine-pointed forceps, such as oculists use, 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 can-
nula by gentle, simultaneous traction on the three hemostats, and tied
firmly in place with a fine linen thread in the groove nearest to the
handle. The cuffed part is next covered with sterile vaselin, being
careful not to get any into the open end. This facilitates slipping the
artery over the cuff. The hemostats are removed from the full edge
and the artery may then be put in place.

1 Jour. Am. Med. Assoc, 1909, Hi, 887.

2 .\nn. Surg., 1909, 1, 786.

'Jour. Am. Med. Assoc., 1911, Ivi, 35.
* Ann. Surg., 1911, liii, 720.

"^ Crile, Hemorrhage and Transfusion, 284 et seq. (Copyright, 1909, by D. Appleton
and Company.)

POSTOPERATIVE HEMORRHAGE

" Owing to the elasticity of the arterial wall, it usually shrinks con-
siderably when the pressure from within is removed, as it is at the
free end. To obviate this, it may be necessary to dilate the end very
gently by inserting the closed jaws of a mosquito hemostat covered
with vaselin and opening them for a short distance. The three hemo-
stats are then applied to the edges, just as with the vein, and the artery
is gently drawn over the cuffed vein on the cannula and tied in place
with another fine linen suture applied in the remaining groove. The
mosquito hemostats are removed, and, finally, the large hemostat

Fig. 34. — Transfusion. (After Crile.)

Transfusion by Crile cannula: a, Threading the vein; b, making the cuff; c, pulling artery over cuffed vein;

d, the artery tied in place.

which has been snapped on the handle of the cannula during all this
time is removed. The process is then completed. After the trans-
fusion the cannula is removed, both artery and vein are ligated, and
the wounds are sutured.

"In making a cannula anastomosis experience will show what size
cannula is suitable for the given vessels. As large a size should be
used as possible, without injuring the intima of the artery by stretching
it too large. Usually there will be no difl&culty in obtaining a large
vein, but the artery may be very small. If too small a cannula is used,
the amount of the flow will be diminished. Moreover, too large a vein

TRANSFUSION 83

will take up too much room in the cannula and the amount of flow
will be diminished.

'' In using the cannula two facts should be particularly remem-
bered. The first is that the long axis of the tube should coincide
with the long axis of the lumen of the vein and artery. A little
experimenting will show how easily the cannula may be made to
slant so that the opening in it will come almost in contact with
the artery wall and shut off the flow in great part or completely.
Actual experience has shown the necessity of placing the cannula
accurately.

'* The second and less obvious fact is that, unless the right amount
of tension is maintained on the vessel which passes through the can-
nula when the blood is flowing across, particularly with a small cannula,
the flow will be diminished or shut off altogether by the elasticity of
the vessel wall on tension in cannula, pushing the outside part of the
vessel in and blocking the way.

*'The exposed vessels should be kept moist and warm with normal
saline solution. Not only is drying harmful, but the flow is increased
through gradual relaxation of the arterial wall.

" Experience has shown that if anything goes wrong in carrying out
this technique, it is best to start again from the beginning, and not to
try to get around any of the details by substitution.'*

Of the other forms of cannulae which have been devised, the most
ingenious is that of Elsberg.^ He employs a cannula ^' built on the
principle of a monkey-wrench, which can be enlarged or narrowed
to any size desired by means of a screw at its end (Fig. 33). 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 cannula can be easily understood from the follow-
ing description of the method of using it:

*^The radial artery of the donor 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 compress 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 milli-

^ Loc. cit.

84 POSTOPERATIVE HEMORRHAGE

meters from the ligature. Small mosquito forceps may also be used.
These are given to an asistant, who makes traction on them while
the operator cuts the vessel near the Ugature. 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 hemostatic clamp has been applied, because 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 pe-
ripherally in the usual manner. A small transverse slit is made in the
vein, the cannula with the cuffed artery inserted into the vein, a liga-
ture tied around the vein and cannula screwed open, and the blood
allowed to flow. The rapidity of the flow can be varied 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 had been isolated, and have
found the entire procedure a simple one. The advantages of the
instrument are the following:

'^(i) One 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 cuflSng of the artery is easily accomplished without
stripping back the adventitia, and, therefore, the traumatism to the
artery wall reduced to a minimum.

*' (6) The vein need 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 lumen of the artery is not diminsihed."

The Elsberg technique is simpler than that of Crile, is more
rapid in execution, and requires fewer assistants. The one cannula
will serve for vessels of any diameter, and it can be employed between
two of marked discrepancy in size. In the hands of some men it has
supplanted the Crile instrument in favor.

Some surgeons prefer the Carrel method of suture of vessels over

TRANSFUSION 85

the use of cannulse.* The advantages claimed are that the anastomo-
sis is not covered in by a mechanical device, which prevents massag-
ing of the vessels at the point of junction if the flow is too slow, and
that the caliber of the vessel is not diminished by such a device. But
on the other hand, arterial suture requires a considerable experience
with the technique in lower animals. ** The chief difficulties to suture
in transfusion are the inequality in size of the vessels, their difference
in texture, and the possibilitits of tension under which the operation
is performed/'^ The disadvantages are sufficient to deter all but
men of special training from employing the technique, when the can-
nula will do the work as well.

General Management of a Transfusion.^ — " The Donor. —
First of all, a suitable donor must be obtained. Both men and women
are suitable. In cases in which no immediate hurry exists, the best
subject is selected from among the relatives and friends who are willing
to serve. After the donor has been selected, he is subjected to a full
cross-questioning as to his family and personal history and a thorough
physical examination. This is for his own benefit as well as for the
benefit of the patient. The regeneration of the blood lost by the donor
is uninterrupted and rapid. From the donor's standpoint the duration
of flow is an important consideration. The best way of determining
when to stop the flow is by watching his symptoms. At first he will
show loss of color in his mucous membranes, pallor of the skin, slight
uneasiness, slight quickening of the pulse and respiration, lowering
of the blood tension, and beginning of shrinkage in the skin of the face.

"r/re Recipient, — As far as the recipient is concerned, transfusion
is a problem in mechanics as well as in therapeutics. There are few,
if any, operations in which more factors must be considered and in
which more care must be exercised.

**From the mechanical standpoint, the chief danger to be feared
is acute cardiac dilatation and subsequent cardiac failure, caused by
transfusion in excessive amount or at excessive rate of flow. Fortu-
nately, a certain amount of dilatation may occur and pass rapidly
away without causing either immediate or subsequent harm. It may
be necessary to shut off the flow altogether, with gentle pressure of
the fingers, for short intervals, giving the heart a chance gradually to

* For the technique, see Pool and McClure: Transfusion by CarreFs End-to-End
Suture Method, Ann. Surg., 19 10, Hi, 433. Ehrenfried and Boothby: The Technic of
End-to-End Arterial Anastomosis, Ann. Surg., 191 1, liv, 485.

2 Ehrenfried and Boothby, loc. cil.y p. 494.

' Crile, loc. cit.

POSTOPERATIVE HEMORRHAGE

assume its added burden by allowing only small amounts of blood to
cross at a time.*

*'The principal symptoms of acute cardiac dilatation are dyspnea,
distress, or pain in the upper cardiac region, cough, and cyanosis, the
pulse increases in rate and may be very irregular in action, tension,
and volume. When acute dilatation has once occurred it must be
promptly recognized, the transfusion must be stopped, the operating
table tilted so as to raise the patient to the head-up position, and rhyth-
mic pressure made on the chest over the heart. If recovery is not
complete in a short time, transfusion should be given up and the
patient put to bed in a head-up position, given carefully graded doses

Fig. 35. — Transfusion. (After Crile.)

Diagram to show arrangement of operating room: i. 2, Operating tables for recipient and donor, respec-
tively; 3, table for arms of recipient and donor; 4, 5, stoob for surgeon and first assistant, respectively; 6,
instrument table; 7, table for dressings, sutures, etc.

of nitroglycerin to insure peripheral dilatation of the vessels, and
digitalin hypodermically in very small doses to stimulate the heart-
muscle directly.

"The treatment is a question of therapeutics when reduced to its
final emalysis. The surgeon takes the place of the internist when he
gives a Mose' of blood. The question of dosage may be very import-
ant, especially when there is hemolysis of the recipient's red corpuscles
by the donor's serum; therefore, in all but emergency cases, prehmin-

* To avoid the danger of acute dilatation of the heart, Dorrance and Ginsburg (Jour.
Am. Med. Assoc., 1910, Iv, 569) recommend the employment of transfusion from vein to
vein. They claim that the operation presents fewer technical difficulties than does
arteriovenous anastomosis.

TRANSFUSION 87

ary hemolysis tests should be made in order to handle a given trans-
fusion more intelligently and protect the recipient more fully. '^^

^'The Operation. — It is a great advantage to have a thoroughly
trained corps of assistants. Two operating-tables are necessary (a
single large bed in a private house will do) . Two small square tables
of the same height as the operating-tables are needed — one for the
instruments and the other to support the arms of the patients. Two
low stools, one for the surgeon and one for the first assistant, complete
the list.

^^From twenty to thirty minutes before being brought to the
operating-room the donor and recipient each receive morphin sulphate,
gr. J, hypodermically, unless there is some special reason for its being
contraindicated.

"When each is in place on his respective table, the tables are so
arranged that the left arm of each will rest comfortably on the small
table, placed for the purpose between the operating- tables (Fig. 35).
The patients are told that there will be no pain beyond the first needle-
prick. The nurse who is detailed to care directly for the patients re-
lieves the monotony of waiting by bathing the forehead, giving water
to drink if desired, and, in short, doing anything permissible to afford
comfort.

"The next step is the dissection of the blood-vessels. 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 one, on account of its size and easily
accessible position."

In infemts and children the median basilic or median cephalic
vein is, as a rule, too small to allow of easy handling; the femoral vein
is to be preferred. With the thigh abducted and rotated outward, it
will be found to run along a line extending from just external to the
spine of the pubes to a point just behind the internal condyle of the
femur. In adults, where for any reason a vein of the arm cannot be
used, the saphenous vein may be taken in the lower leg or at the ankle.

"Local anesthesia is obtained by injecting cocain in yV ^^ ^ P^^
cent, solution with a few drops of i : 1000 adrenalin chlorid solution.
Several hypodermic syringes should be ready, so that there need be no

^ For the technique of these tests, see Crile, loc. cit., 313. Ordinarily, transfusion cases
are emergency cases to the surgeon. A blood relative should be chosen wherever possible,
parent, child, brother, or sister; next to that, husband or wife. In 8 personal cases in
private practice, where no opportunity was allowed for hemolysis tests, but where care was
exercised in selecting the donor, no untoward efifect was observed.

88 POSTOPERATIVE HEMORRHAGE

delay on account of having to stop to refill a single one. The injec-
tions are first made in the skin and then more deeply around the
vessels.

*^In making the dissection it is necessary to have good light.
Mosquito hemostats are used to catch every vessel that shows even
a drop of blood. The vessel should be kept absolutely clean. The
donor's radial artery is isolated for a distance of about 3 cm. at the
point of election in the wrist. Here there are a number of small side
branches which must be carefully isolated and tied with a No. i
Chinese twist silk before being cut. The artery is then tied at its
distal end, and a Crile clamp is gently screwed in place over the ap-
proximate part, as near to the place where it comes out of the undis-
sected tissues 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, and is
then ready for the completion of the anastomosis. The result should
be that the operator has about 2^ cm. of the exposed radial artery free
from branches, the cut end open, and the blood prevented from coming
out of it by the clamp.

"The next step is the dissection of the vein. It is exposed for the
same distance as the artery, the branches are tied off in the same way,
and the ligature is also applied at the distal end. The second Crile
clamp is applied just as before, the vein cut near the ligature, and it
in turn is ready for the completion of the anastomosis.^'

It requires a certain amount of experience to tell just how long
to allow the flow to continue. No stated time can be set, although
with vessels of equal size, about that of the radial, and with an un-
interrupted flow, a half -hour is long enough. The best guide is the
condition of the recipient, as estimated from his pulse and color,
though, of course, the donor should not be neglected. Oftentimes
it is diflScult to tell whether the blood is flowing through or not; in
this case it will be wise, before disconnecting the anastomosis, to dis-
sect the vein up to a small branch, and cut this, to see if the blood flows.
One should be careful that the vessels do not dry up, that they are
not twisted, that they are not relaxed so that they pucker up inside
the cannula, and that they are not stretched, for in either case the
flow will cease. If there is evident a marked pulsation in the vein
at some inches from the anastomosis, the flow is too rapid.

Interesting work is being done on the fate of the transfused blood.

TRANSFUSION 89

It IS evident (Boycott and Douglas) that the red cells survive only
temporarily in the circulation of the recipient. Sooner or later,
probably within a few days, they are disposed of just as effete cells
are normally taken care of, through destruction and assimilation
by phagocytes.^

Mrs. B., seen (Dr. Crandon) in consultation with Dr. C. N. Cutler, in
Chelsea, Massachusetts, was a former patient who had been operated on
for left extra-uterine pregnancy six months previously. Forty-eight hours
before was taken with collapse, pallor, gasping respirations, low abdominal
pain, and tenderness. Diagnosis, ruptured extra-uterine pregnancy. Her
condition, which at first was too poor for operation, improved slightly,
and operation was done, with the assistance of Drs. Cutler, Ehrenfried,
and Osgood. A median celiotomy revealed free blood and clot. On right
parovarium ruptured pregnancy mass was found; a fetus size of thumb-nail
floating free among intestines. Tube was removed, abdomen cleaned of
clot and blood, salt solution was poured in, and abdominal wall closed by
mass sutures. Meanwhile i quart of adrenalin salt solution (i : 50,000) had
been given under breast. Total duration, sixteen minutes. Patient cold,
no radial pulse, respirations 40.

Transfusion was at once performed, using the Crile technique, from left
radial artery of patient *s brother into her left median basilic vein, and
continued twenty-five minutes. The vessels were large and the volume of
the brother's pulse was full. At the end of twenty-five minutes the trans-
fusion was stopped. The patient had a fairly good pulse at the wrist, rate
156, the skin had changed from cadaveric yellow to a more natural color,
and there was a distinct pink in the lips; the gasping respiration ceased
entirely and the patient slept quietly.

Uneventful recovery.

B. B., aged eight, seen (Dr. Crandon) in consultation with Dr. Provandie,
in Melrose, Massachusetts. The patient had had his tonsils removed by
guillotine about nine hours before, had apparently been bleeding down his
throat all day, and at 6 p. m. collapsed, with pulse 160, temp)erature 97.2° F.,
respiration 42, slight cyanosis.

A Crile transfusion was done, using the mother, under cocain, as the
donor, the boy being etherized. The flow was carried on fifty-six minutes,
at the end of which the boy was nearly normal in color, pulse better vol-
ume, but still 140 in rate. It seems likely that he had too large a dose
of blood, though no increased cardiac area could be made out. The next
dayj to bear this out, there were some signs of congestion of the lungs,
but recovery was uneventful.

. * See also Hopkins: Phagocytosis of Red Blood-cells After Transfusion, Arch, of
Internal Med., Sept., 1910.

go POSTOPERATIVE HEMORRHAGE

Mr. C, seen (Dr. Ehrenfried) in consultation with Dr. F. C. Whitehouse,
in Bedford, Massachusetts, had sufifered from p)emicious anemia for six
years. For some weeks he had shown marked anemia (red count about
500,000), with depression of all vital functions. A few days before his
condition had become worse, with collapse and stupor. When seen he was
yellowish and pasty, with a radial pulse that could be made out with diffi-
culty. Under the excitement of the operation he became more or less alert.

Transfusion was done, with the assistance of Dr. W. M. Boothby, by the
Elsberg technique, imder cocain, using the wife as donor. Extreme diffi-
culty was experienced in finding a vein, and it took nearly an hour's search
before one was located in the doughy fat of the patient's arm large enough
to employ. Although the vein was much smaller than the artery, the
Elsberg cannula worked well. The blood was allowed to run forty minutes
on account of the small size of the vein.

Report from the attending physician showed immediate slight im-
provement. The red coimt twelve days after operation was 1,632,000, and
a week or so later the patient was up and about, working in his garden. He
continued happy and well imtil about six months later, when he died sud-
denly, within a few hours.

Mrs. F., seen (Dr. Crandon) in consultation with Dr. F. A. Mahoney,
in Chelsea, Massachusetts, had missed two periods, and had thought
that this might be due to beginning climacteric. Thirty hours before she
had been suddenly taken with abdominal pain and dizziness, which had in-
creased constantly. She was a large and obese woman, pale and sweating.
The pulse, which could not be found at wrist, was 158 by stethoscope; res-
pirations 36; abdomen distended, and in a state of spasm. Operation
was performed with the assistance of Drs. Mahoney and E. J. Powers.
Median celiotomy revealed a right tubal pregnancy ruptured at proximal
end of tube. This was tied off and removed, together with a large amount
of clot and fresh bkxKi, and the abdomen was closed full of hot salt solu-
tion. Time, thirty minutes.

Immediate transfusion, using the Elsberg cannula, was done, the patient's
brother was donor, and both were under ether. At time of starting trans-
fusion the recipient's pulse was 180 by stethoscope and she was, to all ap-
pearances, dying. The flow of blood began thirty-five minutes from the
beginning of transfusion operation, this great time being due to the fact that
the vein was hard to uncover in a very fat arm. The artery had to be
massaged to start the flow. The transfusion continued for nineteen min-
utes; at the end of this time the recipient's pulse was 120, respiration 22;
she was pink in the face, and the nose, which had been cold, was warm.

The dose of blood in this case again seems to have been too large.* For
three days the patient had some distress in left front of chest and crackling
r^es in both backs. Recovery was otherwise rapid and uneventful.

CHAPTER VII

SHCXX: CAUSES, SYMPTOMS^ TREATMENT

Shock is a condition of reflex depression of the vital functions which
occurs after serious injuries and operations, but may, apparently,
result also from mental excitement induced and accompanied by com-
paratively slight bodily injury. Every operation of any severity is
accompanied by some degree of shock. It may vary in intensity,
from a transient state of weakness, which reacts readily to stimulation,
to the most profound condition of vital depression which resists all
efforts at alleviation and is the cause of death. Races with less stable
nervous organization, the American, Hebrew, and Irish, are said to
be more susceptible than the more phlegmatic peoples, the Scotch,
German, and Chinese.

We may consider the exciting causes of shock to be psychic, as
profoimd emotion, fear, or sorrow; irritative, such as might follow the
irritation of peripheral sensory nerve-endings by extensive skin wounds,
superficial bums, and destruction by caustics; toxic, as from the in-
fluence of anesthetics; and, finally, mechanical, either from trauma
or operative handling and exposure of tissues, nerves, and viscera.
Thus, shock will follow severe blows upon the head, larynx, abdomen
("solar plexus"), testicle, or spermatic cord, abdominal wounds and
visceral injury, gunshot wounds of the intestines, and perforation of
the bowel in typhoid or appendicitis. Hemorrhage causes collapse
and not shock, although the clinical distinction between the two is
often difficult.

Postoperative shock may be the result of any one or more of the
factors mentioned, but particularly the two last. It most frequently
follows procedures involving the abdominal contents and visceral
peritoneum; next, the visceral pleura; third, the male generative
organs. In abdominal operations the state of shock seems to bear
some proportion to the amount of manipulation the visceral perito-
neum receives, or the amount of exposure of the viscera. In ab-
dominal surgery the tendency to shock is least after operations upon
the pelvic organs, and greatest in operations on the stomach and
duodenum. In operations on the extremities the amount of shock

92 shock: causes, symptoms, treatment

seems to bear a proportion to the sensory nerve supply of the tissues
exposed or injured. Pain is an important factor in causing or pro-
longing shock.

The etiology of shock is still under discussion. One theory
has it that cardiac exhaustion is the prime cause, another holds that
shock is due to a reflex inhibition of the activity of the centers of the
cord. The hypothesis which is receiving the widest acceptance
among surgeons to-day is that originally enunciated in 1864 by
W. W. Keen, S. Weir Mitchell, and C. W. Moorehouse,* which ex-
plained shock as due to vasomotor exhaustion. This theory has
been elaborated and apparently confirmed by Crile^ and Romberg,^
who independently observed that during shock the blood-pressure in
the peripheral arteries fell. Crile states the doctrine essentially as
follows: As the result of the cumulative effect of excessive or unusual
stimulation of afferent nerves the vasomotor center becomes de-
pressed and, finally, completely exhausted, and as a consequence
of this exhaustion there occurs a paralysis and dilatation of the
peripheral vascular system, with the accumulation of blood in the
venous trunks. The output of the heart diminishes and the cir-
culation gradually fails.

This theory has been recently disproved by the experimental
researches of physiologists. W. T. Porter* says: *'The hypothesis
which constitutes the hitherto generally accepted definition of shock
declares that the vasomotor cells are depressed, exhausted, or in-
hibited by excess of stimulation of afferent nerves. The fall in the
blood-pressure and the accompanying symptoms are the result of this
depression. The experiments cited in this paper demonstrate that the
vasomotor cells are not thus depressed or inhibited, and experiments
show also that stimulation of afferent nerves does not materially
lessen the blood-pressure. The present hypothetic basis of shock is
thus removed. '' And Seelig and Lyon^ have advanced definite ex-
perimental data to prove that the peripheral vascular system is not
paralyzed and that no inhibition of the vasomotor center exists, even
in profound shock.

To replace this doctrine there has been recently advanced, by

^ See Circular 6, Surgeon General's Office, 1864.

'-^An Experimental Inquiry into Surgical Shock, Philadelphia, 1899; Blood-pressure
in Surgery, Philadelphia, 1903.

' Deutsch. Archiv. f. klin. Med., 1899, Ixiv, 652.

* Porter and Quimby, Amer. Jour, of Physiol., 1908, xx, 500; also Porter, Harvey
Lectures, 1906, 1907.

' Jour. Am. Med. Assoc., 1909, liii, 45; Surg., Gyn., and Obstet., 1910, xl, 146.

ETIOLOGY 93

Yandell Henderson of Yale, the theory of acapnia as the underlying
cause of shock. Haldane* has stated, and it is now generally ac-
cepted, that the carbon dioxid in the blood is the chemical regulator
of the respiration (except in states of anoxemia, when certain acid
radicals, products of incomplete tissue combustion, act to assist the
carbon dioxid in stimulating the respiratory center). In other words,
the respiratory activity is adjusted to maintain a uniform carbon di-
oxid content in the blood; for example, if the proportion of carbon di-
oxid in the air inspired is increased by .2 per cent., the respiratory
activity is doubled. Henderson confirms, experimentally, this
theory, but he goes further and asserts that the carbon dioxid in the
blood may be nearly as important in the regulation of the circulation
as of the respiration, postulating a hitherto unrecognized venopressor
mechanism.

Stated in brief, Henderson's explanation of the mechanism of shock
is as follows: Voluntarily forced respiration in man induces symptoms
of shock. Emotion, pain, ether-excitement, irritation of sensory
nerves without conscious suffering, and other conditions known to
produce shock, involve excessive respiration (hyperpnea). The result
of this overventilation of the lungs is a fall in the proportion of carbon
dioxid in the blood (acapnia). Another source of loss of carbon
dioxid is by evaporation from exposed intestines during operation.
The primary result of this withdrawal of the natural stimulus of the
respiratory center is a cessation of respiration (apnea), which, if
sufficiently prolonged (about eight minutes) , will cause death from oxy-
gen starvation of the heart. This is respiratory failure.

A no less important secondary efifect of acapnia is an increase in
the rapidity of the cardiac contractions. This quickening of the
heart-beat occurs at the expense of the diastole, which is thereby
shortened, and as a result time is not allowed for complete filling of
the auricles. The output of the heart accordingly diminishes, which
causes a fall in blood-pressure. Simultaneously the venous pressure
falls and the blood stagnates in the veins. The failure of circulation
in shock is, therefore, fundamentally a venous stasis, and the under-
lying cause of this stagnation is diminution of the carbon dioxid con-
tent of the blood.

Acute acapnia diminishes the volume of available blood as efifect-
ively as does an extensive hemorrhage, says Henderson. The apparent
failure of the heart is due to a diminution in the venous stream to the

^ For a recent exposition of the physiology of respiration see his article in Encyclo-
pedia Brit., 191 1, xxiii, 187.

94 shock: causes, symptoms, treatment

right auricle. Clinically, an increasing pulse-rate and a rise in dias-
tolic pressure indicates the approach of shock.

This theory opens up definite therapeutic possibilities, which will
be considered later.

Whatever hypothesis as to the fundamental cause of shock we
accept, if wemay accept any, there are certain essential factors which
we can at this time take for granted. In shock the blood-pressure falls,
but not from paralysis of the peripheral arterial system and the con-
sequent aboUtion of peripheral resistance, nor directly from the stim-
ulation or irritation of afferent nerves. The peripheral arteries are
contracted in an effort to maintain the circulatory equilibrium.
Irritation or excessive stimulation of the afferent nerves, with or with-
out conscious pain, may induce shock. No exhaustion or inhibition
of any sort occurs in the vasomotor nervous system. On the contrary,
this is active to compensate for the lessened blood-stream. The pulse
accelerates. The blood accumulates in the venous trunks and the
output of the heart diminishes; the force of the heart-beat lessens.
The heart is not weakened primarily.

Symptoms. — Chnically, shock may be immediate, coming on dur-
ing or immediately after an operation; deferred, six to twenty-four hours
after operation; and continued, coming on soon after operation and
lasting twenty-four to forty-eight hours or even three or four days.
The two latter varieties are imcommon. What is called deferred
shock may sometimes be the collapse of secondary hemorrhage. Con-
tinued shock is like ordinary shock, except that the symptoms are
slower in developing and that it runs a longer course. It is apt to occur
after prolonged operations, in cases accompanied by severe mental
shock or pain, and in anemic women.

The symptoms are analogous in all forms and extremely typical.
Rarely the onset of shock will be so sudden and its development so
rapid that the patient will die on the table. This fulminating form
is not to be confounded with asphyxia due to the anesthetic. Usually
the condition develops gradually as the operation proceeds, the pulse-
rate increases, and soon the volume and tension decrease, the surface
temperature drops, the respiration becomes faster and less deep, the
face and lips become pallid, and the pupils dilate. The immediate
indication is to end the operation and treat the patient; patients in
this stage may be expected to react. As the condition proceeds the
pulse becomes irregular and thready, the skin cold, pallid, and cov-
ered with a cold sweat, the lips become blue, and the respiration
shallow and irregular. The patient is put to bed in a state of dull

TREATMENT 95

torpor, which gradually develops into coma. The pupils are dilated
and the eyes half-closed and staring. There is loss or impairment
of surface sensibility, and the phlegm which collects in the throat is
audibly churned with the respiration. Occasionally there is hiccough,
nausea, and even vomiting; there is loss of muscle control; there may
be incontinence of feces, lessened secretion, and retention of urine.
Rarely, instead of the conmionly expected picture of mental inactivity
and apathy, we find excitation and maniacal delirium, which exhausts
itself rapidly and develops into coma.

If the patient responds to treatment, there will be a gradual devel-
opment of consciousness, often preceded by vomiting, and the patient
in a husky voice will ask for water. The corneal and cutaneous reflexes
will be reestablished, the pulse become stronger and slower, the skin
become warmer and lose its clammy appearance, the respirations
become slower and deeper, and the kidneys begin to secrete urine.
If there is no pain the patient will often sink into normal sleep, to awake
in a few hours much improved.

Treatment. — In treatment the matter of prophylaxis has an
important place. Before operation the bowels should be empty,
although overf ree saline catharsis causes depletion of tissues and should
be avoided. Starvation should not be practised; the patient should
be well fed, and may even have a cup of bouillon or coffee and a cracker
an hour before ether is started if she feels the need of it, or a nutrient
enema may be given one-half hour before the operation. The patient
should be in a quiet frame of mind, and should have a good night's
sleep, otherwise, if she is restless or in pain, morphin, gr. |, and atropin,
gr. r5ir> should be administered one-half hour before operation. On the
whole, it is wise to avoid the routine preoperative use of drugs to pre-
vent shock; drugs should be withheld until a definite indication for
their use appears. Gas-oxygen and, second to that, ether are always
the anesthetics of choice if shock is feared.

If the patient is brought to the surgeon in a state of severe shock, as,
for instance, from a mutilating trauma, he will have to decide whether
to superimpose upon the existing condition the shock of ether and oper-
ation or to temporize and combat shock before operation. There seems
to be among active surgeons a growing tendency in favor of the latter
course. Many a forlorn hope has been rushed to the table to expire
during the operation or soon after its close, where the operative risk
might have been lessened in cases that could wait if a few hours were
given first to the treatment of shock.

During the operation much may be done to forestall shock; if shock

96 shock: causes, symptoms, treatment

is expected, all precautions should be taken. In the first place, the
operation should be rapid, even to going through the abdominal' wall
with one stroke of the knife if indicated. All preparations should be
made and everything well planned before the anesthetic is started. It
is vastly important that the period of anesthesia be as short as pos-
sible. Everything should be made ready for the treatment of post-
operative shock while the operation is going on, and, if the occasion
demands, hypodermoclysis of normal salt solution may be carried
out beneficially while the operation is under way.

All measures should be taken to prevent the loss of body heat. The
room should be warm, about 72° F., and an operating- table heated by
steam or electricity may advantageously be used. The body and
limbs should be well wrapped in blankets; hot- water bottles should be
used freely if necessary, and especial care should be taken that the
patient is not lying exposed upon uncovered cold glass plates or that
the blankets or towels are allowed to become wet without being
changed. The room should be well ventilated, especially in opera-
tions of any length, so as to allow the patient a proper supply of
oxygen.

Loss of blood should be scrupulously avoided, especially in anemic,
cachectic, or exsanguinated persons. All unnecessary exposure or
manipulation of intestines should be guarded against; coils of intestine
should be replaced with considerate gentleness as soon as practicable,
and, if exposed necessarily, should be kept covered with sterile towels
or large pads, hot with sterile salt solution frequently renewed. The
omentum is much less sensitive to handling than the intestines. In a
limb the cocainization of the sensory nerve-trunk supplying the part —
'' blocking '' the afferent track — before any gross mutilation or rough
handling is to be performed, as in cleaning up and repairing an ankle
after a bad crush, will forestall or lessen shock. If shock is imminent,
the lowering of the head by the assumption of the Trendelenburg pos-
ture will relieve cerebral anemia.

With the condition of shock established, certain indications for
treatment present themselves. These we shall consider in the follow-
ing order:

(i) Fall in blood-pressure.

(2) Venous stagnation and the withdrawal of blood from the active
circulation.

(3) Anemia of the brain and of the vasomotor center from lessened
blood-supply and consequent poor oxygenation.

TREATMENT 97

(4) Cardiac exhaustion from progressive weakening of the heart-
muscle, resulting from its attempt to maintain the circulation.

(5) Acapnia.

(6) Pain as an element in causing or prolonging shock.

(7) General measures in the care of patients.

It may be accepted that one of the main factors in shock is a
general fall in the blood- pressure in the peripheral arteries, with a
coincident stagnation of blood in the venous trunks. Leaving the
abdomen full of sterile salt solution after a celiotomy will temporarily,
at least, create a positive pressure which will partially counteract
or prevent dilatation of the splanchnic vessels, and will, by absorp-
tion of the fluid, increase the volume of the circulating blood. It
is here also that the usefulness of the vasoconstrictors is apparent, and
of these we shall consider adrenalin, caffein, and strychnin. On
the whole, the results of drug treatment of shock are not encouraging.

Adrenalin is the most active member of this group, and perhaps its
best indication for use is in shock. It induces a prompt and marked
rise in blood-pressure by acting directly on the muscle-tissue of the
arteries to cause contraction of the peripheral vessels. The ordin-
ary dose is 5 to 15 minims of the i : 1000 solution. It must be given
subcutaneously or intravenously, as its vasomotor action is absent
when given by mouth. ^ Adrenalin may conveniently and rationally
be given in salt infusion, 15 minims to the quart (i : 50,000 solution).
Its action is very transitory ,2 lasting only about ten minutes, so that if
the desired effect is not obtained, it must be repeated. Its effect in
increasing the blood-pressure may be so marked as to lead to acute
dilatation in a diseased or weakened heart from the suddenly increased
amount of work thrown upon it.^ For this reason, as well as on ac-
count of the occurrence in animals of an arteriosclerotic condition* if

* The administration of drugs by mouth should be avoided in shock, as patients do
not react normally to sensory stimuli, and the reflexes connected with the act of swal-
lowing are dulled, so that the irritating fluid may readily pass into the larynx.

* D. D. Jackson (Prolonged Persistence of Adrenalin in the Blood, Amer. Jour, of
Physiology, igog, xxiii, 226) says adrenalin does not persist in the blood after its visible
eff^ects in the rise of blood-pressure have disappeared. In the dog adrenalin disappears
in about one minute.

* Merkens (Zentral. f. Chir., igio, xxxvii, No. 42) reports a fatality in a man of fifty
following closely upon the injection of 10 drops of adrenalin in i liter of normal salt solu-
tion.

* N. Waterman (Arteriosclerosis after Injections of Adrenalin, Virchow's Archiv,
1908, cxci, 202) says that research shows that the arteriosclerosis induced in animals
after injection of adrenalin closely resembles ordinary arteriosclerosis in man.

qS shock: causes, symptoms, treatment

the use of adrenalin is long continued, the drug must not be given in
too large doses or over long periods.

Caflfein is a vasoconstrictor of rapid action, which causes a rise in
blood-pressure that is maintained about one and one-half hours. It is
said to act better when the heart structure is diseased or weakened, as
in acute infectious diseases, than when it is normal. It is useful in an
emergency, and may be given in the form of strong coffee by way of
the rectum, in doses of 2 to 4 ounces. Caffein is otherwise given sub-
cutaneously in 2- or 3-gr. doses. On account of the poor solubility of
the alkaloid in water (i in 45.6 parts), the form ordinarily used for
hypodermic medication is the freely soluble caffein and sodivmi benzo-
ate (N. F.), which contains 45 per cent, caffein, and should be given in
doses of 3 to 6 gr. It may be repeated in two to four hours.

Strychnin is the least dependable of all the vasomotor drugs of this
class. From recent investigations it appears that its action at best is
inconstant, and that a rise in blood-pressure, through direct stimula-
tion of the vasomotor center, is produced only when the drug is given
in quantity approximating the toxic dose. A comparatively safe ac-
tive dose is j\ gr. ; this may be followed in fifteen minutes by ^V gr., and
then ijV gr. given every two hours. It must be borne in mind that,
though no toxic symptoms appear during shock, the patient may be
taken with convulsions, if larger doses are given, as soon as the condi-
tion of shock disappears, as the result of the cumulative action of the
drug, which, in the state of shock, has not been eliminated.

Alcohol must be considered here, for though it is ordinarily classed
as a vasodilator, recent works seem to show that moderate amounts
given by mouth or rectum induce, coincident with the peripheral dila-
tation, a constriction of the splanchnic vessels. These findings bear
out the clinically often-observed stimulant effect of alcohol in shock.
It may be given in the form of brandy diluted with an equal part of
water — i ounce by mouth or 2 ounces by rectum.

Animal investigations lead us to believe that the rapid action of
the heart occurring in shock is not due — in the early stages at least —
to exhaustion of the organ, but rather to the fact that the heart has an
insufficient quantity of blood to work upon. The situation has its
parallel in the damage which is done to the engines of an ocean liner
going at full speed which suddenly has her propellor lifted clear of the
water, and may be compared with the exhausting futility of working
a pump with no water in the tube. Crile found that if salt solution or
blood were supphed to take the place of the blood stagnant in the

TREATMENT 99

venous trunks, the heart at once began to work more slowly and
forcibly. We shall consider four methods of supplying the needed
fluids:

(i) Emptying the peripheral vessels.

(2) Salt solution infusion (h3^odermoclysis).

(3) Intravenous infusion of salt solution.

(4) Transfusion of blood.

(Rectal absorption is too slow to make this route of any value in
early shock. The drop method may be advantageously employed in
continued shock or in connection with other methods.)

It has been clearly demonstrated that blood can be forced into
the general — so to speak, vital — circulation from the extremities. The
vascular content of the arms and legs is considerable, and elastic pres-
sure exerted on the limbs will empty these peripheral vessels, cut them
off in great part from the circulation, and force their content of blood
into more vital channels. This is the fundamental principle of the
elastic suit of Crile, an arrangement by which, pneumatically, measured
elastic pressure could be exerted on the legs and abdomen. On ac-
count of its inconvenience and complexity this apphance has not gen-
erally been adopted, but the underlying principle can be met to a de-
gree by simple elevation of the lower portion of the body, in the Tren-
delenburg posture, by massaging the hmbs and abdomen, and by tight
bandaging of the extremities with elastic rubber or fabric bandages
from toes to groin and fingers to shoulder. A broad bandage of
flannel applied over sheet wadding or absorbent cotton will distribute
the pressure evenly, without risk of cutting off the blood-supply. The
pressure may be graduated; if it is so great as nearly completely
to shut off the circulation, the apparatus cannot be safely worn longer
than five minutes. The bandages may be left in place, or a tourniquet
may be put on at their upper limit, as the groin, and the bandages
removed. Thus, after both legs have been emptied, a tourniquet may
be applied about the abdomen, at the level of the umbilicus, and with
a pad over the aorta. These measures are effective in raising the
blood-pressure.

In cases of shock, and those due to hemorrhage particularly,
the injection of salt solution is a valuable mode of treatment. When,
however, the trouble is due to primary heart failure, the increase in
the quantity of fluid means an added strain upon the heart, and is,
therefore, contraindicated.

Hypodermoclysis is, on the whole, the most satisfactory method of
supplying fluid to the circulation; the procedure has already been

loo shock: causes, symptoms, treatment

described in the chapter on Thirst (Chapter III). Fully twenty
minutes should be allowed for the injection of 3 pints, at a temper-
ature of 110° F. Care should be taken that the fluid does not become
cooled below body temperature in transit through the tube. Extreme
care should be exercised to preserve asepsis, and too large a quantity
should not be given in one area, on account of the possibility of slough.
There is usually to be noted a rapid improvement m the circulatory
condition after its administration, as shown by a rise in blood-pressure.
This improvement may, however, be only temporary, and show signs
of wearing ofT at the end of an hour, so that one should be prepared
to repeat the infusion if indicated. It is a mistake to give too large
a dose; a safe and eflfective rule is 2 or 3 pints, repeated hourly
if indicated. Hypodermoclysis — just as transfusion of salt solu-
tion and of blood — ^is most valuable when hemorrhage has been an ele-
ment in the causation of shock. It is important, also, that no fluid be
infused while there is actual bleeding, and care must be exercised that
the volume and pressure of the blood-current is not raised too high or
too suddenly where clotting has been relied upon to stop hemorrhage.
Intravenous infusion of salt solution is being largely superseded by
hypodermoclysis. Its disadvantage is in its much slower and more
difficult technique. Its advantage lies in the immediate relief which
it gives to the vascular system. On the other hand, if the saline is too
rapidly infused, the blood taken into the heart will be extremely di-
luted, imperfect aeration and dyspnea will be induced or acute dila-
tation ensue, and immediate death may occur. One of the larger
superficial veins of the upper arm is usually chosen — the basilic or
cephalic. This is made to stand out by a loose tourniquet applied
above, and, aseptically, it is dissected out through a longitudinal in-
cision about an inch long. Two silk ligatures are passed under it.
The lower one is tied; between the two the vein is nicked, the end of the
cannula attached to the tube from the salt solution bottle is introduced
(taking care that there is no air in the tube), and the upper ligature
tied once about its tip. Not more than 2 pints had best be given
at one time. After the bottle is slowly emptied the cannula is slipped
out and the upper ligature drawn taut, so as to tie off the proximal
end of the vessel. The skin is sewed and a sterile dressing applied.
There are disadvantages beyond those of technique, as shown in the
following case:

A well-formed young woman, acrobat, was seen in a state of extreme
collapse from some intra-abdominal condition. An immediate celiotomy

INTRAVENOUS INFUSION

lOI

was performed and simultaneously an intravenous infusion of salt solution
made. The patient recovered, but the incision for the infusion became
infected and left a small scar. She threatened to institute suit against the
operator, on the ground that the infusion was performed without her permis-

III

Fig. 36.— Intravenous Infusion.

/, Exposure of median basilic vein; //, passing the upper ligature; the lower one is tied; ///, opening the

vein; IV, infusion cannula tied in place.

sion, and that the scar was unsightly and thus interfered with her earning
capacity in her profession.

For the transfusion of blood, see p. 68 ei seq.

I02 shock: causes, symptoms, treatment

Anemia of the vasomotor center will be combated by the measures
already detailed for the purpose of equalizing and stimulating the
circulatory system. It is rather important that the patient he in bed
without a pillow, and that the foot of the bed be raised on blocks. This
position facihtates the return of the blood from the extremities and
increases the quantity suppUed the brain. Alcohol is of some use in
dilating the cerebral vessels. If imperfect aeration of the blood is an
element, as evidenced by cyanosis of the lips and under the finger-
nails, inhalation of oxygen is indicated. If shock has developed before
the patient has recovered from the anesthetic and the breathing has
become rapid and shallow, oxygenation of the blood may be improved
and elimination of the anesthetic assisted by the use of artificial
respiration for a short period, or atropin may be given to stimulate the
respiratory center.

The treatment of intrinsic cardiac exhaustion resolves itself prac-
tically into the consideration of the application of digitalis; the stagna-
tion of blood in the vessels of the venous trunks and the resulting
lowering of blood-pressure in the general circulation having been com-
bated, so far as possible by the measures already suggested, a suf-
ficient amount of fluid having been supplied by means of infusion or
transfusion for the heart to work upon, and anemia of the cardio-
vascular centers having been to some degree overcome by these and
other measures. Digitalis induces, by direct action upon the heart,
a slower and more complete emptying of the ventricles; this increases
the volume of blood in active circulation, and consequently raises the
blood-pressure, and, by inducing a better circulation in the coronaries,
improves the nutrition of the heart-muscle itself. There is a secondary
action on the vessels, consisting chiefly in the constriction of the splanch-
nic arteries and an accompanying dilatation of the peripheral vessels,
including those of the brain.

Given by mouth, digitalis is slowly absorbed, taking from twelve
to thirty-six hours before its action becomes evident. Moreover, it is
cumulative in action, and for that reason it is liable to be poisonous
when given in large doses. It is irritating also to the mucous mem-
brane of the stomach. On account of its cumulative action, it should
be withdrawn gradually after the indication for its use has disappeared.
An overdose is shown by an abnormal slowing of the pulse. The
digitalis of commerce varies markedly in strength and may be prac-
tically inert. One should use a standardized tincture of reliable origin*

MASSAGE OF THE HEART IO3

the active, isolated parts and derivatives, of which there are many in
the market (digitaUnum verum, digitalin, digitoxm, digalen,^ soluble
digitalone, etc.), are clmically uncertain and are apt to be unstable.
Insomuch as absorption by mouth is probably interfered with in
shock, the drug had best be given hypodermically. This method en-
forces certain absorption, prompt action, and does away with gastric
irritation.

A reliable preparation of strophanthin (Boehringer or Burroughs,
Wellcome & Co.), given intravenously, is sometimes dramatic in its
stimulatmg effect in profound cardiac exhaustion. ^ It is given from
a hypodermic needle into a vein of the elbow-flexure in a dose of ^\
gr., to be repeated in an hour if necessary.

For acute cardiac failure, such as might occur in the course of an
operation, more immediately active measures must be taken. Slap-
ping the diaphragm and dilating the anal sphincter should be re-
sorted to if necessary. The application of the faradic current to the
diaphragm is indicated if apparatus is at hand. Atropin should be
given subcutaneously to stimulate respiration. Amyl nitrite should
be volatilized under the patient's nostrils. This increases the cerebral
circulation. Rapidly acting stimulants, such as ammonium carbonate,
camphor, ether, or aromatic spirits of ammonia, may be given sub-
cutaneously.

If the patient collapses on the table during a celiotomy, especially
under chloroform anesthesia, and other means of resuscitation fail to
elicit any response, direct massage of the heart may be justified. The
heart is grasped through the diaphragm, the left hand being inserted
through an incision above the umbilicus, the ventricles are squeezed
rhythmically between the fingers, or the heart is pushed against the
front wall of the chest. The massage must be kept up for a long time,
supporting the spontaneous contractions, or otherwise the heart's
action will flag again. In some cases fifteen minutes elapse before the
heart responds to the massage. Artificial respiration should be main-
tained simultaneously, with possible tracheotomy or intubation, to
insure the rhythmic supply of oxygen to the lungs. The pelvis should
be raised and the abdomen compressed to aid in increasing the blood-
pressure by overcoming the paralysis of the vasomotor mechanism.
This procedure, though rarely used in this country, has been applied
with some reported success in Europe.

* Jour. Am. Med. Assoc, Sept. 11, igog, liii, 869.

2 A. K. Stone, Boston Med. and Surg. Jour., 1909. cLxi, 586.

I04 shock: causes, symptoms, treatment

M. V. Cackovic (Ueber direct Massage des Herzens als Mittel zur Wiederbelebung,
Archiv. f. klin. Chir., iqoq, Ixxxviii, 910) reports a case of death under chloroform in
a boy nine years old, in which the heart was exposed and massaged. He found 1 7 cases
in the literature in which massage was practised for resuscitation, q of which completely
recovered. In the rest the heart failed again after working for a longer or shorter interval.
In all but 5 of the cases the syncope occurred under an anesthetic. The best results were
obtained by massage applied from below the diaphragm. The outcome was better the
earlier after the syncope the massage was undertaken. The first five minutes gave the
most cases of success, while the massage failed constantly if ten minutes had elapsed after
the onset of the syncope before the massage was commenced. The prosj^ects are more
favorable for direct massage of the heart when the syncope is of circulatory rather than
respiratory origin.

Mocquot (La Reanimation du Coeur, Revue de Chir., Paris, 1909, xxix, 696; 924; 1 184)
reviews all cases on record and adds unpublished cases. Complete success in 9 cases out
of 22. Two complete successes with massage through the chest-wall. Best mode of
access is through the abdomen. The diaphragm may be too taut. In this case it should
be relaxed by raising the pelvis. The heart is sometimes so flabby that it cannot be felt
through the diaphragm, but after a few compressions it regains its consistency under the
massage. It is probably not necessary to take hold of the heart itself to apply effectual
massage. It is easier and more effectual merely to compress the ventricle against the wall
of the thorax by means of the hand introduced flat under the diaphragm behind the heart,
without incising it. While massage is being applied, artificial respiration should be kept up
to relax the diaphragm. The Sylvester method interferes with the massage. The best
technique is by direct insufflation through a tube. The rhythm of the massage should be
about 60 a minute. The best success has been in chloroform syncope. The best chance
exists when it is commenced not later than fifteen minutes after the arrest of the heart.
.\drenalin is a valuable aid in stimulating the heart to contract, associated with massage.

The treatment of shock in accordance with the theory of acapnia
consists in restoring carbon dioxid to the organism. Theoretically,
this should give effective relief in all except extreme stages of the
condition; this subject is so recent that reports of clinical results have
not yet appeared in the literature. The theory seems to be supported
by the report of Gatch/ who found no evidence of shock in several
hundred anesthesias during which the patients were allowed to re-
breathe some of their own carbon dioxid.

The means of supplying carbon dioxid are limited only by the ave-
nues for absorption of the gas. It may be given as oxygen is, by con-
necting a funnel to the tank and hanging it inverted over the patient's
face. A cradle can be placed over the patient's head and thorax and
covered with a sheet to form a sort of tent, under which he can re-
breathe his own carbon dioxid. It will be absorbed in the stomach
from charged waters, siphon soda, ginger ale or champagne, and through
the skin in a carbon dioxid bath. Normal salt solution saturated with
carbon dioxid (by allowing the gas to bubble through it) may be in-
jected intravenously (with some possibility of danger from embolism)

* Jour. Am. Med. Assoc., 1910, liv, 775.

TREATMENT IO5

into the peritoneal cavity, or instilled into the bowel by the drop
method.^

The patient should be kept quiet, undisturbed by visitors, and, so
far as possible, free from pain. His fears should not be aroused by the
inadvertent talk or attitude of his attendants. Annoying routine
measures in a hospital should be omitted, and the overuse of drugs
avoided. The surgeon should give the impression of assurance, and
the nurse should be agreeable and encouraging.

In shock persisting over any length of time it becomes important
to administer nourishment regularly. Usually the rectal route is the
one selected, and a nutritive enema (see Chapter XII) may be re-
peated every two hours. A good stimulating enema in practice is the
following:

I^ . Black coffee 5 vj;

Brandy 5ij;

Tr. digitalis njx;

Ammon. carb gr. xx;

Tr. opii njix. — M.

At the same time it must be seen to that the patient's comfort is looked
out for, his tongue kept moist, and distention of the bladder avoided.

* It is too early as yet to allow anything to be said as to the ultimate adaptation of
this theory to clinical surgery. It promises well in a field where previous doctrines leave
much to be fulfilled. In Boston it is being tried out clinically by Dr. F. J. Cotton and Dr.
W. M. Boothby, who will probably report later. We know p)ersonally something of
their cases, and in some instances the effect of treatment has been striking.

CHAPTER VIII

COMA: DIABETIQ UREMIC; COLLAPSE; SUDDEN DEATH

The development of coma after an operation is infrequent, but
when it occurs it is usually of serious portent. It may follow so closely
upon the operation that the patient never regains consciousness, or it
may take some days to develop. We shall consider three forms — the
diabetic, uremic (including puerperal eclampsia), and simple collapse.
It must not be forgotten that a comatose condition may be due to
scopolamin given antecedent to the anesthesia, to an overdose of
morphin, or the action of a moderate dose upon a patient with an
idiosyncrasy.

It was formerly one of the traditions of surgery that sugar in the
urine was an absolute contraindication to anesthetization. Nowadays,
unless we are dealing with an undoubted and progressing case of dia-
betes mellitus, it is generally considered that with the exercise of proper
precautions the risk is slight.

The patient should be properly prepared by dieting during as long
a period as the nature of the surgical indication will allow, so that the
sugar content of the urine is diminished as much as possible. One
should take care, however, that the patient is not starved. The anes-
thetic should be carefully and evenly administered. The period of
anesthetization should be as short as possible. Chloroform is contra-
indicated on account of its effect on fat metabolism in the liver.
Usually in the case of middle-aged glycosurics, who have been main-
taining a more or less constant output of sugar for some years with only
slight disturbance to health, with these precautions little need be
feared, although, if the sugar percentage is high, a protracted etheriza-
tion may disturb the metabolic balance and lead to fatal results.

In undoubted diabetes, especially in those cases where the sugar
cannot be reduced by dieting, operations should be put off so far as
possible, and their performance should be as rapid as the surgeon's
technique will allow. Other things being equal, the proportion of
casualties in diabetics under thirty is greater than in those over thirty.
Carbohydrates should be administered after the operation with the
hope of staving off coma. There is no question but that the post-

106

UREMIC COMA 107

operative administration of carbohydrates in reasonable amounts
assists the healing of wounds in diabetics.

When the diabetic coma supervenes, it may come on shortly
after operation, so that the patient who has been under ether for twenty
minutes, to allow of the excision of a carbuncle, may be dead in from
four to twelve hours. Usually it takes two, three, or more days for
coma to develop, and the danger is past if it does not make its appear-
ance within a week. The urine and the sugar percentage rapidly in-
crease, the patient becomes restless and mentally disturbed, and the
breathing and pulse-rate ascend. Then coma sets in, the face be-
comes pallid, the body and extremities cold, and the temperature
falls to subnormal. There is deep sighing respiration, and the urine
decreases in quantity and shows the presence of acetone.

Recovery from postoperative diabetic coma is rare. The usual
treatment of coma in diabetes should be instituted. The patient's
bowels should be emptied and injections of sodium bicarbonate (6
drams to the pint) should be given under the skin, and fluids, alkaline,
if well borne, should be forced.^

Uremic coma after operation may be due to several causes.
Among these we have to consider uremia in patients with chronic
Bright's disease, anuria, dependent upon a tying in of the ureter
by mistake, uremia, in cases where an only kidney has been removed
or a non-functionating kidney left behind, and, for convenience,
eclampsia in pregnant women.

Eclampsia rarely occurs primarily after an operation. Oftentimes
the uterus may be emptied by operative means because of eclampsia,
and in this case after operation there is a decided improvement, or else
the eclamptic condition continues and the patient dies. Rarely
after operations upon pregnant women primary eclampsia may be
induced.

In middle-aged and eldefly persons with impaired renal functions
ether should always be used with circumspection. A prolonged anes-
thetization even in persons presumably normal may be followed by the
exhibition of fats and albumin in the urine. In nephritic patients
after an operation there may be a marked increase in the amount of
albumin, renal excretion may gradually diminish in quantity and

^ Becker (Deutsche med. Woch., 1894, xx, 359; 380; 404) reported 3 fatalities following
anesthesia in diabetic patients, in which acetonuria was present at the time of operation.
He reported other cases in which death followed anesthesia in diabetic patients. He was
led to believe, therefore, that diabetic patients were liable, owing to some change in the
process of metabolism, to pass into a condition of coma and death.

io8 coma: diabetic, uremic; collapse; sudden death

quality, and a comatose condition may develop. After a varying
number of hours or days of semiconsciousness the patient dies. Not
only is this to be feared in persons with Bright's disease, but it is espe-
cially to be guarded against in elderly prostatics who have been carried
along for an extended period on catheterization. In these cases one
is apt to find a small, thickened, corrugated bladder, markedly dilated
ureters, dilated renal pelvis, all containing more or less pus, and a
notably decreased secreting substance in the kidney. These cases
after operation may react poorly, their urinary secretion may dimin-
ish steadily, and the patient sink from coma to death.

Rufus HalP considers that patients with fatty hearts are liable to have
suppression of urine after sections. In one of his cases, in which this condi-
tion was diagnosed, he performed hysterectomy. In the first nineteen hours
after the op>eration she secreted 24 ounces of urine, heavily loaded with
albumin. During the next seventy-four hours there was almost complete
suppression. Coma became marked, but it was promptly relieved by steam
baths and catharsis. At the end of seventy-four hours she was catheter-
ized, and li ounces of urine obtained. From this onward she improved.

Hall also operated on a patient, aged sixty-three, and performed ab-
dominal hysterectomy for cancer of the uterus. Her arteries were athero-
matous. Before the operation there was a diminished quantity of urine,
but no albumin nor casts. Chloroform was administered. During the
first twelve hours she secreted 5 ounces of urine, heavily loaded with albu-
min. The urine gradually decreased in quantity, until at the end of fifty
hours there was scarcely any secreted. She remained in a condition border-
ing on coma for two days. She then commenced to secrete from 6 to 9
ounces of urine in twenty-four hours. This improvement lasted for more
than a week; then there was a sudden suppression and she was profoundly
comatose for ten or twelve hours. At the end of the third week following
the operation she had suppression for the third time. It lasted two days.
She recovered, and the albumin entirely disappeared.

Uremia may be the result of anuria caused by some surgical acci-
dent. A ureter may be cut or tied off accidentally, and cases are on
record where both ureters have been accidentally divided during hys-
terectomy. Then, again, a nephrectomy may be performed without
first ascertaining if the patient has another functionating kidney.
In case the only secreting kidney is removed, the condition develops
rapidly and death may occur within twenty-four hours. The tem-
perature falls to subnormal, there may be profuse perspiration, but

' Am. Jour. Obst., 1898, ii, 679. Quoted by ^IcKay, Section Cases, 1905, 486.

HEAT-STROKE DURING OPERATION ICQ

the skin soon becomes dry. There are vomiting and contracted pupils.
There have been cases, however, that have lived for a week or ten
days before coma ended in death. In all cases where there is suspicion
of anuria being caused by ureteral obstruction the abdomen should be
reopened and an attempt made to remedy the condition. The general
treatment of these cases consists in sweating the patient profusely by
means of hot air and a tent, by hot packs, the use of salt solution sub-
cutaneously, or by rectum, or under the breast, and the administration
of digitalis and potassium acetate; pilocarpin may also be used, as well
as dry cupping, but pilocarpin should only be used in strong patients,
gr. I every four hours, three to six doses. Patients with nephritis
should always be anesthetized with care, using a minimum amount
of ether.

For postoperative nephritis, see Chapter XVIII, p. 198.

Sometimes a comatose condition after an operation will represent
simple collapse on the part of the patient. In this case the coma is
not attended by the symptoms which we should expect to find in dia-
betes and uremia. In cases where doubt as to the etiology of the con-
dition exists, the urine should be obtained through a catheter and
examined for albumin and sugar. The pulse is somewhat rapid and
weak, but the temperature is about normal and the color is fair.
Ordinarily, collapse and shock are carelessly classed together. Col-
lapse may occur, however, in nervous patients particularly, on com-
paratively slight provocation. Under usual circumstances the milder
methods of treatment suggested in the last chapter will be of avail
in restoring the patient.

HEAT-STROKE DURING OPERATION

Three times in twelve years we have seen patients on the operating-
table, or immediately after, show signs and symptoms of sunstroke
or heat-stroke. The most important line of treatment, naturally
enough, is preventive. At any time when the operating-room has a
temperature over 90 T., a large ice-cap should be held by the etherizer
on the patient's occipital region. If, however, the condition appears,
with its very high temperature, rapid pulse, and delirium in sunstroke,
or with its subnormal temperature, high pulse, and excessive sweating
in heat-stroke, the appropriate treatment in the way of cold or warm
packs and stimulation is given.

We append here a case of this sort observed by Dr. David D. Scan-
nell:

no coma: diabetic, uremic; collapse; sudden death

*^ A boy twenty- three years of age had suffered three days from unrecog-
nized appendix abscess, temperature 103° F., pulse 120. At the time of his
sickness the heat and humidity were high. During the third day, indeed,
the climatic temperature averaged 100° to 101° F. and the humidity was
far in excess of normal. He left a seaside resort at 8 a. m. with a body tem-
perature of 103.5° F- ^^^ climatic temf>erature of 100° F. He was con-
veyed five miles by steamer and in the city was carried over the hot streets
to the hospital for immediate operation. The local conditions were merely
those of a gangrenous appendix and a large abscess (i pint of pus). The
patient's condition on leaving the table was good except for sharply flushed
areas on the cheeks. The temperature of the operating-room was 100° F.
and the humidity was intense. I was exhausted at the end of the opera-
tion.

'^One hour after operation the patient's temperature had gone up to
107° F., and his pulse to 180. The physical examination showed him to be
still under the influence of ether and markedly irrational. I could not de-
termine whether this mental state was due to ether or to the heat. The
skin all over was intensely dry and reddened; the eyes were glistening, more
so than with an ordinary ether recovery. The cheeks glowed and the
tongue and lips were dry. The heart action was rapid and weak, but there
was nothing about the abdomen to give surgical worry. The urine drawn
by catheter was of very high color and small in amount (i ounce).

** Under cold packs, electric fans, manual fanning, and the commoner
cardiac stimulants the temperature gradually came down in less than
twenty-four hours to 100° F., the greatest drop being in the first three hours.
Subsequent convalescence was normal.'*

SUDDEN DEATH

It sometimes happens in the practice of the most experienced sur-
geon that a patient who is under ether, or who is apparently progress-
ing favorably in convalescence, without complications, suddenly dies.
Death may occur within a matter of minutes, no premonitory signs
having appeared. Usually the diagnosis is made after death, and then,
in default of an autopsy, with some degree of uncertainty. To the
friends, explanation is usually difficult.

The causes which may lead to sudden death are considered under
their respective headings. There remains a residuum of cases where
the diagnosis cannot be satisfactorily made, even after an autopsy.
The term status lymphaticus has been used loosely to cover some of
this class. In their causation certain elements are involved, of which
we have as yet no well-defined knowledge. The recent article on the
subject by John Babst Blake^ is worth quoting at length:

* Ann. Surg., 1908, 1, 43.

SUDDEN DEATH III

*'It is obvious (therefore) that emotion, exercise, and exertion are
very frequently the exciting cause of sudden death, and a moment's
consideration reveals the fact that these are precisely the conditions
preceding and accompanying the average surgical operation. The
apprehension and fright are very obvious, while the effect of the anes-
thetic upon pulse, respiration, skin, and kidneys is precisely that of
moderate exercise; furthermore, the effects of long-continued and very
serious surgical interference are again analogous to very severe exer-
tion. We have, therefore, in the routine of modern surgery, repro-
duced with considerable accuracy the conditions under which a major-
ity of sudden deaths occur. Is it not a fair inference that many of the
all-too-frequent deaths said to be due to anesthesia are simply co-
incidental, and would have occurred with equal certainty under any
other procedure which reproduced these precise conditions?

*' Sudden deaths before, during, or immediately following operation
are too common, and undoubtedly many occur that are not reported.
The writer has been informed of 6 in the past year in which, with
perhaps one exception, neither the anesthetic nor the operation seemed
a sufficient cause. It is notorious to those who concern themselves
with anesthesia that ether and chloroform are frequently blamed for
catastrophies for which they are not wholly, or at times even in part,
responsible.

**The more we know of the real nature of these deaths the better
shall we be able to avoid them. Certain facts stand forth. We can-
not yet predict with any certainty the individuals who are doomed to
sudden death, nor the time of its occurrence, but we do know many of
the pathologic conditions which predispose to it and the circum-
stances under which it most frequently occurs, In endeavoring to
guard against it we must remember:

" (i) The comparative frequency of status lymphaticus. At least 8
cases have come to medicolegal autopsy as the result of sudden death
in Boston within the past year, and in the experience of only two
medical examiners. Another has been withheld from operation by the
skilful diagnosis of a physician; another died shortly after a simple
circumcision. It is believed that the diagnosis can often be made in
advance by attention to the possible presence of a thymus, bowing of
the femurs, a thick, short neck, and, in men, pubic hair of the female
type. Of the 8 cases upon which autopsy was done, 6 died almost
instantly and 2 some hours after a slight injury was received.

" (2) The invariable necessity for a more thorough and complete

112 coma: diabetic, uremic; collapse; sudden death

physical examination and personal history before operation even of a
minor character.

*' (3) The importance of diminishing to a minimum pre-anesthetic
fright, apprehension, and intense emotion for the sakf of the patient's
safety as well as comfort.

** (4) The very great importance of complete histories and autopsies
in every case of sudden death, an end which can be best attained by
securing the active cooperation of medical examiners and coroners'
physicians.

** (5) The necessity of the careful report of every case of operative
sudden death, even if no autopsy is obtained, by the surgeon in charge
of the case. It does not seem essential that such reports should be
originally presented to the world at large, but they might well be made
to a small committee of this Society, and by them examined and ana-
lyzed and the essential fact brought to the attention of the medical
public.'^

Yandell Henderson, in a recent paper,^ has, by his work in experi-
mental physiology, done much toward interpreting the causes of sud-
den death under anesthetics. The majority of all deaths during anes-
thesia, he says, fall into one or the other of two general classes: those
of primary respiratory failure and those in which cardiac standstill
is the critical feature. Most surgeons blame the first on the anes-
thetic and the second on the patient, to whom they impute one or
another of three defects — ^hypersusceptibility to anesthetics, heart
disease, or status lymphaticus.

Henderson explains that the normal stimulus to the respiratory
center is the carbon dioxid in the blood. In normal life the sensitive-
ness of the respiratory center varies extremely little, and the automatic
rate and depth of breathing maintain the carbon dioxid content of
the blood extraordinarily constant. Anesthetics, however, alter the
sensitiveness of the respiratory center to an extraordinary degree.
Ether-excitement, light and especially intermittent administration
of the anesthetic, as well as fear, pain, and intense emotion, which may
accompany the induction of anesthesia, increase this sensitiveness
greatly, and accordingly cause rapid respirations, overventilation of
the lungs, and a resulting diminution in the carbon dioxid content
of the blood (which he calls acapnia). Full anesthesia restores the
normal sensitiveness, while deep anesthesia renders the center less
sensitive than normal.

' Heart Failure in Normal Subjects Under Ether, Surg., G>ti., and Obstet., 191 1, xiii,
161.

SUDDEN DEATH II3

Overventilation of the lungs, by withdrawing the normal stimulus
to the respiratory center (carbon dioxid), is soon followed by a quies-
cence of this center. In this state breathing will stop when the res-
piratory center, becoming less sensitive as the anesthesia becomes
deeper, no longer responds to the amount of carbon dioxid at that
moment in the blood. The heart in these cases continues to beat for
a time with undiminished force, and if artificial respiration is admin-
istered soon enough, spontaneous breathing can usually be restored
and death prevented. So much for the respiratory t>pe of fatality.

The cardiac type of death is just as readily explicable, Henderson
says, on the basis of modern physiolog>\ The condition of increased
sensitiveness of the respiratory center and the resulting overventila-
tion of the lungs induce deleterious effects upon the heart, so that a
patient will become hypersusceptible to the anesthetic; that is, a dose
of chloroform or anesthol which would be borne with impunity under
normal conditions is liable to cause sudden cardiac failure in acapnia.
Ether is far less toxic, but even it will cause death from primary* cardiac
failure in the case of hypersusceptibility induced by acapnia. Cases of
this sort occur in the hands of inexpert anesthetists who are afraid to
keep their patient sufficiently well under the anesthetic, and particu-
larly during light and intermittent anesthesias, such as for operations
on the tonsils and adenoids. Fatalities of this class occur rarely in
evenly conducted and profound or prolonged anesthesia. When death
does occur, it is not the happenings of the preceding five or ten minutes,
but the treatment the patient received a half-hour or an hour before,
which kills him.

CHAPTER IX

THROMBOPHLEBITIS; PULMONARY EMBOLISM; PYLE-
PHLEBITIS; SUBDIAPHRAGMATIC ABSCESS

THROMBOPHLEBITIS

Thrombophlebitis of the veins of the pelvis and extremities occurs
from time to time after confinements and celiotomies. It is especially
common after operations upon the uterus and adnexa and in oper-
ations about the rectum. Although thrombophlebitis in itself is a
troublesome and not particularly serious complication, its occurrence
must always be viewed with anxiety on account of the potentiality
that exists in every thrombus to become an embolus. It commonly
attacks the veins of the calf and thigh, and more usually the left than
the right, and in cases of this sort, if the patient lies quietly in bed, the
prognosis is good. After operations about the uterus, thrombosis is
set up in the veins of the broad ligament. If the process extends along
the uterine veins to the iliac or femoral vessels, or along the ovarian
vein to the vena cava, the prognosis is serious, on account of the great
facility with which clots may gain entrance to the vena cava and so be
carried to the pulmonary vessels. Cases are reported following ap-
pendectomy,^ as well as operations upon the female pelvic organs^
and after deUvery.^ Thrombosis of the lateral sinus may occur fol-
lowing operations on the mastoid,^ and in the orbit after attempts
to sterilize the lacrimal sac.^

Klein^ reports that he has met 70 cases of postoperative thrombosis
in 5851 gynecologic operations performed in ten years. Over one-
half of these followed ceHotomies, and one-third followed myomecto-
mies. In 20 per cent, of the cases fatty degeneration of the myocar-
dium was found. Schweninger^ states that 22 cases of femoral throm-
bophlebitis occurred in 13 15 cases operated upon in four years at the

^ Sartoli, Gaz. deg. Osp., 1909, 121.

2 Bland-Sutton, Lancet, iqoq, i, 147.

^ Hofmeier, Cent. f. Gyn., 1909, xxxiii, 21.

•• Wood, Lancet, Oct. 22, 10 10.

^ Lamm, Hygiea, 1910, Ixxi, No. 12.

^ Archiv. fur Gynak., 191 1, xciv, No. i.

^ Monats. f. Geburtshiilfe u. Gynak., 191 o, xxxii, No. i.

114

THROMBOPHLEBITIS 1 1 5

Munich Hospital for Women's Diseases. It may be fairly stated,
therefore, that the condition occurs in from i to 2 per cent, of all
gynecologic operations.

Thrombosis occurs usually between the tenth and twentieth day.
It is most apt to occur in cachectic or anemic subjects, those who have
suffered from profuse and prolonged menorrhagia due to the presence
of a submucous fibroid, the cancerous or tuberculous, those with
infectious processes or heart disease, the corpulent and flabby, and
those who have been subjected to prolonged operation. Klein^
states that thrombosis may be expected in one-third of all cases of
myoma of the uterus, especially those removed by celiotomy.

Its etiology has been open to differences of opinion, but the recent
experimental researches of Kelling^ have gone far toward clearing the
matter up. It is generally the result of infection, and it represents a
defensive action on the part of the organism. Sometimes in a clot
which forms in the ordinary course of the obliteration of a vessel
behind a ligature low-grade infections will start up, and the clot will
disintegrate, and particles may be carried in the circulation to other
points and there set up thrombosis anew, or in cases of stitch-abscesses
infection may spread directly to the femoral and iliac vessels along
branches of the superficial and deep epigastric veins. The phlebitis
is usually secondary to the septic thrombus, which communicates
infection to the wall of the vein in which it lies. Other factors in the
causation are stasis and changes in the composition of the blood.

Large varicosities on the lower extremities afford a predisposing
cause for thrombophlebitis. In a number of cases autopsy showed
that an embolus in the pulmonary artery came from a fresh coagulum
in a varicose vein of the leg.^

Embolism, a result of thrombosis, rarely comes on until the third
week after the operation, and is not to be expected after six weeks have
elapsed. This period represents the time during which the clot is
brittle and likely to disintegrate. Separation of a portion of a clot
is apt to be preceded by some unusual effort, such as getting out of bed
for the first time after operation or straining during defecation.

Symptoms. — The blood-clots that ordinarily organize in the ves-
sels of the broad ligament after pelvic operations offer no symptoms
to attract attention so long as they remain sterile. If, however, a

' Op. cit.

^ Studieniiber Thrombo-Embolie, insbesondere nach Operationen, Arch. f. klin. Chir.,
1910, xci. No. 4.

A. Frankel, Archiv. f. klin. Chir., 1908, Ixxxvi, 531.

Il6 THROMBOPHLEBITIS — SUBDIAPHRAGMATIC ABSCESS

clot becomes infected, diagnosis will usually make itself evident on
vaginal examination by the presence of tenderness and swelling on the
affected side. In addition to this spot of tenderness in the iliac region
the leg on the same side may be swollen and painful. The Mahler
pulse, that is, a high, rather irregular pulse with a normal temperature,
is sometimes observed, as a premonitory or initiatory symptom. Usu-
ally the pain will start in the calf of the leg, the pulse rise to 1 20, and the
temperature to 101° to 102° F., and theremay be a mild initiatory chill.
The whole limb may become so swollen and excessively painful that the
patient will not allow it to be moved. The infected vessels will stand
out like cords on palpation, and their course will be marked by a red
line upon the skin over them. The phlebitis may occur on the side
upon which the operation was performed, on the opposite side, or upon
both sides. The acute symptoms gradually subside, and it will be
three weeks or a month before the patient will be able to set foot to the
ground. She usually carries for many months after recovery evidences
of the condition, in the shape of edema or varicose veins of the leg and
ankle.

Infrequently, thrombosis may occur in the mesenteric vein after
operation,* causing symptoms of intestinal obstruction. It may occur
in the hypogastric vein, causing swelling of the nates and sometimes
of the genitals, or in the azygos vein, causing edema of the back.'
RosenthaF reports a case in which thrombophlebitis following an
operation for appendix abscess caused priapism, which was relieved
by puncture of the right corpus cavernosum.

Prophylaxis against thrombophlebitis should alw^ays be an im-
portant consideration in the after-treatment, particularly in cases
involving the female pelvis. In flabby persons of low cardiac and mus-
cular tone, the operation should be preceded when practicable by a
systematic attempt to prepare the organism for the ordeal it is to
undergo. A fortnight of well-regulated regimen, diet, exercise, mas-
sage, and hydrotherapy, carefully supervised by the physician, will go
a great ways to lower the incidence of phlebitis. Patients with
poorly compensated vascular disease or myocardial insufficiency are
better off for a preliminary course of treatment tending to restore the
competency of the heart.

During operation much may be done to avoid thrombosis. When
superficial veins are prominent, as in cases of ascites or abdominal

' Mann, Jour. .\m. Alcd. .Assoc, iqio, Iv, 1922.

- Kclling, £)/>. cil.

^ Berlin, klin. Woch., iqio, xlvii, No. 4.

THROMBOPHLEBITIS II 7

tumors, the incision should be planned so as to avoid them. Injury
of the veins, by rough manipulation or sponging of the cut tissues,
should be avoided. If large veins have to be divided, they should be
snapped first, on either side as far away from the center of the opera-
tion as possible, cut, and each portion tied behind the hemostat.
In this way long dead spaces in the veins, favorable foci for coagulum
to form, are avoided, and the vein is less exposed to injury during
manipulations.

With the patient in bed, frequent change of position should be
encouraged. The dorsal decubitus continued for long intervals is
harmful, in so far as it allows stasis in the pelvic veins. The patient
should be turned to one side or the other, and even on her stomach,
at intervals of an hour or two. When pelvic thrombosis is anticipated,
it is advisable to raise the foot of the bed; this helps to prevent the
stagnation of blood in the pelvis, and stimulates the vital centers in
the medulla. Massage and systematic movements of the legs help
to keep up the circulatory tone and to prevent thrombosis in the
legs. The massage should be carried out three or four times daily,
and should be accompanied by bending exercises of the ankle, knee, or
hip. The pulmonary circulation may be assisted by breathing exer-
cises; the patient should be taught to breathe deep, and once an hour
she should be instructed to take ten or twelve long breaths. The
intestinal functions should be started early.

Some virtue is supposed to reside in the copious drinking of water.
The quantity of body fluids should not be allowed to run low, and
deficiency should be supplied either by drinking, subcutaneous in-
fusion, or rectal installation of salt solution. The latter method has
the advantage of promoting circulation in the pelvic veins.

Much milk should not be allowed patients just operated upon,
because the calcium which milk contains promotes coagulation. If,
however, sodium citrate is added to the milk in the proportion of 2
gr. to the ounce, this disadvantage will be overcome. The following
prescription may be employed, and one teaspoonful added to the ounce
of milk:

rj. Sodium citrate gr. xlviij;

Oil of peppermint npij;

Distilled water 5 iv. — M.

Patients should be gotten up and out of bed early, but gradually.
The activity of walking is the best preventive of stasis. In clinics
where this practice is a routine, the proportion of cases of thrombo-

Il8 THROMBOPHLEBITIS— SUBDIAPHRAGMATIC ABSCESS

phlebitis after operations on the pelvic organs has fallen decidedly.
Cases of embolism occur, but probably less often than where early
rising is not followed. Standing still, erect, is worse than lying down,
and should be avoided.

Treatment. — Absolute rest in bed for at least five weeks must be
enjoined. The patient must be moved as little as possible, and getting
in and out of bed should be absolutely forbidden. This is on account
of the grave danger of the detachment of a portion of the clot. For the
same reason, an active purge should never be given, but enemas em-
ployed instead when called for. Over the region of the pain hot appli-
cations should be made. The foot and leg should be wrapped in a
thick layer of absorbent cotton, the foot should be elevated upon a soft
pillow, and movements of the foot and leg should be prohibited by
means of sand-bags placed on either side. Belladonna ointment may
give relief. Morphin will sometimes be necessary. Pressure from
the bed-clothes should be relieved by means of a cradle placed over
the leg. Massage of the limb in every sense should be strictly avoided.
Operation has been performed for the removal of a thrombus.^

PULMONARY EMBOLISM

Pulmonary embolism following operation is usually consecutive
to thrombosis in the deep epigastric or pelvic veins and in the veins of
the lower extremities or in the mesenteric veins. Injury to the vessel
or changes in the blood sufficient to cause clotting at any particular
point may be followed by a dislodgment of the entire clot or of a small
portion, which may be broken off and carried away in the blood-stream.
When this happens, it is carried by the blood-current until it reaches
a vessel which is too small for it to pass through. As postoperative
thrombosis is practically always venous in origin, the stopping-place
of the embolus is usually in the lung. If the emboli are of sufficient size
or number to block the more important branches of the pulmonary
arteries or the artery itself, immediate death will ensue. If the clot
is broken up in its passage through the right heart, so that the block
is just incomplete, death will be preceded by a more or less prolonged
respiratory struggle. If the emboli are smaller, strong heart action
may suffice to overcome the effect and the patient survive. When
minute emboli lodge in the smaller branches of the pulmonary arteries,
infarction of the lung occurs.

It is estimated that embolism occurs in about 20 per cent, of all
cases of postoperative thrombosis. It comes on, as a rule, anywhere

* Lecenc, Archiv. des Maladies du Coeur, March, 1909.

PULMONARY EMBOLISM IIQ

from four to ten days after the operation, but it may be postponed
until two or more weeks. The fatality is variously stated at about 50
per cent.^ Le Normant^ found that embolism occurred after i of i
per cent, of all celiotomies, and Ranzi, in i\ of i per cent. Almost
invariably it has been known to follow some slight unusual exertion
on the part of the patient. This may be as small a thing as a move-
ment to accommodate himself in bed, perhaps during a change of
dressing, or it may be due to getting out of bed for the first time, sit-
ting up in bed, and particularly straining during defecation. Death
may occur within a few minutes of the beginning of symptoms, or
two days may elapse before the fatal termination.^ In the cases of
longer duration it is evident that the embolus gradually increased in
size, by accretion of clot, or that there occurred a series of emboli.
As a rule, there is an interval of three to six hours from the onset of
symptoms to the fatal termination. Diagnosis is made during life in
only a small proportion of cases. That fatalities are not uncommon
are shown by the report of Fraenkel,^ which stated that during 1906
in the Vienna General Hospital 18 deaths occurred from postoperative
embolism of the pulmonary artery.

It is said to be more likely to follow operations in persons who are
debilitated; nevertheless, it is known to happen in persons who are
robust, and the patient may be apparently perfectly well and have en-
tirely recovered from the operation. Young individuals are more or
less exempt, and, if affected, may perhaps recover, presumably on ac-
count of the yielding elasticity of their vessels, which may allow the
blood to push its way beside a clot.^

The onset is always sudden. The patient finds it difficult to breathe,
soon becomes cyanotic, raises some bloody sputum, and cries out from
a sense of suffocation. His face takes on an anxious look, his lips are
livid, he becomes restless and complains of pain, he gradually becomes
pallid, the pulse weakens and becomes intermittent, and the respira-
tion becomes gasping and distressed. Unconsciousness develops and
death ensues.

Recovery depends upon the size and situation of the embolus
and the integrity of the heart and lungs. If only one branch of the

* Mauclaire, Archiv. Gen. de Chir., June 25, 1908.

2 Postoperative Embolism in the Lung, Archiv. Gen. de Chir., igog, 221.
' Ranzi, Postoperative Lung Complications of the Nature of Embolism, Archiv. f.
klin. Chir., 1908, Ixxxvii, 350.

* Postoperative Thrombosis-embolism, Archiv. f. klin. Chir., 1908, Ixxxvi, 531.

^ C. L. Gibson. Pulmonary Embolism following Operation, Med. Record, 1909,
Ixxv, 45.

I20 THROMBOPHLEBITIS — SUBDIAPHRAGMATIC ABSCESS

artery is occluded, a strong cardiac action may tide over the individual.
If the embolus is so situated that the collateral circulation through the
pulmonary capillaries is sufficient, the patient will recover. The area
of lung tissue which is cut ofT from the circulation then becomes an
infarct.

Prophylaxis is a matter of importance in this condition. It is a
good rule never to operate in the presence of varicose veins of the
lower leg without first ligating or removing them. Operations should
not be performed where phlebitis or anemia is known to exist. If the
pulse is small or irregular, digitalis should be given for a few days
before operation. *^ Varicose veins in the vicinity of abdominal tumors,
such as are not infrequently seen in the female pelvis in connection
with myomata of the uterus, should be extirpated with the growth or
Hgated as far as possible toward the pelvic wall to avoid the likelihood
of thrombosis. '^^ In operating, the veins should be handled carefully,
and, especially, injury to the vessels in the epigastrium should be
avoided, as well as friction on the femoral vein and manipulation of the
spermatic cord. After confinements, operations about the rectum,
and operations on the uterus and adnexa, particularly where the pos-
sibility of sepsis exists, and in other cases where predisposition to
thrombosis might exist, all the precautions detailed under the pro-
phylaxis of thrombophlebitis should be carried out.

Treatment. — In cases of large embolus and sudden and com-
plete blocking of one of the main branches of the pulmonary artery,
death may occur before the surgeon has time to arrive upon the scene.
If the patient survives the first shock of the occlusion, or if the occlu-
sion is incomplete, the opportunity for treatment should not be neg-
lected. Stimulation should be supplied by means of hypodermic in-
jections of quick-acting and freely diffusible agents, such as camphor,
ether, and ammonium carbonate. A mixture such as the following,

Camphor i ;

Ether 3;

Olive oil 6,

is excellent for use in emergencies. Oxygen and artificial respiration
are indicated where the patient is laboring for breath. So long as the
heart's action is strong, hope for recovery should be maintained.

The body should be kept warm by means of water-bottles and the
room should be kept absolutely quiet. Complete repose should be en-

* Bartlett and Thompson, Occluding Puknonary Embolism, Ann. Surg., 1908, xlvii,
717

PULMONARY EMBOLISM 121

joined. If the patient is restless, morphin should be administered in
small doses until she rests comfortably. If she lives for hours, there is
a possibility of collateral circulation about the block asserting itself,
and everything should be done to assist in maintaining the circulatory
equilibrium. The patient should be allowed plenty of fluids, but no
milk, calcium salts, or carbonate of magnesia.^ If the patient pro-
gresses favorably, the area of lung which has been shut off from the
general circulation will organize and become a hemorrhagic infarct,
which, after a few days, will reveal itself to physical examination of
the chest as an area of consolidation. The infarct in itself may prove
fatal, or secondary pneumonia develop as a result.

Operative Treatment. — Recently, under the leadership of
Trendelenburg,- the possibility of relieving cases of pulmonary em-
bolism by the bold procedure of cutting down upon the pulmonary
artery and removing the embolus has been urged, and the operation
actually performed with sufficient success as to promise some ad-
vantage in suitable cases.^

The advisability of operative interference depends upon the rapid-
ity of the course and the accuracy of the diagnosis. As to diagnosis,
the characteristic picture has already been described. In addition,
there may be minor indications, such as a previous operation in which
the larger veins were exposed or ligated, the presence of an evident
thrombosis of the femoral or other veins, fracture of one of the lower
extremities, or varicosities.

As to rapidity, death does not always result as suddenly as is gener-
ally supposed. Of 9 cases, Trendelenburg found that only 2 died sud-
denly in from one to two minutes. In the other 7, ten minutes to one
hour elapsed before death occurred.

He operates by making a transverse incision on the left side over
the second rib, and a vertical incision on the left side of the sternum.
Three or four inches of the second rib, in addition to the adjacent
sternum, is resected. A vertical incision is made through the pleura
and into the pericardium at the level of the third rib. The vessels lie
a little underneath the sternum ; they are pulled forward and a rubber
tube is passed behind the aorta and the pulmonary artery and after-
ward drawn up tight. Work must then be proceeded upon with the
utmost celerity. He incises the pulmonary artery, pulls out the em-

^ Bid well, Pulmonary Embolus and Thrombosis after Laparotomies, Practitioner,
Feb., 1909.

- Central, f. Chir., 1908, No. 35, Beilage.
' See Ann. of Surg., 1908, xlviii, 772.

122 THROMBOPHLEBITIS— SUBDIAPHRAGMATIC ABSCESS

bolus with a pair of forceps, and immediately closes the incision in
the arterial wall with clamps, using no more than forty-five seconds.
He then releases the compress and sutures the skin at leisure. He has
operated three times — the first man died on the table; the second
recovered, but died fifteen hours later from heart failure; the third sur-
vived the operation for thirty-seven hours, and then died from post-
operative hemorrhage from the internal mammary artery.

The embolus is generally located in the main trunk of the artery
or in one of its chief branches, so that, anatomically, there is no great
difficulty in finding and removing it. The chief obstacle so far has been
the failure to recognize the condition in time. Sievers, following the
Trendelenburg technique,^ removed an embolus in a pulseless patient,
who survived the operation fifteen hours. Trendelenburg reported
another case in a man of forty-five years,^ and Murphy^ successfully
removed an embolus from the common iliac artery.^

HEART-CLOT

In a few rare cases autopsy has shown that sudden death after
operation has been caused by the lodgment of a large clot in the heart
itself. It is said that if the clot is small, it may cause no symptoms, or
nothing more than transitory murmurs as the clot encroaches upon one
or another of the valves of the heart. In some cases which recovered
the diagnosis was made on the presence of a murmur, feeble and tumult-
uous action of the heart, and attacks of dyspnea. Such a symptom-
complex may be followed in a few days by evidences of pulmonary
embolism, which can be interpreted to mean that the clot, freeing itself
from the heart, has been carried into the pulmonary artery, where it
has lodged as an embolus, or that there has been an extension of clot
formation into the pulmonary artery and subsequent embolism.

' Fall von Embolic der Lungenarterie nach der Method von Trendelenburg operiert,
Deut. Zeit. f. Chir., 1908, 93.

- Operationen der Embolic der Lungenarterie, Deut, med. Woch., 1908, xxxiv, 1172.

^ Jour. Am. Med. Assoc., 1909, 52, 1661.

* Busch (Ueber plotzliche Todesfalle mit besonderer Beriicksichtigung der ludikations-
stellung fiir die Trendelenbergsche Operation bei Lungenembolie, Deut. med. Woch.,
vol. XXXV, July 22, 1909) states that of 878 fatalities in 9727 patients in Korte's surgical
service in Berlin during the last four years, 22 of the deaths occurred suddenly, and the
symptoms indicated pulmonary embolism. Of these 22 cases, in 12 death was instanta-
neous. Autopsy in 7 showed embolism in 4. One showed a thrombus which could readily
have been removed by the Trendelenburg operation. In 10 cases the symptoms per-
sisted ten minutes to three hours before death. Autopsy revealed embolism in 6, and con-
ditions would have been favorable for operative intervention in 5. In 4 other cases the
assumed embolism did not exist, death having been due to fatty degeneration of the
heart.

FAT EMBOLISM 1 23

In cases which end fatally, differentiation between heart-clot and
pulmonary embolism cannot be made certain without autopsy. In
the following case, which was diagnosed clinically as heart-clot, we
regret that autopsy was not permitted:

Male, forty-eight years old. Operation two years before for acute ap-
pendicitis; right rectus incision, splitting fibers. Third day a subsequent
sepsis in wound; a complete disorganization of the ligatures and sutures, and
gradual development of ventral hernia at site of operation. Present opera-
tion for repair of hernia. Sac excised; found to contain most of omentum,
transverse colon, and many coils of small gut. Omentum tied off in mass
with interlocked sutures and intestines freed with difficulty from sac. Ad-
hesions ligated, peritoneum closed, and fibers of rectus muscle brought to-
gether with mattress sutures. Rectus sheath closed in the same way. Good
ether recovery, there being almost no vomiting. Subsequent convales-
cence up to the tenth day uneventful ; normal temperature and pulse through-
out; gas pains singularly absent, there being no necessity for enemas more
than once or twice. On the tenth day climax of good subjective feeling;
temperature and pulse normal, appetite good, and patient looking forward
to sitting up; subcutaneous stitch had been removed two days previously.
On the afternoon of the tenth day patient was awakened out of his sleep by
intense precordial pain. The pulse could at that time be felt, but was weak,
occasionally fluttering, with the rate at about 100; respirations were 40;
patient was gray, as with the fear of death, but there was no cyanosis. A
hot-water bag was put over the heart and hypodermic stimulants of various
kinds given. He failed to rally, the distress remaining constant about the
heart. There was no dilatation of that organ apparent; no cyanosis ap-
peared even to the end. He died in about forty minutes from the first
onset of symptoms.

FAT EMBOLISM

Fat embolism occurs chiefly after fractures, operations on bones,
and occasionally after bums.^ The condition is the result of small fat
particles entering a wounded vessel and, finally, lodging in the vessels
of the brain. The symptoms are those of cerebral embolism, usually
beginning with a convulsion, and ending in paralysis of greater or less
extent.

The treatment consists in absolute quiet, ice to the head, and mor-
phin. A. Schanz^ has recommended the intravenous or, in more
subacute cases, the subcutaneous use of salt infusions with a view to
washing the particles away from their site of lodgment. He has
had 8 cases successfully treated by this method.

1 G. Pacmotti, Gaz. degli Ospedali e. delle Cliniche, 1910, xxxi, 857.

2 Centr. f. Chir., 1911, xxxvii, 43.

124 THROMBOPHLEBITIS — SUBDIAPHRAGMATIC ABSCESS

AIR EMBOLISM

Sudden death may follow the introduction of air through a wound
in the jugular vein in the course of operation upon the neck, or the
introduction of air into the uterine sinuses after parturition. Death
is usually instantaneous, the air reaching the heart and interfering
with its contraction.

L. V. Lesser,^ working on animals, has found that after experiment-
ally produced air embolism he can resuscitate the animal by inject-
ing salt solution directly into the right ventricle. This is certainly
worth attempting in such desperate cases.

PYLEPHLEBITIS

Ascending septic infection of the portal veins after appendicitis is
by no means rare. Gerster- reports that it was found nine times in
1 187 cases of apf>endicitis operated upon at the Mt. Sinai Hospital.
Munro^ reported a series of 9 cases.

The condition appears to originate in the thrombosis which natur-
ally occurs in the appendicular veins after their obliteration. There is
a direct line of communication open between these veins and the portal
system through the superior mesenteric vein. The case need not be
clinically a septic one, for the complication occurs after clean interval
operations as well as operations performed during the acute stage and
those complicated by abscess formation. Occasionally it occurs
when no focus of infection can be found to account for the condition.

The pathology has been studied by Thompson^ in a series of 8 cases.
Septic, partly disintegrated thrombi are found at autopsy to extend
from the veins draining the appendix region to the portal vein, and
this is either filled with pus or occluded by thrombus. Small bits of
septic clot, becoming dislodged from the mass in the portal vein, are
carried up into the liver until they are arrested in the finer branches,
and there they are found to set up multiple abscesses in the liver sub-
stance, usually by preference on the anterior superior surface of the
right lobe.

The condition is not always readily or correctly diagnosticated,
partly because of its rapid course. Occasionally a case will run for
three or four weeks.^ It is most likely to be confused with a secondary

' Centr. f. Chir., 1910, xxxvii, 313.

- New York Med. Record, 1903, June 27.

' Boston Med. and Surg. Jour., 1902, 81.

*• Boston City Hospital Med. and Surg. Reports, 13th series.

* Moschcowitz, Ann. Surg., 1911, liii, 549-

SUBDIAPHRAGMATIC ABSCESS 1 25

peritonitis. It should always suggest itself whenever a patient,
shortly after an appendectomy, develops chills, a high white count,
and an irregular temperature, fluctuating from normal to 105° or 106°
F. Other signs to be looked for are tenderness along the outer border
of the right rectus muscle, painful enlargement of the spleen and liver,
with, in most cases, jaundice and rapid and profound prostration.

The prognosis is poor because of the frequency of the occurrence of
liver abscesses. A single abscess may be drained and the patient
recover, but in the face of multiple abscesses, which is the rule, opera-
tion offers little hope for relief. Nevertheless, exploratory operation
should always be performed and abscesses evacuated and drained,
as in subdiaphragmatic abscess.

SUBDIAPHRAGMATIC ABSCESS

Subdiaphragmatic abscess may occur after operations, particularly
about the stomach and appendix.^ After stomach operations it may
represent a local peritonitis following a leak in a posterior gastro-
enterostomy; it may be the result of the extension of infection along the
subperitoneal lymphatics from the appendix or of abscess of the liver
following pylephlebitis. Any suppurative inflammation originating in
or about any viscus in the upper half of the abdomen will tend to gravi-
tate free pus, provided the patient is flat on his back, to the capacious
hollows under and about the liver. It may result accordingly from
suppurative cholecystitis, perinephritis, perforation of the diaphragm
in empyema, or it may represent the last focus of a general peritonitis.

Generally speaking, abscesses following appendicitis and liver ab-
scess occur on the right side of the suspensory ligament of the liver, those
originating in the stomach, on the left. Pleurisy with effusion, either
serous or purulent, occurs as a complication in over half of the cases.
Gas in varying quantity, the result of bacterial decomposition, is
present in about half of the cases; indeed, the cavity may contain
but little else. When gas and pus are both present in sufficient quan-
tity, shifting dulness may be demonstrated as the patient turns.

The symptoms are usually slow in developing, and are apt to be
readily confused with those of pleurisy with effusion and empyema.
The temperature is irregularly elevated, and there is often cough and
shallow respiration. There is localized pain and tenderness and there
may be chills. As the collection of pus increases the symptoms become

' See A. Lawrence Mason. Subphrenic Abscess, Boston Med. and Surg. Jour.. 1803,
cxxix, p. 217, for history. See also Catz and Kendirdjy, Les .\bces Sous-phrcniques,
Rev. de Gynec. et de Chir. Abdom., 1908, xii, 469.

126 THROMBOPHLEBITIS — SUBDIAPHRAGMATIC ABSCESS

aggravated. The lower edge of the liver is pushed down perceptibly
and the intercostal spaces are likely to bulge. Some cases show local
edema. The diflSculty in diagnosis, where the history of the case does
not give any assistance, is complicated by the presence of the pleural
effusion, which nearly always accompanies a subdiaphragmatic abscess.
The aspirating needle is always of service in locating the pus-cavity; to
reach the perihepatic space the needle must pierce the chest-wall and
then pierce the diaphragm. If the diaphragm is not paralyzed by the
inflammation or pressure, the needle which has pierced it will move up
and down with respiration. Pus from below the diaphragm flows on
inspiration; pus above the diaphragm is expelled by expiration. If
nothing but air or gas escapes, the probability is that it issues from below
the diaphragm.

The prognosis is serious. With operation it is far better than
without, although in rare cases the abscess resolves, or it discharges
externally, into a bronchus, or through one of the hollow viscera. Un-
operated cases sometimes drag on for weeks and months. The mor-
tality of subdiaphragmatic abscess from all causes is generally stated
at about 50 per cent. Two-thirds of the cases that recover get well
with operation and one-third without.

The treatment consists in incision and drainage; aspiration is to
be considered as a diagnostic method only. It is often wise to have the
operation follow immediately upon the aspiration if this be positive.
If there is bulging at any point, the incision is made over this area, other-
wise it is preferable to go in through the bottom of the pleural cavity or
just below the reflexion of the parietal pleura. About two inches of the
ninth and tenth ribs are resected in the posterior axillary line. The
pleura may be pushed up and the diaphragm incised below it, or the
pleural cavity may be incised and the surfaces of the pleura sewn together
above. If need be, an empyema and a subdiaphragmatic abscess may
be drained through the same wound. Drainage should be ample and
rubber tubing is usually more eflScient than gauze.

CHAPTER X

ARTinCIAL RESPIRATION; OXYGEN; ELECTRiaTY

During the first half of the last century mechanical apparatus for
maintaining artificial respiration had a popular vogue. Some de-
pended on intralaryngeal tubes; some, on tracheotomy cannulae, made
of metal, rubber, or leather. Some had a simple bellows, others had
compound bellows for alternately injecting and aspirating the air,
which, in some of the apparatus, was warmed. They were to be found
as part of the regular equipment of many hospitals, jails, fire and life-
saving stations in England and on the Continent, and they were used
without hesitancy in cases of asphyxiation from smoke or gas, in
drowning, and drug poisoning. But the method fell into disrepute as
a result of mishaps which depended upon rough use and too forcible
pressure, so that when postural methods were introduced they were
immediately accepted. These have enjoyed undisputed sway since,
and it is only during the past few years that interest has again been
aroused in mechanical appliances.

Artificial respiration has its chief place in surgery in relation to
anesthesia. It must be resorted to whenever respiration fails while
the patient is under the influence of the anesthetic, and again whenever
asphyxia threatens a patient recovering from anesthesia. In the former
case the patient has to be dealt with on the table. If the anesthetic is
ether, removing the cone and exerting rhythmic pressure on the ster-
num two or three times will usually suffice to start up respiration. If
chloroform is being used the outlook is more serious, as with this agent,
in contradistinction to ether, the cardiac action may cease simultane-
ously with, or closely following, the cessation of respiration. In either
case, where the respiratory failure is due to direct action of the agent,
and not to mechanical causes, the value of artificial respiration will
depend upon whether the heart has been so far weakened as to be un-
able to carry on the circulation. Practically, then, if the heart is beat-
ing rhythmically and a pulse can be felt, if the anesthetic is removed
and artificial respiration be immediately instituted, it should invariably
be successful. If, however, a highly concentrated vapor has been in-
haled and the heart has been weakened thereby, and has ceased to
beat or is feebly fluttering, the prognosis is not good.

127

128 AKTIFICIAL RESPIRATION; OXYGEN; ELECTRICITY

In rt-covcry from the anesthetic tht; proposition is somewhat differ-
ent. Here the failure in respiration arises from some mechanical inter-
ference. Fatal accidents have resulted from such foreign objects as
[)lates of false teeth, plugs of gum, or tobacco falling into the air-pass-
ages. The common causes of postanesthetic asphyxia are the aspira-
tion into the larynx of vomited matter or accumulated blood or saliva
in the mouth and the closing off of the larynx by the tongue, in a state
of relaxation, falling back into the throat. The treatment of this form
resembles that for asphyxia by drowning.

We shall consider two forms of postural artificial respiration: the
supine and the prone. 'Ihe supine is ordinarily better when asphyxia

occurs on the operating-table: the prone is of advantage in cases where
asphyxia is due to obstruction.

The supine method- named for Sylvester (1858)^ — attempts to
imitate natural inspiration by increasing the capacity of the chest.
This is effected by drawing the arms upward toward the head {Fig, 38).
Expiration occurs as the arms are gradually lowered (Fig, 39) again to
the sides, and is completed by exerting pressure on the thorax (Fig. 40 1,
This maneuver requires three persons— one stanndig on either side
to manipulate an arm and one forcilby to hold forward the tongue by
means of tongue forceps and to swab out the mouth if necessary.
The two operators should work slowly and in unison and the rhythm
should be that of normal respiration.

ARTIFICIAL RESPIRATION

129

In cases of emergency arising after the anesthetic, especially where
the attendant is alone and cannot get help, there are many advantages
in the " prone pressure method " recently described by Schaefer.' In
this method the patient is laid belly down upon the floor, face to

one side, and arms at right angles to the body. The operator kneels
at his side and places his hantis over the lowest ribs of the patient, one
on either side. Then, swinging slowly forward and backward, by

allowing his weight to fall rhythmically on and off his wrists, he can
compress not only the thorax, but also the abdomen against the ground,
thus forcing the air from the lungs. As the pressure is relaxed the

' Jiiiir. .\ni. Mod. Assoc-., mo,S. i;. Soi.

13°

. respiration; oxygen; electricity

elasticitj' of the parts causes them to resume their natural shape and air
is drawn in through the glottis. The pressure is exerted gradually
and slowly over a space of some three seconds. It is then removed for
two seconds and again applied, and so on, at the rate of about twelve
times per minute. This method does not tire the operator; it requires
only one man; the tongue falls naturally forward and does not need to
Ix" held; mucus, vomitus, or blood drain readily from the mouth.'

Rough artificial respiration may be the finishing touch. The first
should always be expiratory, not inspiratory. Rapid and violent
eiTorts may lead to dilatation of the heart.

Laborde- introduced the method of reflex stimulation of respiration
by means of rhytltmic traction on the tongue. The tip of the tongue is

seized in tongue- forceps, and it is pulled out its entire length rhyth-
mically, at the rate of about eighteen times a minute. Sufficient force
should be exerted to lift the glottis clear away from the trachea: the
novice will be surprised at the extent of the tongue which appears
when the procedure is properly performed. This method should
always be carried on with the supine form of artificial respiration
when some one may be spared to perform it. The extension of the
tongue should be synchronous with inspiration; otherwise, before ar-
tificial respiration is commenced, a free airway should be insured by
some means of holding forward the tongue, such as tying a silk thread
through its tip and about the patient's ear.

s Mcthcxls of .\rlilkiat Kcspira-

' Sec also A. Keith, Mechanism UnderiyinE the Va
1, Lancet, iqog, i.
' Les Tractions Rhythmics dc la Lanci

8»s-

ARTIFICIAL RESPIRATION 13I

The subject of artificial respiration by means of mechanical ap-
paratus has been greatly enlightened by the recent work of Sauerbruch,
Brauer, Willy Meyer, Robinson, Meltzer, and others, with negative
and positive pressure as applied to thoracic surgery. The adaptation
of positive pressure to artificial respiration requires only a source of
air, such as a single bellows or pump, to which oxygen can be added if
desired, a means of supplying this to the airways of the patient, which
may be an intratracheal tube, an intubation tube, a tracheotomy tube,
a face-mask, or a cabinet in which the head may be enclosed, and a
valve for shutting off the air current at rhythmical intervals, to allow
the lungs to collapse. The best-known American apparatus is that of
Fell, which he introduced in 1887, ^^^ to which he accords the credit
of saving 28 lives. The elaborate cabinet of Janeway and Green,
operated by electricity, has the added advantages of being absolutely
automatic, the frequency of respiration and the ratio of the duration
of inspiration to expiration can be varied at will. No instrumentation
of the larynx or trachea is required. The latest principle is that of
intratracheal insufflation, evolved by Meltzer and Auer, which relies
on introducing the stream of air directly into the lungs through a tube
passed along the trachea to the bifurcation. A simple apparatus of
this sort has been described by Ehrenfried.^

Oxygen may be used simultaneously with artificial respiration,
either by introducing it mixed with the air in mechanical respiration,
or through a catheter passed into the patient's nose, or by means of a
funnel hung inverted over his face. Kuhn^ advises passing the oxygen
directly into the trachea through an O'Dwyer tube or a laryngotomy.
Schmidt and David^ warn against using too concentrated a stream of
oxygen, on account of its injurious action on the bronchial and alveolar
epithelium.

The use of electricity has been widely advocated. The faradic cur-
rent acts beneficially by stimulating respiration. The current should
not be strong, as cardiac action may be inhibited. The diaphragm may

^ See Matas, History and Methods of Intralaryngeal Insufflation, Southern Surg,
and Gyn. Trans., 1899, xii, 52.

Fell, Artificial Respiration, Surg., Gyn., and Obstet., 1910, x, 572.

Green and Janeway, Artificial Respiration and Intrathoracic Esophageal Surgery,
Ann. Surg., 1910, lii, 58.

Ehrenfried, Intrathoracic Insufflation Anesthesia, Apparatus, and Cases, Boston Med.
and Surg. Jour., 191 1, Ixiv, 532; Transactions Mass. Med. Soc., 191 1.

2 Resuscitation in Apparent Death by Means of Oxygen and Intubation, Therap.
Monats., Nov., 1908, xxii.

^ Munch, med. Woch., 191 1, Iviii, No. i.

132 ARTiFiaAL respiration; oxygen; electricity

be excited to contraction by stimulation of the phrenic nerve. One
pole should be placed over the pit of the stomach, the other at the angle
of the jaw, near the anterior border of the sternomastoid.'

^ See E. A. Spitzka, Resuscitation of Persons Shocked by Electricity, Jour. Med.
Soc. of New Jersey, 1909, v. 549. Crile (Surgical Anemia and Resuscitation, Am. Jour.
Med. Sciences, 1909, cxxxvii, 469) describes the following technique for resuscitation after
the heart stops beating from chloroform: The patient in the supine posture is subjected
at once to rhythmic pressure on the chest, with one hand on each side of the sternum.
This pressure produces artificial respiration and a moderate arterial circulation. A
cannula is inserted toward the heart into an artery. Normal saline. Ringer's or Locke's
solution (see page 50), or, In their absence, sterile water, is infused by means of a funnel
and rubber tubing. As soon as the flow has been begun, the rubber tubing near the
cannula is pierrcd with a needle of a hypodermic syringe loaded with i: 1000 adrenalin
chlorid, and from 15 to 30 min. is at once injected. The injection is rapid, in a minute if
needed. Synchronously Nvith the injection of the adrenalin, the rhythmic pressure on the
thorax is brought to a maximum. The resulting arterial circulation distributes the adrenalin
and spreads its stimulating contact with the artery, bringing a wave of powerful contrac-
tions and producing a rising arterial pressure. When the coronary pressure rises to 40 mm.,
the heart is likely to spring into action. As soon as the heart-beat is established, the cannula
should be withdrawn. Bandaging the extremities and abdomen tightly over large masses
of cotton is very useful.

CHAPTER XI

DIET AFTER OPERATION

Ether, rather more than chloroform, is apt to occasion nausea and
vomiting during the period in which the patient is recovering conscious-
ness and after. The degree to which this occurs seems to depend on the
duration of anesthesia, the amount of anesthetic given, the evenness
of its administration, the length of time consumed in going under, and
the amount of food in the patient's stomach. The vomiting may,
however, be considerable in cases where no reason can be assigned and
in susceptible persons. Usually there will be no desire and no necessity
for food until the effects of the anesthetic have passed off, and then if
a tendency to nausea persists, the diet should be a fluid one, consisting
of an ounce or two of milk, buttermilk, beef-tea, cocoa, tea, or coffee,
according to the patient's desire, and so long as the gastric irritation
remains.

If the operation has been a severe one, or if the patient is suffering
from hemorrhage or shock, it may be of importance for him to receive
fluid or nourishment immediately, and in this case it may be given by
rectum or subcutaneously, even before he has fully recovered from the
anesthetic.

In abdominal sections it may be wise to give the gastro-intestinal
tract complete rest by abstaining from all food by mouth for twenty-
four hours, and in operations on the stomach the patient may be sus-
tained by rectal enemata for ^vo or three days. The danger in these
cases from the occurrence of vomiting, or of stasis fermentation and
flatulence, is far greater than that of inanition from abstinence from food.
In general it may be laid down as a good rule that if there is any opera-
tive lesion of any portion of the ah'mentary tract, that portion should
be given as complete rest as possible for a reasonable length of time.
After mouth-feeding has been started articles of diet should be selected
which do not call for digestive action by the particular portion of the
gastro-intestinal canal which has been involved in the operation.

In selecting the diet stress should be laid upon one other point,
namely, not to include any food-stuff which in the process of digestion
is likely to give rise to fermentation or formation of gas and so cause
flatulence and distention. Certain staple articles of food, such as milk,

133

134 DIET AFTER OPERATION

are extremely likely, under the conditions of intestinal stasis which
exist after a celiotomy, to be improperly digested by the stomach, and
give rise to fermentation, and as curd it may pass a long way down
the intestines and cause flatulence. Peptonized milk has not these
drawbacks, but patients rarely hke it; flavored with cocoa it may be
relished. Sir A. E. Wright^ observes that the time-honored milk diet
in acute diseases and after operation is a direct stimulation to the onset
of thrombosis, owing to the large amount of calcium present in such a
diet increasing the coagulability of the blood. Thus, milk, even when
peptonized, is not to be considered a proper food for mouth-feeding
after abdominal operations.

An excellent substitute for milk — unirritating, easily digested
without gas formation — is albumin- water, made by beating up the
whites of three eggs in a pint of water. It may be flavored with
lemon and sugar, and 2 pints may be taken to represent a fair amount
of nourishment for twenty-four hours.

Another form of fluid nourishment which can often be made use
of to great advantage is the homely drink, *^ raisin tea.*' This is
made by pouring a glass of boiling water upon a half-cup of chopped
raisins, stewing gently for an hour, and straining. The filtrate may be
given full strength or diluted with water or albumin- water, hot or cold,
as the patient desires. It is highly nutritious, representing a high pro-
portion of grape-sugar, the most readily assimilable form of carbo-
hydrate. To the patient it is palatable and refreshing.

Beef- tea, as ordinarily made, and so often added to the invalid's
diet, must be considered only as a stimulant. Beef-juice, extracted
from fresh, juicy beef-steak by means of a meat-press or lemon-
squeezer, is nutritious, although it contains hardly more albumin
than milk. It may be served shghtly warmed, with a pinch of salt.
Hericourt^ extols the virtues of raw meat and raw meat juice in
wasting diseases of whatever nature, in convalescence and after
hemorrhage. The proprietary beef-extracts are hardly worth con-
sidering. All types of patent foods should be shunned, in spite of
their exaggerated representations, as of relatively Uttle value com-
pared with natural foods, properly selected. Where acetonemia is
anticipated, it should be forestalled by a diet rich in carbohydrates,
such articles of food as baked potato, cornstarch pudding, gruels, and
mush.

Ordinarily, one regulates with some care the quantity of food

* Folia Therapeutica, Jan., 1909.

* Lancet, Jan. 7, 191 1.

DIET AFTER OPERATION 135

consumed, and gives little heed to the food value of the separate
items, except in so far as they are commonly accepted as simple, easily
digestible, and nutritious. With patients in bed and on a liquid diet
a knowledge of food units is of particular importance. One patient
may be starved and another overfed, without intention, unless the
available calorimetric value of the various elements of their diet is
understood.

Franklin W. White^ has recently published a suggestive table:

I glass of milk equals 160 calories.

I glass of i milk and \ (4 tablespoonfuls) 20 per cent, cream equals
240 calories.

An egg-nog (i glass milk, i egg, 2 teaspoonfuls sugar) equals
approximately 300 calories.

A plate of cream soup equals 160 calories.

A glass of skimmed milk or buttermilk equals 80 calories.

An equal amount of gruel equals 75 calories.

A glass of albumin-water (white of i egg) equals 20 calories.

A cup of beef-tea or clear soup equals 5 to 20 calories.

''Let us take/' he says, ''a 150-pound patient in bed who needs,
approximately, 1800 calories a day, and who receives ten feedings
of a glass (8 ounces) of liquids a day. Some combinations of liquids
allowing for agreeable variety will abundantly nourish him; other
combinations mean partial starvation. For instance:

"Two glasses each of milk (320), gruel (150), thickened soup
(320), egg-nog (600), milk and cream mixture (480); total, 1870
calories.

''Two glasses each of milk (320), buttermilk (160), gruel (150),
albumin-water (40), beef-tea (20); total, 690 calories.

"It is easy to increase the food value of a liquid food. Take
a glass of milk (160 calories) ; each addition of a tablespoonful of cream
(20 per cent.) gives 30 more calories, each addition of a teaspoonful of
sugar (preferably milk-sugar) gives 33 more calories, the addition of
an egg gives 70 more calories.

"The great value of soft solids is easily seen. One tablespoonful
(^ ounce) of milk equals 10 calories; a heaping tablespoonful of cooked
cereal equals 35 calories; of custard, 55 calories; of ice-cream, 135
calories.'^

Recently, in part as the result of the investigations of Metchnikoff,
buttermilk has come into some favor in the postoperative dietary.
This is a wholesome, cooling, and diuretic drink, and is often fancied

^ Boston Med. and Surg. Jour., 191 1, clxv, 545.

136 DIET AFTER OPERATION

by patients to whom whole milk is obnoxious. Its food value is about
that of skimmed milk, and it consists, besides water, chiefly of al-
bumin, finely coagulated casein, and sugar, which has been converted
largely into lactic acid. It is, as a rule, readily digested, even in
cases where the proteids and fats are not well borne, and there is said
to be less gas formation and residue than with milk. It should be
drunk fresh and cold, perhaps diluted with siphon soda. Buttermilk
made by inoculating milk with strains of bacteria represented in the
various forms of tablets now on the market has no advantage in this
connection over fresh buttermilk obtained from a clean dairy. ^

The stimulation value of sipping should be remembered. Sir
Lauder Brunton^ says:

"More people in this country shorten their lives by overeating than by
starvation, and an unnecessary excess of animal food not only leads to
physical disorders, but to an irritable and irascible frame of mind. In-
stead of trying to remo\'e the depression between eleven and four by
taking a glass of wine or spirits, a much better plan is to sip a glass of
water or soda-water and eat a biscuit. If a greater stimulus than this is
needed, a glass of hot eau sucree with a lemon squeezed into it may be
taken. It is not a matter of indifference whether the water be drunk
down at a draught or sipped, for the act of sipping has a very extra-
ordinary effect upon the circulation, as my friend. Professor Kronecker,
has shown ; during the act of swallowing the power of the restraining nerves
upon the heart seems to disappear, and if any one will count their pulse
before they take a sip of water and while they are taking it, they will find
that while they are swallowing the pulse becomes nearly twice as quick
as before. It has long been known that while sucking ale through a

' "If the purest milk obtainable is used, the putrefactive bacteria which are always
present in the milk — even of the best grade — will not develop because the normal lactic
acid bacteria antagonize them. It is clear that if the same dairyman who, by observing
cleanliness in his establishment, furnishes a good quality of sweet milk, will observe the
same care in handling cream for making butter, his buttermilk also will be wholesome
and clean. More criticism of a similar nature could be made in regard to the use of com-
mercial preparations for fermenting milk. Where clean, certified milk can be obtained,
the use of these various preparations seems imnecessary. Inasmuch as it is not always
feasible to obtain certified raw milk, however, boiled or pasteurized milk is to be preferred.
It is here that the artificial 'starter* is of value. After the first inoculation, the same
product can be obtained by inoculating pasteurized or boiled milk with a small amount
of the first lot inoculated, with proper precautions of cleanliness. Once started, this
process may be continued for a long time without having to renew the 'starter.'" (Jour.
Am. Med. Assoc., editorial article, Jan. 30, iqoq. Hi, 397, quoting the results of Heinemann;
Lactic Acid as an Agent to Reduce Intestinal Fermentation, Jour. Am. Med. Assoc, 1909,
Hi, 372.)

-On Disorders of Assimilation, Digestion, etc., London, 1901, 108.

DIET AFTER OPERATION 137

Straw a person becomes drunk much more quickly than when the
same quantity is taken at a single draught, and it is probable that
this alteration in the circulation by the process of suction has had
much to do with this curious result/'

The healing of all surgical injuries is promoted by an abundant
nourishing diet. When it can be taken, therefore, such a one of ready
digestibility should be selected. Care should be taken, however, with
a patient in bed to supervise the evacuations, or otherwise the channels
for the removal of waste may be clogged and the object in view defeated.
With this caution in mind there is no harm, as a rule, in allowing a
patient suffering from some minor surgical disorder, or kept in bed
during the healing of a wound or fracture, or after a slight operation, in
the absence of fever or sepsis, to satisfy his appetite on the animal and
vegetable diet to which he is accustomed. If, in a prolonged con-
valescence, the appetite flags, it will be of advantage to vary the diet,
or it may become necessary to prescribe beer, sherry, or brandy and
soda, to be taken with meals.

If, on the other hand, the patient has been severely injuredy or has
passed through a considerable operation and is suffering from shock or
loss of blood, or is in pain, food is less desirable than rest and stimula-
tion. In such a case overfeeding is attended by positive harm. Coffee,
milk, and broths may be offered, but it is unwise to urge food upon
the patient where there is nausea or indifference. It is better to utilize
the rectum, when necessary, for feeding and even for medication, until
the stomach recovers its tone.

In surgical inflammatory conditions^ such as sepsis, the patient's
strength should be supported, as in any fever, by a sufficient amount
of readily assimilable food. In severe cases the patient should be made
to take milk, or milk with one-half the quantity of hot water, or milk
diluted by one-third with siphon soda, in quantities of 4 to 6 ounces.
At an occasional feeding beef-juice or strong chicken or mutton broth
may be substituted. If the pulse becomes feeble, stimulants, such as
whisky or brandy, should be given. If the patient has any appetite,
semisolids, such as gruels, custard, beef jelly, or a raw egg beaten in
sherry, are to be recommended. As improvement occurs, rice, cream-
toast, scrambled egg, macaroni, bread and butter, tenderloin steak,
or breast of chicken may gradually be added. Water should be pro-
vided in abundance, and acidulated drinks, sour lemonade, and car-
bonated waters are useful, but on an empty stomach only. In chronic
purulent conditions fresh fruits and green vegetables are serviceable,
both for their antiscorbutic and their laxative effects. Thus lemonade,

138 DIET AFTER OPERATION

oranges, baked apples, and stewed prunes are recommended. Fats
are also especially needed, and, when the patient is able to digest
them, should be liberally provided in the form of cream, butter, olive
oil, or cod-liver oil.

A work of this sort cannot go thoroughly into the matter of food —
its preparation and administration — without opening the great subject
of cookery and being led afield into the details of the nursing profes-
sion.

We believe it to be unwarrantable during convalescence for the
doctor to undertake to prescribe with minute exactitude, irrespective
of the patient's tastes, the kind and amount of food. Every patient
who is to any degree reasonable knows what he likes, and knows what
seems to digest without trouble in his particular case. Each indi-
vidual is, in a sense, a specialist on his own digestion. He has infor-
mation on the matter such as no other person can have. It seems
reasonable, also,- even more perhaps in sickness than in health, to
give heed to appetite and desire, since it is probable that acquired or
conventional tastes disappear under these conditions and rightful
instincts are more likely to be exhibited. It is better, therefore, in
late surgical convalescence certainly to let the patient suggest the
way in the matter of food and drink, always modified and limited by
the pathology in the particular case.

The Serving of Food. — There are many obvious and trite con-
siderations which should be here set down. While the patient should,
in a general way, be consulted as to what he wants, nevertheless the
particular item which is to come at a given meal may well be served
without immediate announcement — come, in a measure, as a surprise.

In judging the appetite of a patient it must be remembered that the
apparent lack of desire for food may be due to poor cooking, serving
meals unattractively or at inopportune moments, as well as to the
selection of articles of diet not to the patient's taste. It is the func-
tion of the nurse to study the Hkes and dislikes of her charge, and to
yield to them so far as her instructions will allow. If her orders are
vague or insufl&cient to cover any condition which may arise, she
should make it a point to have them made clear at the next visit of the
physician. The doctor, though he should on his part be explicit in his
directions as to the sort and quantity of food to be given immediately
after an operation, should provide also that, on the one hand, the
patient shall not starve for want of food which is agreeable to him, or,
on the other hand, suffer from overindulgence in a diet which has been
left to the nurse's discretion.

DIET AFTER OPERATION 1 39

Meals should be served at regularly appointed intervals, for a pa-
tient who was eager to eat at the time appointed may lose interest if the
meal is delayed. Food is better when concentrated; a patient easily
tires of swallowing dilute victuals. If the appetite flags, the appear-
ance of some new or unexpected article of food on the tray is very
pleasing.

Food should be served either hot or cold; lukewarm food is un-
palatable. The cooking and preparation of food should be done where
the noise and odor cannot reach the patient. The tray should be neat
and inviting, the china attractive, the linen clean, and the food fresh,
for a person confined in bed becomes fastidious of details which might
appear trivial to others. The quantity of food offered should not be
in excess of the Hmit of his capacity; a patient may take half from a
cupful of broth and reject the rest with disgust, where if he were offered
a cup half-full he would drain it with gusto. The tray and the rem-
nants of the meal should be removed at once after the patient has
finished.

A person who has become accustomed to alcohol from excessive
indulgence is very apt to develop delirium tremens (see Chapter XXX,
p. 310) in the course of a few days after receiving a severe injury or
undergoing an operation, even though he has indulged in no stimula-
tion for some weeks previously. In cases where it is suspected that
the condition is about to develop, it may be wise to forestall it by allow-
ing a certain quantity of alcoholic stimulant. Some surgeons prefer
to treat cases not acute by entirely withholding alcohol, but in cases
of emergency alcohol should always be used.

Special diets are prescribed where indicated under Special Opera-
tions in Part II. In the Appendix are given a number of food recipes
for convalescents.

CHAPTER XII

RECTAL FEEDING

The use of the absorptive powers of the mucous membrane of
the rectum and lower bowel in the nourishment of the weak and sick
comes down to us from the days of Galen. It is comparatively re-
cently, however, that the experimental investigations of Voit, Leube,
Ewald, and others have established rectal feeding on a scientific basis.
In rectal alimentation we now have a practical method: first, of sup-
plementary feeding, in cases where the stomach is unable to digest enough
food to maintain the equilibriiun of waste and repair; second, of sus-
taining life independently of all other means of nourishment for a short
time.

Rectal feeding may be indicated: (i) In conditions of great
weakness, where but litde food can be taken by mouth, or where food is
not retained. In patients exhausted by a serious abdominal operation
rectal feeding is a temporary expedient of great value. In prolonged
reflex vomiting after an anesthetic, nutrient enemas may be our sole reli-
ance. (2) In conditions of obstruction to the entrance of food into the
stomach, such as paralysis of the muscles controlling deglutition, stric-
ture of the esophagus, foreign bodies, new-growths, or inflammatory
conditions of the mouth, pharynx, or esophagus, irritability of the
alimentary canal from ulceration or corrosion. (3) In diseases of the
stomach, such as gastric ulcer, gastric carcinoma with obstruction.
(4) In conditions of shock, coma, or delirium. (5) In the after-treatment
of operations on the stomach, gall-bladder, or small intestine, where
peristaltic activity might interfere with repair. (6) After plastic opera-
tions on the face, where mastication might tear out stitches.

The technique of administering a nutrient enema is as fol-
low^s: If the patient can be moved about, he is brought to the edge of the
bed and placed with his knees drawn up toward his chest in an exaggerated
Sims posture, upon his left side; otherwise he is to lie flat on his back,
with knees flexed. In either case the buttocks should be elevated as
much as is comfortable upon a small hard pillow or the foot of the bed
should be elevated; in this way gravity is brought to aid in the reten-
tion of the enema. A long, soft rectal tube, about 32 French in diam-
eter, with open end and two lateral eyes, is employed ; in children an

140

THE TECHNIQUE OF ADMINISTERING A NUTRIENT ENEMA I41

ordinary soft-rubber catheter may be used. The tube should be so
soft that it will not damage the rectal mucosa, and yet it should be
stiff enough so as not to be likely to kink or double upon itself inside
the ampulla. Long soft tubes coil themselves up, press on the in-
testinal wall, and stimulate peristalsis and straining, thus preventing
the successful administration of enemas. To its end, by means of a
short piece of glass tubing which is to serve as a window, is attached
about a foot of similar rubber tubing coming from a glass or hard-
rubber funnel.

The tube should be lubricated sparingly with olive oil or vaselin;
glycerin should not be used, as it excites peristalsis. The funnel is
partly filled with the enema, and after this has run down the tube to
expel the air, the tube is pinched and introduced through the anus. Air
in the tube is likely to be driven into the intestines, where it will set up
peristaltic movements and lead to the expulsion of the enema. If the
tube is passed slowly and gently, it may readily be carried in 6 or 8
inches.^ The higher up the fluid goes, the more extensive is the ab-
sorbing surface that it comes in contact with, and the less is the likeli-
hood of its being rejected. (See also Chapter XV, p. 165.) The
\eins of the lower rectum, also, empty into the vena cava directly and
do not drain through the liver. To prevent the tip of the tube from
engaging in the valv^es of Houston, causing the tube to kink, the intro-
duction should be slow and deliberate, the tube meanwhile being rolled
or twisted slightly from side to side between the fingers.

The enema should be poured into the funnel slowly, and the funnel
should be held at such a level (not over 2 feet) above the level of the
outlet that it takes about ten minutes for the entire quantity to pass in.
As the tube is withdrawn, a gauze pad is held up against the anus to
prevent the enema from gushing out. The patient should lie quietly
in bed for an hour or so after the injection and should be told to try to
retain the enema. If it appears likely that the fluid will leak out, a pad
should be held firmly pressed against the anus for fifteen or twenty

^ Soper (The Colon-tube and High Knema, Jour. Amcr. Med. Assoc, 1909, liii, 426)
concludes that only in rare cases of abnormal development of the sigmcid is it possible to
introduce a soft-rubber tube higher than 6 or 7 inches in the rectum without it bending or
coiling upon itself. With the aid of the sigmoidoscope the middle of the sigmoid can be
reached, but nothing further. He substantiates this by .r-ray photographs. The short tube,
6 inches in length, is therefore best for all sorts of enemas: (i) When water, etc., is intro-
duced for the purpose of causing fecal evacuations; (3) when retention of fluid is desired,
as in administering saHne solution, oil, nutrient material, etc. The attempt to pass the tul^e
higher into the bowels is not only unnecessary, but because of the coiling that inevitably
occurs such a manipulation tends to produce irritability of the bowel. This, of course, vsill
very probably cause expulsion of the fluid.

142 RECTAL FEEDING

minutes or longer. A patient is likely to reject enemas at first, but can
soon be trained to retain them effectually.

In feeding by rectum it is important that the condition of the rectum
be carefully watched, especially if it is likely that the administration of
the enemas will have to be kept up for more than a few days. Patients
have been maintained on rectal feeding exclusively for six months (Leube)
and ten months (Riegel), but four to six weeks may be accepted as the
ordinary limit, and, indeed, in most cases two or three weeks is likely to
produce irritation and mucous diarrhea, which will interfere seriously with
absorption. For this reason all sources of irritation should be avoided.
The bowel should be cleaned of mucus and fecal matter by a daily
cleansing enema, best given in the morm'ng, some time before the first
nutrient of the day. For this purpose i or 2 pints of saline solution
or of soapsuds and water may be used at about 95° F. If the rectum
is inflamed, i pint of boracic acid solution (i dram to i pint of water)
may be used once or t^vice a day or before each feeding; if there is
much mucus, sodium bicarbonate may be used in the same dilution.
The nutrient should not be given until all the wash-water has come
away, otherwise the enema may be immediately ejected.

Opium, about 10 minims of the tincture, is frequendy added to the
nutrients as a routine measure to prevent peristalsis and thus favor the
retention of the enema. If enemas are rejected at first, from nervous
irritability of the rectum, it may be wise to use opium until the bowel is
accustomed to the procedure, when it becomes unnecessary. Opium
may, however, interfere somewhat with absorption, and for this reason,
especially if the use of enemas will have to be continued for some days,
its use should be postponed, if possible, until it becomes necessary on
account of the irritated condition of the mucous membrane. In this
case the opium acts better if administered alone or mixed with 2 ounces
of starch-water one-half hour before the enema is due. Red wine
is frequently employed on the Continent of Europe as a constituent of
nutrient enemas. The small percentage of alcohol it contains is
readily absorbed, and its astringency and slight acidity seem to favor
retention of the enema. Thus, a little claret or Burgundy will some-
times act as eflBciently as opium for this purpose.

Sometimes the presence of hemorrhoids will interfere seriously with
rectal feeding. If this complication occurs, it will be wise to use a
smaller, softer tube, well lubricated. In addition to local treatment
it may become necessary, on account of pain, to apply a 2 per cent,
solution of cocain to the hemorrhoids before each injection. The
presence of wicks or glass or rubber drains in the pelvis or vagina may

COMPOSITION OF NUTRIENT ENEMAS 143

interfere materially with the use of rectal feeding. It should also be
remembered that if any suturing has been done on the large intestine,
enemas should not be started for at least forty-eight hours, for retro-
peristalsis may carry the fluid back with sufficient force to tear out the
stitches.

Ordinarily, 6 ounces (175 cc.) of fluid is given every four hours. In
some cases it will be necessary to lessen the quantity and increase the
frequency of the enemas; 4 ounces (100 cc.) may be given every two
hours. There is a distinct advantage, however, in favorable cases in
giving a larger quantity less often. If given slowly, 8 or 10 ounces (250-
300 cc.) may be retained, and the patient will suffer less from thirst
and there will be less likelihood of inflammatory changes being set up
in the rectum. Such an enema need be given only three or four times
a day, which is of some importance in gastric cases, for it has been
shown that each injection stimulates gastric secretion.

The sensations of hunger and thirst may be annoying to a patient
who is being started on rectal feeding. They rarely persist after twenty-
four hours; the thirst may be met by additional enemas of saline solu-
tion or of plain water once or twice a day if the patient cannot take
water by mouth. All enemas, to be retained, should have a tempera-
ture of 95° F., or about body temperature. Fluids much warmer or
cooler than this are likely to set up a peristalsis, which will lead to their
ejection.

The material for the enema should be selected with a view to ab-
sorbability and absence of irritating qualities; substances which theo-
retically should be readily absorbed, like the peptones, may be so irritat-
ing that they are not retained;, other substances, which are absorbed
only in small proportion, if at all, may interfere w^ith absorption of the
other elements of the enema by causing irritation, as the starches, or
by forming a coating over the mucosa, like unemulsified fats. Many
extended metabolic experiments on human beings have been carried on
with a view to determining the relative absorbability of the various
classes of food-stuffs, and, although these show woeful lack of agree-
ment, they may be summarized as follows:

Proteids are usually supplied in the form of egg-albumen, milk,
beef-juice, and peptones. Egg-albumen and, indeed, all proteids not
predigested are better absorbed if salt is added in the proportion of 15
gr. per egg. Milk, if peptonized and not too rich in cream, is very
satisfactory, and is commonly used as a basis of nutrient enemas. Beef-
juice raw is absorbed to a certain degree, but had better be peptonized.
Leube has used meat chopped up with one-third its weight of fresh

144 RECTAL FEEDING

pancreas, on the theory that the meat is digested within the rectum
and the products absorbed. Except in his hands, however, the method
has not been found wholly satisfactory, and meat, if used, had better be
predigested before introduction by the use of fresh extract of pancreas.
A glycerin extract should not be used in any amount on account of the
aperient action of the glycerin. Commercial peptone, 2 or 3 oz. in 8 or 10
oz. of water, will often be well absorbed, especially in the presence of a
little alcohol. It has the disadvantage of being expensive and it may
set up irritation. On the whole, proteids are but poorly absorbed, the
proportion varying and depending apparently on individual peculiarity
and not on the amount injected. Roughly speaking, it may be said
that in favorable cases 35 per cent, of the amount injected is absorbed
if predigested; if not predigested, about 20 per cent.

Fats are usually given as yolks of egg, milk, cream — ^natural emulsi-
fications. Unemulsified fats are but slightly absorbed and are useless.
Olive oil may be emulsified by saponifying a small portion and shaking
all together. Fat is important, in that it seems to lessen the loss of
tissue nitrogen. Emulsified fat, in small quantities, is slowly absorbed
in direct proportion to the quantity injected — about 25 per cent.

Carbohydrates are supplied in the form of glucose (grape-sugar or
dextrose), flour, or starch. Pure glucose, in 10 to 20 per cent, solution
in water, forms a nutritious and easily absorbed element. The com-
mercial glucose should be avoided, as it may contain traces of sulphuric
acid and arsenic, either of which might give rise to irritation. About
80 per cent, is absorbed. Boiled flour or starch or raw starch is some-
times added in small quantity for its nutriti^'e \'alue and to thicken the
fluid.

Alcohol diluted may be added in small quantity to any enema, both
for its stimulant action and to promote absorption of the nutrient.
\\'hisky, brandy, or any red wine may be used, being careful not to
cause precipitation.

Salt, up to I per cent., facilitates absorption of the enema, especially
if it contains proteids; a large proportion causes irritation. To any acid
mixture such as is likely to result if peptones are used, enough sodium
bicarbonate should be added to make the reaction slighdy alkaline.

Drugs, as indicated, may be administered by rectum, by adding
them to an enema, providing they do not cause precipitation.

Proprietary preparations have been variously recommended for
purposes of rectal feeding. Among these may be mentioned liquid
peptonoids, bovinin, malted milk, nutrose, somatose, maltine, plasmon,
proton, eucasin, sanatogen, panopepton.

NUTRIENT SUPPOSITORIES 1 45

Rectal suppositories are now being supplied by manufacturers to
replace the ordinary method of feeding by injection. They are made
of predigested and evaporated milk or meat- juice and cocoa-butter.
They are convenient on account of the readiness with which they are
administered and retained, but where the patient is being fed by rectum
alone, they are not practicable on account of the small amount of
material they supply. Containing so large a proportion of fat, and
being placed so low down in the bowel, it is probable that only a small
percentage of the food-elements is absorbed. Alternate suppositories
of meat and milk may be given every two hours.

Boas^ considers nutrient enemas of little worth; various writers have
placed the limit of absorption by rectum at from 200 to 500 calories a day,
where the average adult in bed needs 1800 to 2cxx). Repeated three times a
day, in conjunction with the necessary cleansing enemas, they are trouble-
some and sometimes distressing, and the necessary handling may use up
strength which can hardly be spared. They may cause injury or inflam-
mation of the rectal wall, formation of gas, colic or tenesmus, and require
the use of narcotics. (If given by the drop method, as he advised in 1900,
they cause less pain and spasm, there is less likelihood of the occurrence of
colitis, and they are better retained.)

For three years, accordingly. Boas has substituted suppositories for
nutrient enemas. He has made up a suppository about 2^ inches long by
h inch in diameter. Its components are crystallized egg-albumen and dex-
trin, with about 2i per cent, of salt, and cocoa-butter as an excipient; 5
drops of tincture of opium are added for cases of extreme sensitiveness.
Each suppository represents 45 to 50 calories, and 5 are given per day, pre-
ceded early in the morning and followed late at night by a pint of salt solu-
tion by the drop method, to supply the necessary fluid. Apparently they
are nearly completely absorbed in three or four hours. They are usually
well tolerated, they are clean and handy, and patients are more comfortable
and better kept than with enemata. They do not, of course, represent a
sufl5cient nourishment, and they should not be given for longer than three
to five days, but, on the whole, Boas considers that they will do all that
enemas will do, and in a much better fashion.

In many patients the institution of rectal feeding is marked by
satisfaction of hunger and thirst, mental relief, and apparent mainte-
nance of general condition or even increase in weight. ^ Nevertheless,

* Ueber Nahrsuppositorien, Berliner klin. Woch., 1910, xlvii, 617.

2 It is stated (Sternberg, Munch, med. Woch., 19 10, Ivii, No. 28) that if hunger and
thirst are not satisfied, they may be subjectively abolished by the administration of smaU
doses of cocain or chloroform water by mouth.

146 RECTAL FEEDING

rectal feeding is at best a poor substitute for feeding by mouth, and in
the most favorable cases the patient is being subjected to partial star-
vation, for it is now generally agreed that the limit of absorption per
rectum is less than one-fourth the nourishment required to maintain
metabolic equilibrium in normal persons. Gain in weight, where it
occurs, is due to the rapid absorption of water to satisfy the marked
depletion of the tissues which ensues after severe hemorrhage or pro-
tracted vomiting. Some of the beneficial effects of nutrient enemas
may be assigned to the psychic influence of the procedure. Moreover,
the water content of the enema serves as a vehicle for the elimination
of the waste products resulting from the combustion of the body tissues,
which if retained would cause auto-intoxication. Where rectal feeding
is the sole source of nourishment, the composition of the enema, the
technique of its administration, and the condition of the rectum should
receive the constant and particular attention of the surgeon himself.

FORMULAS FOR NUTRIENT ENEMAS

The egg and sugar enema (Ewald) is efficient and commonly em-
ployed. Boil a teaspoonful or Uvo of starch or wheat flour in a half-
cupful of 20 per cent, solution of glucose (grape-sugar) and add a
wineglassful of claret. After this has cooled sufficiently to prevent the
coagulation of the albumin, stir in slowly two or three eggs which have
been beaten up smooth with a tablespoonful of water.

Egg and milk: 3 eggs, beaten, in

Peptonized milk 3 oz. (250 cc);

Salt 2 (T 3 pinches (2 gm.).

Sugar and milk: Grape-sugar 2 oz. (60 gm.);

Peptonized milk S oz. (250 cc).

Leube: Milk 3 oz. (250 cc);

Peptone .2 oz. (60 gm.).

Riegel: Milk 3 oz. (250 cc);

Egg 2 or 3;

Salt 2 or 3 pinches;

Red wine .1 tablespoonful

Boas: Milk 8 oz. (250 cc);

Yolk of 2 eggs
Pinch of salt

Red wine . , . . . i tablespoonful;

Starch or flour i tablespoonful.

FORMULAS FOR NUTRIENT ENEMAS 147

Boyd: Yolks of 2 eggs

Pure dextrose 1 oz- (30 g"^-);

Salt 7gr- (5 g"i-);

Peptonized milk 10 10 oz. (300 cc).

Baumgarten: Dry peptone

Sugar of milk (of each) i oz.;

Alcohol J «z-;

Tincture of opium 10 drops;

Water to make 9 ^z-

The following formula is to be recommended :

Separate the whites and yolks of 3 eggs, add the whites to 200 cc.
of milk, and peptonize it. Stir in the beaten yolks. Add 2 oz. of pure
grape-sugar dissolved in 80 cc. of water, 20 cc. of red wine, and 2
pinches of salt:

Milk, 200 cc 146 calories:

3 eggs 200 •

2 oz. of grape-sugar . . . . 246

2 pinches of salt
20 cc. red vsdne.

592 calories.

References

Thompson, Practical Dietetics, 1902.

Friedenwald and Ruhrah, Diet in Health and Disease, 1909.

Boyd, Rectal Alimentation, Trans. Med. Chir. Soc. of Edin., xxv, 1906, 126.

Moore, F. C... Rectal Feedings, Practitioner, 1907, Ixxix, 668.

CHAPTKR XIII

GAVAGE AND OTHER FORMS OF ARTIFICIAL FEEDING

Gav.\gi-; is the name given to tlie method of feeiiing
pouring iiijuids through a tube into the sioniach. It is m
iisc(i in jHJstopcrative treatment, but it may l>e indicated;

1. In infants or young children wlio persistently refuse
too weak to take nourishment in sufficient quantity.

2. As an alternative for reclal feeding in persistent v.
an anesthetic, provided there is mi slomach lesion.

|)aUent by
commonly

3. As a method of forced feeding in acute infections, coma, delirium,
insanity.

4. ^^■hc^c swallowing is interfered with, as after operations on the
head and neck, in diseases of the mouth, lockjaw, or postdiphtheritic
paralysis.

The technique and ajtparatus are the same as for gastric lavage, A
highly polishc-<] soft-nibber tube, about 30 to 32 French, should be

GAVAGE 149

selected, of medium flexibility, with a conic enil— liaving two open-
ings, one at the end and another on the side, about ij inch above. In
children an ordinary soft-rubber catheter may be used, about 21 to 25
French, according to age. It should be attached by a short i)iece of
glass tubing, which serves as a window, to a rubber tube coming from
a glass or hard-rubber funnel. As a lubricant, glycerin, olive oil, butter,
plain warm water, or ice-water may be used.

The patient should be sitting or lying in a comfortable position, the
head not tilted back or inclined to one side or the other. He should be
directed to breathe slowly and deeply. A child might better be wrapped
in a sheet and held seated on the
nurse's lap, with its head sup-
ported on her shoulder, or laid flat
on its back on a table. The tul>e
should be held some inches from
the ti]>, and with one motion it
should be passed rapi<lly o^■er the
median line of the tongue down
through the pharynx into the
esophagus. It is not necessary to
hold a finger in the mouth; as
soon as the tip strikes the pos-
terior wall of the pharynx the
patient will begin to retch and
gag, but if he will make sc\'eral
rapid swallowing movements and
can resist the impulse to seize the
lube and pull it out, all will be
well. If the tube is held too ^^^ _,^v„,

near the lip, the tip will be in suai<-n ,.n,i sirii..Ti.iKC.

contact with the pharyngeal wall

while the operator is shifting his hold, and the tube will probably be
rejected. In the unconscious or delirious, as well as in children over
two years of age, it is adx'isable to use a mouth-gag. In the uncon-
scious, also, one must be sure by the patient's respiration that the
tube is in the stomach and not the trachea before fluid is poured in.

Some nenous patients will experience respiratory embarrassment
the first time the tube is employed. This can always be controlled if
the patient will but breathe deeply and slowly while the tube is being
passed. Patients readily get accustomed to the tube. It should be
used with caution in jiersons with cardiac disease.

150 GAVAGE AND OTHER FORMS OF ARTIFICAL FEEDING

The tube is passed to the point where h'quid is found to flow in
without obstruction, usually about 22 inches to the line of the teeth
in the adult. If there is any gas on the stomach, it should be allowed
to escape by elevating the funnel before the feeding is poured in. After
the liquid, in quantity proper to the age of the patient, has passed in,
the tube is pinched tighdy and withdrawn rapidly with one sweep.
A slow withdrawal of the tube, or the tricklings of the last drops of the
fluid from the tube in its upward passage, may be sufficient to excite
reflex vomiting. If the fluid is vomited, the feeding should be repeated.

The materials ordinarily employed in feeding through a stomach-
tube are milk, eggs, meat-juices, or broths. If indication exists, the
meat broth or milk may be peptonized. A common feeding through a
stomach-tube in an adult is t\vo eggs (beaten), stirred into ij pints
of warmed milk, with a pinch of salt, administered four times daily,
or alternated with beef-juices or chicken broth, thickened with tapioca
or sago.

Care should be taken, first, that the fluid is not hot enough to bum

the stomach; and, second, that the capacity of the individual stomach is

not exceeded.

NASAL FEEDING

Nasal feeding is a substitute for gavage which is employed rarely
except in children. It is indicated in those cases where the stomach-
tube cannot be passed by mouth on account of ulcerative stomatitis,
after operations about the mouth, after tracheotomy, where great ner-
vous excitement is induced, and in children in general.

-The simplest method is that of pouring the fluid nourishment from
a spoon into the nostril. This is employed in comatose states, and it
obviates the necessity of opening the mouth. A teaspoonful should be
given at a time, making sure the dose is swallowed before it is repeated.
If the patient is lying back, the fluid will trickle down the posterior
pharyngeal wall and excite the reflex of deglutition. Any excess of
fluid will be regurgitated through the other nostril and the likelihood
of choking is slight.

It is usually better, however, to use the distal half of a small-sized
soft-rubber catheter attached to a small glass funnel. This is lubri-
cated with olive oil or vaselin, introduced gendy into one nostril, and
held in place while the fluid is poured in. Just suflBcient is poured
in at a time to allow the child to swallow. The patient should be wound
in a sheet, so that he may not struggle, and held firmly on his back. In
either of these methods there is some danger o£ setting up irritation or
inflammation of the middle ear by way of the Eustachian canal.

SUBCUTANEOUS FEEDING 151

It is safer, therefore, to pass the tube through the nose into the
esophagus and stomach. If the patient is lying flat, with his head in
the median line, there will be no difficulty in passing a soft, small-
sized stomach-tube, well lubricated, along the floor of the^nose into
the esophagus. Before pouring in the feeding it must be seen that
the patient is breathing freely and that the tube is not in the larynx.
This is the method used and advised by Dr. John H. McCoUom at the
South (Infectious Diseases) Department of the Boston City Hospital.

SUBCUTANEOUS FEEDING

The method of introducing fluid nourishment into the system by
subcutaneous injection has not yet been generally accepted, although
it has been practised since 1850. In desperate emergencies, where
conditions have been such that nourishment could not be administered
either by mouth or rectum, solutions of food substances have been
injected under the skin, directly into the veins of the arm, or into serous
cavities with some apparent success. In animals, olive oil has been
used in this way, as well as diluted milk and solutions of sugar or al-
bumin, and absorbed without ill effects.

The food material selected must be a fluid which, first, needs no
digestion, and, second, which can be sterilized by boiling. The more
closely it simulates blood in osmotic tension, the less irritation will
there be at the site of injection. Pure glucose in 5 per cent, solution in
distilled water fulfils these conditions well and may be given under the
skin freely, in case the stomach will not retain food. Olive oil has
been recommended in doses of 100 cc. injected in divided portions
into various parts of the body. It should be sterilized by heat. It
absorbs slowly and causes some pain, and the danger of fat embolus
must not be overlooked. Milk and peptone solution have also been
used in doses of 6 or 8 oz.

The injection must be made with all precautions as to asepsis. A
sterile glass syringe, such as is commonly called an antitoxin syringe,
is adaptable for the purpose. The injection should be made slowly,
and once or twice a day is sufficient. The fluid should be at blood heat.

In view of the well-known efficacy of the subcutaneous method of
supplying water to the system where the tissues have been deprived
of this constituent, in persistent vomiting, in shock from loss of blood,
in cholera, as well as in toxemias, it seems probable that the successes
reported by some of those who first used this method of feeding were
due in large part to the introduction of fluid without reference to its
food value.

152 GAVAGE AND OTHER FORMS OF ARTIFICIAL FEEDING

Berendes* recommends a 5 or 7.5 per cent, solution of grape-sugar in
0.9 per cent, salt solution, representing 200 to 300 calories to the liter.
He has used it subcutaneously or intravenously in 40 cases, without pain
or inconvenience. Slight glycosuria may appear after several days' use.
D'Amico*^ is of the opinion that subcutaneous nutrient injections are, next
to the natural route, the only rational and effective means for supplying
nourishment. The most efficient food material, in his mind, for this purpose
is fresh fertilized yolk of egg. To the yolk he adds 5 gm. of a i per cent,
iodized glycerin and 5 gm. of normal salt solution, and the mixture he injects
into the buttock. He has had favorable results with this method during
four years. Kausch,^ after considerable investigation, has determined that
grape-sugar can be given advantageously in 10 per cent, solution into a vein,
or in solutions up to 5 per cent, under the skin, in a daily dose not exceeding
1000 cc. The method is to be commended in surgical after-treatment, in-
asmuch as it supplies fluid as well as nourishment.

FEEDING IN GASTRIC FISTULA

After a gastric fistula has been established feeding may be started,
if necessary, within a few^ hours. For this purpose a glass funnel should
be attached to the drainage-tube leading to the stomach and small
amounts of liquid poured in. An egg beaten up in a glass of milk, with
a pinch of salt, may be given every two hours. The patient should be .
kept upon mush and soft solids for about a week after operation.

If the operation has been performed for non-malignant stenosis,
the digestive powers of the stomach suffer very little, and the patient
can be given solid food, such as meat chopped into bits, which may
be pushed down the tube with a glass rod. At the end of three weeks
the patient may be put on his normal diet — potatoes, meat, bread
and butter, vegetables — which he masticates, introduces into the tube
or funnel from his mouth, and pushes along into his stomach with a
rod.

In cases of carcinoma food should be given which makes the least
demand on the digestive powers of the stomach and which is rapidly
passed on. Peptonized milk may be used and solutions of peptone or
glucose. The patient, however, is usually extremely desirous of being
allowed to chew^ and taste his food, and for this purpose gruels, soft-
boiled eggs, and toast may be given.

^Zentralbl. f. Chir., 1910, xxxvii, No. 37.

2 Gaz. degli Osi>ed., 1910, xxxi, No. 132.

3 Deutsche med. Woch., 191 1, xxxvii, Xo. i.

AFTER LARYNGEAL OPERATIONS 1 53

AFTER LARYNGEAL OPERATIONS

Tracheotomy is performed for obstructions of various kinds, such
as foreign bodies — a tin whistle or a piece of meat — edema of the glottis,
new-growths, accumulation of diphtheritic membrane, Ludwig's angina.
The presence of the tracheotomy tube is well borne, as a rule, and inter-
feres in no way with deglutition after the patient has become accus-
tomed to its presence, provided it be of the right size and well adjusted.
We know, for instance, of one patient, a well-nourished negro, who has
worn a tube for complete obstruction for twelve years. At first, ap-
prehension on the part of the patient may be a factor in making the
feeding a matter of some difficulty. If the patient be propped up by
pillows to a sitting posture and liquids given by means of a glass or
china *^ feeder, '^ to the spout of which a rubber tube may be attached,
the difficulty is usually readily overcome. Until he can begin to take
semisolids, fluids should be given in small quantities at frequent inter-
vals. Should the patient resist, or should his condition be such as
to preclude any cooperation on his part, and feeding be imperative,
nasal feeding should be used without hesitation or delay.

When intubation of the larynx has been performed, usually for
diphtheria, the patient is apt to find trouble in swallowing without draw-
ing food into the trachea. It is difficult to close the epiglottis with the
tube in position, or to draw up the larynx beneath the root of the tongue
to the extent which should occur in normal deglutition, and hence fluid
food in particular is liable to trickle through the tube into the trachea,
exciting violent dyspnea and spasms of coughing. Semisolid food or
solid food, such as mush eggs, junket, cream, gelatin, rice, tapioca,
ice-cream, is more liable to glide over the instrument without being
sucked in through it during inspiration. Very young infants, who are
dependent upon a milk diet, can swallow best if laid upon the back
across the nurse's lap with the head downward, supported below her
knees. While in this position the bottle is given. Regurgitation
through the nose may occur, but that is of little moment compared with
the accident of inhaling milk through the tube into the lungs. Older
children and adults can usually learn to swallow well while wearing
the tube with a little practice in holding the head and the avoidance of
inspiration at the moment of swallowing. Otherwise, when neces-
sary, the passage of the esophageal tube may be resorted to, though
this irritates the throat and may spread the diphtheritic membrane along
the esophagus. Where the dyspnea is not extreme, the tube may be
removed while the child takes nourishment, or, indeed, it may be well
to resort to rectal alimentation for a few days to avoid the necessity of
swallowing while the tube is in situ.

CHAPTER XIV
CATHETERIZATION; CYSTITIS; CATHETER FEVER

CATHETERIZATION

Difficulty with urination is frequently the source of much dis-
comfort after operation. Sometimes the nature of the operation seems
to be the deciding factor; operations about the rectum and for hernia
are h'kely to be followed by retention. It frequently seems to be a sort
of neurosis, and as such is particularly liable to occur in nervous per-
sons, especially after celiotomy. Sometimes it is dependent, in women,
upon a low-grade cystitis, anteceding operation. Oftentimes the po-
sition of the patient in bed accounts for the difficulty in urination, as
any one who attempts for the first time to urinate while lying upon
his back can testify. Retention is likely to follow pelvic and vaginal
operations in women, and rectal and hernia operations in men. Post-
operative urinary retention is very frequently the result of swelling
and edema about the internal urinary orifice, say Jacobson and Keller.^
A 2 per cent, solution of boric acid in sterile glycerin injected through
the urethra into the bladder has been found of striking value, and it
should be used as a routine in all cases of ordinary retention before
the catheter is resorted to. When catheterization has become neces-
sary, if 5 or lo cc. of the solution are injected into the bladder, through
the catheter after it has been emptied, there will usually be no further
difficulty.

Everything which can be done to encourage the patient to urinate
spontaneously should be tried before a catheter is employed. If the
patient is conscious and intelligent, nothing should be done until he
calls attention to his desire to urinate, then, if difficulty is experienced,
simply turning the patient on his side, or allowing him to stand, sup-
ported, beside the bed, — if the nature of the operation has been such
as to make this allowable, — is likely to give relief. After the patient
has once urinated, there will be no necessity for calling the catheter
into requisition.

Ordinarily the urinary secretion is inhibited to a certain degree by
anesthesia, so that, as a rule, after celiotomy the patient may be allowed
to go sixteen to twenty hours before resorting to the catheter. When

^ Post-operative Cystitis, Jour. Am. Med. Assoc., igii, Ivii, 1980.
154

CATHETERIZATION

155

the catheter is being used as a routine, once every eight hours is fre-
quent enough. This routine, once estabhshed, should not be continued
indefinitely, but, on account of the danger of cystitis, the patient should
be made as early as possible to realize that he must take care of his
own bladder function.

If. during the operation, the bladder has been opened, or its coats
weakened in any way, or if adhesions between the bladder and other
organs have been separated, distention should be a\'oided. Accord-
ingly, the catheter should be passed six hours after operation and c\'ery
four or six hours subsequently, or else permanent drainage should be
instituted by tying in a catheter.

A good nurse will be competent to pass a catheter through the
normal urethra, male or female, and into the l)Iadder, with skill and

gentleness. Lack of dexterity and of care in the performance of this
responsible duty is shown immediately by the pain which is caused
the patient, and later, possibly, by a cystitis. A surgeon should ne\er
order a nurse to pass a catheter until he is sure that she is able to do it
without causing pain or injury to the urethra and in an aseptic manner.
In catheterizing women the female catheter of glass should lie used.
This can be readily washed clean and boiled. It should be sterilized
before using, and should be handled only by the sterile hands of the
nurse. The practice of passing a catheter under the bedclothes, by
the sense of touch, is mentioned only to be condemned. It is unintel-
ligent and dirty. The parts should be exposed and the meatus urin-

156 catheterization; cystitis; cathetek fever

arius should be sponged with weak corrosive. Then, with the lingers
of the left hiind separating the labia, the catheter can be introduced
painlessly, without fumbling, and without danger of carrying in in-
fective matter from the bedclothes, anus, or vagina. Infection, when
it occurs, is usually the result of allowing the poorly cleansed labia
minora to fall against the catheter during its passage.

For the normal male urethra, the best catheter for routine use and
in inexperienced hands is that of soft rubber. This ordinarily can read-
ily be introduced if properly lubricated, and with it it is practically im-
possible to injure the patient. It is relatively easy of sterilization^
by washing thoroughly in soap and water and then boiling for three
to five minutes. It stands boiling very well, but gradually loses its

resiliency, when it should be discarded. If it is thin walled and very
flexible, it sometimes gives trouble. Size 22 or 24 French is convenient
in the normal urethra. If difficulty is c.\i>er!enced at a!!, it is at the neck
of the bladder, where spasm of the sphincter prevents the catheter from
entering. If continuous light pressure is exerted on the calheter, ihe
spasm will gradually yield and allow the catheter to ]>roceed.

Catheters of metal are sometimes advantageous and even necessary,
as, for instance, in prostatic cases. They are readily and completely
sterilizable. A [X)lished silver catheter is probably, in skilled hands,
the most agreeable of all catheters to the patient. On account of the
jHJSsibility of tearing the urethra, however, its use should never hi:
allowcfl except by trainefl and competent persons. Orilinarily, the gum-

CYSTITIS 157

elastic or silk-webbing catheters, which carry stilets and can be bent to
maintain any curve after being immersed in hot water, or the '' coude "
or elbowed catheter, may be employed instead in prostatics. The
disadvantage of this form of coated catheter is that with it com-
plete sterilization is difficult. The ordinary English webbing catheter
is roughened and spoiled by boiling; some of the better grade of French
webbing catheters can be boiled carefully a number of times without
injury. The means of sterilizing the cheaper grades which is ordinarily
employed is a soap-and-water wash, followed by a prolonged soak in
an antiseptic solution. Another fairly adequate means of sterilizing
these catheters is in the metal containers which have recently been
placed upon the market in which pastils of formalin are burned. The
previously cleaned catheter should be kept in contact with the vapor
for twenty-four hours or longer; before using it should be washed off
in sterile water or boric acid solution, that the urethra may not be irri-
tated by the formalin.

Whatever catheter is employed, particular care should be taken that
it is absolutely sterile. Aseptic precautions should be taken with re-
gard to the hands of the physician or nurse and the penis. The fore-
skin should be drawn back and the glans penis and the meatus should
be washed off with weak carbolic or corrosive solution. Boric acid
solution is too weak.

For lubrication, one of the sterile and somewhat antiseptic com-
mercial "artificial mucus" preparations should be used. They come
put up in wide-mouthed jars, into which the tip of the sterile catheter
can be inserted, or in squeeze tubes, from which a sufficient quantity
of the lubricant may be projected on the tip of the instrument. With
care in using the sterility can be maintained indefinitely. Ordinary
vaselin does not long remain sterile when exposed, and, like all oily
substances, it is injurious to soft-rubber and webbing catheters and is
difficult to clean off. The excess of the lubricant should be wiped off
on the meatus, so as to insure that none be carried into the bladder.
If the catheters are to be boiled, some olive oil or vaselin can be poured
into the sterilizer. The boiling ensures the sterility of the lubricant,
which floats in a film on the surface of the water, and automatically
gives a thin even coating to the catheter when it is lifted out.

CYSTITIS

Unless scrupulous care is exercised in employing the catheter —
and sometimes apparently in spite of scrupulous care — a troublesome
cystitis is likely to be set up which may last for many weeks. It does

158 catheterization; cystitis; catheter fever

not appear ordinarily until a week or more has passed from the time
the use of the catheter was begun. Cystitis may appear where a
catheter has not been used; a woman with an atonic bladder wall
who is restrained for a long period to the dorsal position in urinating
will be unable to empty her bladder completely; the residual urine
may decomj)ose and start up an inflammation.

Cystitis following catheterization of the normal urethra is due to the
introduction of infective matter into the bladder. Any pyogenic bac-
terium may cause it — most frequently the colon bacillus, next the
staphylococcus or streptococcus. The gonococcus apparently acts to
pave the way for invasion by some other organism, as it is found only
in association with one of those already mentioned. The catheter
may be clean and yet carry infection into the bladder, for the heathly
urethra is the normal habitat of several species of bacteria which are
capable of producing cystitis. The more frequent source is by conta-
gion from contiguous organs. In the female particularly, as cathe-
terization is commonly practised, it is extremely likely for the catheter
or the fingers of the nurse to be contaminated by organisms from the
rectum or vagina. Cystitis is especially likely to occur where retention
of urine exists. In the female susceptibihty seems to be increased dur-
ing menstruation or the puerperium.

The earliest symptoms of acute cystitis are increased frequency
and urgency of micturition and pain, which may be stabbing in nature,
across the lower abdomen. The patient feels compelled to urinate
immediately the desire arises, and the expulsion of the last few drops
is accompanied by sharp, scalding pain. The irritable condition of
the vesical sphincters and of the urethra may cause the passage of urine
every few moments. Sometimes, on account of pain attending the
passage of urine, there is retention. There is usually a continued
low-grade fever, and the patient is restless and sleepless and loses his
appetite. The urine is cloudy and contains pus and may contain blood
in considerable amount. In acute cases the urine may be strongly
acid or alkaline, depending upon the responsible organism. In the
presence of the colon bacillus the urine is acid.

Sometimes the condition of irritable bladder will resemble cystitis
so closely as to be confounded with it. This not infrequently arises
in any condition attended by a highly concentrated urine, such as
usually occurs just after anesthetization. The symptoms are probably
induced by the hyperemia of the bladder wall which results from
irritation by such a urine. The indication in this event is to increase
the amount of body fluids by copious drinking, instillation of water

CYSTITIS 159

by rectum or subcutaneous infusion, with, if necessary, the exhibition
of such drugs as potassium citrate or acetate, hyoscyamus, or digitalis.

The treatment of postoperative acute cystitis may be considered
under the following heads: prophylactic, medicinal, local, and operative.

Prophylactic, — The catheter should be employed only when other
expedients fail, and its use should be discontinued at the earliest
opportunity. The importance of asepsis in all the details of cathe-
terization needs no further emphasis. If an acute gonorrhea exists,
a catheter should not be used, even if the only alternative is suprapubic
puncture of the bladder. The danger of passing a catheter under a
sheet, with its impossibiUty of asepsis and its danger uf traumatism
to the urethra, has already been dwelt upon. The internal use of
urotropin (hexamethylamin) before catheterization, to inhibit the
growth of pyogenic organisms in the urine, is sometimes advisable.

General and Medicinal, — In order to avoid tenesmus the patient
should be kept quiet upon his back in bed until the acute symptoms
have mitigated somewhat. Ordinarily, patients find it comfortable
to draw up the knees, as this relaxes the abdominal muscles and so
diminishes pressure upon the bladder. The use of hot applications will
usually be found efficient in relieving pain — hot suprapubic applica-
tions should be applied several times daily, stupes or fomentations
should be applied to the perineum, hot water may be run through a
rectal siphon plug, or, if the patient can be moved, he can be placed
in a hot sitz-bath. If tenesmus exists, morphin should be given in
moderation. It acts most efficiently if given in the form of a supposi-
tory, with extract of belladonna, of each, \ gr. For intense tenesmus
the instillation of 10 minims of a 20 per cent, solution of cocain into
the deep urethra by means of a Keyes-Ultzmann syringe should be tried.
Anything which decreases the pain or tenesmus and helps to quiet the
bladder in so far assists the cure.

Internally, the administration of urinary antiseptics is indicated, to
render the urine bland and unirritating, and inhibit, as far as possible, the
growth of the bacteria in the bladder. Urotropin (hexamethylamin,
cystogen, helmitol) may be given in the dose of 5 or 74 gr. every four
hours for some days. As this group of drugs, whose activity depends
upon the generation of formaldehyd, tends to irritate the kidneys, their
use should not be maintained constantly for too long a time. If much
water is being drunk, the drug is diluted and its irritating action is de-
creased. Salol is efficient in doses of 10 gr. If the urine is strongly
acid, alkalis, such as bicarbonate of soda in 20-gr. doses, or potassium
citrate or acetate, in doses of 10 or 15 gr., should be given. An ac-

i6o catheterization; cystitis; catheter fever

ceptable method of administering these drugs is in lemonade, a pitcher
to be kept constantly by the bedside containing the proper amount.
If the urine is alkaline, its reaction may be modified by the administra-
tion of acids. Sodium benzoate should be given in 7- or lo-gr. doses
every four hours in a glass of water. Benzoic acid is also useful in 10-
to 15-gr. doses; it is given dissolved in water, with borax or sodium
phosphate added to increase its solubility and cinnamon-water added
to flavor.

The concentration of the urine should be combated by copious
drinking of water. To avoid disturbance of rest during the night by
the necessity for urination, the drinking should be confined largely to
the morning and early afternoon. Ordinary water, botded waters,
carbonated or still, albumin- and barley-water, and toast-water may be
given, but all stimulating and fermented beverages, tea and coffee,
must be avoided. The diet should be simple and light, and in the
early stages of a severe acute cystitis should be limited to milk. Rich
and highly spiced or seasoned foods should not be allowed — particularly
meats, fish, and salads. The bowels should be kept active by means
of mild laxatives; purgatives and drastic cathartics should be avoided.

In cases of chronic cystitis, where the colon bacillus is demonstrable
in the urine, the use of an autogenous vaccine is to be recommended.
For the technique of its production and administration, see Chapter
LII.

Local, — Ordinarily in acute cystitis irrigation of the bladder is not
indicated, and as a routine measure should not be employed. If, how-
ever, the condition should fail to clear up under the regime just pre-
scribed, or if the urine becomes foul and shows the presence of de-
composing pus, intravesical irrigation is necessary. The washing
should be begun with normal salt solution or the mildest of antiseptics,
such as 2 or 4 per cent, boric acid solution. In the acute stage astrin-
gents and strong antiseptics should not be employed. If the condition
does not improve under the boric acid irrigation, it will become neces-
sary gradually to work up to the stronger antiseptics. Argyrol may
be used in i : 1000 solution; silver nitrate, i : 8000, gradually increasing
to 1 : 500; or potassium permanganate, i : 6000, gradually increasing to
i: 1000. Of these, the most commonly employed is silver nitrate;
when pain follows its use, it must be abandoned.

Irrigations should be practised every other day, daily, or twice a
day, depending upon the urgency of the case and the character of the
urine. All fluids must be distinctly warm at the time they enter the
bladder. The urine is passed or withdrawn before the washing is

CATHETER FEVER l6l

begun, and the irrigation is maintained until the wash-water returns
clean. The hydrostatic pressure obtained by hanging the bag so that
its contents are 2 or, at most, 3 feet above the level of the bladder
is sufficient. In order to avoid instrumentation it is preferable to
irrigate without the use of the catheter. A patient with a little effort
can learn to relax his abdominal muscles, and the pressure of the fluid
will overcome the natural resistance of the sphincters; 6 or 8 ounces
may ordinarily be introduced, when the irrigating tip is removed
from the urethra or the catheter and the fluid are allowed to come away.
As soon as the patient announces a feeling of discomfort, the introduc-
tion should cease. As the natural tendency is for the bladder to con-
tract in cystitis, sometimes the amount of fluid which can be retained
is small. It is good practice to leave in an ounce or so of the irrigating
fluid, or to inject an ounce of 5 per cent, argyrol solution, to remain
until the next urination.

Howard A. Kelly^ cites a case in which irrigation combined with
progressive distention of the bladder gave good results in chronic
cystitis. Each day the bladder was irrigated thoroughly with warm
boric solution, which was followed by distending the bladder to three
or four times its capacity with i : 200 carbolic solution. On blotting
paper a graphic record of the amount the bladder would hold was kept,
and it was found that in seven weeks' treatment the capacity was in-
creased from 40 cc. to 420 c.c

Operative. — In subacute or chronic cystitis permanent drainage
sometimes becomes necessary. A catheter a demeure, or an ordinary
soft-rubber catheter held in by adhesive plaster, will give rest to a con-
tracted bladder and will allow for frequent irrigations. A cystoscopic
examination will show the extent of the inflammatory process, and, if
repeated, will serve as a guide to the efficacy of the treatment. Some-
times in the male it is necessary to afford drainage by means of a supra-
pubic cystotomy or a perineal urethrotomy, and in the female by dila-
tation of the urethra and suprapubic or vaginal cystotomy. Curet-
tage of the bladder is rarely indicated.

CATHETER FEVER

It was observed for many years that instrumentation of the male
urethra was not infrequently followed by an amount of constitutional
disturbance. This was given variously the name of catheter chill,
catheter fever, urinary fever, etc., but was never carefully studied until

* A chart to aid in the treatment of cystitis by distention of the bladder, Ann. Surg.,
1910, Hi, 664.

i62 catheterization; cystitis; catheter fever

Thorndike^ analyzed the condition and classified four forms, which he
called urethral shock, acute urinary fever, chronic urinary fever, and
septic infection.

Urethral shock, frequently called catheter chill, is a condition of
nervous shock ordinarily manifested by the occurrence of a chill with-
out fever directiy or very shortiy after instrumentation. This condi-
tion is common and may follow the simple passage of an instrument in
a normal urethra. It is especially apt to follow the patient's first in-
strumentation— that is, if a patient does not exhibit these symptoms
after his first instrumentation it is unlikely to follow repetitions of the
instrumentation. Patients who have had chills are likely to have more.
It is sometimes speedily fatal. The patient becomes faint and may
completely- lose consciousness. The chill is short and sharp, is of a few
moments' duration, and, if not fatal, is followed by little if any con-
stitutional disturbance.

Acute urinary fever, sometimes called catheter fever, comes on usually
several hours after the instrumentation and generally shortly after the
first urination following the passage of the instrument. The patient
experiences a distinct chill. He looks badly, takes on an uncomfortable
expression, and complains of pains in his head and back. The tem-
perature rises sometimes as high as io8°F., and there maybe vomiting.
The fever lasts a few hours and is- followed by exhaustion and perspira-
tion. After twenty-four hours the patient has recovered his former
condition. This complication will also follow operations upon the
urethra, such as internal urethrotomy, particularly where there is con-
tact of urine with the operated surface. It is probable that these febrile
attacks are due to poisonous material of some sort, either chemical or
bacterial, furnished by the urine and absorbed through the wound
made by the operation, or through the mucous membrane of the urethra,
which has been stretched and possibly torn by the instrumentation.

Chronic urinary fever comes on after catheterization in cases where
destructive disease has preexisted in some form for a long time and is
particularly likely to follow the passage of a catheter for the relief of
a more or less distended and atonied bladder. The catheter is passed
and the residual urine is drawn off. A few days later the patient ex-
periences chilly sensations and becomes feverish. He loses his ap-
petite, suffers from thirst, and feels wretched. Evidences of a cystitis
are present. This condition may persist for weeks and yet the patient

^ Paul Thomdike, Disturbances Which May Follow Instrumentation Upon the Male
Urethra and Bladder, Com. Mass. Med. See., 1892, v, 401; see also L. J. Hammond,
Catheter Fever, Ann. Surg., 1909, xlix, 90.

CATHETER FEVER 1 63

recover. On the other hand, he may die. In the fatal cases autopsy
shows advanced ascendmg disease of ureter and kidney, such as con-
tracted bladder, dilated ureter, hydronephrosis, and pyonephrosis.
Two conditions are essential to bring about this condition: one is a
preexisting degeneration of the secretory substance of the kidney;
second, an alteration, from obstruction, in the intrarenal pressure,
whereby the ureters, pelves, and calices of the kidneys become dilated.
The sudden release of the increased pressure caused by long-standing
urethral obstruction of some sort starts up a state of active congestion
in the kidney.

Septic injection from an unclean instrument may cause merely a
mild cystitis. The cystitis may be severe and extend upward and cause
septic trouble in the kidney, or it may manifest itself as a true general
septicemia or pyemia.

The treatment of these manifestations is a matter of intense im-
portance to any surgeon who may be brought in contact with operative
genito-urinary work. Much more can be done in the way of prophylaxis
to prevent such complications from arising than in the way of treatment
once they have arisen.

Urethral shock appears to be independent of absorption, because
it shows itself inmiediately after the instrumentation and before suflScient
time has elapsed for the effects of bacterial absorption to make them-
selves evident. The condition is apparently in the nature of an over-
powering impression upon a susceptible nervous system. Fear, anxiety,
and pain are strong contributing factors in the production of urethral
shock, and if the patient is overwrought and apprehensive, so that shock
in connection with urethral instrumentation is a probability, anticipatory
measures must be taken. Freedom from pain and anxiety may be
insured by the ample use of local and general sedatives and morphin,
and the instillation of cocain through the Keyes-Ultzman syringe should
always be employed preceding the first instrumentation in a nervous
patient and before instrumentation in those who have had urethral
shock before. The gradual education of the patient and urethra to
the point of tolerance of instrumentation is an element in prophylaxis
of no mean value. With the condition once established, the hypodermic
use of morphin is indicated.

In the other forms absorption of bacteria and their products is the
essential element, which must be attacked both for prophylaxis and
relief. The importance of surgical asepsis need only be mentioned.

Absorption may be prevented, first, by neutralizing the injurious
elements before their absorption, that is, by internal antisepsis; second,

164 catheterization; cystitis; catheter fever

by washing them out of an involved urethra before or after instrumenta-
tion; and, third, by securing complete and effective drainage of the
urethra. Internal antisepsis is furthered by the administration of uro-
tropin, salol, and the other urinary antiseptics already mentioned.
Digitalis is strongly supportive and stimulating to the renal secretion.
Local antisepsis and asepsis are best secured by copious and frequently
repeated irrigations of the urethrovesical tract with a solution of nitrate
of silver, argyrol, boric acid, or potassium permanganate. It should
be the rule to precede all instrumentation (such as the use of sounds
after a urethrotomy) by the administration of hexamethylamin and
to follow it by a urethral irrigation. With these precautions ordinary
soundings need not be feared.

As a result of recent experience it has been amply demonstrated that
extensive urethral manipulation may be carried on with impunity if co-
incidentally free and constant drainage of the bladder is provided. Thus,
it has come to be the practice of conservative surgeons, especially in
doubtful cases, to add external urethrotomy to operations for stricture,
and perineal drainage in operations upon the prostate and bladder.
Under these circumstances urethral fever, which was formerly the bug-
bear of genito-urinary surgery, is now rarely observed. In case this
rule is not for any reason followed, a large calibered soft-rubber catheter
should be tied in through the urethra for several days, or the urethra
should be kept clean by frequent irrigations.

When urinary fever intervenes, in chronic or debilitated cases, the
best method of maintaining bladder drainage is by means of a large
double rubber drainage-tube or two soft-rubber catheters sewed back
to back with silk, introduced through a perineal incision. In urgent
cases a constant stream of warm sterile saline or boric acid solution
may be maintained under low pressure through one tube, with the out-
let by means of siphonage through the other.

CHAPTER XV

CARE OF THE BOWELS: CATHARTICS, ENEMAS,
DISTElSmON, FOMENTATIONS

In normal active adults nature makes ample provision for the regular
evacuation of the intestinal residue. Peristalsis is excited reflexly and
mechanically by the presence of food in the gastro-intestinal tract;
mechanically, by coarse foods, rich in fiber and cellulose, and indigest-
ible elements such as bran, seeds, and the skin of fruit. The presence
of food in the stomach not only induces activity in the intestines, but
stimulates also the colon and rectum to motion, provided a sufficient
quantity of material has been collected in them. Bile is also an im-
portant element in natural purgation in a way not yet clearly under-
stood, for obstinate constipation is frequently observed if the biliary
secretion is prevented from reaching the intestines, and some of the
drastic purgatives, such as rhubarb and podophyllin, fail to act in its
absence. This biliary secretion is provided for by the massaging, so
to speak, which the liver, gall-bladder, and its ducts receive during
exercise, such as walking. Thus, in active persons nature provides
mechanical and chemical stimuli to evacuation which, provided the
fecal content of the intestines is not allowed to become hard from in-
sufficiency of water, should suffice. To these may be added the psycho-
logic stimulus of regular habit, such as having a movement of the bowels
daily after breakfast, which is important but valueless after it has once
been broken, for it has to be re-formed.

When a person, for one cause or another, is obliged to give up active
life and keep his bed, all these agents are interfered with in their
functioning — ^he is deprived of the beneficial effects of ordinary exercise,
his habit is broken by the unaccustomed circumstances in which he
finds himself, his diet is freed in great part from the coarser elements
which exert a salutary influence in exciting peristalsis. In addition to
these considerations is the purely mechanical one of position — the habit
of defecation in the supine posture is sometimes difficult to acquire. As
a result a patient may be allowed to become constipated, partly from
oversight on the side of the surgeon, partiy from lack of energy and of
desire on the side of the patient, and it is not infrequent that the fecal

165

1 66 CARE OF THE BOWELS

content becomes packed so hard and so tight in the rectum as to require
digital or instrumental removal. Constipated patients often develop
anorexia and complain of headache and a feeling of weight in the lower
abdomen, all of which may interfere with progress toward recov^ery.
Frequently hemorrhoids develop, or, if already present, become aggra-
vated and complicate treatment of the constipation.

In any given case the natural conditions under which the patient
has lived should be approximated as closely as possible. If there is
no contra-indication, the abdomen should be massaged for a few minutes
morning and night, a trick which any competent nurse can be taught by
one demonstration. The food should as closely simulate that to which
the patient is accustomed as his condition will permit. There should
be plenty of fluids and liquid foods, and farinaceous foods, jellies, jams,
and marmalade, fruits, raw or stewed, prunes or figs. The patient
should understand that he is to be expected to defecate at about a cer-
tain hour every morning. If it can be allowed, the patient should be
permitted to get out of bed, with assistance, and move his bowels sitting
upon a closet or stool; and, finally, the responsibility over the state of
the bowels should never be left with the nurse or attendant; the surgeon,
Ignoring any sense of false modesty on his part or the part of the patient,
should acquire the habit of automatically asking the patient directly,
at the time of his morning visit, whether or not the bowels have moved
during the past twenty-four hours.

It may be taken as a general rule that patients who are kept on their
backs for weeks or months will require at some time medication of a sort
to assist in maintaining intestinal activity. Whether the bowels should
be moved daily or every other day depends partly on the patient. Some
persons who have been accustomed to ev^acuate their bowels daily, or
even twice a day, may develop considerable physical discomfort, along with
mental irritability and inability to sleep, if they are obliged to go forty-
eight hours without a movement. Others, of a more or less constipated
habit, may go for some days or a week before they will call the atten-
tion of the doctor to the state of things. If a movement of the bowels
be attended with discomfort or inconvenience, as, for instance, in a case
of wired fracture of the hip, with more or less cumbersome apparatus,
the rule should be a movement every other day. In other cases the
surgeon will be governed by conditions, never, imder ordinary circum-
stances, allowing the intestinal residue of a person on a fairly free diet
to accumulate more than forty-eight hours.

CATHARTICS 1 67

CATHARTICS

A simple and not unpleasant measure to assist in moving the
bowels is the employment of one or another of the numerous
bottled laxative waters — natural or artificial; a wineglassful taken
slowly before breakfast is usually just sufficient to prevent the fecal
mass from becoming hard and dry and difficult to move onward; or a
tablespoonful of olive oil, taken with each meal, may be just sufficient,
by mechanically lubricating and preventing the intestinal content from
becoming dry and impacted, to allow of one gentle movement daily.
A small dose of castor oil, one-half or one teaspoonful, taken every
morning, will often keep the bowels in excellent condition where other
and more irritating drugs may fail. It can be used freely, because it
is safe and has no bad effects. It may be agreeably taken in beer or
tea, according to the taste of the patient. A pleasant way of serving
it, so that the patient does not taste it at all, is to wet the inside of a
wineglass, pour in a litde water or peppermint water, float on top of
this the castor oil, and then pour in a little brandy, which, being lighter
than the oil, will cover it, forming a sort of "sandwich," which should
be drunk at one gulp. A teaspoonful of the compound licorice powder,
more or less, may be taken at night, stirred up in a litde water; or cascara,
the extract, in the form of pills, or, better, as the fluidextract, which may
be made to taste more pleasant by the addition of aromatics. Some
patients prefer the officinal A. S. and B. or the compound cathartic pill.
Phenolphthalein,* in one or another of its proprietary forms, is agreeable
to take and works, as a rule, gently and pleasantly in small doses. There
is a considerable adv^antage in the occasional use of laxativ^es, in that
it prevents straining at stool, with the uncomfortable effects this may
have on hemorrhoids or hernia. Moreover, straining is attended by
a considerable increase in intra-abdominal pressure, which, by causing
a congestion in the vessels of the brain, may be sufficient to determine
an apoplexy in elderly persons, or it may be the exciting cause in the
setting free of an embolus.

If the bowels require stimulation stronger than that given by
the laxative measures detailed above, it will become necessary to giv^e
these drugs in larger doses or to employ purgatives. These range from

^ Berthoumeau and Daguin (Purgative Properties of Phenolphthalein, Presse Medicale,
Paris, 1908, x\'i, 378) rexiew the literature on this comparatively new agent and report ex-
tensive f)ersonal experimental research. The results show that phenolphthalein increases,
on direct contact, the contracting power and the secretion of the intestines. Beyond this
action on the intestines the drug does not seem to induce any noticeable modification in the
other functions. In the dose of from 0.5 to 0.8 gm. (7I to 12 gr.) it purges without griping.
The laxative dose is 4 or 5 gr. or less.

1 68 CARE OF THE BOWELS

Epsom salt and calomel to the drastic cFoton oil or elaterin. Calomel
in small doses gives soft stools, generally without pain or straining,
apparently through acting as an intestinal irritant. Calomel has this
peculiarity, that its cathartic action is not increased in direct propor-
tion to the dose, for calomel itself is insoluble, only the portion which
is changed to the gray oxid is active, and the major part of the large
dose is thrown out unchanged in the stool, and for this reason the best
effect is obtained by administering small doses (from y o to i gr.) at
half-hour intervals until a movement results. It is tasteless, and is
not, as a rule, rejected by the stomach even when there is vomiting.
If it fails to act, it should be followed by a Seidlitz powder, Epsom
salt, or an enema.

The salines commonly employed are magnesium sulphate^ (Epsom
salt), magnesium citrate (effervescent), and the double tartrate of

' W. F. Boos (Boston Med. and Surg. Jour., 1909, clxi, 122) has shown that magnesium
poisoning following the use of Epsom salt is probably more frequent than is generally
supposed, the true cause of the toxic condition remaining unknown in most cases. Two
of the 3 cases which the author had the opportunity to study were brought to his notice
merely through the high sp)ecific gravity of the urine, in i case 1070 and in the other 1080.
These 2 cases recovered, while the third case ended fatally. Eraser reports a case of
his owTi, and discusses 6 others which he found in the literature; 5 of these ended fatally.
In the author's 3 cases the intoxication was undoubtedly caused by the absorption of large
quantities of magnesium sulphate from the gastro-intestinal tract.

The author finds that in the absence of hydremia the tendency of magnesium sulphate
to be absorbed increases with the concentration of the solution, the dry salt being com-
pletely absorbed without action on the bowels. This fact was shown by Hay to be true
also of Glauber salt. In hydremic conditions, however, the salt, even when it is given in
very concentrated solution, is not absorbed. It appears, therefore, that the practice
of giving very concentrated solutions of magnesium sulphate to deplete the system of
excessive water is rational, but perhaps not without fX)ssible danger.

In the absence of edema or ascites to produce efficient catharsis without incurring the
danger of intoxication from absorption, the salt is best given in solutions not exceeding
6 per cent. Above this concentration more or less magnesium sulphate is absorbed
and is lost to catharsis, while its presence in the circulation is a menace to the patient's
life. In the wards of the Massachusetts General Hospital the patients are now given \ oz.
of Epsom salt dissolved in 3 oz. of water, to be followed immediately by a glass of water
(6 oz.); this represents approximately a 6 per cent, solution.

Boos has made a further study of this subject (Jour. Am. Med. Assoc., 1910, Iv, 2037),
and concludes:

1. Magnesium sulphate in bulk or in concentrated solution is absorbed, in part at
least, from the gastro-intestinal tract into the blood.

2. If a sufficient amount of the salt is absorbed at a given time, poisoning will result;
of the 10 cases reported, 6 resulted fatally. The symptoms and autopsy findings in these
cases agree very well with those obtained in animals after the intravenous application of
magnesium sulphate.

3. On account of the slowTiess of its excretion from the system, magnesium sulphate,
given repeatedly in concentrated solution, may produce poisoning by cumulation.

4. In normal conditions of the bowel, magnesium sulphate, in proper dilution, is a

CATHARTICS 1 69

sodium and potassium (Rochelle salt, usually administered as pulvis
eflfervescens compositus or Seidlitz powder). These act, not by irri-
tating the intestine, but, having a higher osmotic pressure than the
blood, by inducing a secretion of fluids from the intestinal wall, until
the weight of this, added to its own weight and bulk (being itself prac-
tically insoluble), induces increased peristalsis and the whole is evacu-
ated. All these must be given in solution; if, however, the solution is
weak, or if the blood and tissues are impoverished of fluid, evacuation
is less likely to occur. As they act rapidly, they are best given in the
morning. Many persons are nauseated by Epsom salt, and espe-
cially after ether is vomiting likely to occur; in either case the salt
should be given cold and dilute. On account of the depressing action
of magnesium sulphate it should not be used in case the patient is in a
state of exhaustion, nor should any of the salines be used where the
tissues have already been depleted of fluids.

Croton oil may be given in doses of J to 2 minims on a crumb of
bread, on a lump of sugar, or mixed with butter or olive oil. It is a
powerful irritant, and in any but small doses acts as a poison. It
acts effectually and without causing much pain or inconvenience
after other drugs have failed. Elaterin is a powerful hydragogue
cathartic, which acts rapidly by irritation. It is given in the form of
the oflScinal trituration of elaterin, in the dose of J gr. The disad-
vantage of employing the more powerful drugs is that their action is
always unpleasanat to the patient and the evacuations are loose.
Oftentimes the action of the drug may be continued over an hour or
more, so that the patient is annoyed and distressed and may be con-
siderably weakened by frequent watery movements of scanty amount.

As a result of the work of the English physiologist. Starling, it has be-
come accepted that certain organs, during the performance of their normal
function, elaborate as by-products substances which act to stimulate the
functional activity of other organs. These substances have been named

valuable cathartic; Hunyadi water, for example, is practically a 3 per cent, solution of
Epsom salt (magnesium sulphate 1.5 per cent., sodium sulphate 1.5 per cent.).

5. It is not wise to give magnesium sulphate indiscriminately in cases of so-called
acute intestinal obstruction, because when peristalsis is much diminished or absent, and in
cases of mechanical obstruction of the bowel, even dilute solutions will be absorbed, with
consequent danger of poisoning.

6. In cases of suspected magnesium poisoning, large quantities of normal salt solution
should be given intravenously. Dilute solutions of lime-salts given hypodermically may
also be of benefit.

7. The subcutaneous use of magnesium salts to produce catharsis, as proposed by
Wade, is not only absolutely irrational, but dangerous.

lyo CARE OF THE BOWELS

hormones. Ziilzer^ has demonstrated that the spleen is the repository of
the hormone which stimulates intestinal peristalsis, and he has claimed that
this active principle can be isolated and applied with success therapeutically
to cases of constipation, tympanites, and postoperative paresis. Hor-
monal, as the marketed preparation is called, is given intramuscularly
or, better, intravenously in doses of 20 or 40 cc. Occasionally its admin-
istration is followed by a slight rise in temperature and pulse-rate, and
rarely by slight prostration.

It is not always necessary to excite peristalsis of the small intestine
by means of drugs in order to clear out the bowel, because not infre-
quently the want of activity depends, not upon the small intestine, but
upon the rectum, which, by training or habit, has become so accus-
tomed to the pressure of fecal matter that it no longer irritates to the
extent of setting up a reflex desire for defecation. In other cases, there
is a distinct disadvantage in exciting intestinal activity. In either
event we resort to the use of local measures — enemas or suppositories.
One of the best means of ridding the rectum of accumulated feces is the
employment of glycerin. This works immediately when it works at all.
The stool which results is of ordinary consistency; there is but one
movement, and that is unaccompanied by pain or colic. Its action
depends largely upon its lubricating quality, partly upon its ability
to excite a watery secretion from the mucous membrane with which
it comes in contact, and chiefly by providing, through its irritant action,
the reflex stimulus which was lacking. The glycerin should be in-
jected low into the rectum, in a dose of i to 2 teaspoonfuls. The more
convenient mode of administration is in the form of suppositories, the
oflScinal suppository being made up of 45 gr. of glycerin gelatinized by
means of soap. These weaken with age as the glycerin tends to escape.
An almost equally eflScacious suppository is that made by whittling out
a piece of Castile soap to shape. This should be moistened before intro-
duction.

Digital Evacuation of Rectum.— If it becomes evident that
there is impaction in the rectum to such an extent that these measures
are inefficient, or result only in painful watery evacuations, it will be
necessary to explore the rectum digitally. A rubber glove or finger-
cot should be worn, well lubricated with vaselin. The exploring finger
should break up the masses, if soft enough, and remove whatever is
within easy reach. This procedure should be followed by a soap-suds
enema. Often one will find the rectum filled with masses as hard as

^ Die Hormontherapie. I. Das Peristaltikhormon, " Hormonal," Therapie der Gegen-
wart, May, 191 1.

ENEMAS 171

marbles, worn round by their play upon each other. If these cannot

be broken up, the smaller may be removed entire by the finger; the

larger will necessitate the introduction of a silver spoon or a gall-stone

scoop. If this procedure is attended by much pain, it should be followed

by a low enema of 6 oz. of starch containing 10 drops of tincture of

opium.

ENEMAS

There has been a discussion of long standing as to the relative value
of catharsis by mouth and of enemas in the treatment of postoperative
constipation. It has been shown* that after abdominal operations
involving the alimentary tract the enema is preferable. General peris-
talsis is excited only to a less degree, and the diseased part is maintained
at rest. The large intestine is kept empty, and distention with gas,
which is mostly formed in the colon, is rarely considerable. Hardened
fecal masses cannot remain to block the exit of gas or attempts at evac-
uation. Straining at stool, with its pull on abdominal wound and on
newly forming adhesions, does not occur, and such nourishment by
mouth as the patient has been induced to accept is not unduly hurried
along at a time when the patient needs all the strength he can acquire.

Mild Enemas.— When the bowel is filled higher up with fecal
matter, it will become necessary to employ larger quantities of fluid,
and to employ somewhat greater care and gentleness in making the
Injection, so as to insure the fluid being carried into the sigmoid with-
out distendmg the rectum and thus exciting a desire to defecate.
Ordinarily, a mild enema will sufifice to induce the desired action, and
of these, plain water, normal salt solution, and soapy water are efliica-
cious, given warm, 95° to 100° F., in quantity about i pint for an
adult; or an ounce of castor oil may be given in 12 to 16 oz. of thin
starch solution. Another good enema is milk and molasses, equal
parts, to make from a pint to a quart. Warm enemas cause no reac-
tion and excite little peristalsis; cold water (about 70° F.) stimulates
bowel peristalsis much more powerfully. Where there is no contra-
indication, a half-pint of cold water may be injected into the rectum
through a funnel, retained ten minutes, siphoned off, and the pro-
cedure repeated once or twice. The water may be gradually cooled.
Large quantities of any solution should not be injected on account of
the atony of the bowel which results. A quart should be the maxi-
mum employed, and if this amount is injected and does not come away

^ Crandon, Catharsis in Abdominal Surgery, Boston Med. and Surg. Jour., 1901,
cxliv, 639.

172 CARE OF THE BOWELS

within a reasonable time, it should be withdrawn, particularly if another
enema is intended to be administered.

More Drastic l^nemas. — In abdominal cases not infrequently
emergencies arise in which, on account of distention or intestinal
paresis, evacuation of the colon becomes a critical necessity. In
this event much more drastic enemas may be employed in conjunc-
tion with other means of exciting peristalsis — enemas so irritative that
their use should ordinarily be avoided. Such an enema is that of
suds and turpentine:

Turpentine 2 ounces;

Warm suds 8 **

This mixture must be stirred continuously while it is being given, other-
wise the oil will float on top and the patient will get all the oil in the
last few ounces. Shaking up the oil first with half its bulk of mucilage
of acacia or white of egg will assist in holding it in suspension. Another
combination which is commonly used is:

Turpentine,
Glycerin,

Epsom salt aa 2 ounces;

Warm water 7 **

The turpentine here also should be emulsified with the white of one
egg. In this enema the proportion of turpentine to water may be
increased or diminished as the case demands. Before any enema con-
taining turpentine is administered, the region about the anus, as well
as the buttocks and sacrum, should be well oiled, to protect the skin
from blistering. Heat seems to have an important influence in stimu-
lating peristalsis, and for this reason some surgeons are in the habit
of injecting into the colon 6 oz. of hot olive or cotton-seed oil or hot
glycerin. The old-fashioned milk and molasses enema, of each one
pint, if given high and hot, is usually followed by good results, and it
is not so irritating as the enemas depending upon turpentine or glycerin
for their action.

No enemas are of constant value, however, and if one mixture will
not work, another should be tried. Ill success should not always be
laid to the nature of the material used. In cases of fully developed
paralytic distention, particularly if angulation of the bowel has oc-
curred, enemas, which act primarily only on the colon, cannot be ex-
pected to be of much avail. They may be relied upon, however, if
employed early, before these conditions have developed.

ENEMAS 173

There is one precaution to be always borne in mind in the adminis-
tration of an enema, and that is to see that due care is exercised in the
passing of the tube. If the rubber rectal tube is pushed in carelessly
or hurriedly, the tip is likely to catch on one of the valves of Houston,
and the tube will coil up within the rectum and perhaps tear or injure
the valve. For a high injection the tube should always be passed
slowly and with great gentleness, upon the well-lubricated gloved fore-
finger of the left hand, inserted as far as it will go. If the patient lies
upon his left side, gravity will aid in guiding the tube toward the sig-
moid flexure. A valuable contribution to the question of the practica-
bility of the high enema is that of Soper (see also Chapter XII, p. 141).
It seems to be the belief of the majority of physicians that the soft-
rubber tube can be passed beyond the sigmoid flexure, though this has
been disputed by high authorities. Soper's experiments with the
:r-ray show that in most cases the soft flexible tube ordinarily used can-
not be made to pass beyond the dome of the rectum, and that it is only
in exceptional conditions of dilatation and hypertrophy of the colon
that it can be successfully introduced beyond the sigmoid flexure.

The need of introducing the injection-tube beyond the rectum is
probably in most cases an imaginary one. Soper has demonstrated
the possibility of flushing the entire colon by using a large-caUber (§ in.)
short tube. It is much easier to depend on an enema finding its own
way beyond the flexures than to endeavor to carry it beyond them. A
tube of sufficient rigidity to force its way would hardly be advisable
for general use.^ Soper^ says, ^^I believe that it is only in those rare
cases of abnormal development of the sigmoid that it is possible to
introduce a soft-rubber tube higher than 6 or 7 in. in the rectum with-
out it bending or coiling on itself. With the aid of the sigmoidoscope
only the middle of the sigmoid can be reached. The practice of allow-
ing liquids to flow through simultaneously with the introduction of the
tube serves to smooth out the kinks and adds to the illusion that the
tube is going higher. The short tube (6 in. in length) is, therefore,
best for all sorts of enema (a) when water, etc., is introduced for the
purpose of causing fecal evacuations, using the fountain syringe or
funnel and long tube in the usual way. It is possible, as I have fre-
quently demonstrated, thoroughly to cleanse the entire colon by using
a large-caliber (J in.) short tube. This is connected by rubber tubing
with a large funnel, elevated from 3 to 4 ft. above the patient, pouring
in the solution until he experiences a feeling of distention or desire to

^ Editorial, Jour. Am. Med. Assoc., liii, Aug. 7, 1909.
' Ibid., 426.

174 CARE OF THE BOWELS

evacuate, then lowering the funnel until the outflow has ceased, repeat-
ing this maneuver in exactly the same manner as in gastric lavage.

"The short tube is also best (b) when retention of liquid is desired,
as in administering saline solution, oil, nutrient material, etc. The at-
tempt to pass the tube higher into the bowels is not only unnecessary,
but, because of the coiling that inevitably occurs, such a manipulation
tends to produce irritability of the bowel. This, of course, will very
probably cause expulsion of the fluid.''

After any operation involving the lower rectum, as after a prostatic
enucleation, a Whitehead or a Kraske, care must be exercised lest the
thin mucous membrane be torn by the tip of a stiff tube, or the line of
suture separated, and the enema be poured into the peritoneal cavity
— which we have known to happen with fatal result. Likewise, after
any operative procedure involving a suture of the intestines, especially
if it be low down in the gastro-intestinal tract, enemas must be post-
poned until it is felt that the line of union is sound, and then they
should be given gently and with little pressure. Even so, retroperistal-
sis may be set up, which will carry the fluid backward with consider-
able force along the gastro-intestinal tract.

DISTENTION

After any operation, but chiefly after celiotomies, we are accus-
tomed to note the accumulation of a moderate amount of gas in the
gastro-intestinal tract. This distention usually involves the intestines
chiefly, but it may be limited to the stomach. The occurrence of
distention seems to be about in proportion to the amount of exposure
and handling which the intestines have received.^

Gas is normally present in some amount in both stomach and in-
testines. This normal quantity is added to after operation by the fer-
mentation of such food as remains in the gastro-intestinal tract. If
the patient has been well cleaned out before the operation, fermenta-
tion will be practically nil. In addition, there seems to be a failure on
the part of the mucous membrane to absorb the gas. The flatus is
sometimes increased considerably by air swallowing or '' cribbing."
With some persons this is simply a nervous habit; after operation a

* Henderson, whose investigations of acapnia have already been referred to, has shown
definitely by experimental methods that the loss of tone of the gastro-intestinal track
which follows celiotomy is due largely to loss of carbon dioxid by exhalation from the
peritoneal surface during exposure. This exhalation is increased, he asserts, by the prac-
tice of keeping exposed viscera wrapped in towels moistened with hot saline. He suggests
as therapeutic measures to combat the condition the bathing of the bowel in salt solutioa
saturated with the gas, and its injection into the peritoneal cavity.

DISTENTION 1 75

patient may swallow considerable air with the saliva which he is con-
stantly gulping down to relieve the parched feehng in his throat. The
gas accumulates in the intestines because the patient will not relax
his sphincters to release it, because of failure of peristalsis to expel it,
and because the abdominal muscles, if they have been injured by the
surgeon's incision, cannot or will not contract to assist the intestines.
As the volume of gas increases the intestines become inflated and
stretched, offering less and less resistance to the expansion, and become
paralytic, until they lose their tone entirely.^

Ordinarily, the accumulation of flatus is simply a matter of discom-
fort to the patient, and in cases other than abdominal usually responds
to simple remedial measures. The hard-rubber rectal nozzle of a
household syringe may be passed, well lubricated, through the sphinc-
ters, and worn an hour at a time, three times a day, usually with great
relief. To encourage the belching of gas accumulated in the stomach,
one should try one or another carminative, as peppermint water; Hoff-
man's anodyne, 20 minims, on cracked ice; or 5 drops of turpentine on a
lump of sugar. Position seems to have an important influence on the
accumulation of gas; allowing the patient to turn upon his left side and
to draw up his knees will render easier the passage of flatus. Massage
of the abdomen is an efficient aid in promoting peristalsis, especially
in persons with flabby abdominal walls. As the first evacuation of
the bowels usually carries off with it the gas which has accumulated
since the operation, the bowels should be moved as soon as conditions
indicate. For this purpose castor oil, calomel, or Epsom salt may be
given by mouth, or an enema of soapsuds administered.

After celiotomies, distention may have a serious significance, and,
besides being so frequently a forerunner of peritonitis, is always of
itself a source of anxiety to the surgeon. The causes (leaving the con-
sideration of mechanical obstruction to the next chapter) are sepsis
(the result of disturbed innervation of the intestinal wall from septic
absorption), atony (from general causes), and interference with in-
nervation, direct, from handling the gut or from operative trauma, and
reflex. In the latter case the theoretic sequence of events is about
as follows: Operative handling of the peritoneum and viscera causes
an irritation of the splanchnic nerves, which when stimulated exercise
an inhibitory effect on the plexuses of Auerbach and Meissner, which

^ It has been held that the Trendelenburg position favors the occurrence of postopera-
tive distention, because the abnormal position in which the intestines are sometimes left
interferes with the ready expulsion of gas. It is important that after the table is let down
the intestines and omentum be replaced in their normal positions.

176 CARE OF THE BOWELS

are located in the intestinal wall and control its muscular activities.
As a result of the atony and diminished peristalsis, flatus tends to
accumulate and the bowel becomes less able to expel the collected gas.
Putrefactive changes go on in the small bowel, chiefly, as a rule, in the
ileum, where the bacteria are most numerous, and distention progresses
until the bowel is so stretched that it could not contract even if its
innervation were not interfered with. This distention may prove fatal
in itself, or a fatal termination may result from a kinking or angulation
of the dilated intestine. The diaphragm is driven up, and may seriously
impede the action of the heart and lungs.

In any abdominal case the surgeon should percuss the abdomen at
each visit, until the bowels have acted, to satisfy himself that there is
no overdistention. This can be satisfactorily done, as a rule, through
the swathe; if there is any question, the swathe should be removed. If
gas has not been freely passed within twenty-four hours after the
operation, the simpler measures detailed above should be put into
play. If these fail to act, or the distention increases, no time should
be lost in bringing to bear every means of forestalling a possible fatal
meteorism.

In paralytic distention purgation by mouth generally fails to act,
and may aggravate the existing condition by stimulating the secretion
of intestinal fluids. We should rely chiefly, therefore, upon drastic
enemas, given high and frequently and in large amount. Of these,
the best are the turpentine and suds, the turpentine, Epsom salt, and
glycerin, the milk and molasses, the hot glycerin, and the ox-gall and
water. Another enema which has a good reputation in the removal
of flatus is the enema of asafetida:

Tincture of asafetida 6 drams;

Warm thin starch-water 8 ounces.

These act to empty the large bowel of gas and so encourage more
to descend from the small intestine. The rectal tube should be passed
as high as it will go freely without kinking, and left in place to allow
a free exit for gas. If there is no marked relief following the first
enema, 6 oz. of hot cotton-seed oil should be injected through the tube
every hour, and every fourth hour another enema administered.

In addition, peristalsis should be stimulated by external applica-
tions, either of heat, in the form of flaxseed poultices or turpentine
stupes, covering the entire abdomen, repeated every two hours, or cold,
in the form of ice-bags. As the distended abdominal wall is insensitive
and seems particularly easy to bum, the skin should be greased with

DISTENTION 177

cold cream or vaselin before the application. Turpentine stupes are
made by wringing out old flannels or squares of blanket in hot water to
which turpentine has been added in the proportion of about a table-
spoonful to the quart. Another maneuver, which is often followed by
good results, is to run slowly a lighted wax taper or a Paquelin cautery
tip heated to a dull red over the abdomen, just close enough to the skin
to burn the hairs, beginning at the cecum, following up the ascending,
across the transverse, and down the descending colon. Apparently
the concentration of heat over a small area has some effect on exciting
peristalsis; what part the mental effect plays cannot be definitely stated.
In addition, strychnin may be given hypodermically, on the theory
that it increases the activity of the alimentary tract.

Atropin is sometimes advocated, as it is given in various forms of
colic to lessen spasm and to allow the passage of intestinal contents.
Postoperative tympanites, however, is less often due to spasm than
to paralysis, and atropin theoretically acts but to increase this
paralysis. However, Lederer^ reports lo cases of grave paralytic
ileus in which he got immediate benefit from the injection of ^\ gr.
atropin, repeated up to ^V or yV gr. Physostigmin salicylate is highly
commended by some surgeons. It is ordinarily given during or after
the operation in the dose of ^V gr., and repeating every two hours for
two or three doses. We have had no experience with it.^

There may arise an acute postoperative dilatation of the stomach
and duodenum, apart from dilatation of the intestines. Its onset is
sudden, with pain and vomiting, which is usually not fecal, and which
frequently passes off as the condition progresses, and distention, which

^ Med. Klinik, igii, vi, No. i.

2 D. C. Craig, of Boston, has used this drug extensively and speaks highly of it (Am.
Jour, of Obstet., etc., April, 1904; New York Med. Jour., March 13, 1905). If the patient
is known to react readily to cathartics, he uses ^V gr.; if she is of a constipated habit, jV
gr.; when atony of the intestinal muscles exists, he gives up to V^. The medium dose is
ifn, to be repeated on the first indication that it is inadequate. It should always be given
with atropin, which antagonizes all the undesirable actions of the eserin. The atropin
should be given first, because it acts more slowly. The best time to give this is just before
the operation, gr. yig, subcutaneously. The eserin is injected under the skin after the
abdomen is opened, as soon as it is evident that no contraindication exists, such as
would demand absolute intestinal rest and quiet. It should be withheld, therefore, in
cases where strong or numerous adhesions are encountered, until it is evident that the
adhesions may be freed without damage to the intestinal musculature. Its use is contra-
indicated in cases of intestinal anastomosis or resection, and whenever we are led to sus|)ect
that some more or less septic material is being left behind in the peritoneal cavity, until
healing is well established. Moennighoff (Jour. Missouri State Med. Assoc., Oct., iqo8)
uses eserin salicylate hypodermically in celiotomies as a prophylactic against distention,
giving gr. -f^ immediately after the patisnt has returned to bed.

1-2

lyS CARE OF THE BOWELS

gives the succussion sound if any fluid is present in the stomach. The
pulse and temperature rise and there is a rapidly developing collapse.
The condition cannot be readily distinguished from acute obstruction;
diagnosis is made, in suspected cases, by the succussion and the absence
of any fecal quality to the vomiting. Chronic cases develop more
slowly, but show the same signs. About 70 per cent, die if untreated,
probably in many cases from pressure of the enlarged stomach upon the
heart. In any case of tympanites accompanied by nausea a tube
should be passed into the stomach to relieve it of accumulated gas and
fluids, for in a given case it is usually difficult to differentiate distention
of the stomach and intestines. (For treatment of this complication
see Chapter XVI, p. 183.)

An unrelievable tympanites may represent a distention of the in-
testines behind a kink, which constitutes a true intestinal obstruction
and tends to a fatal termination. Frequently distention is the initial
sign of peritonitis. Sometimes patients die with distention and no
peritonitis, or only a beginning peritonitis is evident at autopsy. It
is clear in these cases that death is not the result of peritonitis. A
theory has been put forward that death is the result of anemia of the
centers at the base of the brain, due to the stasis of blood in the splanch-
nic area. Another theory attributes the lethal result to a reflex action
on the central nervous system from irritation of the nerve-filaments in
the intestinal wall, while some investigators hold it to be caused by
auto-intoxication from some product of disturbed metabolism secreted
in the affected intestine. But the researches of Murphy and Vincent*
have demonstrated rather conclusively that death is due to a toxic
substance which is found in the obstructed intestine, bacterial in
origin, absorbed by way of the lymphatics. They assert, however,
that interference with circulation of the obstructed intestine is the
vital factor in the production of the typical symptoms of acute ileus,
and the obstruction of the venous return is the most important element.

On account of the possibilities of obstruction, any case of post-
operative tympanites which progresses in spite of treatment should be
considered operative. So long as the abdominal wall remains soft,
the patient being in good condition, there is hope of obtaining response
to treatment. If the abdominal wall becomes tense and hard, and
the general condition begins to fail, operative measures should not be
delayed. The best method of procedure is to treat the case as one of
acute postoperative intestinal obstruction along lines to be detailed in
the next chapter.

^ Boston Med. and Surg. Jour., 191 1, clxv, 684.

DISTENTION 1 79

There have been advocates, in the past, of simple puncture of the
intestine by means of a fine trocar or long hypodermic needle shoved
at random through the abdominal wall into the intestine for the pur-
pose of allowing the escape of gas, and recoveries after this procedure
have been reported. The method is unsurgical and the danger of set-
ting up a peritonitis from leakage about the trocar is great. Moreover,
the intestine must usually be punctured in several places and many
times, because each puncture will relieve but one loop of gut, and the
gut above and below will be shut off by kinking. The procedure is in-
dicated practically only in moribund cases where an extreme distention
is causing excruciating pain. It should be performed in the flank over
the cecum, because this is a fixed point and will not give rise to kinking.
A puncture here will relieve the colon, and may also relieve the small
intestine gradually through the ileocecal valve. The trocar or needle
may be left in situ for some while. If there is a leakage of intestinal
contents at this point, it is less likely to spread over the peritoneal cav-
ity and it may wall off.

It is far better, if the patient's condition will allow it, to perform
an ileostomy under cocain, tying in a Paul tube by a purse-string
suture. This can be done through a short incision, either in the
middle line, above or below the umbilicus, or in the left flank. The
immediate relief is usually great, the bowel, emptied of accumulated
gas and liquid juices (which may have to be siphoned off), is allowed to
collapse, and it recovers its tone. If the circulation reestablishes
itself, peristalsis is instituted and the patient is saved. Where, on
account of angulation of the gut, only a portion of the intestine is
drained, the relief will be found to be simply temporary, and another
drainage site will have to be established. The small fecal fistulae
which persist frequently close spontaneously; if not, operative meas-
ures can be taken later. If it happens that the enterostomy be made
high up in the intestinal track, there may result painful autodigestion
about the fistula, and the patient may become greatly weakened from
inanition.

CHAPTER XVI

ACUTE INTESTINAL OBSTRUCTION; ACUTE GASTRIC

DILATATION

ACUTE INTESTINAL OBSTRUCTION

Acute intestinal obstruction is one of the most disastrous of the
sequelae which the abdominal surgeon has to face. Its occurrence is
not mfrequent and the mortality is high.^ Several classifications of
the various types of obstruction have been proposed. Two forms are
ordinarily recognized, the mechanical and the septic- Finney"*
speaks also of an adynamic type, but this we have already considered
under the name of Paralytic Distention. It is simpler to consider all
cases of acute obstruction as mechanical; cases in which exists no
mechanical obstruction of the lumen of the gut should be classified
as distention. The distinction is of importance, because the non-
operative methods which can be relied upon in distention of the bowel
usually are of no avail in obstruction. A distended gut may, however,
become obstructed.

We shall consider here only early obstruction; late obstruction,
occurring weeks to years after operation, will be considered under
Adhesions (p. 332). Ordinarily, in early obstruction, the obstruction
is or soon becomes complete; in late obstruction, partial and complete
obstruction have to be differentiated.

Htiology. — The commonest cause of acute intestinal obstruction
is an angulation or kinking of the intestine, a condition in which the gut
doubles back on itself at an acute angle, so as to form a valve-like
closure. This is most frequently due to paralytic distention; in this
case, if the paresis is not too great, sometimes under the treatment
already suggested peristalsis is set up and the angulation is overcome.
It may be due to the adhesion of a loop of gut to an unusual situation,
as deep in the pelvis, to another loop, or to the parietes. This occurs
not uncommonly after appendectomy with drainage, where a few firm
adhesions have united the cecum and an adjacent loop of small intes-

* Gibson, Ann. Surg., Oct., 1900, x.\ix, places it at 47 per cent.

2 Forbes Hawkes, The Prevention of Intestinal Obstruction Following Operation for
Appendicitis, Ann. Surg., iqoq, .xlix, 192.
^ Ann. Surg., June, 1906, .xliii.

180

ACUTE INTESTIN.AX OBSTRUCTION l8l

tine. It may be due to the hernia of knuckle of intestine through an
opening in the mesentery, or to a twist or volvulus. Distention be-
hind an angulation acts to close it more firmly, by pressure of the
inflated proximal limb upon the flattened distal portion. The lumen
of the gut may be closed by a band or adhesions, particularly in cases
of local or general peritonitis, or by pressure from a drainage-tube or
packing.

Strangulation of the intestine impHes an interference with the
circulation of a loop of gut. It may be due to volvulus, intussuscep-
tion, for instance, at the point of an intestinal anastomosis, to pressure
from a band of adhesions, or to herniation. It is usually accompanied
by obstruction, but the important factor is stasis of the blood-supply,
which eventually leads to thrombosis and gangrene of the gut, and
complicates the condition.

The term septic obstruction is one that is given to the condition
which follows upon the development of general suppurative peritonitis.
This form is likely to manifest itself immediately after any celiotomy
which discloses a diffuse septic peritonitis. The formation of adhe-
sions seems to take no part in the causation of this form of obstruction;
the intestinal stasis can be referred partly to a disturbed innervation of
the intestinal wall from septic intoxication, and partly to the forma-
tion of massive flakes of fibrin and the cohesion of coil to coil. This
form of obstruction should be forestalled by instituting intestinal
drainage at the time of operation in all cases of spreading septic perito-
nitis. Through a gridiron incision in the flank the ileum should be
seized as low down as possible, incised, and drained through a Paul
tube. If one waits for fecal vomiting before performing a secondary
operation, the effort is usually wasted. Another cause of early
postoperative obstruction in cases of extensive peritonitis, described
by Woolsey,^ is secondary abscess. He has found that without ex-
ception the obstruction was relieved by the evacuation of pus, and
infers accordingly that the explanation of the condition lies in the
pressure of the abscess upon coils of gut so restrained by adhesions
that they cannot escape.

Diagnosis. — The onset of symptoms is usually late, from three
to nine days after the operation. They appear suddenly in cases
where the obstruction is primary and complete, or they develop more
slowly where the condition is secondary to a paralytic distention.
In the former event there may be sudden sharp pain, particularly

* Postoperative Intestinal Obstruction, Surg., Gyn., and Obst., igio, x, 608; a com-
prehensive and scholarly consideration of the subject.

l82 ACUTE INTESTINAL OBSTRUCTION; ACUTE GASTRIC DILATATION

in volvulus or strangulation. Colicky pains of some degree are usually
present, but they are less severe and persistent in cases due to atony.
The passage of flatus ceases and distention develops. Distention
occurs without peristalsis, and is more marked and uniform in the
cases due to atony than in primary mechanical obstruction, where it
is apt to be asymmetric, with visible peristalsis of the distended coils.
There is obstinate constipation, and rectal enemas, after the lower
colon is emptied, come back as they went in. Vomiting appears
early, and rapidly becomes putrescent.

The diagnosis is often obscured by the conditions which preceded
or occasioned the operation, and it may be confused with other post-
'operative complications, such as peritonitis. A diflferential diagnosis
is frequently impossible, particularly as a spreading peritonitis is usu-
ally accompanied by a certain degree of paralytic distention.

The treatment may be considered under two heads, prophylactic
and operative. Inasmuch as most cases are due to operative trauma,
adhesions, or sepsis, conditions encouraging these factors should be
guarded against. The bowel should be handled as little and as
gently as possible, denuded surfaces and conditions inviting the forma-
tion of adhesions should be avoided. In the presence of peritonitis
the operation should be simple and rapid, without trauma to the
peritoneum, and the after-care, particularly as regards catharsis,
should be strictly overseen. In any case of distention palUative meas-
ures of the sort advised in the previous chapter should be taken at
once, with the purpose of forestalling an obstruction: gastric lavage,
enemata, hot fomentations, physostigmin. Kappis^ advises that
a soft stomach-tube be passed through a nostril into the stomach and
allowed to remain. After the stomach-contents are siphoned ofif, vomit-
ing and hiccough stop, and the abdomen is relieved of the pressure of
the filled stomach. The tube should not be worn more than twelve
hours at a time, or esophageal ulcer may result. Generally speaking,
if in marked distention palliative treatment does not show results
within a few hours, operation should not be long delayed.

The question of when to operate in any form of postoperative ob-
struction is usually not easy to decide in the individual case. This
difficulty may be referred entirely to the doubt that arises over the
diagnosis. Frequently the surgeon puts off his decision from day to
day, hoping against hope that the condition will clear up under pal-
liative treatment, and by the time the s>Tnptoms have developed so
that there is no question about the diagnosis, the chance of recovery is

*MUnch. Med. Woch., 1911, Iviii, No. i.

ACUTE GASTRIC DILATATION 183

small. If, after a fair and deliberate consideration of the symptoms,
the probability of acute intestinal obstruction seems estabUshed,
operation should be performed immediately. The following signs
and symptoms are to be considered as incriminating evidence:
(i) Distention, with or without vomiting.

(2) Local pain or tenderness, which is extending.

(3) Increasing resistance or rigidity.

(4) ChUls.

(5) An increasing pulse-rate, without a corresponding elevation of
temperature.

(6) The peritoneal facies.

The question of whether to operate can be dismissed in a line. In
the words of Sir Frederick Treves, ^^ There is no avoiding the fact that
acute intestinal obstruction if unrelieved ends in death." Delay is far
more serious than operation, which is not to be considered as the last
resort, but rather as the first resource.

The extent of the operative procedure will depend upon the condi-
tion of the patient. If the operation is undertaken early, with the
patient in fair condition, without marked distention, particularly where
a primary mechanical cause is suspected, an exploratory laparotomy
should be performed, through a median incision or the opened-up
wound, and a careful search should be made to unearth and relieve the
cause of trouble. If the mechanical cause is found, it can be removed;
if a collection of pus is brought to light, it can be drained; if no causa-
tive factor appears, an ileostomy should be performed by sewing in a
Paul tube, using a purse-string suture and inverting the edges. On
the contrary, with the patient in bad condition, particularly in the
presence of sepsis, a rapidly accomplished enterostomy performed low
down, under cocain anesthesia, may be the most radical course which
can be considered. If, after some hours of relief, and without blocking
of the drainage, the distention increases, it will be advisable to repeat
the enterostomy in some other location.

ACUTE GASTRIC DILATATION

An acute dilatation of the stomach (gastrectasia, gastric paresis,
gastromesenteric ileus) may follow operation. The condition is
analogous to distention of the small intestine, which it frequently
accompanies, and in the majority of the cases probably represents
similarly a reflex paresis. Some investigators state that it is due to
occlusion of the duodenum from the pressure of the mesentery which

184 ACUTE INTESTINAL OBSTRUCTION; ACUTE GASTRIC DILATATION

overlies it, and that the dilatation and ptosis of the stomach are
secondary. As this condition (called duodenal ileus or gastromesen-
teric ileus) is usually to be definitely diagnosticated only at autopsy, it
will remain difficult to determine finally in the individual case whether
the dilatation and ptosis cause kinking and occlusion at the duodenum,
or whether the weight of the small intestine dragging on the root of the
mesentery causes the occlusion and secondary dilatation.

Occurrence. — The importance of this acute and serious compli-
cation of abdominal section has only come to be understood within the
past ten years, and it is still more recently that we have begun to pay
attention to its treatment. Recent discussion has convinced us that
it occurs much more frequently than we formerly supposed, and that
in itself it is very likely to cause death. The possibility of its occur-
rence must be borne in mind in the after-care of any case in which ab-
dominal symptoms present themselves. Polak^ found that it was
recognized in xV ^^ i pcr cent, of 1000 celiotomies. Laffer*' har
recently collected 97 cases after operation; 69 per cent, of these oc
curred after laparotomies. Of a series of 217 cases from all causes,
63 i per cent. died.

Etiology. — It is most frequent after operations on the biliary
system, next after operations on the kidney, and less frequent after
appendectomies, curettage, uterine operations, herniotomies, operations
on the stomach, and on the extremities. Several cases are on record
of its occurrence following the application of a plaster jacket for Pott's
disease or fracture of the spine. ^

The significance of anesthesia in its production is still undeter-
mined. Laffer states that in 20 cases where the anesdietic was
recorded, chloroform was used twelve times and ether eight. Atten-
tion has been called to the fact that it may follow prolonged narco-
sis. Woolsey^ mentions that in the first case in his experience in
which the condition was recognized, the patient had been under the
influence of chloroform for two days before operation on account of
pain. Lichtenstein^ states that it may occur when no general anes-
thetic has been used.

It is said to be common in thin, weakly individuals, especially those

» Acute Gastric Dilatation as a Postoperative Complication, New York Med. Jour.,

1909, Ixxxix, 1 184.

2 Acute Dilatation of the Stomach and Arteriomesenteric Ileus, Ann. Surg., 1908,

xlvii, 533.

* Hanssen, Norsk Magazin Laegevid, 1910.

* Loc. cH.

* Akute Magenlahmung, Central, f. Gyn., 1908, xx.\iii, 615.

ACUTE GASTRIC DILATATION 1 85

with general enteroptosis.^ Abdominal trauma, errors of diet, the
accumulation of gas due to fermentation of retained foods, as em-
phasized by Naunyn,^ drinking a large quantity of fluids, especially
carbonated waters, and tight abdominal binders, have aU been blamed
as the source of this complication. Haruzo Karu^ advances the theory
that certain classes of cases are due to a lack of adrenal secretion, which
acts to regulate the action of the stomach, and he advises the use of
this drug. Connor^ makes the statement that obstruction of the duo-
denum by pressure of the overlying mesentery of the small intestine
(first suggested by Rokitanski) must be regarded as a factor in the
development of one- third to one-half of all cases of acute gastrectasia,
and Polak^ states that there can be no doubt but that the Fow-
ler posture favors constriction of the lower end of the duodenum
between the root of the mesentery and the vertebral column. Ma-
thieu® holds that the underlying cause is air swallowing, aerophagia.
An uneasy, nervous patient sucks air into her stomach while retching;
the stomach walls, being weakened in some way not yet explained,
yield, and the dilatation is started. The dilating stomach pulls down
on the mesentery below the duodenum, thus tightening the pressure
on the duodenum and giving rise to a vicious circle. To prevent air
swallowing he advises that the mouth be held open by a cork between
the teeth during retching or hiccough. Dilatation of the stomach
may occur in paralytic distention and peritonitis, as well as in acute
intestinal obstruction.

The onset of the condition is usually sudden, within twenty-four or
thirty-six hours after operation; it may be more gradual, but it prac-
tically always appears within three days. We have twice known
acute dilatation to occur before sewing up the abdominal wall — once
in personal practice, once in a case of Dr. Torbert's,^ both during
Cesarean section. The dilatation was sudden and enormous, the
stomach practically half-filling the entire peritoneal cavity. In the
first case the stomach was emptied by gentle and persistent pressure;
in the second by incision through the stomach wall. Both cases
recovered without untoward symptoms.

The vomiting is the first symptom to attract attention. It occurs

^ Borchardt, Akute Magenektasie, Berlin, klin. Woch., 1908, xlv, 1593.

^Mitteil. a. d. Grenzgebiet. d. Med. u. Chir., 191 1, xxiii, No. 2.

3 Ibid.

* Am. Jour. Med. Sci., 1907, cx.xx, 345.

^ Op. cH,

" .\rch. des Mai. de TApp. Digestif., 191 1, v, No. 8.

' Boston Med. and Surg. Jour., Aug. 12, 1909.

l86 ACUTE INTESTINAL OBSTRUCTION; ACUTE GASTRIC DILATATION

in 90 per cent, of the cases. The few cases in which no vomiting occurs
are apt to end fatally. The vomitus is copious in quantity — appar-
ently much in excess of the amount of fluid taken. It is usually con-
tinuous. It comes up in gulps, without strain or effort, in quantities
of 8 to 12 oz. In nature it is yellowish green, or sometimes brown or
black, sour smelling, but rarely ever feculent.

Signs of collapse begin to appear after a few hours, and they de-
pend, among other things, on the loss of body fluids, toxemia, and in-
terference with respiration and cardiac action by upward pressure of
the dilated stomach.

Distention of the abdomen appears first in the upper half of the
abdomen, soon becoming general. Sometimes in early cases the lower
border of the stomach can be outlined by the peculiar quality of the
percussion tympany, which may even replace to some extent the
normal cardiac dulness. Splashing sounds in the stomach can fre-
quently be elicited on rocking the patient from side to side. The dis-
tention may be so great as to tear out the abdominal sutures. It is
usually unaccompanied by tenderness or rigidity, except toward the end.

Diffuse abdominal pain is usually present in a severe form, increas-
ing with and depending on the amount of distention. Thirst is usu-
ally present and may be agonizing. The facies shows anxiety, and the
patient exhibits restlessness. The temperature rises little or not at all,
and as the signs of collapse increase, it may become subnormal. There
is a steady increase in the pulse and respiratory rate as the distention
increases; if this is relieved, the pulse and respiratory rate fall. The
bowels are usually in a state of constipation and the urine is scanty.
Enemata may result in the passing of some flatus.

The diagnosis is difficult only to the surgeon who has never
recognized a case. It is usually confounded with peritonitis, para-
lytic distention, or acute intestinal obstruction. The persistent vomit-
ing, in gulps without effort, of olive-green vomitus, which does not
become feculent, is characteristic. The marked degree of distention,
with no rigidity, little if any tenderness, and considerable pain, in the
presence of the succussion splash, are pathognomonic. The normal
or subnormal temperature accompanying signs of collapse serves to
differentiate it from peritonitis. The diagnosis can be made absolute
by the passage of the stomach-tube.

It must be remembered, however, that the condition may com-
plicate paralytic distention, peritonitis, or acute obstruction. Hans-
sen^ reports 2 cases in which the dilatation of the stomach was

* Nordiskt. Med. Arkiv., 1910, xliii, Internal Med., No. 2.

ACUTE GASTRIC DILATATION 187

recognized and treated, but later investigation in both cases, in one
by operation, in the other by necropsy, showed a coincident volvulus
of the small intestine.

It is evident that prophylaxis assumes immediately a position of
importance. Wherever dilatation of the stomach is known to exist
before operation, and in any case in which the complication might be
expected, particular care should be taken in the matter of postopera-
tive diet. No large meals should be allowed while the patient is in
bed. Water should be given in small quantities, and at first only sub-
cutaneously or by enema. The patient should be made to assume a
position upon the side or abdomen as much as possible.

Previous to any celiotomy, food should be restricted for forty-eight
hours, especially with reference to weight and the amount of liquids,
and purgatives should not be used immediately before operation.
Handling of the stomach, and particularly pulling on the pylorus, as
has been shown by Kennan,^ favors shock and gastro-intestinal paral-
ysis. Cooling of the viscera should be avoided in all celiotomies, as
well as rough sponging and gauze packing. It is important that the
quantity of anesthetic be limited to the least possible amount, be-
cause the ether which is reexcreted in the stomach may be a factor of
some importance. The swallowing of mucus should be avoided so far
as possible by wiping out the mouth occasionally with gauze. The use
of atropin before operation will usually limit the secretion of mucus.
Sometimes it seems probable that the irritation from the presence of a
drain in the neighborhood of the duodenum, such as might be intro-
duced after operations upon the gall-bladder or its ducts, has some
causal influence in setting up gastric dilatation. When suggestive
symptoms occur, such a drain should always be loosened and removed.

Treatment. — Cases of acute dilatation of the stomach when
uncomplicated and recognized early usually respond promptly and
effectually to treatment. All food by mouth should be stopped and the
stomach-tube should be put into service at once, no matter how badly
off the patient seems. The stomach should be emptied completely
and promptly, and it should be emptied repeatedly. Between the
periods of gastric siphonage the patient should be made to lie on her
abdomen, or, if this is impracticable, should be placed in the exag-
gerated Trendelenburg position.

Complete emptying of the stomach in its dilated condition is some-
times difficult. The fluid may be, and often is, down as far as the
pelvis. It is a good plan to pass the tube so far in that we are sure

^ Gastro-enterostomy and Pyloroplasty, Ann. Surg., 1905, 690

l88 ACUTE INTESTINAL OBSTRUCTION; ACUTE GASTRIC DILATATION

that it has reached the level of the fluid, and then place the patient in
the knee-chest position and siphon off as much as will come away in
this position, withdrawing the tube slowly, so as to allow all the fluid to
run out. The abdomen should then be tightly bound in a swathe.

Some writers insist on the importance of the occlusion of the
duodenum in maintaining the distention, and of the advantage to be
gained by relieving it of the pressure of the overlying mesentery.
Hardouin^ states that in 3 cases he got immediate relief and cessa-
tion of all disturbances by turning the patient on to her abdomen, or
placing her in the knee-chest position. Two cases, which were not
recognized in time, died. Others (Rosenthal, Borchardt) have
reported aggravation of the condition from postural treatment.
Raising the foot of the bed, and placing the patient upon her left side,
will facilitate the outflow of fluid through the stomach-tube.

Saline solution under the skin or by rectum should be given freely
and stimulation as indicated. Morphin in small doses must be given
when indications arise. Strophanthin, gr. ^, may be indicated by a
failing pulse. Some authorities speak highly in favor of the repeated
lavage of the stomach with normal salt solution or sodium bicarbonate.
Ordinarily this would seem to be contraindicated. Feeding should
be by rectum. If the stomach can once be emptied by means of
posture and siphonage through the stomach-tube, and is kept from
filling through the agency of an abdominal swathe and the forbid-
dance of anythmg by mouth, as well as occasional repetition of the
siphonage, the patient may be expected to recover.

Operative interference, drainage of the stomach through a gastro-
enterostomy, has been advised by some as a routine. This treatment
is to be deprecated. Early recognition and prompt institution of the
proper non-operative measures will generally afford the necessary
relief. There has always been, however, a certain proportion of cases
where the expected relief has not appeared, where the condition has
progressed in spite of treatment, and death ensued. The possibility
of the existence of volvulus or acute intestinal obstruction from other
causes will always have to be considered in these cases, and the ad-
visability of operating for the relief of the obstruction determined.
Mathieu^ records 8 cases in which the stomach was incised for this
condition, all of which resulted fatally.

^ Presse Medicale, 1910, xviii, No. 66.
* Op. cit.

CHAPTER XVII

BURSTING OF THE ABDOMINAL WOUND

The accidental reopening of a celiotomy wound may result from
infection of the wound or from purely mechanical causes. The accident
is infrequent. It occurs usually after a median incision of some length
and least often when the wound has been sewed up in layers. In-
stances are on record where a wound has reopened within a few hours
of the operation, during a fit of coughing or vomiting or following an
attempt on the part of the patient to sit himself up in bed. Some-
times the exercises of a patient in delirium will result in a bursting of
some of the stitches in a wound which has been united by mass
(through-and-through) sutures. Sometimes there is apparent lack
of union between the layers of the abdominal wound, probably on
account of faulty apposition, and in these cases the wound has been
known to reopen, after removal of the sutures, as late as the eighth or
tenth day.^

^ Madelung (Ueber den F>ost-operativen \^orfalI von Baucheingeweiden, Archiv. f.
klin. Chir., 1905, Ixxvii, 347) states that bursting of the wound (postoperative eventration,
secondary dehiscence of the wound, spontaneous {jostoperative evisceration) is more com-
mon than is ordinarily suspected, and it occurs even after the most approved technique
of wound closure. He makes two classes, the immediate and the late. He cites in detail
157 cases of the immediate type, taken from the literature. Of these, 118 are given as
occurring in women, and 2$ in men. The patients were of all ages, and the occurrence was
apparently independent of whether or not masses were removed from the abdomen.
The incision was given as below the umbilicus in 124 cases, and above in 16; the majority
of incisions were in the median line. It occurred in 5 per cent, on the day of operation,
20 per cent, from the first to the fifth day, 57 i>er cent, from the fifth to the tenth day, and
in 18 per cent, after the tenth day. The critical days with celiotomies were apparently
the eighth and ninth. Of the 148 cases of which the end results were given, 43 died.

Many causative factors are to be considered, such as poor catgut, anemia, and inter-
ference with healing of the wound caused by stitches too tightly drawn or too closely
placed, insufficient apposition of structures in layer or mass sutures, and poor closure of
peritoneum, allowing protrusion of omentum. Increase of intra-abdominal tension by
reduction of massive herniae has to be mentioned, as well as rapidly forming ascites, tym-
panites (Olshausen), sepsis in the wound (Kaltenbach), and trophic disturbances (Jareis).

Four of Madelung's cases occurred in patients having tuberculous peritonitis, and to
this list Sarra Rabinova (Ueber das Aufplantzen der Bauchnarbe nach Laparotomie wegen
Tuberculoser Peritonitis, Prag. Med. Woch., 1909, xxxiv, 315) adds another.

Madelung has found 18 cases of late dehiscence, occurring in the scar from five months
to twelve years after celiotomy, with an average of four years. There were 16 women and
2 men. The rupture has usually been sudden, without premonitioa. except in a few cases

189

190 BURSTING OF THE ABDOMINAL WOUND

A woman of thirty had a median incision from umbilicus to pubes for a
pelvic tumor. On account of poor condition at the end of operation the
wound was closed by through-and-through sutures. The stitches were re-
moved on the eleventh day, but no adhesive strips were put on afterward.
Half an hour later a coughing effort split the whole length of the wound and
the entire intestinal mass came out into the bed. The patient died of
shock within the hour.

The element of sepsis may be important in preventing the firm
adhesion of the wound edges. Sometimes simply the outer layers
of the abdominal woimd may separate. This will be followed by a
hernia of the bowel covered with peritoneum and fascia. Reopening
of the woimd from sepsis is now fortunately uncommon. The use of
the muscle-splitting incision and of the right rectus incision wherever
these are practicable obviates to a large measure the possibility of the
bursting of the woimd in ordinary cases. Wherever a long median
incision, however, has to be used, especially if the edges are held ap-
proximated only by through-and-through sutures of silk-worm gut,
the possibiltiy of reopening of the wound must not be forgotten. The
patient must be compelled to lie quietly, coughing and vomiting should
be controlled so far as possible, and due care should be exercised in
transferring the patient from one bed to another if this becomes neces-
sary. The sutures should always in these cases be reinforced by strips
of zinc oxid adhesive plaster, going across the abdomen from loin to
loin.

In case the wound should accidentally give way and the intestines
protrude, a dry sterile dressing should at once be applied. The nurse
should then sit on the bed and so hold and control the hernia mass
(covered by sterile dressing) that no more shall protrude till the sur-
geon arrives. If the parts are sterile and the woimd has been covered
by a sterile dressing since the operation, nothing should be done until
the surgeon appears. Then, with aseptic precautions, the bowel
should be returned into the abdominal cavity. Under cocain a few
sutures should be inserted to close the wound, and reliance should be
placed upon strips of adhesive plaster to prevent the accident from
recurring. Sometimes this occurrence is accompanied by a con-

which showed thinning of the scar and a small hernial tumor. In some cases there may
be a drainage site which is covered over with skin, and very little else. The rupture has
occurred in bed, while straining at stool, and it has been induced by sneezing, coughing,
heavy lifting, jumping from a wagon. The patient may show no signs of shock, and
may even walk to the doctor. The omentum or gut which comes out is usually small in
amount; in this series there was no fatality.

BURSTING OF THE ABDOMINAL WOUND 191

siderable shock to the patient, but the accident in itself need not be
serious. If the parts are not sterile, great care should be exercised
in seeing that the bowel is thoroughly washed with warm saline solu-
tion before it is replaced. If only a small tab of omentum protrudes,
which sometimes happens, this may be tied off and the incision closed.

Failure of the carefully sutured abdominal incision to unite is sometimes
referred to a local anemia of the healing line resulting from internal pres-
sure, as in distention (C. H. Mayo), trophic disturbances (T. C. Wither-
spoon), as well as sepsis and constitutional dyscrasias, such as chronic
nephritis and anemia (C. H. Wallace).^ Failure of repair in wounds of the
abdominal wall after stomach operations is explained by Morris^ as due to
trophic or neurovascular disturbance associated with sensory nerve dis-
turbance in the stomach zone of Head.

* Jour. Am. Med. Assoc., 1910, liv, 148, 149.
*Ibid., 191 1, Ivi, 1798.

CHAPTER XVIII

SEQUEUE OF THE ANESTHESIA: CONJUNCTIVITIS,

ETC, PNEUMONIA, NEPHRITIS

Sore Jaw. — There are some minor inconveniences which a patient
is liable to experience as a direct result of the anesthesia, which should
be recognized and so far as possible alleviated. Sometimes he will
complain of a soreness about the angle of the jaw, with pain on opem'ng
the mouth. This is due to the holding forward of the jaw which the
anesthetist has found necessary, lest the tongue fall back against the
glottis and impede or obstruct respiration. A flabby state of the
tongue under anesthesia is not uncommonly found, especially in
persons without teeth; sometimes holding the head turned to one
side will prevent its sliding backward. The soreness usually wears
off in two or three days; if severe, a menthol pencil may be applied
over the articulation or chloroform liniment rubbed in.

Sore Tongue. — If it has been found necessary to resort to the
use of the tongue-forceps, or to sew a silk thread through the tip of
the tongue, in order to hold it forward, especially if Laborde's rhythmic
traction has been performed, the tongue may become sore and painful.
The forceps which induces the least traumatism to the tongue is the
Carmalt, which has a single prong (Fig. 12, p. 7,2). Forceps which
depends upon pressure for its grip, and especially hemostatic forceps used
in an emergency, may cause some laceration and superficial slough. A
tongue may be rather severely lacerated by being caught between the
teeth and bitten in the state of spasmodic contraction of the jaw muscles,
which is apt to precede attempts at vomiting during recovery from
ether. Ordinarily rinsing out the mouth with a warm mild antiseptic,
as boric acid or Dobell's solution, will give relief and conduce to the
comfort of the patient. If there is any slough or ulceration, a 10 per cent,
solution of silver nitrate should be applied and a potassium chlorid
mouth-wash used.

Sore Chest. — Not infrequently a patient will call the doctor^s
attention to a soreness in the lower chest, or a pain in the sternum and
lower ribs which is aggravated by deep inspiration. This may be due
to violent retching during recovery or to artificial respiration resorted

192

CONJUNCTIVITIS 1 93

to during or after the operation. This soreness is likely to persist
only two or three days, and some relief may usually be obtained by
rubbing with liniment. If the pain is severe, a tight chest swathe may
be applied. If a patient has been hung up in the Trendelenburg posture
during a long operation, she may complain later of pains under the
knees and in the calves, and there is probably an increased likelihood
of a phlebitis of the calf occurring under these circumstances. If her
weight has been resting against metallic shoulder supports, she will
probably experience some soreness in her arms and shoulders.

Paralysis may appear as a result of pressure or of a strained posi-
tion of the arms or legs during operation. The commonest form is
musculospiral paralysis, which occurs if an arm is left hanging without
support over the edge of the opera ting- table (Fig. 14, p. 34). There
may be paralysis of the entire arm from pressure on the brachial plexus,
if the patient is allowed to lie on his arm during operations on the kid-
ney performed in the lateral posture. These paralyses are usually
ephemeral, passing off in at most a few weeks; sometimes they persist
for months after the operation. Strychnin, electricity, and massage
are indicated in the treatment.^

Bums may be the result of using hot-water bags or bottles with-
out adequate protection of the skin, or of using water for washing or
irrigation which is too hot. These are sometimes severe and may be
serious. Bums of slight degree may occur about the mouth and face
from the action of liquid chloroform or ether. It is more likely to
occur if the drop method is used, and, to prevent it, the face should be
smeared with vaselin before the anesthesia is begun, and the ether
should be spread over a sufficiently large evaporating surface and not
allowed to drop on one spot.

Conjunctivitis should not occur with an experienced etherizer
under ordinary circumstances. It is the result of strong ether vapor
or of the ether itself getting into the eye. If the eyes are held closed,
there will be no chance for the vapor to cause irritation; a drop of
ether may accidentally be spilled if the patient is unusually refractive
in going under, or in the flurry of vomiting or artificial respiration on
the table. If there is any suspicion in the mind of the anesthetist that
ether may have come in contact with the eye, he should, as a prophylac-

* A. E. Halsted (Wisconsin Med. Jour., 1908, vi, 511) gives a series of cases showing
varieties of paralysis following and dependent upon the administration of a general anes-
thetic. He describes two forms, peripheral and central. The peripheral may be averted
by proper handling through narcosis. The central cannot be prevented, though its danger
may be avoided by limiting the quantity of anesthetic and by a preliminary hypodermic
of morphin in ether anesthesia to control excitement.

194 SEQUEL.E OF THE ANESTHESIA

tic measure, irrigate the eye thoroughly at once, if possible, with warm
water, normal sahne, or boric solution, whichever is at hand. This is
done by dipping a gauze sponge into the solution, and, holding it a few
inches above the eye, allowing the solution to drip gently on the con-
junctiva. If, in the neglect of, or in spite of, this precaution, the eye
on the second day begins to look injected and feel irritated, a drop
of a solution containing one grain each of zinc sulphate and cocain
hydrochlorid to the ounce of sterile water may be instilled, warm, into
the eye every few hours, and boric acid irrigation carried on twice a
day so long as any secretion appears.

Postanesthetic Pneumonia. — The occurrence of pneumonia
and other lung complications after anesthetization has been a moot
point in surgery. There is no question but that lung complica-
tions arise as a direct or indirect result of the use of a general anesthetic,
especially after capital operations, although some of the cases reported
are undoubtedly due to the coincident action of other causes. When
they do occur, they are troublesome because of the discomfort and dis-
tress to which they give rise, and because of the possibilities of danger
which arise in reference to the effect of the strain of coughing on liga-
tures and sutures; they are extremely likely to become serious, par-
ticularly in elderly and debilitated persons, because they come at a
time when the patient's condition is already below par and his resistance
lowered. The occurrence seems to increase direcdy with the length of
anesthesia and inversely to the protection of the patient. This latter
includes the maintenance of a proper temperature in the operating
room, keeping the patient dry, and protecting from draughts during
recovery. In private practice the occurrence is less than in public
hospitals, where the patient is often trundled inconsiderately out of a
warm operating room along a corridor for some distance to the recovery
ward.

It is generally stated that the liability to lung complications is less
after chloroform than after ether. Upon this statement is based the
assertion that ether should not be the anesthetic of choice where there
is present any disease of the lungs or air-passages, any condition which
results by pressure or otherwise in a lessening of the lumen of the trachea
or bronchi, or in any case where the Trendelenburg posture will have
to be assumed and maintained for a considerable length of time, the
pressure of the intestines against the diaphragm interfering with the
free action of this organ. Ether acts as a local irritant in exciting a
stimulating effect upon the glands of the bronchi so that the secretion
of mucus is increased. The secretion may be so considerable as

POSTANESTHETIC PNEUMONIA 1 95

effectively to block some of the small bronchioles. The irritant action
of the ether may set up a bronchitis or even a pneumonia. The irritat-
ing effects are less likely to occur if a dilute vapor is used and if the
ether is fresh and pure, for ether decomposes if allowed to stand in con-
tact with air in a warm or light place.

Chloroform may prove equally irritant if it is kept in a bottle con-
taining air and exposed to the light. Chloroform vapors, moreover,
are decomposed by an open flame into chlorin and carbon compounds,
which are highly irritating when inspired. The prolonged use of chloro-
form in a poorly ventilated operating-room lighted by gas may induce
serious respiratory conditions in the surgeon and attendants as well as
the patient.

Of all the respiratory complications, hronchitis is the most frequent.
It may be due to the lighting up, under the local irritant effect of the
ether, of a previously existing or a chronic bronchitis. There can be
no doubt, hov/ever, that it sometimes arises as a direct result of the
inhalation of considerable volumes of cold and concentrated ether
vapor, and from undue exposure or chilling of the body surface in
persons not strongly resistant, as a result of age or general condition.
It may, by extension, develop into a bronchopneumonia. It may be
borne in mind that it is particularly improper to leave the patient
wrapped in clothes which have become wet with irrigating solutions,
for, because of evaporation, the loss of heat is greater in wet clothes
than in no clothes at all. Pulmonary edema has been reported,^ but
this must be considered as dependent on cardiac weakness, asso-
ciated, perhaps, with the fact that under the influence of ether the
pulmonary vessels lose their tone and dilate and thus become more
pervious.2 The postoperative occurrence of pleurisy has been occa-
sionally noted, as well as the lighting up of previously existing tuber-
culous foci.

The occurrence of postoperative lung complications varies widely
in different clinics and in different countries, and it depends upon
the nature of the operation, the anesthetization, and the after-care.
They are less frequent in private than in hospital cases. They follow
celiotomies five or ten times as frequently as other procedures, and
of celiotomies, they follow stomach operations about twice as fre-
quently as operations about the bile-passages, and about four times as
frequently as herniae.

1 Nauwerck, Deutsch. med. Woch., 1895, xxi, 121.

2 Lindemann, Centralbl. f. allg. Path., 1898, ix, 442.

196 SEQUELAE OF THE ANESTHESIA

Homans/ collating the statistics of 16,043 laparotomies reported
from German clinics, including those of Czerny, von Mikulicz, Kron-
lein, and Trendelenburg, found an average mortality due to lung com-
plications of about 4.4 per cent. The combined statistics of Munroe^
(Carney Hospital), Risley^ (Massachusetts General Hospital), and
Graves* (Free Hospital for Women), covering 3089 celiotomies, show
a mortality of 0.4 per cent. The apparent discrepancy is probably
explained by the fact that the cases in the Boston series were carefully
anesthetized, ether by the drop method being used in the majority
of cases, that the preparation and after-care were rigidly followed up,
and that the percentage of septic and desperately ill cases was low.

The morbidity of the Boston series was 1.8 per cent. (57 cases).
There were 34 cases of pneumonia, 20 cases of bronchitis, and 3 cases
of pleurisy; 6 cases were postoperative flare-ups in patients previously
tuberculous. Graves is of the opinion that most of the cases of post-
operative limg complications are caused by the lighting up or aggra-
vation of pre-existing focal infection. Homans^ classifies the pneu-
monias in three groups: ether pneumonias, hypostatic pneumonias,
and embolic pneumonias. There seems to be general concurrence on
the rarity of the lobar type of pneumonia. Hewitt (Anesthetics) and
Prescott* go so far as to say that if it occurs the ether cannot be
held alone responsible, and that it must be regarded as a coincidence.

Chapman^ presents an account of experiments upon the irritant
effects of ether, and states that surgical pneumonia may be divided
into two classes: first, one in which infectious particles are drawn into
the lungs by the violent inspiratory efforts incident to anesthesia; the
other, in which organisms of particular virulence find in the post-
operative state soil suitable to their growth and multiplication. He
concludes that ether has a distinct irritant effect upon the lungs,
causing a swelling of alveoli, congestion of the alveolar tissue, and
even intra-alveolar hemorrhage, which increase with the length of
etherization and with the amount of forcing or crowding of the ether.

Postoperative complications on the part of the lungs are, on the
whole, more common than generally recognized. Many a slight in-
crease in temperature in the first few days after aseptic operations is

* Johns Hopkins Bulletin, April, 1909.
'Jour. Am. Med. Assoc., 1909, liii, 425.

* Boston Med. and Surg. Jour., Jan. 20, 19 10.

* Ibid., 191 1, clxiii, 497.

* Loc, cit.

* Boston Med. and Surg. Jour., 1895, cxxxii, 304.
^ Ann. Surg., 1904, xxxix, 700.

POSTANESTHETIC PNEUMONIA 1 97

the result of minor pulmonary complications. They may disappear
entirely in a few days without inconvenience, but they may provide
the soil upon which pneumonia develops. The method of anesthesia,
provided it be given carefully by a skilled person, has no influence
upon the development of postoperative complications, which agrees
with the rarity of pneumonia due truly to the inhaled anesthetic. An
embolic process is evidently responsible for the postoperative pul-
monary complications in the majority of septic cases, but hypostatic
congestion must be accepted as the cause of a few isolated cases, par-
ticularly in the aged.

Among the contributing causes, apart from the anesthetic, may be
mentioned previous tuberculosis, peritoneal trauma, general and local
sepsis, old age, and poor hygiene of the mouth and pharynx.

Pasteur ^ considers that deflation of the lungs may be a predispos-
ing cause of pneumonia, and that this deflation is prone to occur after
abdominal operations, particularly such as involve the handling of the
viscera above the umbilicus. Any extensive abdominal incision will
tend to limit the excursion of the diaphragm, and pain or inflamma-
tion in its immediate neighborhood will fix it entirely, and as a result
there is inactivity or even collapse of the lower lobes, with a greatly
increased possibility of infection.

It is a significant fact, observed by Risley,^ Spassokukotzky,^
and others, that lung complications are more prevalent during the
winter months, when windows and doors are kept closed. Spasso-
kukotzky infers, accordingly, that one of the predominating factors is
improper aeration of the lungs during convalescence, due either to
insufficient ventilation and air-space, vitiation or contamination of the
air by crowding of wards or by ministrations of nurses, visits of friends
or students, or to the fact that during the first few days after celiot-
omies patients avoid normal breathing on account of the pain which
it causes in the wound.

The prophylaxis covers preparation, etherization, and after-care.
The preparation of the mouth and teeth should be thorough; the
teeth should be scrubbed for ten minutes twice during the twenty-four
hours preceding operation. The mouth and pharynx should be rinsed
and the nasal passages douched with DobelFs solution. The anes-
thesia should be carefully conducted, preferably by the open or semi-
closed method. If the Trendelenburg position is necessary, it should

* Lancet, 191 1, i, 1329.

^ Loc. cit.

^ Mitteil. aus den Grenzgebiet. der Med. und Chir., 191 1, xxiii, No. 2.

198 SEQUELiE OF THE ANESTHESIA

not be too extreme, nor should it be maintained for too long a period.
Manipulation in the region of the diaphragm should be limited. The
operating-room should be properly heated, without draughts, and the
patient should not be allowed to lie in a pool of fluid, or in contact with
wet sheets or blankets. He should be well wrapped, to prevent ex-
posure during operation, with a blanket underneath to keep him from
contact with the cold table-top. In the transference back to bed, he
should have ample protection against the sudden change from the
heated operating-room to the cool corridor. The convalescence
should be conducted in a room with plenty of air space, well ventilated
with clean air. Drugs, such as morphin, which depress respiration,
should be avoided. Water should be given liberally to keep down
thirst and prevent the dirty mouth that goes with lack of moisture.
The diet should be as liberal as the circumstances allow and the
patient will take. He should be encouraged to move body and limb,
and, except in a comparatively few conditions, such as hernia, he
should be propped up to a sitting posture in bed soon after he is out of
ether. The old and feeble should be gotten up into an armchair after
forty-eight hours, and all cases should be gotten out of bed as early as
possible.

Bronchitis makes its appearance ordinarily on the day after opera-
tion, but it may be delayed, as pneumonia occasionally is,, until three
or four days or even a week later. The first sign of pneumonia gen-
erally appears in the form of a rise in temperature to 101° F. or over
during the second twenty-four hours after operation. The patient
generally suffers severely, and in some ways the condition resembles
lobar pneumonia, although there is neither the profound toxemia nor
the high temperature of the latter form. The treatment should be
the ordinary treatment of pneumonia in the adult. The course is
usually short and acute. Inasmuch as the patient is already in a state
of more or less exhaustion as a result of the operation, there should be
no hesitation in exhibiting cardiac stimulation from the inception of
the disease without waiting for evidences of cardiac weakness to
present themselves.

It is a serious complication and is the actual cause of a large per-
centage of the fatalities in old and debilitated cases.

Nepliritis. — After anesthesia the urinary secretion is much less-
ened and continues abnormally low, though gradually increasing for a
week or ten days. Thus, Penrose^ showed that after laparotomy the
average secretion in 1 1 1 cases during the first twenty-four hours was

* Ann. Surg., 1895, xxvi, 184.

POSTANESTHETIC NEPHRITIS 1 99

13.4 oz., or about one-quarter the normal quantity. During the sec-
ond twenty-four hours it was 14.6 oz., and the third, 19.6. Grieg
Smith^ observed 128 cases and got similar though higher results.
The diminution, however, as shown by Buxton and Levy ,2 is chiefly in
the water rather than in the solids, and depends largely on the lessened
amount of fluids taken and retained, purgation, sweating, etc. Cases
of complete suppression of urine and death have been reported as due
to the anesthetic. They are rare, although the secretion may become
very slight in case of severe shock or hemorrhage, and ordinarily in
postoperative anuria some other cause may legitimately be sought,
such as tied, cut, or kinked ureters, or Bright's disease. Good ob-
servers have reported cases where ether in elderly persons with Bright's
disease or arteriosclerotic kidneys has been followed by gradual sup-
pression and death, with no cause but the preexisting nephritis demon-
strable at autopsy. Primary acute nephritis occurring after anesthesia
is extremely rare, if it occurs at all.^

In spite of this, abnormal urinary constituents are found after
ether in^ large percentage of all cases — particularly in one-quarter to
one- third — immediately after operation; there are abundant casts,
hyaline, fine and coarse granular and epithelial, and, somewhat less
frequently, albumin. The occurrence after chloroform anesthesia is
considerably less, although chloroform undoubtedly also acts as an
irritant during elimination. These abnormal elements will have usu-
ally completely disappeared in from eighteen to twenty-four hours, but
they may last forty-eight hours or longer in septic cases or cases doing
badly, in case of complication arising, such as pneumonia, or in the
case of a previously existing nephritis.

The cause of the " shower *' of casts which is so likely to follow on
etherization may be the renal congestion resulting from the chilling of
the relaxed surface of the body, renal irritation from the anesthetic or
toxic or septic products, or the concentrated state of the urine. If
albuminuria or cylindruria exists before the operation, it is usually
temporarily increased by ether, but more frequently by chloroform.
It is the generally accepted opinion that ether does little or no lasting

* Abdominal Surgery, 1896, 137.

* Brit. Med. Jour., 1900, i, 833.

' Bovee (Amer. Jour. Med. Sciences, Jan., 191 1) has observed that the renal function
is greatly lessened while the patient is in the Trendelenburg position. In 16 cases, 8 under
ether and 8 under chloroform anesthesia, it was shown that almost no urine was received
into the bladder so long as the position was maintained. If this is borne out by further
investigations, it will be demonstrated that the use of the Trendelenburg position involves
an element of danger in arteriosclerosis, cardiac and renal conditions.

200 SEQUEL.^ OF THE ANESTHESIA

harm to the kidneys, even though renal disease is already present.
Chloroform bears a bad reputation in nephritis, and if this exists, ether
should be given the preference. Chloroform may bring about fatty
degeneration of the kidneys, just as it sometimes causes fatty liver and
heart.

Hirsch^ states that the effect of chloroform and ether on the kid-
neys is merely one manifestation of a general intoxication of the system
from the drug. Ether or chloroform can be used with the ordinary
technique if the kidneys are known to be sound, but if the kidneys are
abnormal, chloroform is absolutely contraindicated. Under all con-
ditions the amount of the anesthetic used should be the smallest
possible. As less of the anesthetic is used when administered drop by
drop, the limit of tolerance is less rapidly reached by this method.
Loss of blood, he says, should be combated in every possible way, as
this favors the degenerative action of the anesthetic and contributes to
the possibility of chloroform intoxication. It is also important to
refrain from administering a general anesthetic several times to the
same patient within a short interval. If the chloroform intoxication
is superimposed on a preceding similar intoxication before the kidneys
have had time to recuperate completely, there is liable to be serious
trouble. The danger in the second anesthesia is far more imminent
than in the first. The interval should be at least a week, and the second
anesthesia should never be attempted until the urine is free from al-
bumin.

Treatment. — As a prophylactic measure when nephritis exists,
ether should always be used, and the least possible quantity of anes-
thetic should be employed. Carefully avoid dampness, draughts, and
exposure. If suppression threatens, give water by the mouth, subcu-
taneously, and by rectum. Promote sweating by hot packs and hot-
air baths. In case of emergency do venesection, and after bleeding
give salt solution intravenously. In any case promote urinary and
bowel secretion. Give digitalis and potassium acetate or citrate.
Combat nephritis in septic cases.

* Centralb. f. d. Grenzg. der Med. u. Chir., 1908, xi, 929.

CHAPTER XIX

ACETONEMIA ; ACID INTOXICATION ; DELAYED CHLORO-
FORM POISONING; FATTY DEGENERATION OF THE
LIVER

Soon after cMoroform came into general use as an anesthetic it was
noted that in some cases, especially in children under fifteen years of
age, a profound intoxication, characterized often by incessant vomiting,
would make its appearance from two to five days after the anesthetic.
This was called delayed chloroform poisom'ng. In some cases sugar
and acetone were found in the urine, and in these it was supposed that
the symptoms were due to an unrecognized diabetes, especially as the
patients frequendy died in coma. In other cases, in which post-mortem
examinations were made, nothing was found to account for death except
a more or less general infiltration of the heart, kidneys, voluntary muscles,
and liver with fat; the condition was usually especially pronounced in
the liver, so that it resembled the liver of phosphorus-poisoning, and
there were sometimes necrosis and contraction, as in acute yellow atrophy.

As more attention began to be paid to this condition, it was found
that the urine in practically all the cases showing this symptom-complex
exhibited an excess of acetone. It was then felt that the symptoms
were due to an acidosis or acid intoxication as a result of some acute
disturbance of metabolism.

Acetone was first discovered in the urine in 1857 by Fetters in a case
of diabetes. Further investigation demonstrated (Miiller) that it is to be
found often in minute quantities in the urine and blood of normal in-
dividuals, and in increased amount if the patient is subjected to tem-
porary starvation. Then it was determined that the amount of acetone
in the urine became regularly increased after narcosis,^ and it was at
first believed that this was due to opening the peritoneal ca\nty or to
the use of corrosive sublimate. It was found that this postnarcotic
excess lasts from a few hours to several days after operation,^ and that
if acetonuria is present before the operation, narcosis increases it.^
J. A. Kelly* reported that out of 400 postoperative cases observed

* Conti, Vratsch, Dec. 7, 1893; Grevan, Ueber Aceturie nach der Narkose, Bonn, 1895.
^ E. Becker, Arch. gen. path. Anat. u. Phys., 1895, cxl, i.
^Abram, Jour. Path, and Bact., 1896, iii, 430.
*Ann. Surg., 1905, xli, 161.

201

202 ACETONEMIA — FATTY DEGENERATION OF THE LIVER

at the Boston City Hospital 46 showed acetone and symptoms of in-
toxication, with 6 deaths. J. C. Hubbard ^ concluded, after an ex-
amination of 145 postoperative cases at the Boston City Hospital, that
the occurrence of acetone after operation was frequent. H. Baldwin '
found acetone in the urine of 64 out of 78 operative cases the day
after operation, and Telford and J. L. Falconer ^ reported 3 fatal cases
after chloroform, and symptoms from the presence of acetone in 34 out
of 118 postanesthetic cases. A. G. Rice* reported that an excess of
acetone was found in 90 per cent, of 202 cases after etherization at
the Boston City Hospital in which no sugar was present before opera-
tion. It appeared most commonly on the second and third day, and
after the fourth day it was rare. Of these, 10 per cent, showed symp-
toms suggestive of acid intoxication. Only 2 cases, however, were
severely sick, and of these, i died. J. W. Sever ^ found that after 681
etherizations at the Children's Hospital acetone occurred in the urine
of 662 and symptoms of acid intoxication in 60. It appeared, as a
rule, at once after the operation and lasted on the average three days.
Death occurred in 16 cases, in 7 of which the acid intoxication was
probably the determining factor.**

The condition began to assume clim'cal importance with the publica-
tion of fatal postanesthetic cases apparently depending on a systemic
acetone intoxication. Among others, Brewer ^ reported i fatal case;
Brackett, Stone, and Low ® reported 7 cases from the Children's Hospital,
with 3 fatalities. R. Campbell * reported 3 fatal cases after chloroform,
and A. N. McArthur*® reported one fatality after chloroform. Bevan
and Favill^^ collected from the literature 29 undoubted cases of this con-
dition, in addition to i of their own, of which 28 died. They called
attention to the liver as the probable source of the toxemia, and to the
similarity which existed between this condition and acute yellow atro-
phy, phosphorus-poisoning, puerperal eclampsia, and diabetic coma.

^ Boston Med. and Surg. Jour., 1905, clii, 744.
^ Jour, of Biol. Chem., 1906, i, 239.
^Lancet, 1906, ii, 1341.

* Boston Med. and Surg. Jour., 1908, clix, 47.
^ Am. Jour, of Ortho. Surg., 1909, vi, 408.

* Ladd and Osgood (Ann. Surg., 1907, xlvi, 460) found that after 120 cases of etheriza-
tion by the cone method at the Boston City Hospital 106 showed acetone, 88^ per cent.
After the drop method of anesthesia they found acetone in only 26 per cent, of 222 cases.

^ Ann. Surg., 1902, xxxvi, 481.

* Boston Med. and Surg. Jour., 1904, cli, 2.

® Medical Press and Circular, 1907, Ixxxiii, 198.

*^ Intercolonial Med. Jour., Melbourne, 1907, xii, 434.

^^ Jour. Am. Med. Assoc., 1905, xlv, 691, 757.

ACETONEMIA 203

It is at present generally assumed that fat is the principal source of
the acetone bodies, and that their place of formation is chiefly in the
Uver.* Acidosis is not to be considered, however, as the result of an
excessive consumption of fat, but it depends usually upon the absence
of carbohydrates.^ It is caused or accompanied by some marked
change in the fat metabolism of the body and, accordingly, L. Guthrie *
infers that acid intoxication is liable to occur in all cases in which the
liver is excessively fatty. Twenty of the 24 cases in the series of
Bevan and Favill, which came to autopsy, showed fatty changes in the
liver.

The conditions in which the existence of a superfatted liver may be
suspected, which should be avoided in general anesthesia, are numer-
ous and include diabetes, deprivation of carbohydrates (starvation),
sepsis (acute and chronic), specific infections, as diphtheria and pneu-
monia, and poisoning with phosphorus and chloroform. The work
of the liver is to take up the fat from other parts of the body and
bring about certain changes in it, the result of which is to make this
material available for the use of the organs in which its potential energy
IS required. Too active a mobilization of stored fat, or too little activity
in dealing with it on the part of the liver, will result in an accumulation
of the unfinished product in that organ. A fatty liver is then the result.*
The condition implies a defective metabolism and oxidation, and the
further perversion of metabolism and oxidation by a general anesthetic
may give rise to a fatal toxemia, accompanied by a general breakdown
of all hepatic functions and fatty acid intoxication, which in extreme
cases may go on to an acute atrophy.

The action of chloroform, particularly upon the liver, was noted
some years ago without being clearly understood. Recently it has been
shown in dogs* that central necrosis of the liver occurs after a single
chloroform anesthesia of two hours, and intense fatty changes when
chloroform is given for a shorter period. Under proper conditions
repair begins on the second or third day, and the liver returns to a
practically normal condition in ten days.® The solvent action of ether

1 E. H. Goodman, Arch. Int. Med., 1908, i, 397.

* Bainbridge, Lancet, 1908, i, 911.

* Brit. Med. Jour., 1908, ii, 1158.

* Leathes, Lancet, 1909, i, 593.

* Rowland and Richards, Ann. Surg., 1909, xlix, 419.

Whipple and Hurwitz, Jour. Exp. Med., 191 1, xiii, 136. With the necrosis there is
a coincident loss of fibrinogen in the circulating blood, so that it may be almost eliminated,
and uncontrollable hemorrhage may occur. The fibrinogen reappears in the blood as the
liver effects its repair.

204 ACETONEMIA — FATTY DEGENERATION OF THE LIVER

and chloroform upon fats is well known, and K. Reicher^ shows that
the important liquids and fats are expelled by the cells under the influ-
ence of the anesthetic. H. G. Wells^ divides the cases of delayed
chloroform poisoning into two classes. In one, chiefly children, the
symptoms are those of acidemia or acetonuria without jaundice. In
these cases the changes of the liver are not very marked, consisting
chiefly of fatty degeneration about the periphery of the liver lobules.
The other type is observed chiefly in young adults, and cUnically is
marked by a profoimd jaundice, hemorrhage, and the usual symptom-
complex of a rapidly fatal acute yellow atrophy, the liver being reduced
in size, flabby, yellow, and showing microscopically an extreme degree
of necrosis, beginning in the center of the lobule, with more or less fatty
peripheral degeneration. There are intermediate cases which do not
follow distinctly one or the other of the two types. Torek^ records 2
cases in which death from *^ acute yellow atrophy '^ of the liver fol-
lowed the use of anesthol as an anesthetic.

Youth appears to be an important factor among predisposing
causes. All the 7 cases of Brackett, Stone, and Low were in children;
of the series of Bevan and Favill, one-half the cases were imder ten
years and two-thirds under twenty. K. Schrack^ observed that chil-
dren were frequently likely to exhibit acetone in their urine, especially
in febrile affections and gastro-intestinal derangements. Marpan and
Edsall showed the intimate relationship of acetonuria with cyclic
vomiting in infants. Hecker^ asserts that children are especially liable
to exhibit acetonuria as a result of disturbed metabolism, and that it is
probably due to a defective development of the function of breaking
down of fats. Brackett, Stone, and Low believe that the mental state
is to be considered of importance in etiology. Homesickness, fright,
confinement in the hospital, and change of food in children of a high-
strung nervous temperament may cooperate with the anesthetic and
the operative shock to induce an acute metabolic upset.®

The association of acetone with preganacy has been noticed. Acute
yellow atrophy of the liver is said also to occur most frequently in preg-
nant women and in the latter half of pregancy. L. Knapp^ reports

' Zeitsch. f. klin. Med., 1908, Ixv, 235.

2 Arch. Int. Med., 1908, i, 589.

^ Ann. Surg., 1910, Hi, 489.

■• Fortschritte der Med., 1889, vii, 746.

^ Munch, med. Woch., 1908, Iv, 1485; 1828.

* v. Brun (Clinica Chirurgica, 1908, xvi, 417) states that the use of chloroform in
children is severe on the liver. Glycosuria often follows its administration and albumin-
uria is also very frequent. He has seen several deaths, two with fatty liver.
Centralb. f. Gynak., 1897, xxi, 417.

FATTY LIVER FROM CHLOROFORM 20$

lo cases of acetonuria in pregnant and parturient women, all of whom
gave birth to dead children, and from this he inferred that acq,tonuria
in a pregnant woman is a sure sign of the death of the fetus. H.
Thompson^ reports a case with the symptoms of acute yellow atrophy,
in which the woman sank into a stupor, gave birth to a macerated
fetus, and died two days later. Couvelaine^ and Scholten' demon-
strated a marked increase in the acetone of the urine in the large ma-
jority of all cases (94 per cent.) immediately after labor and lasting
about three days. It was most abundant after difficult and prolonged
labors. J. B. Williams^ believes that some of the cases of severe
vomiting in pregnancy are "cases of toxemic vomiting allied to yellow
atrophy."

Authorities* seem to agree unanimously in stating that chloroform
is far more apt to induce acid intoxication than ether. Of Bevan
and Faviirs 30 cases, e{her was the anesthetic agent in only 4. It is
generally assumed also that the danger is greater the more protracted
is the anesthetization, although in some cases — probably extremely
susceptible — a fatal acetonemia has supervened on a short anesthesia.
It is stated as of particular importance, in a patient at all predisposed,
that if anesthesia has to be repeated within three or four days, and
chloroform was given the first time, ether should be the anesthetic on
the second occasion. The nature of the operation seems to be of no
importance in determining the subsequent presence of acetone, al-
though it is most conmionly reported as occurring after laparotomies.
This may be partly owing to the relatively longer time ordinarily con-
sumed in performing laparotomies, as compared with other operations,
and partly to the varying degree of starvation to which the patient
who comes to the operating-table is usually subjected before an ab-
dominal section is decided upon, and which he necessarily, or by choice,
undergoes after the operation.

Other causes which have been considered as predisposing to the
occurrence of acetonuria after operation are chronic disease of the
liver or kidney; exhaustion from hemorrhage, starvation, and wasting
diseases, such as carcinoma; fatty degenerations, as in the limbs after
infantile paralysis; and lowered general vitality, as in sepsis; diabetes;
and in the presence of a dead fetus.

The symptoms of postoperative acidosis are usually mild and transi-

^ Central b. f. Gynak., 1898, xxii, 1227.
2 Annales de Gyn. et d'Obst., 1899, i» 353-
' Beitrage zur Geb. u. Gyn., I9CX3, iii, 439.
* Johns Hopkins Hosp. Bull., 1906, xvii, 71.

206 ACETONEMIA — FATTY DEGENERATION OF THE LIVER

tory. At any time from the second to the fifth day after operation
the patient, who has previously been doing perfectly well, except pos-
sibly for a distaste for food, begins to vomit. In serious cases the
vomiting soon becomes persistent, and concurrently the sweetish fruity
odor of acetone is to be noticed on the breath.^ The patient rapidly
develops a state of collapse and looks desperately sick, — his face shows
a gray pallor, his eyes are sunken and staring, and the skin cold and
moist; the pulse becomes weak and rapid, and the temperature rises.
There may be icterus in varying degree. As the condition progresses
the patient becomes restless, even to the point of delirium and con-
vulsions, between the paroxysms of vomiting; then he will quiet down^
and become apathetic and stuporous. Thus he will alternate, until
the periods of restlessness become gradually less pronounced and the
stupor finally deepens into coma. Then he develops an extreme dysp-
nea, cyanosis and Cheyne-Stokes respiration make their appearance,
and death supervenes.

Some cases start suddenly, with mental symptoms, run a short
course, and end fatally. On the third or fourth day after operation the
patient, having previously been doing well, becomes irrational and rest-
less, starts to scream, and may shortly become maniacal, so as to require
forcible restraint. A slight yellowish coloration of the conjunctiva is
noticed, and icterus rapidly spreads over the body. Under restraint
or sedatives the patient becomes delirious, the temperature and pulse
rise, and exhaustion gradually develops. The acetone odor appears
on the breath. Convulsions occur, accompanied by incontinence, and
finally coma, with Cheyne-Stokes respiration, carries him ofT, after
thirty-six to forty-eight hours from the beginning of symptoms.

The test commonly employed for determining the presence of an excess
of acetone is that of Legal: To lo cc. of urine in a test-tube add a small
crystal of sodium nitroprussid. Make strongly hyaline by the addition
of a saturated solution of sodium hydroxid. Shake. If acetone is present,
a deep red color will appear, which will change, on the addition of a few
drops of glacial acetic acid, to a purple, which will color the foam if the
test-tube be shaken.

A convenient bedside test for diacetic acid is the following: Add a few
drops of a lo or 15 per cent, solution of ferric chlorid to a half test-tube of
urine. A Burgundy-red color shows the presence of diacetic acid. The

^ There has been noted (Gates, Surg., Gyn., and Obstet., 191 1, xiii, 517) a bright red
appearance of the fingers and mucous membranes. The venous blood appears arterial, and
the whole body may be pinkish.

TREATMENT OF ACETONEMIA 20^

depth of color is to a certain extent a guide as to the intensity of the aci-
dosis. This is best judged by putting one or two fingers behind the
test-tube to test the transmission of light. If the fingers cannot be seen
through the urine, the acidosis is severe. If diacetic acid is present, acetone
is sure to be.

The treatment of acetonemia consists, besides stimulation as indi-
cated, in purgation, diaphoresis, and the employment of sodium bi-
carbonate in large doses, by mouth or by rectum, subcutaneously or
even intravenously, in an attempt to neutralize the acids in the blood.
There can be no question but that the exhibition of alkalis in sufficient
quantity is followed by immediate and gratifying relief of all the symp-
toms in mild cases. Sodium bicarbonate should be started as soon as
the diagnosis is made, and should be continued until it is clear that it
is no longer needed. By mouth it may be given in the dose of 20 gr.
every hour. In case the vomiting interferes with its absorption by
mouth, it should be given continuously by rectum, in a saturated solu-
tion, by the drop method, through a tube carried as high as possible.
The solution is readily absorbed by rectum, and this route is usually
the most pleasant and eflicient of all. In case of emergency a solution
(6 dr. to the pint) may be given under the breast or into the axilla;
there is considerable likelihood of abscess formation, however, as a
result.^

Some cases are apparently incurable from the start, and upon these
alkaline treatment makes little or no apparent impression. After
coma has set in, its probable value is slight. There is no argument,
however, for the abandonment of the use of sodium bicarbonate early
in the attack. Guthrie {op. cit.) and others hold that it is extremely
doubtful if fatty acid intoxication is ever the sole cause of death.
Wilbur^ has shown experimentally that the acetone bodies in the
blood, even after being neutralized by sodium bicarbonate, are toxic,
although in a less degree. Bainbridge {op. cit.), laying stress upon
the importance of carbohydrate deprivation in etiology, declares that
a plentiful supply of carbohydrates, not only in a postanesthetic
intoxication, but also as a routine preventive measure before opera-

^ J. B. Nichols (Washington Med. Ann., 1908, vii, 133) recommends the free adminis-
iratioa of alkalis. Sodium bicarbonate, 225 gr. a day, plus calcium carbonate, 45 gr., and
sodium citrate, 75 gr., by rectum, subcutaneously, or intravenously. But even this,
he says, will produce no effect in some cases.

2 Jour. Am. Med. Assoc., Oct. 22, 1904, 1228.

2o6 ACETONEMIA — FATTY DEGENERATION OF THE LIVER

tion, appears to be rational treatment.^ We have personally observed,
in confirmation of this statement, that diabetics recover after opera-
tions with fewer complications and more rapid healing of wounds if
they are put upon a moderate carbohydrate diet after operation.
Considerable amoimts of glucose in normal saline may be given by
rectum or under the skin (see Subcutaneous Feeding for technique).

^ See also W. Hunter (Delayed Chloroform Poisoning, Its Nature and Prevention,
Lancet, 1908, i, 993) and A. Sippel (Ein typisches Krankheitsbild von protrahirten
Chloroformtod, Archiv. f. Gynak., 1909, Ixxxviii, 167).

CHAPTER XX

HICCOUGH: CAUSES; TREATMENT

Hiccough, which we ordinarily consider simply as a common and
trivial personal discomfort, may in diseased conditions assume a posi-
tion of considerable importance. In early times it was considered as
a disease in itself, and was so classified by Linnaeus. Nowadays it
is regarded only as a symptom, although cases of apparently autogenetic
singultus have arisen, persisted for days, weeks, or even months, and
have gone on to a fatal termination, without anything having been
observed during the course of the disease or at autopsy to account
directly for the phenomenon. John Hunter first recorded its occurrence
after operation, and it may arise as a complication in any disease at-
tended with prostration.

Pathology. — Hiccough is a reflex spasmodic contraction of the
diaphragm, excited usually through irritation of the terminal filaments
of the pneumogastric nerve, in the pharynx, larynx, thorax, esophagus,
stomach, or intestinal tract. It would seem, however, less frequently
to be due also to direct irritation of the phrenic nerve or of the dia-
phragm itself, from conditions in the lung or pleural cavity, or inflam-
mations or growths contiguous to the diaphragm. Normally, the
descent of the contracting diaphragm is synchronous with the opening
of the glottis; the abnormally sudden contraction of the diaphragm
in hiccough often catches the glottis closed or half open, and the in-
coming colunm of air rushing through the narrow orifice causes the
characteristic *'hic,*' which gives the popular name to the condition.
It usually interferes with sleep, which adds to its seriousness; in sleep
it may disappear altogether, to reappear, however, with awakening;
in well-developed cases it frequently persists in spite of sleep, though
with less frequent rhythm. When it once starts, it is apt to continue
indefinitely from habit, even after a trivial and momentary exciting
cause has disappeared, and this is especially apt to be true in persons
exhausted from illness or after operation.

The commonest cause is the ingestion of gastric irritants, such as
alcohol, condiments, iced drinks. It may be the expression of an
irritation lower down in the alimentary canal, as from worms, enteritis.

14 209

2IO hiccough: causes; treatment

In the neurotic it niay occur from mental emotion, fright, or, arising
from some irritative cause, be continued as a habit. It may occur in
the course of a chronic nervous disease, as epilepsy, hysteria, myelitis.
It is not uncommon in organic diseases — gout, Bright^s disease, con-
gestion of the liver, pleural effusion or adhesions, chronic bronchitis,
or unresolved pneumonia, phthisis.

The most important surgical causes are pharyngeal abscess; sub-
diaphragmatic abscess, empyema, or other intrathoracic conditions;
visceral inflammation, peritonitis, gastritis, incarcerated or strangulated
hernia, meteorism or tympanites; and renal insufficiency after opera-
tions on the kidney or genito-urinary tract, especially in elderly men.

Prognosis. — An attack of singultus coming on in a person past
middle age, exhausted by a recent abdominal or genito-urinary opera-
tion, as on the bowel, kidney, or prostate, is generally considered of un-
favorable import. In any patient convalescing from a serious opera-
tion, if unchecked, it may become a factor of grave importance.

Treatment. — Since the days when Pliny suggested the sudden
exhibition of repulsive reptilians, to the present, the treatment of hic-
cough has been much discussed, and the list of sovereign remedies is
scarcely shorter than the list of men who have written on the subject,
but even now cases are reported of patients dying unrelieved, just as
cases appear in which the hiccough stops as suddenly as it started, with-
out reference to treatment.

It is reasonable to consider the treatment of hiccough under three
headings — physiologic, empiric, and antispasmodic.

It is important, if possible, to find the cause and relieve it. If no
direct cause can be found to exist, treatment should be directed toward
any contributory cause — renal insufficiency, gout, distention, con-
stipation.

If direct or indirect cause cannot be found, or, if found, is not amena-
ble to treatment, it will become necessary to resort to empiric measures.
Of these, it is wise to have a considerable number at one's disposal, for
often many have to be tried before one succeeds. In mild cases hold-
ing the breath, the administration of hot water or ice, tongue traction,
or tight pressure, corset fashion, on the costal margins, enough to
actually relax the diaphragm, should first be tried. This last pro-
cedure IS called "throttling the belly'' and should be applied with
both hands for intervals of three minutes. A tight adhesive swathe
may be bound about the lower chest. Local counterirritation may
be applied by means of ice, or ether or ethyl chlorid spray over
the epigastrium, the application of a mustard plaster to the epigas-

hiccough: treatment 211

trium, turpentine stupes to abdomen, ice-bag to spine, or electricity
to diaphragm.

Depletion may be tried, if indicated, by means of bleeding, leeches
to the anus or epigastrium, or by hot mustard foot-baths. In neurotic
cases, mental shock or the revulsive effect of a cold shower-bath may
be efficacious. Success has been reported following continued painful
pressure of fifteen or twenty minutes on the supra-orbital nerve and
after continued pressure on the phrenic nerve in the neck. The sip-
ping of water, whisky, or vinegar for the purpose of bringing on a series
of frequent acts of swallowing is said in many cases to be of good ser-
vice, on the theory that when the vagus nerve is busy with the mech-
anism of swallowing it will weaken the effect of the reflex to the dia-
phragm. Swallowing rapidly a considerable quantity of mush, gruel,
or sago, swallowing lumps of ice, the rapid eating of ice-cream, have
all been stated to have an effect in diminishing the frequency of the
spasm or in stopping it altogether. Spraying the pharynx and
larynx with an anesthetic solution, such as cocain and menthol in
chloroform water, and gargling have been of use, and a severe case has
been reported cured by the use of apomorphin to induce vomiting.
Stimulation is sometimes of avail in the weak.

Finally, if the case is not one in which a direct cause of the phenom-
enon can be arrived at or relieved, and if the repeated application
of the empiric measures have resulted in no benefit to the patient, it
will become necessary to resort to antispasmodics and sedatives. Of
these, the following have been recommended: aromatic spirits of
anmionia, compound spirits of ether (Hoffmann's anodyne), chloral,
amyl nitrite, cocain, atropin, morphin, and, as a last resort, to produce
sleep in cases which have become exhausted, inhalations of ether or
chloroform.

References

C. O'Leary, Hiccough, Trans. Rhode Island Med. Soc, 1894, v, 91.

W. L. Symes, On Hiccough, Dublin Jour. Med. Sciences, 1892, xciv, 488; 1895, xcix, 15.

CHAPTER XXI

THE TONGUE: ITS SIGNIFICANCE

Observation of the tongue in patients recovering from operation
may be of considerable value in aiding the surgeon to determine whether
the patient is progressing favorably or otherwise. In the old days
much reliance was placed upon this observation, and many fine points
of distinction were drawn in the endeavor to work out the significance
of the changes which were apparent. Nowadays we have got into
the habit of relying chiefly upon the points of pulse, temperature, and
respiration. The tongue, however, can assist us in some doubtful
conditions. In examining the tongue attention should at the same
time be paid to the following points: the age of the patient, time of
observation, and temperature. Of the tongue itself the following
characteristics are to be observed: first, the color; second, the coat;
third, the degree of moisture; fourth, the movements.

Of first importance are the coat and degree of moisture. This
coat is due to an alteration in the amount and depositions of the epi-
thelium covering and to the accumulation of epithelium and bacteria.
The coat may be slight, in which case the tongue presents a moist,
thin, gray coat with a pink background and the sides and tip are clean.
If the coat is thicker, the tongue is gray and in places yellow, or even
white where the coat is thickest; if the patient has been taking black
coffee, the coat may be stained brown; grape juice gives a purple color;
if there has been vomiting of bile, the coat may assume a yellow or even
an olive-green color. The excess of epithelium, due either to over-
production or retention, may proceed to such a point as to give the
tongue the appearance of being roughly plastered over. In this condi-
tion the breath is foul, and there may be ulcers or tooth-marks along
the margin. Sometimes the filiform papillae increase much in size
and become lengthened so that they stand out conspicuously. This
gives us the appearance which is called the furred tongue. This
condition is undoubtedly due to disuse and to want of moisture.

The coated tongue is usually moist. In contrast with this we may
have a tongue which is clean and without coat, dry, and glazed. This
type of tongue is to be regarded with apprehension. In contrast to

212

COATED TONGUE 213

the coated tongue, which is broad and flat with a rounded tip, this
tongue is narrow with a pointed tip. For the most part the surface
is smooth and devoid of papillae. The tongue is liable to crack across
its surface. These cracks may intersect so as to give the appearance of
crocodile hide; in color it may be pale red or yellowish. It is dry and
smooth, as if covered by a thin coat of varnish. The mouth above
shows an entire absence of salivary secretion, and the patient is unable
to expectorate. A tongue dried by evaporation soon becomes moist
if rolled about in the mouth, and its appearance is like the moist, coated
tongue already described. Dryness of the tongue is an unfavorable
sign when the patient cannot, by an effort, raise sufficient saliva to
moisten its surface.

The movements of the tongue when it is projected have some
significance. The tongue may be tremulous in any condition ac-
companied by prostration. The way a patient reacts to the order
to stick out his tongue may help in interpreting his condition.

Changes in the condition of the tongue are frequently of local
origin. The tongue owes its moisture to the saliva, and any deficiency
in saliva will cause dryness of the tongue. Saliva is deficient when
fever is present, and hence the tongue is dry. Dryness of the tongue
may be due to increase of evaporation, from keeping the mouth
open, as well as to diminution of the salivary secretion. In chronic
fever the effect of the temperature upon the secretions in general
is to cause a diminution, and this includes the salivary secretion.
Also the general dehydration of the body causes dryness of the
tongue, even without apparent local diminution of secretion. A
tongue which otherwise might be dry is sometimes moist by vomit.
Prostration has the same effect as chronic fever in causing diminution
of the secretion.

The ingestion of food influences the coating and the degree of mois-
ture. The act of eating cleanses the tongue. In such conditions,
accordingly, as are accompanied by the decreased ingestion of food,
it is natural for the fur upon the surface to become more prominent.
This is also true in conditions where the diet is limited to fluids, par-
ticularly milk.

Clinical experience has shown that certain conditions in the tongue
are associated with certain general conditions which make the appear-
ance somewhat diagnostic. This term must be qualified because the
changes are so often local or are modified by conditions independent
of the general system. W. H. Dickinson^ describes twelve classes and

^Lancet, 1888, i, 558, 609, 657

214 THE tongue: its SIGNIFICANCE

three subclasses in his lectures on the appearance of the tongue in
disease. The most important of these are:

First, the stippled or dotted tongue. The tongue is moist and
dotted with littie white points representing an excess of white epithelium
on the papillae. It is usually seen in persons in poor health, usually
from some chronic disease which is not grave, and which is not accom-
panied by a rise in temperature.

Second, the coated tongue. The papillae are covered with white
epithelium, gind the intervals between the papillae are almost filled with
epithelium and accidental matters, so as to form a continuous coat.
This tongue, whether moist or dry, is seen in acute and febrile diseases
with considerable degree of prostration and fever.

Third, the plaster tongue. The tongue is covered with a thick,
uniform coat. The papillae are elongated. The intervals are crowded
with accumulations. Saliva is deficient. Fever and prostration are
marked.

Fourth, the furred or shaggy tongue. Papillae are greatly elongated.
This tongue represents an advanced stage in the course of a disease. It
is the result of disease and want of moisture. The saliva is deficient.
It indicates that there has been fever and that probably but little food
has been taken.

Fifth, the dry brown tongue. The surface is covered with a dry,
thick, felted coat, which is continuous and is largely parasitic in nature.
It occurs in fevers with high temperature associated with prostration
and absence of saliva. As the patient gets better the incrustation dis-
appears, leaving a bare, red, dry surface.

Sixth, the red, dry tongue. This indicates a more serious condition
usually than the dry, brown tongue. It is the tongue of chronic
wasting diseases, with or without fever. The tongue is shrunken, red,
polished, and smooth. The papillae have disappeared and the epi-
thelium is stripped off in patches.

Dickinson has not been able to discern any relationship between
any state of the tongue and particular gastro-intestinal conditions apart
from that which might occur from loss of appetite or restriction in the
amount of food. The state of the tongue is dependent not upon the
intestinal lesion, but upon the constitutional disturbance. The tongue
does not point to particular organs or isolated disorders, but is the
gauge of the effects of disease upon the system.

The condition of the tongue is, accordingly, due to — (i) dehydra-
tion, (2) exhaustion, (3) pyrexia, (4) local conditions about the mouth.
The degree of fever, the state of the nervous system, the maintenance

COATED tongue: TREATMENT 21 5

and abeyance of secretion, and the failure of vitality are roughly in-
dicated by the condition of the tongue. The return of the moisture,
the removal of fur, and subsidence of tremor at once indicate that the
patient is getting better. The persistence and increase of these signs
show that the disease is getting the better of the patient. The dry
and bare tongue is of serious prognostic omen in all conditions.

So far as is consistent with the surgical conditions present, treat-
ment may be directed to any attributable cause, local or general.
Intestinal putrefaction should be prevented by the reduction or
removal of proteid, especially meat, from the diet, by the use of carbo-
hydrate food, such as bread, cornstarch, cereals, etc., and by the use
of laxatives, buttermilk, and, if necessary, internal antiseptics, such as
salol or the salicylates. Locally, the tongue should be cleaned daily
with a tooth-brush, and the use of an alkaline liquid, such as liquor
antisepticus alkalinus, will facilitate the removal of the coating. The
teeth should be looked after, if possible, before every abdominal opera-
tion.

CHAPTER XXII

BANDAGING

Bandaging to-day is an art much simpler than as practised a few
decades ago. This is in accordance with the general trend of surgical
technique, and is due to our more exact knowledge not only of the
pathologic conditions present, but also of the means of correcting them.

The almost umVersal adoption of the gauze bandage has greatly
helped this simplification, as, on account of its texture, it can be made
to adapt itself easily to the uneven surface presented. Plaster-of-Paris
bandage is used for more or less permanent fixation, especially of joints
and limbs. Flannel bandages and bandages made of specially woven
material, such as the "Ideal" bandage, may be used on account of their
elasticity for the support of strained joints and for varicose veins.

The other chief factor in simplification is the almost exclusive use
of the '^figure-of-8'' instead of the *^ spiral reverse'' for the purpose of
closely and evenly fitting a part, the diameter of which is increasing.
In fact, this figure-of-8 principle, when thoroughly mastered, can be
varied to fit any condition, and is the basis of most of the "named"
bandages. It can be applied much quicker than a "reverse," it will
hold a dressing better, and, when finished, it is much less likely to be-
come disarranged; if, during its construction, several simple circular
turns are introduced on the upper loop of the "8," all tendency to
slip is overcome, and it is found in good condition after a week's con-
stant wear. Furthermore, on its removal the skin will reveal fewer
and less marked ridges than after a "reverse" bandage; the figure-of-8,
therefore, is less likely to cause localized pressure — sores or venous stasis
— and is of greater value in such conditions as varicose veins, in which
an even firm pressure is desired.

Commercial Roller Bandages.— Bandages may now be
bought of gauze, flannel, or other material at drug-stores and surgical
supply houses. These come in any width, are evenly and tightly
rolled, and are usually economical. The ordinarily employed gauze
bandages come in lo-yard lengths, and in widths from i to 6 in. The
commonly used sizes for practical purposes are the li in. about the
hand and head, and the 3 in. about the limbs and body. In an emer-

216

TO REMOVE A BANDAGE 21 7

gency, of course, any material available can be torn into strips and rolled
into a bandage.

Cleaning^. — The parts to be covered in by the bandage should be
cleaned with soap and water, followed by alcohol, then thoroughly dried
and covered with dusting-powder.

Sheet-wadding for Protection.— Before application of a
bandage a layer of sheet-wadding should always be placed over the
dressing and the part to be covered by the bandage. This material
comes in sheets about a yard square, is very soft and agreeable to the
skin, and nonabsorbent. It is most easily applied by roughly tearing
into strips, 3 or 4 in. wide, and making into rollers, which are then
applied loosely in spiral turns; frequently two or three strips are stitched
together so as to form longer rollers.

It should be an invariable rule that, in the application of bandages
or any other apparatus, no two skin surfaces should come together; this
should always be avoided by the interposition of a piece of sheet-wadding
or absorbent cotton, well powdered (for example, in recurrent bandage
of the hand the fingers should be separated by sheet-wadding).

To Roll a Bandage* — It is frequently necessary to reroU a
bandage. To do so fold one end on itself several times into a tight little
roll; grasp this at the extremities by the thumb and forefinger of the
left hand, which act as the bearings of the revolving axis; the free-
hanging bandage is then played between the thumb and index-finger
of the right hand, which, by the alternating pronation and supination
of the forearm, as in winding a clock, revolves the cylinder and the
roller is formed.

To Start a Bandage. — Hold the bandage in the right hand with
not more than 3 in. free; take the free end with the thumb and finger of
the left hand, lay the unrolled portion against the part to be bandaged;
hold the free end firm with left hand; allow roller to run to the right
naturally round the part; as it passes to the left on the posterior surface
transfer roller to left hand, holding initial extremity firm with thumb
of right hand; in front change roller again to right hand and proceed
as before, making two complete turns. This turn is called a circular turn,
and is used for starting and "fixing." This fixing should always be at a
point where there is little or no variation in diameter, so that it shall
not slip upward or downward (/. e., at the ankle and not on the cone-
shaped calf).

To Remove a Bandage.— Unpin the end and unwind. As the
bandage is being unwound the free portion should be gathered into the
palm of the hand and transferred bodily to the other hand alternately
above or below the limb; it should not be allowed to drag or string out.

2l8

BANDAGING

Figure-Of-S Bandage.— After fixing, say, on the calf of the
leg, allow the bandage to run diagonally u[jward and backward until
it reaches the posterior surface, when it will again naturally become
horizontal; as it comes around on the other side, direct its course onto
the front of the leg diagonally downward and forward, so as to cross

the ascending turn in the middle of the anterior surface. Continuing
to descend it passes backward and becomes horizontal on the posterior
surface; then it rises again obliquely, passes fonvaril, crosses the down-
ward turn in the middle of the anterior surface, and continues upward
and backward as above. Each succeeding turn progresses upward
for from \ in. to one-half the width of the bandage (Figs. 46 and 47).

The crossings on the anterior surface after a little practice naturally
arrange themselves in jierfect alignment. While ai)plying the bandage,
an occasional circular turn helps to fix the bandage firmly and over-
comes all tendency to slip; such a turn usually falls naturally, and
both edges of the bandage lie flat and with even tension.

THE SPICA BANDAGE

219

The spiral reverse bandage was once very generally used
to cover any part conical in shape; it is now superseded by the figure-
of-8. It is put on as follows: after "fixing" and making one complete
upward spiral turn, the hand holding the roller is carried about 6 in,
away from the limb, the thumb of the other hand holds the bandage
against the limb i in. proximal to proposed position of the reverse;
the hand holding the roller is carried toward the limb sufficiently to
slacken the unapplied portion of the bandage, then, by turning the
forearm from extreme supination to pronation, the bandage is twisted
once on itself, so as to form an angle of about 90 degrees, just beyond
the thumb. The reverse is thus completed, and the bandage is al-
lowed gently to fall flat upon the limb; it is then carried around un-
derneath the limb and the desired tension applied. The reverses
should be in a line, but not over prominent parts (/. e.. anterior
border of tibia), as, unlike the ligure-of-8. they cause creases in the
skin which may easily result in pressure sores.

The spica bandage is really a figurc-of-8, one loop of
which is made much larger than the other; there are three situ-
ations where it is commonly used — the thumb, shoulder, and hip.
The hip spica (Fig. 48), one of the frequent dressings for hernia, is
made as follows: the bandage should be of gauze several folds thick,
12 yds. long, and have a width of 8 to 12 in. Patient is placed with
sacrum resting on a basin or spica block, sheet-wadding is applied with
a considerable thickness in groin. The bandage is fixed with a circular
turn about the pelvis; as it passes from back to front it becomes oblique,
runs o\'er the inguinal region into groin, around the leg, up diagonally

BANDAGING

across the inguinal region to the opposite side, and then around the
pelvis; every third turn should be a circular turn around the pelvis and
several safety-pins should be introduced during the application.

The spica of shoulder (Fig, 49) is similarly applied — a figure-of-8
with the small loop about the upper arm and the large loop about the
thorax, and under the opposite axilla.

To Bandage the Heel.— Frequently the heel is left unco\-ered
when bandaging the foot anil leg; if it is desired to include it in the
bandage, it may be done by one of the following two ways:

(i) After making fast by circular turns around the ankle above the
malleoli, the bandage is carried obliquely downward across the foot to
near the base of the toes, at which part a circular turn is made. The
bandage is then carried up the foot by two or three short figures-of-8;
then carried over the point of the heel and around to the dorsum of the

PLASTER-OF-PARIS BANDAGES

foot; then beneath the instep, around one side of the heel, and up
over the instep; from here again beneath the instep around the other
side of the heel and up in front of the ankle, from which it may be
carried up the leg. This is called the French heel {Fig. 50).

(2) After fixing as above, the bandage is carried obliquely downward
across the foot to near the base of the toes, where a circular turn is
made; the foot is covered nearly in with short figure-of-8 turns; when
running across the top of the instep the l>andage passes over outer mal-
leolus, over tip of the heel, and up over inner malleolus; then crosses top
of instep, around behind tendon of Achilles, crossing again on front
part of instep, it then passes beneath the arch of the foot to the front
of the instep. These turns arc continued in the form of figures-of-8,
with the [)oint of crossing stationary, o\er the insteji, and the loops
aiternatcly covering the region of the tendon of Achilles and the arch of
the foot, till the heel is covered in, after which Ihc bandage ascends the
lesr. This is called the testudo (Figs. 51 and 52).

Plaster-of-Paris Bandages. — Plaster of Paris, or gypsum, is
used to maintain complete or partial fixation over a more or less ex-
tended period. It forms a very convenient splint material and is
adaptable to many places and purposes. It is usually applied, in
accordance with the principles of technique just described, in the
form of a bandage. This is made by thoroughly filling the meshes
(16 threads to the inch) of a gauze roller (3 or 4 in. wide) with ordinary
dry plaster. Unwashed crinolin probably makes a more satisfactory

BANDAGING

material. Plaster bandages may be bought af the surgical supply
houses put up in sealed tins. Care should be taken that the plaster

l>einpcli.-i:d IuprF\'eiil Ihc li^tcl ham runnini; out. mces tuu much plusUi,

does not become air-slaked by exposure to damp air, otherwise the
cast will crumble and disintegrate after it is applied. For this reason

PLASTER-OF-PARIS BANDAGES

223

bandages that have been in stock for some time should be baked in
an oven before using.

To apply, cover the leg smoothly and evenly with strips torn from

a sheet of cotton wadding (Fig. 54), protecting amply all bony promi-
nences. Completely immerse the plaster roller in luke-warm water for

and third ruOei

about two minutes, or until all the air-bubbles are out and the bandage
wet through. A pinch of salt dissolved in the water will hasten the set-

2 24

BANDAGIXC

ting; if it i^ not dissolved, it will get into the plaster iind make it crumble.
If allowed to remain too long in the water, the rollers set and become
hard. When taking the roller out of the water, both ends should be
grasped and the water gently squeezed out (Fig. 55); a twisting or
wringing motion (Fig. 56J will force the plaster to run out through
the meshes. Roll around the ieg smoothly, following the natural
cur\'es with spiral or figure -of-8 turns; never use the reverse; never
pull tightly; always keep in mind the danger of localized pressure.
After the plaster has f)een applied about twenty minutes, it is in
suitable condition for trimming, splitting, and cutting of windows.
Use a small, stout plaster knife (shoemaker's knife) and cut the pias-
ter through until the sheet-wadding is reached. This tan be cut later
with scissors. It is best to defer removal of the piece which has been
cut till iJie next day to allow the plaster to harden (Fig. 5Q).

Recttrreut Bandage — Hand or Amputated I,imb.— The ban-
dage is fixed by a few circular turns; then, when the bandage roll is on
the front of the limb, turn it at right angles, putting the thumb of left
hand on the point of folding to hold it in place, carry the bandage
to the end of the extremity, pass over this in the median line, and return
upward on the under surface to a point directly op]>osite the point of
starting; then place the fingers of the left hand on the bandage, double
it u[»n itself, and bring the bandage dircclly back the \vay it came o\-er

MODIFIED BARTON 225

the end of the extremity to the point of starting. Each turn should
overlap two-thirds of the previous one, first on left and then on right
side of median line, until the extremity is covered in; then turn the
bandage at right angles so as to secure the folds still held by thumb
and finger with circular turns; the bandage may then be continued
up the limb by figure-of-8 turns.

Rectirrent Batidag:e of Head. — Fix the bandage by two cir-
cular turns around the head, passing just above the eyebrows in front,
as close to the tops of the ears as possible on the sides, and just under
the occipital protuberance behind; with the roller in front take a
right angle turn, so as to pass over top of head to occiput; double
back, and run directly forward just a little to one side of the median
line to the root of the nose; again double backward to the occiput,
this time keeping just a little to the other side of the median line.

The patient can be made to hold the front angle of turns and the
surgeon the posterior. Continue till head is covered in, then
complete the bandage by several circular turns about the head
to fix the recurrents in place. Pins may be introduced where the
recurrent turns were made to make the dressing more secure (Fig,
60).

Modified Barton. — The bandage should be started by two cir-
cular turns around the forehead and occiput; then, as the bandage
leaves the occiput, it should pass forward in the form of a circular
beneath the ear around the front of the chin and back under the op-
posite ear, where it begins to run obliquely upward, just under the
occiput and under and in front of the parietal eminence, across the

226 BANDAGING

vertex of the skull, downward over the zygomatic arch, under the chin,

then upward over the opposite zygomatic arch and o\er top of the head,

crossing the first turn in the median line and well for^vard. The handage

is then passed obliquely backward and downward under the occipital

protuberance and then out once more over the chin (Fig. 6i). These

fip;ure-of-8 turns are to be continued until roller is exhausted. The

original Barton's bandage omits the

_^^ turn around the forehead; this, how-

^ ^^^t^L-^- ever, adds greatly to its stability,

J^ ^^ ^IB'' '"'^^ Desault Bandage.— De-

J ^^L sault,' about the beginning of the nine-

^^k ^rMk, ^W leenth century, devised the following

^^k k^Jj^k apparatus for treatment of Injuries to

^^H ^^p^^ the clavicle. He place<I a wedge-

^B ^^ ^^ shaped jiad in the axilla, which was

t ^^^^^^ held in place by circular turns around

^^^^^^ the body and over the op])osite shoulder

(first roller) ; the arm was then securely

1.— 4KTos^5^^^^NDAOE EiNG p- baudagcd against this pad by circular

turns, tighter near the elbow than at

the shoulder (second roll) ; forearm supported at right angles in front of

the chest by narrow sling at wrist. The third roller was then applied

to keep the point of the shoulder elevated; starting in front, going

toward the injured side, the first turn passes over the distal end of the

clavicle, runs down back of arm under elbow, across front of chest to

opposite axilla, obliquely up across the back over shoulder, down front

of arm, under elbow, diagonally up and across back to axilla, where it

again goes forward and upward to shoulder as before, these turns to be

continued until bandage is exhausted.

Velpeaa Bandage.— V el peau,^ about 1839, finding the Desault
apparatus apt to cause serious pressure on the brachial vessels and
nerves, adopted the following metho<l of application for injured clavicle:
The inilial extremity of the bandage is placed in the axilla of the well
side; it runs diagonally up over the back and shoulder to the injured
clavicle; the hand of the injured arm is placed on the opposite shoulder;
the elbow, therefore, is over the tip of the sternum, thus throwing point
of shoulder up, back, and outward. The bandage now runs down from

' OeuvTos Chirurpralcs ou Eipose tie la Doctrine cl de la Prallr|uc <lc Dei/iull |>ar
Xav. Bichat, Troisifeme Edition, Paris, Megnignon. 1S13.

' Vdpcau, NouveuJt filemenls de iUdici'ie Operaloire, Deuxieme editiun. Paris,
Bailli,ri^, 1839.

MODIFIED VELPEAU

227

the c]a\ icie, first on the anterior then on the outer surface of the arm,
finally coming on to its posterior surface under the elbow and out
over the forearm and upward to the axilla, whence it started; these
turns are repeated twice to fix the bandage. Having compieted the
second turn, carry the roller transversely around the thorax, passing
over the flexed elbow of the affected side to point of origin; from here
it runs obliquely across the back to the injured shoulder as before;
these alternating turns are applied until arm and forearm are bound
firmly to side.

Neither the Desault nor the Velpeau bandage as originally described
is frequently used at the present time, but instead the following modi-

fication; this is useful for any injury about the shoulder or whenever
it is desired to have the arm immobilized against the thorax.

Modified Velpeau. — First the proper amount of padding is
placed in the axilla to fill in the hollows, but this is not of such a
material as to cause pressure on the axillary vessels and nerves; sheet-
wadding is placed also between the forearm and chest (Fig. 62). The
bandage is fixed by two circular turns around the arm and thorax; when
the roller reaches the axilla of the well side, it passes diagonally upward
across the back, over the shoulder at its outer point down to the front

2 28

ND AGING

I,und Swathe.'— The ^

of the arm, under the elbow, up the biick of the arm, over the tip of the
shoulder, across the chest to the
other axilla (Fig. 62). From here it
runs backward around the thorax
and arm, just at the tip of the
elbow, returning to the axilla; then
the first turn is repeated over the
shoulder, down the front of the
arm, under the elbow, up the back
of the arm, over the shoulder,
across the chest to starting-point,
from which a circular turn is
made (Fig. 63.) These turns are
repeated, leaving one-third of pre-
ceding turn uncovered, up the arm
and shoulder until all is co\'ered in
''•>■ (Fig. 64).
wathe as described by Lund is a most

efiScient method of immobilizing with comfort the forearm acutely

flexed at the elbow. A cotton swathe

of the width of the shoulder, and long

enough to make a figure-of-S around

the elbow and body, is passed under the

flexed elbow, horizontally, its center being

at the point of the elbow. The forward

end is carried snugly up around the fore-
arm and backward o\-er the shoulder,

diagonally downward across the back and

under the opposite arm, where it is

pinned to the other end, which is brought

fonvard to the front and carried in the

form of a circular about the thorax. A

simple modification of this which is often

used is to continue the part that passes

across the front of the chest and under

the opposite arm all the way across the

back, lo be pinned to the part surround-
ing the flexed arm, thus making a com-
plete circular turn around the body and siamnK ihc jipiJiciHion,

fixing the arm to the body ; the part brought over the shoulder is pirmed
' F.B. Lund. Med. and Surg. Rcporls. if the Boston Cily Hospital, eighth scries. 1807, p. 3,

Fig, fis— Ti

BREAST BANDAGE

to this circular piece as it crosses the back (Figs. 66 and 67). This
swathe can also be apjiiicd aci\'antageously after the method of Sayre.

Breast Bandage.— The Boston Lying-in Hospital ' bandage may
be easily extemporized by fastening together in the shape of a T two
strips of very stout linen cloth, such as towels. The strip, which forms
the tail of the T, should be about 4 in. broad, and long enough to a
little more than half encircle the patient's chest. The cross-piece
should be nearly double that length, and wide enough to extend from
a position one inch below the patient's breast to the edge of the areola.
This bandage is applied by drawing the tail of the T beneath the patient's
back, in such a position that its ends appear at the sides, on a line with
the nipples, and with the junction of the tail and cross-bar well external
to the edge of the breast on that side. The lower edge of the lower
half of the cross-bar should then be drawn tightly across the chest, care
being taken to see that it is below the lower border of the glandular
tissue. It is fastened by a safety-pin to the free end of the tail-piece,
and is prevented from slipping upward by attaching it lo the upper
edge of the obstetric binder, at two points, which should be opposite
the most dependent portions of the breasts. The upper edge of the
other half of the cross-bar is then drawn across the chest, entirely abo\-e
the breasts, and is pinned lo the other corner of the free end of the tail-
piece. It is prevented from slipping down by shoulder-straps, not less
than 2 in, wide, which are attached to it opposite the upper edge
' Reynolds and Newell, Pratlite of Obslctrics, 1902, p. 505,

230 BAXDAOING

of the breasts, carried o\'er the shoulder, and pinned to the tail-piece
in the middle of the back. The whole surface of the breasts should
then be thoroughly dusted with jJOH'dered starch or some other powder
and a large \\'ad of absorbent cotton placed between Iheni. The breasts
are then drawn strongly inward by the hands of the patient, and the
bandages pinned together on each side of the axilla, begirming at the
outer edge and then working upward toward the nipple, care being
taken that the pressure is uniform; the edges of the strips are then
brought together between the breasts with safety-pins.

When used to exert pressure uj)on badly caked breasts, it should
be drawn as tightly as possible «-ithout seriously embarrassing respira-
tion. Its pressure there almost invariably results in the expression
of al! the milk, but produces so much discomfort that it has to be loosened
after a few hours.

To catch the discharge from the breast a dressing can be placed
over the nipples and held in place by lightly pinning an extra piece
over the front (Figs, 141, 142, 143, pp. 44;, 448).

Many-tailed Bandage.— This consists of a piece of colton cloth
of Ihe desired length and wide enough to considerably more than sur-

round the part; into each side tears about 3 in. apart are made. It
is extremely adaptable and very con\enient for holding in place wet
dressings that have to be frequently changed. The lower pair of tails
are knotted once and the ends layed upward; the next pair are knotted
over the ends of the first; these ends are laid upward and the third pair
knotted over them, etc.. until the last pair are reached ; they are tied in a
bow-knot, so as to be readily opened (Fig. 68).

Swathes. — Swathes are used for maintaining in place abdominal
and thoracic dressings, and are merely pieces of cloth the desired width

LACED ADHESIVE DRESSING

231

and length to go around the body and are fastened by pins {see Fig.
153' P- 486).

T-Bandage. — This consists of a narrow belt, to the middle of
which one or two pieces are sewed at right angles. It is used to hold
perineal dressings and vulvar pads in place. The cross-bar of the T
goes about the waist, the vertical limb, starting from the middle of the
back, passes between the legs and is carried up onto the front of the
abdomen. The three ends meet and are pinned together over the
pubes.

Cunningham Hernia Dressing. — This is made of a piece of
Canton flannel 6 in. wide and 16 in. long, to each end of which is sewed
a strip of adhesive piaster about 16 in. long. The flannel part sur-
rounds the leg; the adhesive pieces cross over the inguinal region and
adhere to the flanks. {For illustration, see Fig. 155, p. 488.)

I,aced Adhesive Dressing. — This belt, which serves at once
to hold the dres mg m place to take tension off the wound, and to do

-^1 i ' ,

■8

away with the necessity of an encircling band or swathe, was first
described in Heister's Surgery,' and was first used in its present form
by Dr. Ernest W. Gushing, of Boston, in 1894. It consists of two
pieces of zinc oxid adhesive plaster {Fig. 70), g to 8 Inches long and
3 to 6 inches wide. One edge is folded over on itself for about i inch
with a stick of wood, such as is commonly used for making swabs,
within the edge of the fold. This stick gives a firm edge to support
'Venice, 1750, Vol, i, p. log.

BANDAGING

the strain of the lacing. Into this turned over margin are now punched
a series of metal lacing hooks about i inch apart. (A hand tool for

Flo. 71. — Laced

applying these can be purchased for $1.50.) The sticky side of the
plaster, from the hook-edge In, is covered for about 2 inches with sheet

ADHESIVE STRAPPING 233

wadding, to prevent its adhering to the dressing. The rest of the
plaster is applied to the skin on each side of the dressing, so far away
that when the edges are thrown back the whole dressing may be
removed, and when laced there may be enough tension to give a sense
of support. For abdominal wounds it is far more comfortable than,
and fully as efficient as, any other retentive appliance. A photograph
showing it applied appears on p. 2,;3.

Strapping the Ankle. — Take about six pieces of adhesive
plaster, 1 in. wide and 18 in. long. To relieve and fixate the internal
ligament start the first piece on the dorsum of the foot, pass outward
around outer edge, beneath the arch, up the inner side diagonally.

up the ajikle to the outer side of the calf. Apply all the strips each
overlapping the next about one-half inch. To splint the external
ligament reverse the direction (Fig. 72).

Strapping the Rihs. — Have six to eight adhesive-plaster strips,
2 in. wide and long enough to encircle the body; direct the patient to
stand with arms elevated and the uninjured side next to the surgeon.
Apply the initial end of one strip to the side and order the patient to
turn around. The patient then proceeds to wind himself up into the
piaster; the amount of tension will be regulated by the resistance which
the surgeon, holding the unattached end of the plaster, offers. Each
strip overlaps one-third of the preceding strip. This is more effective
in controlling the pain accompanying respiration than strapping one-
half of the thorax, as often recommended. When many ribs are frac-
tured, care must be taken not to apply too tightly, as there is danger
of causing inward buckling of the fragments with increase in pain.

BANDAGING

Strapping the Knee.— Take three pieces of adhesive plaster,
ij in. wide and 9 in. long, apply one strip above and one below the

patella, and the third piece directly over the patella, running trans-
versely from one hamstring to the otbcr, overlapping the other two
about I in. (Fig. 73).

Sling.— .A piece of cloth to be used as a sling is usually cut in the
form of a right-angled triangle, with the legs about 20 or 22 in. long for

an adult. It is used to support a part, especially the forearm. The
right angle is placed at the elbow, the forearm rests in the trough as the
ends of the string are brought up, one in front of and one behind the

SUSPENSORY BANDAGES 235

forearm, and tied or pinned at the neck. A pinned sling is much
neater and less irksome than the tied one (Fig. 74). If it is tied, care
should be taken that the knot is to one side or the other of the median
line. The sling should include the entire hand, and a pin or two may
be necessary at the elbow.

Double Sling. — Instead of using a modified Velpeau a so-called
double sling may be employed to support the forearm and hold the
humerus against the side. The first sling should be applied as already
directed. The right angle of the second sling should be placed at the
shoulder and the long edge at the elbow. The two ends are pinned
together in opposite axilla (Fig. 75).

Suspensory Bandages. — The object of suspensory bandages is
to keep the testicles elevated. The objections to the many forms of
commercially made suspensories are in the main two:

First, that they are, as a rule, made in three sizes, and, unless the
physician instructs the patient as to the size necessary in the given case,
the bandage may be too large to keep the testicles elevated or so small
as to exert undesired pressure on the organs. Also if the suspensory
bandage is used for a swelling of the testicles, the bandage becomes too
large as the swelling subsides.

The second objection is that the majority of suspensory bandages
exert pressure in the region of the external abdominal ring, as the belt
holding the bandage usually presses over this area. It is believed that
this sometimes hinders the drainage of inflammatory products through
the vas deferens in instances of epididymitis. It' also exerts a del-
eterious influence in varicoceles of large size, hindering the flow of
blood from the veins of the cord, and thus inducing and maintaining
congestion.

With the end in view of overcoming these objections the fol-
lowing forms of suspensory bandage, which are adjustable in size and
exert no pressure over the spermatic cord, have been devised by Dr.
John H. Cunningham, of Boston, for the purposes indicated.

Hammock Suspensory. — This suspensory is, made of heavy Can-
ton flannel. It consists of an oblong piece of flannel, 16 in. long by
8 in. wide, from the ends of which a V-shaped piece is removed. A
buttonhole is cut in each corner. A webbing belt is placed about
the waist and buckled. On this webbing belt are sewed two buttons,
occupying positions over the anterior superior spines of the ilia. The
suspensory is placed well under the scrotum, with the soft side of the
Canton flannel against the scrotum, and the upper ends of the suspen-

236 BANDAGING

sory buttoned in position (Fig. 76). The lower ends are now turned
up over the scrotum and penis and also buttoned, holding the scrotum
in the hammock {Fig. 77), If there is so much pressure in the peri-

neum as to be uncomfortable, the waistband may then be adjusted.
No perineal straps are necessary. When urination becomes necessary.

Fic. r8. — HAiniocK Suspensory.

the two lower arms may be unbuttoned and the bandage dropped, or
a hole may be cut in the suspensor>- through which the penis is drawn
(Fig. 78).

SUSPENSORY BANDAGES

237

Adhesive Plaster Suspensory. —Thh method of sus|)ension may Ije
used with advantage in all operations upon the scrotum in which the
scrota! incision has been completely closed, in ambulatory cases of
epididymitis, and in all other cases of epididymitis in which applica-
tions to the skin are not used. In operative cases it prevents the scro-
tum from hanging down and thus increasing the tendency to infiltration
of blood into the lax scrotal tissues. In the ambulatory cases of epi-
didymitis the scrotum is su]>porled continuously, and the bandage can-

not be loosened up or remo\'ed by the patient, as is sometimes to be
feared, especially in the class of patients which are accustomed to fre-
quent the out-patient clinics.

The suspensory consists of a piece of adhesive plaster, 5 in. wide
by 12 in. long, and is applied as follows: Patient lies with the legs
spread apart. The scrotum is held ele\-ated by an assistant. The
adhesive plaster is placed across the perineum on a line with the junction
of the scrotum and the [perineum. The plaster is then brought upward
across the scrotum, and split in the center from the upper end down-
ward to a point corresponding to the Junction of the penis and scrotum
(Fig. 7g). The penis is drawn forward into the apex of this slit and
the two ends fastened to the abdomen (Fig. 80J. The plaster is then

238 BANDAGING

made to fit the sides of the scrotum by sticking the two free edgt
gether. In the upright position the testicles are held elevated.

riG. 81. — Perineal Dressisc.

If a large scrotal dressing is employed, an additional strap placed
across the scrotal bandage and fastened to either side of the scrotum
may be of service.

PERINEAL DRESSINGS

239

Perineal Dressing Ba-ndage.— This consists of a waistband, 48 in.
long and 5 in. wide, in the center of which are sewed 2 flaps, 36 in. long,
one of which is split in the center (Fig. 81J. It is applied as follows:
Patient is in the dorsal position, with the legs spread apart. The

waistband is fastened about the waist by safety-pins. The scrotum
is held elevated by an assistant and the perineal dressing applied. The
two flaps are crossed over the dressing and a large safety-pin, including'

the dressing, is placed in the center of the perineum (Fig. 82). The
edges of these flaps are united by safety-pins around the scrotum, which
is held in an elevated position. These flaps are then united to the

240 BANDAGING

waistband by safety-pins (Fig. 83). The perineal dressing is thus
held firmly in position and the testicles are elevated and held securely
away from the perineal wound. The large flap is then turned up and
fastened to the waistband, thus covering the under flaps and scrotum,
aiding in support and in appearance (Fig. 84). If a catheter is placed
in the bladder through the perineal wound, the two flaps are pinned
around it and the outer flap perforated.

CHAPTER XXIII

TREATMENT OF THE OPERATIVE WOUND i DRESSING,
STITCHES, DRAINAGE, AND STITCH ABSCESS

Time for Dressing.^Tlic naturul tendency of wounds is to
heal aseptically by first intention, and accordingly it is not advisable,
as a rule, to disturb the sterile dressing applied at the time of operation
until the time for the removal of the stitches is due. Vet suppuration
may take place where it is tlic least expecled^any one of many factors,
such as septic suture material, stitches tied too tightly, blood-clot in

the wound, etc., may enter in to mar an othenvise perfect healing. Ac-
cordingly, it is of considerable importance to detect the presence of
suppuration at the earliest date possible, that it may at once be ade-
quately dealt with, and prevented, if may be, from spreading to the
whole wound; if this is neglected, when the time comes to remove the
stitches the wound will be found separated and more or less broken
down and the dressing saturated with pus.

The most valuable guide to the septic or aseptic state of the wound is
the temperature chart (see p, 59). Ordinarily, after any perfectly aseptic
operation, it is the rule to find the temperature rising to between 99"
and 100° F. within forty-eight hours after the operation, as has been

242 TREATMENT OF THE OPERATIVE WOUND

detailed before. This is a favorable reaction; in the worst cases it does
not occur or it may be replaced by a depression. The temperature
reaches normal again by the afternoon of the third day. If the tem-
perature does not drop on the third day, or if, having reached nor-
mal, it rises again at any time from the third to the sixth day, sepsis
in the wound is to be strongly suspected, and the wound should be
examined under aseptic precautions. Pain referred to the site of a
wound appearing on the third day or after, under conditions where
pain would not be expected, is frequently a sign of inflammation and
sepsis.

On examination, however, it may be found that the pain is due to
the irritation of the stiff suture ends pricking or scratching the skin, or
to the discomfort of the gauze which is next the wound becoming caked
from the dried blood or serum. In either case relief may be afforded
by applying new sterile gauze next the wound, by means of sterile
forceps, removing the caked gauze, and reapplying the old dressing.
Sutures causing irritation may be rearranged or snipped off. In this
procedure it is not necessary to touch the wound or the gauze except
with sterile forceps.

Aseptic Wounds. — Unless there is some good indication, — for
instance, the dressing has become loose and misplaced, has been soiled,
or soaked with blood or serum, — the dressing should not be disturbed
until the time set for the removal of the stitches. The small amount
of blood and serum which ordinarily soaks into the dressing from a
tightly dosed wound becomes coagulated in the air, at the same time
serving to seal the wound and to splint and support the skin-edges. If
the hemorrhage or serous effusion has been so considerable as to soak
the dressing through, so that the outermost layers are moist and damp,
the dressing should be changed, because the moist areas serve as an
admirable breeding-place for bacteria, along which their growth may
rapidly proliferate imtil they reach the wound. If for any reason it
becomes necessary to change an aseptic dressing, all the proprieties of
aseptic technique should be observed with the utmost exactness. It
is best to leave in place imtouched the innermost layers of gauze which
are in direct apposition to the wound.

STITCHES

A good rule-of-thumb as regards the removal of sutures is "stitches
out on the seventh day.'' This applies to the vast majority of aseptic
cases. If the wounds are small, and if they are on the face or neck,
where healing is rapid and the best cosmetic results are desired, and

REMOVAL OF STITCHES 243

if the stitches axe under no tension and simply maintain the skin -edges
in approximation, they may be removed as early as the third day. If
this is done, it is well to hold the skin-edges together for a few days
longer, either by narrow strips of adhesive plaster or by gauze or cr6pe
lisse and collodion, so that they may not be pulled apart by muscle
action or by any sudden strain. If the woimd is long and deep, if
the sutures hold the parts together under considerable tension, the
wound is so situated that muscle pull would tend to separate the edges
or stretch the scar, or if a great deal depends upon the sutures, as, for
instance, in the case of a laparotomy sewed up rapidly by mass sutures
of silkworm gut, the stitches should not be removed until ten days
or two weeks have elapsed, and then, if there is any question of the
ability of the scar to stand the strain to which it will be subjected, the
strain should be relieved by adhesive straps, a swathe, bandage, or some
other device.

In a long abdominal wound, or in any case where a great number
of skin sutures have been taken, as after amputation of the breast, the
stitches may be removed by stages, at intervals of a day or two, partly
for the comfort of the patient and partly to test the healing of the inci-
sion. As a general rule, the sutures holding the skin-edges should be
removed first and the tension sutures last, unless there is reddening of
the skin about the tension sutures, when they should be taken out first.
Some English surgeons leave their sutures in place after a celiotomy
for as long as three weeks. This does fairly well with silkworm gut or
horsehair, but a silk suture, whether on account of its irritant action
on the tissues or on account of its great capillarity, is apt to show signs
of infection after a week or ten days, and it should not be left in any
longer than that. If the wound has been sutured with a running stitch
of plain catgut, a week or ten days usually suflSces to soften up the catgut
under the skin sufficiently so that a gentle pull will bring away the
remains.

Patients have been taught to look forward with some apprehension
to the removal of stitches. It is only in rare cases that the removal
causes actual pain, and then it is frequently due to a dull pair of scis-
sors or an unsteady hand. The relief that is felt after the sutures are
out, the knowledge that the dread ordeal is over, coupled with the as-
surance from the surgeon that the woimd is healing nicely, more than
suffice to pay for whatever petty discomfort may attend the process
of removal. As with all dressings, — and this applies particularly in
a hospital, — preparations should be made quietly and out of sight of
the patient. The only instruments absolutely necessary are scissors

244 TREATMENT OF THE OPERATIVE WOUND

and forceps. A pair of slendcr-bladed "double-blunt" scissors should
be selected which will cut at the point. They should be tried, before
boiling, on loose absorbent cotton; if the tips do not cut clean, or if
there is any pulling of the fiber, they should, if we are particular of
our patient, be rejected. There is a s]>ecial instrument used at the St.
Mary's Hospital, Rochester. Minn., called the Li ttauer- Paynes stitch
scissors (Fig. 86j. Both of the blades arc blunt, raakinj^ it inapossible
to injure the tissue while removing the stitches. The stitches are
lifted away from the skin by
the hook at the end of the lower
blade.

The forceps should be the
so-called "anatomic" forceps,
witii rather weak spring and
slender points. These, with the
scissors, should be boiled in
sodium bicarbonate water in the
tray from which they are to be
used — not long enough to injure
the cutting-edge of the scissors —
the water jioured off, and the tray placed u])on the table or bedside "car."
The car should carry, in addition, a basin of corrosive sublimate or
weak alcohol for the surgeon's hands or to wipe the skin clean of dried
blood, an empty basin to hold the soiled dressing, sterile gauze in can
or package for the new dressing, a sterile towel, bandage scissors, ab-
sorbent cotton, adhesive plaster, bandage or swathe as needed, and
a clean sheet or t^vo to drape the patient. Before the car is wheeled in
the one in charge should assure himself that everything which may be
necessary is at hand, for nothing suggests to the patient incompetency
so much as the necessity for holding up in the midst of a dressing while
a nurse is scurrying about for some forgotten collodion, adhesive, or other
matter.

The surgeon scrubs his hands clean, using especial care if he has
recently come in contact with a septic case, while the nurse wheels in
the car, arranges the screens, drapes the patient, and removes the
bandage or swathe. Then the nurse removes or turns back the outer
layers of the dressing, down to the gauze in contact with the wound,
which she takes care not to touch. The surgeon can noH' remove the
dressing without breaking his asepsis. So far as possible e\-erything
should be done with instruments — scissors, director, hemostatic or
thumb- forceps (Fig. 82). If the dressing has "caked" and stuck to

REMOVAL OF STITCHES 245

the wound and sutures, the gauze may be moistened with the antiseptic
solution to avoid pain in pulling it off.

In cutting the sutures the surgeon should grasp one end with the
forceps and pull slightly, on one side, so as to expose a bit of the suture
which has been buried. The scissors should now be slipped flat under
the suture, and, the points being depressed so that they will divide a
part of the suture which has not previously been exposed, the suture
is cut and removed by a quick movement of the hand holding the for-
ceps. If these procedures are accomplished rapidly and deftly, with
a steady hand, there will be no pain. The suture should be lifted before
cutting for two reasons — because the exposed portion of the suture may
carry infective material which, being wiped off as it is pulled through the
skin and subcutaneous tissue, may give rise to sepsis in the wound,
and because the suture material, especially if it is stiff, as silkworm
gut, is apt to bend at a sharp angle just at the skin level, and if this kink
is pulled through the suture track, it will cause pain. The direction
of the pull should always be straight upward or toward the incision,
partly because the suture comes out more readily, partly because if the
suture sticks, a pull away from the wound is likely to pull the edges
apart. If the suture does not come away at the first effort, the tips of
the scissors, separated slightly, can be used to make counter-pressure
on the skin on either side of the hole from which the suture is being
pulled. In persons with fat abdominal walls, if considerable tension is
placed upon the sutures, they may be actually buried out of sight. In
this case one of the long ends must be grasped and pulled imtil the knot
is brought to view, when it can be divided below the knot.

If the wound edges have been brought together by intracuticular
stitch, the same procedure should be adopted. If the wound is a long
one, sometimes it is difficult to pull the stitch out; to avoid breaking, it
is wise to take a grip with the forceps — the other protruding end being
cut short below the skin — and slowly wrap the suture about the forceps,
by revolving the forceps bet\veen the fingers while pulling. If the
suture breaks under the skin, as it sometimes does, the wound edges
should be gently separated with the scissors tip at a point about the
middle of the fragment left behind, the suture grasped and removed
through the wound. The separated edges should be held approximated
by collodion or adhesive.

Many fanciful and artistic devices have been suggested for holding
wound edges together by means of adhesive plaster, mostly with the
intent of providing a narrow bridge of adhesive at the point where it
crosses the wound, or of doing away with this bridge altogether. These

246 TREATMENT OF THE OPERATIVE WOUND

include the butterfly and dumb-bell plasters and the dumb-bell and
window plaster previously described, and plaster strips incorporating
hooks and eyes, hooks to be laced over the wound (Fig. 162, p. 506)
or to be approximated with rubber bands, and strips incorporating silk
ties, to be tied over the woimds. These devices are usually unnecessary.
Narrow strips of plaster of good length, if applied while proper approx-
imation is being made, suflSce for this purpose.

DRAINAGE

Drainage is provided for one of three reasons — hemorrhage, serous
oozing, and sepsis. Depending upon the situation, the size of the
wound, and the purpose, a drain ordinarily may consist of one or more
strands of catgut, the selvedge of sterile or iodoform gauze, a piece of
rubber dam doubled upon itself or coiled in the form of a cornucopia,
strips of gauze, or a glass or rubber tube. After operations involving
considerable dissection, if muscle is divided and there is oozing of blood,
as after a thigh amputation, or if there are any pockets in which serous
ooze might collect, as in the axilla after a breast amputation, it is well
to put a drain in at the most dependent point; rubber dam is best, be-
cause it will not plug up the opening and can be removed readily and
without pain. In case of sepsis we are apt to use gauze or rubber
tubing, and this condition we will consider later.

In an aseptic wound it is not desirable to leave drainage any longer
than is necessary to subserve the purpose for which it is placed. It
delays the healing of the wound, it may cause an unsightly scar, and it
provides a moist, warm, nutrient track along which infection may readily
propagate until it reaches the depths of the wound. As all the oozing
which is going to occur usually ceases by twenty-four or forty-eight hours
after the operation, the drainage in aseptic incised wounds should always
be out by this time. At the time of the operation one or two " provisional "
sutures of silkworm gut should have been taken at the site of drainage,
with long ends tied loosely. These now may be firmly tied, the drainage
being out, approximating the separated edges and encouraging primary
union. Aseptic drained wounds should be dressed as little as possible,
for the possibihty for infection from without is great. The best rule is,
leave the dressing alone until twenty-four or forty-eight hours have
passed, depending on the amount of ooze expected; then dress, remov-
ing wick, and tying the provisional sutures. Put on a clean sterile
dressing and leave imdisturbed until the stitches are due.

In the abdomen the indications for drainage are practically the
same — the serous ooze from wounded surfaces and the secretion of

WHEN TO DRAIN 247

the irritated peritoneum; the bloody ooze from raw areas and the
bleeding from fine vessels which could not be found or tied but have
to be controlled by pressure; and infected or seropurulent fluid.

When the normal peritoneum is handled or irritated, as in the manip-
ulations of any intra-abdominal operation, it secretes a serous fluid,
the amoimt of which varies in proportion to the trauma and the extent
of surface which has been injured. For instance, after an easy ap-
pendectomy the amount of exudation will be so limited that it will be
absorbed by the contiguous healthy peritoneum about as fast as it is
formed; if the appendix has been found buried, or if many adhesions
have had to be separated, the advisability of leaving in a drain will be
decided by the condition of the patient and the experience of the operator;
if there has been extensive overhauling of tissues, and considerable areas
of raw surfaces have been left behind, as after a double salpingo-hysterec-
tomy, there may be secreted a very considerable quantity of fluid — faster
than the peritoneum with which it comes in contact can absorb it. As
a result, it tends to gravitate, together with whatever blood may have
oozed out through the lines of sutures, into Douglas' pouch, and here
it is extremely likely to stagnate and become infected, either by decom-
position as a result of the growth of bacteria introduced during the opera-
tion, or, as is likely, from contamination through the wall of the intestine.
To prevent the occurrence of peritonitis any case in which we appre-
hend that there will be considerable exudation should be drained,
especially if there is any possibility of this fluid becoming infected
through the escape of nonsterile fluid or pus into the abdominal cavity,
or through the opening of viscera. ^^ And in any case of doubty^^ says
Greig-Smith, "/7 is wise to drain,^^

It is not conmionly that the abdomen will have to be closed without
the assurance that all hemorrhage has ceased. Occasionally, however,
this happens, after long and extensive operations in the female pelvis,
after operations for abdominal trauma, such as rupture of the spleen,
and in operations for postoperative hemorrhage. The customary pro-
cedure, in case of actual hemorrhage, is to pack tighdy with gauze, so
as to stop the bleeding by pressure; if there is slow capillary hemor-
rhage or oozing, a glass or rubber tube is left in, through which, by capil-
lary attraction or the use of an aspirator, the blood and serum are removed
so as to keep the abdomen dry and encourage clotting.

In case of general peritoneal injection the object of drainage, whether
by tube or gauze, is (i) to allow free escape of septic fluids, the intra-
abdominal pressure being higher than the atmospheric; (2) to encourage
the escape of these fluids by gravity and by capillary siphonage; and

248 TREATMENT OF THE OPERATIVE WOUND

(3) to a greater or less extent to excite by local irritation an increased
peritoneal secretion, both for the purpose of diluting and of antagoniz-
ing the infective matter. If the sepsis is local, drainage has, in addition
to these functions, the purpose of keeping the intestines away from
the infected focus, and of deliberately exciting the growth of adhesions
to form a wall surrounding the focus and excluding it from the rest of the
abdominal cavity.

The oldest form of abdominal drainage is the iflass tube. This,
in its simplest form, is a cylinder about t\vice the diameter of a lead-
pencil and two-thirds as long, with carefully rounded edges, and near
its proximal end a collar to prevent its slipping through the woimd into
the abdomen, and near its distal end two or three fenestra. Nowadays,
in America at least, the use of the glass tube seems to be going out of
fashion, although it clearly has some advantages. It excites the forma-
tion of no adhesions and its lumen is always patent. The discharge
of fluid through it depends upon intra-abdominal pressure and the
capillary attraction of the dressing. It is usually wise to reinforce this
action by means of gauze inserted through the tube or by means of
the "sucker." Either method is practically ideal for aseptic cases.
With a gauze wick run through the tube we have all the advantages of
continuous capillary drainage exerted just where it is applied, and
nowhere else, without exciting adhesions. The drainage action cannot
be shut ofiE by a pinching of the gauze wick by the abdominal wound, and
if the serum clots in the wick, a new one can readily be inserted.

A "sucker" is a sterilizable glass syringe with firm valve packing
having a piece of rubber tubing or a catheter attached, long enough to
reach through the drainage-tube to the depths of the wound. The
syringe is worked reversed, so as to exhaust the drainage-tube of the
blood or fluid it contains. In case of hemorrhage the sucker should
be employed often enough to keep the peritoneum dry — every few
minutes if necessary. If the end and the fenestra of the tube are
blocked by opposing omentum or bowel, the tube should be pulled out
a bit and slightly rotated. If the fluids are thick, or if they clot within the
tube, the "sucker" will have to be used.

As with all drains, the glass tube should be removed as soon as the
case will allow, partly on account of the great risk of infecting the peri-
toneal cavity from without through the drainage tract, and partly on
account of the resulting malapposition of muscle and fascia in the scar,
and the consequent liability to postoperative hernia. If the tube has been
left in for hemorrhage or oozing, it can, as a rule, be safely removed
after twenty-four to forty-eight hours, or as soon as the discharge ceases;

HOW TO DRAIN 249

if for suppuration, it should be left in two to four days and then re-
placed by a rubber tube or gauze wick. The glass tube comes out, as
a rule, more easily than any other form of drainage. Before with-
drawing it should be loosened, if straight, by twisting or rotating it
slightiy. In pulling it out one must be careful that no omentum is
caught in the fenestra; sometimes small tabs will become incarcerated
within the tube and they will have to be tied off. In using the glass
tube care must be taken that the tube does not slip in through the wound
and be lost. Glass tubes have been known to break while the
patient is vomiting or straining. The swathe and dressing should be
adjusted carefully, so that the tube is not forced in hard enough that
by pressure on the intestinal wall it may cause perforation or partial
obstruction.

In applying the gauze dressing, as in all abdominal drainage, whether
depending upon a tube or upon capillary attraction, the principles
governing the siphonage of fluids should not be forgotten. Other things
being equal, the greater the mass of gauze outside the wound, the greater
will be the capillary attraction, and the lower this gauze is massed
below the level of the fluid to be exhausted, the greater will be the force
of the siphonage exerted. In other words, the gauze dressing should
be bulky, and should be carried well down the patient's side and even
part way under his back. If it is moistened with sterile salt solution,
its eflSciency is increased.

The rubber tube was first introduced as a substitute for the glass
tube. It is less dangerous mechanically, inasmuch as it cannot break,
and there is little danger of its causing perforation of the bowel by
pressure. It is used generally for draining particular cavities, such as
the pleural, and hollow viscera — the bladder and the gall-bladder. In
the abdominal cavity its use is practically limited to diffuse peritonitis,
and here it is invaluable, being employed in the abdominal woimd, in
the flank, and through the vagina. It should be thoroughly sterile and
comparatively fresh, otherwise it is liable to decompose and soften if
kept in an antiseptic solution, or else become stiff and brittie if kept dry.
The lumen may be of any size to suit the individual case; it should be
fairly thick-walled, otherwise the lumen is likely to be choked off by
the pressure of the abdominal muscles as it passes through the wound,
especially in the gridiron or right rectus incision. The ends should
be clean cut, and there should be fenestra provided at the end to be in-
serted, so that if one opening becomes occluded, valve fashion, by a
piece of intestine or omentum, others will be provided. If the tube is
fenestrated its entire length, it will interfere with the siphonage, and

250 TREATMENT OF THE OPERATIVE WOUND

will allow of the spreading of infected fluid from one focus among
the intestines and betw^een the layers of the abdominal wall.

Gauze is used as packing to stop hemorrhage, as a drain to draw
off serous and seropurulent fluids by capillary action/ and as a local
irritant to set up a plastic peritonitis and so wall off a localized septic
focus from the rest of the abdominal cavity. Its use to drain the
general peritoneal cavity is limited to about eighteen hours, on ac-
count of its being excluded by adhesions. When used to stop hemor-
rhagic oozing by pressure, it should be out by forty-eight hours. If
during the withdrawal fresh blood appears, part of the packing may be
left in, to be removed twenty-four hours later.

Gauze excites a proliferation of every peritoneal surface with which
it comes in contact Granulation tissue grows into its meshes, making
it oftentimes extremely difficult and extremely painful to remove on
account of the tearing of these granulations, which sometimes bleed
considerably. Before forty-eight hours it will be found to come away
comparatively easily, because by this time the proliferation has not
gone very far. After four to six days from the operation the granula-
tions soften down and retrogress under the influence of the secretion
which has backed up behind the wick, and at this stage it will come
out easily as at first. If it is left in so long, however, it is likely to be
followed by a considerable gush of seropurulent fluid, which has col-
lected, and may be under some pressure, betw^een the wick and the
abscess wall it has created, for plain gauze wicking ceases to serve
as capillary drainage after about forty-eight hours; serum inspissates
within its meshes and clogs its action, so that after forty-eight nours
it may act simply as a plug; medicated gauze goes out of action so far
as capillary drainage goes earlier than plain. The rule with gauze drain-
age, then, is to remove it within forty-eight hours, or not until four days.

If the patient is nervous and dreads the pain that the removal of a
tight wick will cause, it is best to give gas, ethyl chlorid, or chloroform.

* Royster (The Inconsistencies in Gauze Pack, Ann. Surg., 1908, xlviii, 219) states
that gauze, instead of facilitating the removal of wound products, acts as a successful
stopper to the outlet of the wound and impedes the natural outflow from it. When in-
tended for a drain, gauze should be inserted after the manner of a lamp-wick — that is
to say, it should maintain the patency of the wound orifice without either clogging the
cavity or obstructing the opening. WTien used for hemorrhage, it should be packed
in like wadding with a ram-rod. The edges of the wound begin to contract around it and
become adherent to it in a few hours. Unless the secretion be very thin, no capillarity
will be present. There is a field for the use of gauze in packing sinuses, fistulae, and
granulating wounds so that healing may take place slowly from the bottom. Even here,
however, the pack should be loosely done, and the gauze preferably saturated with some
substance which will prevent sealing of the wound edges.

REMOVAL OF DRAINS 25 1

It IS the first pull which is most painful; if the adhesions are separated
by a preliminary jerk, the rest is apt to be less uncomfortable. The
wick should be seized by forceps or with the right hand, while counter-
pressure is being made on either side of the wound with the left, and
rotated or twisted on itself, while it is being gently withdrawn, pulling
first to one side and then to the other. The hands should be sterile,
so that any omentum w^hich is being dragged up into the wound may be
replaced. If bright blood appears on the gauze, part of the drain
should be left in for tw^enty four hours longer. If the wick is being
removed early, in a supposed sterile case, and pus appears on the drain,
another should be left in for three or four days longer, to prevent the
infection from spreading and allow the focus to wall off.

When an infected drainage cavity is well established as a single
cavity without side-pockets, and the amount of discharge is only that
which might be expected from a granulating surface, the wick is left
out and the wound poured full of balsam of Peru or sterile glycerin
and so left. Such an emollient is dehydrating, stimulating, and slightly
antiseptic, and yet prevents the skin from closing over before the depths
are healed. If a wound is draining pus, the wick should not be allowed
to lie upon the skin, on account of the danger of stitch abscesses — it
should be well wrapped in gauze. If the wound or stitch holes tend
to become red or macerated from infections or irritating discharge, dry
the woimd margin and a zone about 2 in. around it in all directions
thoroughly, then apply, with cotton or camePs-hair brush, compound
tincture of benzoin, letting one layer dry, then applying another.

Provisional sutures should be tied only if the drainage has been
removed within the forty-eight hour limit and there is no sign of infec-
tion. For gaping of the woimd later adhesive straps should be used.

Vaginal drains should come out on the second or third day. With
the patient at the edge of the bed, in the Sims posture, and a speculum
in place, the wick may usually be removed with little pain. If it shows
signs of the presence of pus, it should be replaced by a fresh one; other-
wise the vagina is washed out gently and is lightly packed with sterile
gauze.

Sometimes a surgeon will combine one or more methods of drainage;
he will wrap a glass tube in gauze before inserting it down to the pelvis,
he will wrap a gauze strip in rubber dam and call it a "cigarette" wick,*

* F. Hawkes (Ann. Surg., 1909, xlix, 192) states that the force of gravity is important in
draining parts of the abdominal cavity which are not in direct contact with the capillary
drain. A complete emptying of these other parts into the drain should occur within the first
twelve or eighteen hours after operation, for it is exceedingly doubtful if any drainage occurs

252 TREATMENT OF THE OPERATIVE WOXTND

or in a rubber tube split or cut spirally (Fig. 87). A tube wrapped in
gauze usually drains freely, both by capillary action andintemal pressure.

-^^

In a septic case the tube should be removed in about forty-eight hours
and the gauze left in until the fourth or sixth day. The cigarette wick

t has the advantage of being re-

^ moved painlessly and of limiting

I^|^^^HBB| the irrltadng effect of the gauze

^^HI^^HPP to the area about the tip. The

I same may be said of the gauze

'^^^^^^^^A[ wrapped in a spiral cut rubber

'■■ , _ tube. Either should be removed

^ as any gauze wick. Sometimes a

surgeon will use for an appendix
P ' abscess or a localized peritonitis

iiG. a8.-DFAts*0F. ^ rubber tube and a half dozen

A, Rf<i;,i iJuK, iimLiin™ riTPoi rui,i«iuianK; smail gauzc wicks. The small
cariiies."'' '" ""*'"'*" " "inMco jr^t wicks have the advantage of com-
ing out more easily than ihc large.
The tube is removed on the second day, two of the «icks on the third,
two on the fourth, and two on the fifth, and the last ones are replaced by

after this lime, nhatever form of drain be user!, from ihc portions not in lontact with the
drain. \ loosely rolled cigarette drain, without any projection whatever of Rauze from
ils lower end, is the less irritaiinc, and will drain adjacent rcRicms iierfectly for tiielve to
eighteen hours if adhesions have not formed in them Iwfore operation, and if the fluid
to be drained is not ton thick, but no longer. Capillary action is not so im|>ortant u^^ intra-
abdominal pressure. .More surReons are ReitinR away from prc)longed draininRs with
better results. Remove the drain at the first possible moment and allow the wound to
heal.

STITCH ABSCESS

253

Fig. Sg. — Mikulicz Tampon for Peritoxeal Drain-
age.

a single wick, just long enough to keep the wound edges apart. This is
practically equivalent to packing an abscess-cavity.

Unless the peritonitis is well walled off at the time of operation, it
is unwise to remove any drainage until the gauze has caused a wall to
form about it — say, in four or five days — otherwise pus from the wick
may be spread broadcast over adjacent coils of intestine. In an early
general peritonitis, where there are few or no adhesions to interfere,
if the abdomen is left full of salt solution and adequate drainage is pro-
vided, currents of flow are set
up from all directions to the
wricks, which carry off the di-
luted septic material. In pa-
tients with sufficient resistance
the infection is overcome every-
where except about the wicks,
where the septic fluids mass
and concentrate themselves.
Here, in due time, the wicks if
undisturbed create a wall about
themselves, so that in favorable
cases we have, after a few days,

practically a walled-off abscess to treat at each drainage site. If the
gauze drainage in these cases is disturbed too early, the results may be
disastrous from a tearing down of adhesions and a distribution of con-
centrated pus.

STITCH ABSCESS

Stitch abscesses are most apt to occur after abdominal operations.^
They may be superficial, that is, running in the suture track of a skin
suture, or deep, in case the woimd has been sewed up in layers, from
infection about a buried suture or ligature. The source of infection in
practically all cases of deep abscess is unclean catgut. Surface suture

* Dr. W. P. Graves (Boston Med. and Surg. Jour., 1910, clxiii, 610), reviewing 1000
operations personally performed at the Free Hospital for Women, found that 51 cases
had some form of wound infection, in all but one case mild, the organism being in all in-
stances a staphylococcus. Twenty-eight of these infected woimds were after celiotomy, and
the infection consisted mostly (19 cases) of sepsis about a buried catgut knot, the wound
closing immediately after extraction of the knot. Some of the catgut knot infections did
not appear until some time after the patient was discharged from the hospital. Nine
celiotomy wounds were septic to a greater or less extent throughout the wound. Of these,
7 occurred in extensive abdominal hernia wounds (one of which cases died of secondary
endocarditis) and 2 in inguinal hernia wounds. Nine breast wounds were more or less
septic, 10 perineum woimds presented stitch abscesses, and there was infection in 4 other
of)erations about the vagina and cervix.

254 TREATMENT OF THE OPERATIVE WOUND

holes may become infected from unclean suture material, from bacteria
in or on the skin or on the surgeon^s hands, from strangulation of the
tissues by tying sutures too tightly, or from tension resulting under
the swelling incident on normal repair. Abscess in the incision de-
velops secondarily from the infection of coagulated blood or serum
collected between poorly approximated planes of tissue, from an untied
vessel, or a vessel pierced unwittingly in sewing up the skin, or as a
result of bruising of the edges of the incision by stretching or rough
retraction. An abscess may develop either in the incision or in the
suture track from contact with the drainage in infected cases. The
liability to these occurrences is greater in the presence of a thick, fatty,
abdominal wall. If it arises from an infected hematoma, the first dis-
charges have the chocolate color of decomposed blood.

Ordinarily, if the pus forms in the loose subcutaneous tissues, it
either finds its way to the skin surface along a suture track, or else
it burrows its way to the incision line and discharges through this.
If the infection arises below the anterior sheath of the rectus in an
abdominal incision closed in layers, either from buried catgut or from
a hematoma collected between ^ayers, the pus will be under considerable
tension. Unless it finds its way through the suture line in the rectus,
or unless a way for discharge is made for it, it will burrow about in the
abdominal wall between the fascial planes or else burst into the peri-
toneal cavity. It is a wise precaution in any patient with a thick fatty
layer in the abdominal wall and a long incision to insert a strip of
rubber dam obliquely down to the rectus sheath from the lower end of
the wound. When this is taken out after forty-eight hours, it will be
followed by a copious secretion of golden-yellow serum, representing
the accumulation of the exudate from the entire length of the incision.
The provisional suture may be tied, especial care being taken that no
infection is introduced at this dressing. If the sepsis arises from an
unclean catgut ligature, and the catgut does not dissolve or find its
way out, a so-called ligature-sinus will result, which may persist for
months, or a residual abscess gradually develop, and not give rise to
symptoms until months after the operation.

If after a celiotomy closed without drainage the temperature-curve
has not reached normal by the fourth day, or if, having dropped to
normal once, it rises again on the fourth day or after, and no reasonable
cause can be assigned, the wound should be inspected at once. If on
the fourth day or after the patient on turning in bed, on coughing or
vomiting, feejs pain in the region of the wound, the incision should be
examined. Usually there will be both pain and fever to some degree;

INFECTION OF THE WOUND 255

if the infection is of any virulence, there will also be an increase in the
pulse-rate and a leukocytosis. The presence of a high white count
will be of considerable aid in making the diagnosis of deep suppuration
in the abdominal wound. Sometimes, however, the patient will ex-
hibit no fever and complain of no discomfort, and yet when the sutures
are removed, one or more will be followed by a few drops of thin pus,
or the dressing may show a narrow line of pus corresponding to the
incision and the wound itself be healthy and healing, apparently
having spontaneously overcome a low-grade infection. Nevertheless,
it is of extreme importance to make the diagnosis and institute treat-
ment early, for with extensive suppuration there is always great delay
in healing and the scar is wide, unsightly, and thin, with a pronounced
tendency to stretch and give rise to a postoperative hernia. In dressing
wounds with stitch abscess, aseptic precautions should be as carefully
observed as if the wound were healing aseptically, for otherwise new
types of organisms may be introduced, which find a fruitful soil for
growth in the discharges and may result in a more serious type of in-
fection.

When, as a result of tension, there is found an area of redness about
one or more sutures, painful when pressed with a probe, and there is
no pus, simply cutting the suture and leaving it in situ will often abort
a stitch abscess. Cutting relieves the tension causing the inflammation,
and the suture serves as a drain for any exuded serum. If the process
has gone so far before it is seen that pus has already collected, or if
pus exudes as a result of gentle pressure, remove the stitch on the side
of the abscess; if it is only on one side, swab with alcohol and dress with
a sterile moist alcohol pad, taking care not to infect other sutures.
Another method is to press out the pus and fill the stitch abscess cavity
with iodoform powder. If it is necessary to remove neighboring stitches
so as to relieve all tension, do so, for if infected serum is subjected to
tension, which increases with inflammation, it finds its way along the
lines of least resistance, not only into the lymphatics and veins, but
between the planes of fascia, so that the wound and all the adjacent
structures may be dissected apart. If a stitch abscess or two can be re-
lieved before it has spread to neighboring suture holes or to the incision
itself, the temperature will probably fall.

If there is reddening alongside the entire incision, it means that the
incision itself is infected. In this case sufficient sutures should be
removed, whether infected or not, to allow of a separation of the wound
edges. The lips of the wound should be gently drawn apart, and any
encapsulated pus or serum released. If none appear, the wound must be

2S6 TREATMENT OF THE OPERATIVE WOUND

gently dissected open with the flat end of the probe, wherever there are
signs of inflammation, until pus is found if present. In any case a
wick, consisting of a few threads or a selvedge of sterile gauze, should
be introduced to the depths to prevent an immediate resealing of the
wound.

Sometimes there is little reaction, either general or local, to stitch
infection, and when the wound is examined, the process has so far de-
veloped that the incision is red and bulging with, if not discharging,
pus, and all or most of the stitch holes are surrounded by red and shiny
areolae and are oozing a seropurulent fluid. Under these circumstances
radical action must not be delayed. All the stitches are to be removed,
and reliance placed upon adhesive straps laid on over the inner dressing
to hold the wound edges together. The wound must be separated and
all pus and crusts swabbed away. If the condition justifies the pro-
cedure, an irrigation, given very gently and under low pressure with
sterile normal salt solution or weak corrosive sublimate, is eflScient in
washing out the free pus in the wound. Preference should be given
to the normal saline, as the corrosive forms a filmy coagulum of the
albumin in the exudation which covers the entire surface. A female
catheter of glass makes a good irrigating tip, which can be inserted
to the bottom of the w^ound. After this, small gauze drains or a fine
rubber tube should be inserted, and a sterile pad of gauze, wrung out
in hot creolin or carbolic solution, applied over the wound, or a hot
sterile solution of salt, sodium citrate, and water (which we will con-
sider later). If the wound is on the arm or leg, the entire limb may
be immersed in a basin and soaked. Over the dressing are placed
straps which are to hold the wound together, being careful that the
strips are long enough so that they will not be loosened by the moisture
of the overlying fomentations. These are important, because the
moist dressings tend to cause the incision to open up if many sutures
are removed. Then comes the hot poultice or fomentation. This
should be thick and absorbent and should be renewed hot every two
hours. Creolin, chlorinated soda, or corrosive may be employed, and
it should be covered with oiled silk or paper to keep in the moisture
and sheet-wadding to preserve the warmth. As soon as the sepsis is
apparently under control, the bulk and frequency of the dressings may
be decreased, the drainage gradually diminished and discarded, and
the edges more closely approximated by the adhesive.

CHAPTER XXIV

TREATMENT OF SEPTIC WOUNDS: SOAKS, POULTICES;

HYPEREMIA, PASSIVE AND ACTIVE

An aseptic wound should be disturbed as infrequently as the nature
of things will allow; septic wounds, on the other hand, must be dressed
often. An abscess or a cellulitis is to be considered as a breeding-place
for bacteria, which may find their way into the systemic circulation by
way of the l3anphatics or blood-vessels and give rise to pyemia, and as
a center for the elaboration of toxins, which, being absorbed, may cause
septicemia. At the same time, a localized septic process may grow
by extension, as between planes of fascia, and along lymphatic channels,
in the form of lymphangitis, and by implantation of septic material, on
the external surface, in glands, etc. Treatment, generally speaking,
of septic conditions after operation should be directed toward combat-
ing the local septic process, preventing extension, and toward main-
taining or increasing the resisting power of the patient.

The fundamental principles of the local treatment of septic proc-
esses are rest and dratnage. It is essential that any infected wound
be laid open sufficiently to insure a free exit for all infected secretions
or pus. Whether this can be accomplished without the use of drainage
gauze or tubing will depend upon the nature of the case, but, in any
event, it is better to err in the direction of oversufficient drainage. The
skin wound over any septic inflammatory process should be amply
large to allow of access to all parts of the infected area; pockets contain-
ing pus or infected serum if found should be broken open, and they
should be kept open by means of adequate drainage. If a pocket is
deep-lying, there is nothing so good as a piece of thick-walled rubber
tubing, with windows cut in it, or even a fenestrated tube of glass. If
there are two skin wounds, a tube entering at one wound and making
its exit at the other — so-called *4hrough and through" drainage — allows
in a most efficient manner for the carrying off of infected matter as well
as for washing out the depths by means of a syringe and some anti-
septic lotion.

Smaller and well-localized processes, in places especially where the
extent and sightliness of the scar will necessarily be considered, may
often adequately drain themselves if a strip of dental rubber be inserted

17 257

258 TREATMENT OF SEPTIC WOUNDS

in the wound to prevent its edges from adhering. Gauze drainage
should be replaced before its capillary action has been destroyed, which
usually occurs within forty-eight hours.

The principle of rest in the treatment of wounds, which was so
clearly formulated by Hilton in his classic work on Rest and Pain, is
of as much importance in septic as in aseptic healing. An apprecia-
tion of the pathology of septic processes in general will bring one to
feel keenly the importance of the maintenance of rest in the affected
part. If the entire organism is at ease, mentally and physically, the
patient's power of resistance is allowed to work at its best against the
infection. Rest of the part involved is important also mechanically in
the prevention of extension of the local process and to lessen pain. In
some cases it will be important to splint the part; for instance, in a
case of infected compound fracture or infection involving tendon-
sheaths. A splint can be devised of a framework of wire covered with
rubber tubing, or of wood or tin wrapped with oiled silk, which will allow
of easy access to the wound and at the same time not interfere with the
application of soaks or poultices as may be indicated.

Upon whomsoever devolves the duty of dressing a serious septic
wound the importance of avoiding all unnecessary handling and of
overcoming the temptation of twisting and turning a limb without
good reason should be duly impressed. Poultices and dressings should
be applied in such fashion that they may be removed with the least
possible stirring up of the affected part. Bandages and wrappings, so
long as a patient is in bed, should be studiously avoided. A square of
cloth, partly ripped down into strips from the opposite sides to form
a many-tailed bandage (Fig. 68, p. 230), can be readily adapted to
almost any part or surface, and with its use a poultice can be changed
in a minute, practically without disturbing the patient in the least.

The most important therapeutic force which we can enlist in our
efforts at combating a local septic process is hyperemia, active or pas-
sive. Active hyperemia is usually obtained by the employment of heat;
passive hyperemia, by the methods with which we have become familiar
through the work of Bier — the rubber bandage and the suction cup.
Roughly speaking, both depend upon the maintenance of an increased
blood-supply in the locality of the lesion, in the first case of arterial, in
the second of venous, blood.

Heat. — Heat may be applied dry or moist — dry, by means of the
hot chamber; moist, by means of the poultice mass or hot soak. In
postoperative technique the hot chamber has little place — the use of
moist heat is usually more practicable; in the form of the hot soak it

HEAT 259

provides a means for a thorough cleansing of the wound; in the form
of the poultice or hot fomentation it provides for the absorption of the
wound secretions; and in either form it prevents the blocking of paths
of exit by the coagulation of exuded serum. The application of heat
is most comforting to the patient.

Basins have been designed for submerging the limbs, and they are
provided with covers to prevent the rapid loss of heat by radiation.
For a hand or foot an ordinary basin may suflSce; on the body, a bath-
tub may have to be used. The solution may be of sterile water, salt,
and citrate (see p. 262), weak corrosive or carbolic solutions, and
creolin. Of these creolin, in the strength of about i : 4000, or the
salt and citrate, is to be preferred. The sulphonaphthol or creolin is
mildly antiseptic, soothing, and retains the heat; it is not poisonous
and does not coagulate albumin. Where a stronger disinfectant action
is desired, one can choose the oflScinal solution of chlorinated soda, di-
luted about twenty times. To this tincture of myrrh may be advantage-
ously added in small amount, for the odor and the soothing sensation
which it imparts as well as for its antiseptic property. Chlorinated
soda is penetrating, does not crack or chap the skin as corrosive subli-
mate solution is apt to do, and seems to be the only eflScient means of
overcoming the infection w ith the Bacillus pyocyaneus (bacillus of green
pus),which is so apt to contaminate a discharging wound of long standing.

The basin should be large enough to accommodate the lesion com-
fortably and a considerable margin of normal tissue on each side. It
should be half filled with the warm solution and placed where it can
be adjusted to the position of the patient. The dressing should be
removed, and all gauze wicks and packing be withdrawn before the
limb is placed in soak. Then hot water is gradually added until the
patient can stand it no hotter, and this temperature is maintained by
further additions at intervals. The limb is allowed to soak quietly
for twenty minutes to half an hour; it is then removed, any macerated
skin or debris wiped or scraped away, the wicks are reintroduced, and
a poultice of the same solution as the soak is applied, to remain in place
for two to four hours until the next soak.

Wherever, owing to the nature of things, as in a breast abscess, a
hot soak is impossible, the same end may be attained in a measure by
the use of a hot irrigation. For this purpose a glass or a fountain
syringe is employed, the stream being directed so that it may the most
advantageously reach the depths of the wound and wash out any re-
tained pus or shreds of slough or coagulum. If the wound is deep, a
glass female catheter will make a good irrigating nozzle. Ample
provision must be allowed for the exit of the irrigating stream.

2()0

TREATilK.NT OF SLPTIC \VOL-NI>

Poultices.— The jiurposc of the iioullice or fomentation is similar
to thai of the hoi soak. It is sometimes used to substitute for the soak,
and it is [iractically always used where moist heat is to be a])[jlied and
the soak is not practicable. The jioultice should be absorbent, so m
to take u]) the wound secretions as soon as they are formed. It should
be mildly antiseptic, so as to prevent propagation of the infective bacteria
within its own mass or about the skin, and it should be so made as to
retain its primary heat as lonj; as ])()ssible. Many substances have
been employed for this purpose, from the old-fash ionc<i bread-and-
butter and flaxseed poultice mass down to ihe modern glycerinated
earthy substances, as well as gauze saturated with antiseptic solutions.

The advantage of the semisolid masses, like flaxseed and cataplasma
kaolini. is that they lose heat very slowly by radiation. Of the two.
recent experiments have shown that the flaxseed is the better retainer
<if heat-'

The great disadvantage of this form of poultice is the fact of its non-
absorbability. Moreover, the material is not antiseptic, even if it has

'I I

lUhtr. The Rate M Coolina i>f Htvt

- J...

POULTICES 261

been in itself rendered aseptic by heating, so that, other things being
equal, when moist heal is to be applied to a discharging wound, it is
usually preferable fco employ fomentations of sterile gauze soaked in

mj^

Fi(. <ji— Ft^ssEED Poultice 4nd SnF,fi

some antiseptic solution. When desired, however, the flaxseed poul-
tice may be used if a moist sterile dressing is placed Ijetween the wound
and the poultice. For dressing a moist gangrenous process a poultice.
half flaxseed and half pulverized charcoal, made up in the usual way

262 TREATMENT OF SEPTIC WOUNDS

in boiling water, but with a dash of chlorinated soda, will relieve the
pain and destroy the odor. In applying poultices or hot fomentations
we must take care not to bum the skin. To prevent this it may be well
to smear the skin over with sterile oil, vaselin, or boric-acid ointment.

It is sometimes thought that in dressing a septic wound the same
precautions that are used in dealing with aseptic wounds are not neces-
sary. This is not so, for a new type of infection may find entrance if
proper care is not observed, resulting in a mixed infection which may
be more serious than the primary condition.

The poultice exerts a beneficent action upon the tissues only so
long as it is hot. This is strictly true of the semisolid masses of which
we have spoken. It is true, to a somewhat less extent, in common
gauze compresses, which, being absorbent and aseptic, may do some
good in relieving the wound of its discharges. Where we desire, how-
ever, to get the most beneficent action, we should see that the poultices
are changed every two, three, or four hours, and in serious cases this
should be kept up through the night without remission. If a poultice
is properly covered with oiled or waxed paper or oiled silk, and over
this is placed a thick layer of sheet-wadding, the heat will be retained
much longer. Each time the fomentation is changed the skin about
the wound should be gently wiped clean of pus and coagulated serum,
and the wicks and packing should be changed frequently enough to
assure of a definite capillary action.

In some cases, where the process is not so diffuse as in a cellulitis,
but is walled off like a local abscess and is draining well, it may be
considered advisable not to apply heat. Under these circumstances
it may be good practice to apply simply a rather thick dressing of dry
sterile gauze, relying upon its absorbability to take up the discharges,
or an antiseptic powder, such as boric acid or iodoform or some of its
odorless substitutes. Frequently the exudate will coagulate about the
wound so as to interfere with the efficiency of the drainage. To pre-
vent this, it has lately become a custom to employ sterile gauze which
has been soaked in a solution that is known to prevent the coagulation
of exudates. Such a solution (Wright's citrate and saline) may be made
up as follows:

I^. Sodii citratis 5;

Sodii chloridi 20:

Aquae 500. — M-

or for a recipe for home treatment write —

I^. Sodii citratis 12;

Sodii chloridi 48.— M.

Sig. — Teaspoonf ul in glass of hot water to wet dressing.

BIER HYPEREMIC TREATMENT 263

The dressing should not be allowed to become dry. The surround-
ing unbroken skin should be covered with a protective layer of vaselin,
otherwise, on account of the irritative effect of the sodium chlorid,
pustulation will be induced. The solution is contraindicated where
there is a tendency to persistent oozing of blood from the wound, or
where, after abdominal operations, protective adhesions are desirable.
It should be employed only during the acute stage of inflammation,
thirty-six or seventy-two hours after operation. Used longer it tends
to maceration and indolence in heaUng.^

BIER HYPEREMIC TREATMENT

The Bier hyperemic treatment finds its chief field of usefulness
before operation. However, it is declared that, when artificial hyper-
emia is employed and ample outlet for pus is provided, we are able to
accomplish with a small incision what otherwise would necessitate ex-
tensive incision and too often resulting disfigurements, if not disability.
The treatment is applied either in the form of a rubber constricting
bandage applied proximally to the wound or else by means of a suction
cup applied over the wound. For a constricting bandage, the ordinary
Martinis rubber bandage or the Esmarch tourniquet may be employed;
for the suction cup, an ordinary cupping-glass or one of the larger spe-
cial apparatus adapted to the particular part may be used. The rubber
bandage should be applied so tight as to cause venous congestion, but
not tight enough to give rise to pain or entirely to obliterate the arterial
pulse. The bandage should be left in place for a period varying from
twenty minutes to two hours and should be reapplied at intervals.
The wound should be dressed as already described.

An able and complete exposition of the method is presented in the
volume entitled ^^ Bier^s Hyperemic Treatment,^' by Professor Willy
Meyer, of New York, and Professor Dr. Victor Schmieden, of Berlin.
From this work we quote freely, with Professor Meyer's permission.

^' The physician who intends to make use of artificial hyperemia

^Crandon (Annals of Surgery, 1910, Hi, 541) says: "Two years of experience has
amply proved the value of this solution. In office practice an abscess is opened, a
small piece of rubber dam is inserted or not, a dressing with the inner layers wet with
glycerin applied, and the patient is then given a recipe for one or more ounces of sodium
citrate. He is told to go home, to add to a glass (eight ounces) of hot water about two
and a half teaspoonfuls of common salt and a large teaspoonful of the sodium citrate.
With this solution he is to keep the dressing on his septic wound constantly wet and
warm. Inguinal and axillary bubo, abscess of neck, septic fingers, mastoid wounds,
otitis media after paracentesis, all drain most efficiently under this method. At the
end of thirty-six or seventy-two hours the wound is filled with glycerin or balsam of
Peru and is ready to heal."

264 TREATMENT OF SEPTIC WOUNDS

means to increase the quantity of blood in a given diseased part of the
body, hoping thereby to obtain beneficial results. The blood-current
accomplishes its task not only under normal conditions, but as soon as
the body is invaded by disease requiring an increase or decrease of the
blood-current the circulatory conditions become changed. Every one
must come to recognize that the body in such instances, in properly
regulating the blood-current, does a definite delicate work, thereby
often preventing or even curing serious disease.

"He who has followed this train of thought will coincide with Bier
that an inflammation — from the physiologic point of view — does not in
itself represent a diseased condition, but is a phenomenon indicating
the body^s intent to resist a deleterious invasion.

"To increase this beneficent inflammatory hyperemia, resulting
from the fight of the living body against invasion, is the aim of Bier's
hyperemic treatment.

" By deduction from this simple reasoning we are able to discern the
first and most important principle underlying Bier's hyperemic treatment,
namely:

'' The blood must continue to circulate, there must never be a stasis of
the blood. This rule is of paramount importance. Hitherto it was con-
sidered the physician's first duty to fight every kind of inflammation,
since inflammations were looked upon as detrimental. Bier teaches
just the opposite; namely, to artificially increase the redness, swelling,
and heat, three of the four cardinal symptoms of an acute inflam-
mation."

'' If the physician is mindful of the facts that a gentle hyperemia only
is required to produce the desired effect, at least in cases of acute in-
fectious inflammation, in other words, that a 'too much' is absolutely
injurious, he will soon become convinced that in Bier's treatment we
have a most powerful and efficient remedy, altogether unlike any other
known to us before.

"It has been pointed out that hyperemic treatment has its greatest
triumphs when applied prophylactically. Only by an early and correct
definition of the seat and character of the inflammation and prompt
resort to artificial hyperemia can the greatest amount of good be ac-
complished. Nevertheless, in all instances, whatever pus may have
formed must be prompdy evacuated.

" If the destructive work of the invading bacteria has been allowed
to go on unchecked, if thrombosis of the smaller veins within the focus
of infection, or even necrosis, has set in, nothing in the world can save
such a part. The utmost that even the best of methods can do in that

BIER HYPEREMIC TREATMENT 265

event is to assist in eliminating the infective material and then help
in the reconstruction.

/'While hyperemic treatment is not a panacea, it is a powerful
therapeutic agent on a physical basis, an agent which has its indica-
tions and dosage the same as any other remedy. There is much to
learn about it yet.''

'^ There are three methods by which hyperemia may be produced:
(i) By means of an elastic bandage or band; (2) by means of cupping-
glasses; (3) by means of hot air. (i) and (2) produce a passive or
venous hyperemia, (3) an active or arterial hyperemia.

*' Retarding the return of blood to the heart by compressing the
veins at the most convenient place between the focus of inflammation
and the heart, with the help of an elastic bandage or band, represents
the old and typical method of producing artificial hyperemia. The
Germans call this ' Stauungs-hy^eramie ' — a term prescribing cause as
well as effect. This obstructive hyperemia, when produced by means
of the elastic bandage, can be employed only in diseases of the head,
scrotum, testicles, and the extremities.

*^ Where hyperemia by means of elastic compression is not feasible,
it can be produced by suction. This method is used upon the breast,
back, spine, pelvis, and the surface of the whole body whenever a local-
ized acute infection or an open wound (sinus, granulation, etc.) is
present. For this purpose, cupping-glasses of various size and shape
are employed.

*'Hot air is generated in wooden or metal boxes especially to suit
the respective case. This represents an arterial hyperemia.

*' The Elastic Bandage.— Obstructive hyperemia is produced
by means of a soft-rubber bandage, same as is used for the production
of artificial anemia in the case of bloodless operations on the extremities.

"In slightly obstructing the return of the blood from the extremity
to the heart with the aid of such a soft-rubber bandage, the principal
point to be observed is that the circulation be never entirely interrupted.
What must be our aim is to obstruct the return of blood from the ex-
tremity under treatment, in this way increasing the quantity of blood
normally contained therein, but in no way to interfere with the influx
of the blood through the artery.

'' One must at all times be able to feel the pulse below the place
surrounded by the elastic bandage. It is not difficult to find the proper
measure of compression. The degree of obstructive hyperemia is a cor-
rect one if the patient is not in the least annoyed by the bandage applied,

'' The technique is correct, if there is absolutely no increase of pain

266

TREATMENT OF SEPTIC WOUNDS

and if there is visible hyperemia of the part subjected to the treatment.
The portion distal to the bandage must appear bluish or bluish-red —
never while.

"Bier employs a soft-rubber bandage, 2i in, wide which he winds
around the limb about six or eight times, one layer overlapping the
other by about J in. In this manner the pressure is evenly distributed
over a comparati\'ely wide area. The end may be fastened with a safety-
pin or tucked under, or with tapes which are stitched on the bandage.
Only in cases which require the bandage to remain in place for longer
periods^say twenty to twenty-two hours per day — will it be necessary
or desirable to first apply a soft-flannel bandage underneath the rubber

bandage. With the bandage in place, the distal [jart of the extremity
must feel warm, nol cold. E\'ery focus of acute inflammation subjected
to obstructive hyperemia will quickly show increased warmth. First,
we notice a marked redness, then heat and a s\xelling. On seeing the
swelling increase, the practitioner often becomes frightened, but there
is no reason for alarm. .According to Bier, this jjhenomenon is to be
looked upon as a welcome, salubrious reaction.

"The first effect is the diminution of pain, becoming more and
more noticeable with the appearance of the edema.

"The elastic bandage must always be placed on a healthy area
proximally to the site of the disease. It should never touch the latter.

BIER HYPEREMIC TREATMENT 267

"^// dressings ought to be removed while the elastic bandage is in
place, in order to allow the respective part to swell and become hypere-
mic. Wounds or incisions are covered with sterile gauze, which is
kept in place by a towel loosely wound around the same and fastened
by means of a few safety-pins.

" If in the case of chronic diseases a distinct hyperemia does not set
in, it is advisable to place the part in a bath as hot as the patient can
stand it for about ten minutes. This will cause the extremity to turn
bright red, after which the bandage is applied.

" Further, obstructive hyperemia that is continued for several hours
produces edefna. During the intermissions following the application
of the elastic bandage for short periods, say, from two to four hours each
day, the artificial edema always becomes absorbed. In actually in-
fected cases the rapid absorption of this inflammatory edema is often
followed by some rise of temperature; this, however, is of short dura-
tion only.

"It should be stated, as one of the most important rules, that also,
under hyperemic treatment, every abscess has to be opened. The
knife takes care of the pus; hyperemic treatment fights the infection.
With the help of the hyperemic treatment, the large excisions into the
abscess cavity heretofore practised can be dispensed with; often mere
punctures will suffice. These punctures can be made without general
anesthesia, and naturally heal much more rapidly than large incised
wounds. Furthermore, there is no need of the painful tamponade in
the course of the after-treatment, and there is no extensive scar forma-
tion.

"Experience has shown that acute infectious processes require
prolonged application of hyperemic treatment from twenty to twenty-
t^;v^o hours per day. In chronic affections, especially those of tuberculous
origin, shorter sittings, say, two to four hours a day, have been found
sufficient.

'* The physician should at first apply the bandages himself. Later
he may train, in chronic cases at least, nurse or relatives, or even the
patient himself, to do this, but he must never cease to supervise the
treatment, otherwise mistakes or irregularities in the technique may
occur which would mar the result.^'

'' For the testicles a rubber drainage-tube is passed around the root
of the scrotum and the ends held by a clamp or a tied tape.

** Suction Cups. — For other parts of the body suction cups, prop-
erly constructed and applied, have proved to be a most efficient means
of producing obstructive hyperemia. By applied suction hyperemia

268

TREATMENT OF SEPTIC WOUNDS

it will be seen that the skin, plus underlying lissues, are sucked into
the hollow of the glass. This causes a rush of blood into the respec-
tive area, but the hyperemia does not involve the surface only; it also
reaches into the deeper layers.

"Here again the first rule is not to orenlo. The skin should turn
red or bhdsh-red, hut never while

"To be able to employ the method more generally, it was neces-
sary to have cupping-glasses the shapes which were adapted to the

varying contours of the body surface (see Figs. 94-98. For iiiustra-
tions of large vessels suitable for taking an entire extremity, see Meyer
and Schmieden.) In the small-sized glasses suction is obtained by a
small rubber bulb, which is either directly attached to the glass or
communicates with it by means of a rubber tube.

'■ With gentle pressure on the rubber bulb, the cup is put in place
and the hand is removed. The cup will be found to adhere to the
skin with just sufficient firmness not to drop off. To facilitate air-
tight closure of the cup Ufxin the skin it is well to spread a thick layer

BIER HYPEREMIC TREATMENT

of vaselin over the border. Suction must never be too strong and neve
Creole pain.

" The vacuum apparatus of larger size ts applied with a suction
pump, which is inserted in the end of the rubber tube in place of the

270 TREATMENT OF SEPTIC WOUNDS

bulb and regulates the degree of hyperemia. In ail of the large-sized
suction glasses and some of the smaller ones, a three-way stop-cock is
placed in the tube for the purpose of obtaining an air-tight closure of
the cup. after the desired degree of obstructive hyperemia has been
attained, and also to facilitate their removal.

" In making use of this vacuum apparatus, we not only rely on the
artificial hyperemia it pro<luces, but also on its mechanical effect. If
we place such a glass over a diseased area which presents a sinus in its
middle, the pus, and with it bacteria, are aspirated from the depth
slowly and painlessly.

"In thus using the suction glasses in the treatment of suppurated
wounds and fistulous tracts, strict asepsis is, of course, sine qua non.
After using, the glasses must be detached and boiled. The infection
from the aspirated pus may further be a\'oided by anointing with
vasclin the border of the glass and also the immediate neighborhood

of the wound. This precaution is especially indicated when treating
furuncles.

"The suction glasses are applied six times five minutes per day,
with intervals of three minutes between the applications, in order to
give the edema and hyperemic swelling an opportunity to disappear.
Thus the entire time of treatment is three-quarters of an hour each
day."

"Hot Air.— Any part of the body brought near a source emitting
strong heat becomes heated and turns bright red or hyperemic. The
hyperemia produced by this is artificial." Dry heat is considered
useful only for chronic exudates, infiltrations, adhesions, etc.

" Dry hot air permits the use of a very high degree of heat without
injury or pain to the part. It is applied either by hot-air boxes or
ovens, or by a hot-air douche.

BIER HYPEREMIC TREATMENT 271

"Most useful ovens are quadrangular, made of copper or wood,
inexpensive in construction. The oven is provided with a lid with
openings for the reception of the limb. These openings are lined with
cuffs of felt or heavy cloth, which are fastened around the lamp by
means of straps and buckles. In one side of the oven is an attach-
ment for the reception of the chimney of the lamp, through which the
current of hot air enters. For the purpose of a more even distribution
of the hot-air current and the better protection of the lamp a board is
placed inside the oven, not far from the internal aspect of the opening.
For the same reason, the oven must not be of too small size.

" The patient's own feeling ought to be the best guide for the proper
temperature. There must be no pain, or even annoyance, from the
heat. If the temperature is gradually increased, a surprisingly high
degree of heat can be borne by the patient — often as high as 250° F.

" It must be borne in mind that great heat makes the part less sensi-
tive. If due care is not taken, a burn of the second degree may occur
without the patient knowing it until after the sitting. The patient
should be in as comfortable a position as possible during the treatment.
First, the extremity is comfortably placed in the box and the opening
closed. Then the lamp is lighted and placed underneath the funnel.
When a comfortable degree of heat has been obtained, it must be the
operator's aim to continue the same temperature. After one-half to
one hour the light is extinguished, the lid opened, and the part allowed
to cool down. Treatment may be given daily or every other day."

H. F. Waterhouse^ gives a thorough and practical consideration of
the theory and application of Bier's hyperemic treatment. The most
frequent indications for the employment of the constricting bandage,
in his estimation, are as follows:

1. Whitlows: but in the majority, that is, where pus is present, a
tiny incision is required prior to the application of the bandage to
give vent to pus.

2. Suppurative arthritis of the joints of both upper and lower
limbs after incision into the articulation.

3. All varieties of pyogenic infections of the limbs, including cellu-
litis, osteomyelitis, and lymphangitis.

4. Tenosynovitis of tuberculous, pyogenic, and gonorrheal origin.

5. Gonorrheal arthritis, so frequent in the knee-joint in the male
and the wrist in the female.

6. Ununited fractures, or rather delayed union of fractures, in
order to expedite the process of repair.

^ Brit. Med. Jour., 1911, ii, 1577.

272 TREATMENT OF SEPTIC WOUNDS

7. Crushing injuries of hand or foot, where the hyperemic treat-
ment has a marked influence in preventing suppuration in cases in
which this is anticipated.

8. Chilblains, in which the hyperemic treatment often acts as a
charm.

Suction, by means of cupping glasses, he has employed with great
satisfaction in

1. Furuncles and carbuncles, usually after a punctured incision,
but occasionally, as in blind boils, without this preliminary. In such
instances the treatment has afforded results that have been uniformly
excellent.

2. In acute and chronic abscess after incision.

3. In sinuses persisting after evacuation of a chronic abscess.

4. In mastitis, whether acute or chronic, in the former occasion-
ally, after an incision has been made.

In every case on the above list he claims that the suction treat-
ment has been beneficial. Boils and carbuncles have extruded their
sloughs and healed readily; blind boils have aborted; abscesses have
run a rapid course toward recovery; sinuses of long duration have
closed within days or weeks, and many cases of mastitis, both acute
and chronic, have quickly improved. In all the above recovery has
occurred considerably sooner than would have been anticipated under
any other method of treatment.

The heated air chamber is chiefly of value in chronic arthritic and
osteitic affections, in hastening the absorption of adhesions and exu-
dates, and in the alleviation of neuralgic pains; in all of which the
elastic bandage will in general prove equally efficient. The hot-air
douche he has found to work well in sciatica and occipital neuralgia,
and in cases of chronic osteitis, whether of syphilitic or pyogenic origin,
involving superficially placed bones, for example, the tibia and mas-
toid process.

CHAPTER XXV

SINUSES AND FISTULAE: LYMPHATIC FISTULA, FECAL

FISTULA, AND ARTIFICIAL ANUS

SINUSES AND FISTULA

A SINUS, in surgery, is a long, narrow, hollow tract leading from
some center of tissue destruction to the surface, and serving as a means
of exit for pus or other pathologic discharges. A sinus may arise from
a deep-seated abscess in the superficial tissues, or within the abdomen
or pelvis, or from an osteomyelitis; it may take its origin from a foreign
body acting as either a source of irritation or infection, such as a loose-
lying ligature of silk or catgut, or a piece of necrotic tissue, such as a
bony sequestrum, or a sloughed-oflf appendix; and so long as the oflfend-
ing body or disease remains, the sinus will persist, although it may close
up temporarily at intervals. When a tract leads from a viscus, an
excretory duct, or a glandular structure, it is called a fistula, and is
named for the organ or viscus from which it leads, as renal, biliary,
vesical, salivary, gastric, anal, urethral, lachrymal, mammary, etc. If
it leads from one viscus to another, it is named for the organs it connects,
as vesicovaginal. A fistula ordinarily serves to carry off the normal
secretion or excretion of the organ or gland it drains, and it will tend
to close of its own accord if all impediment to drainage through the
natural exit is removed.

A sinus leading from a superficial abscess is generally not difficult
to handle, provided the acute process has subsided and there is no
sequestrum, slough ("core"), or foreign body to keep up the suppura-
tion. If the sinus tract is long and tortuous; if as a result of chronic
inflammatory changes its walls are thickened and cartilaginous, the
process of healing will be long and tedious, even after the primary
disease process has been overcome. A sinus must be kept open by
drain or tube until the abscess cavity from which it takes origin has
filled in or become obliterated; if the cavity is large, and is so situated
that it cannot collapse, as, for instance, a bone abscess, or if its walls
have become infiltrated and thickened so that they will not come together
and so obliterate the cavity, it will have to fill up by granulations and
the process of scar tissue formation, which will sometimes be a matter

18 273

274 SINUSES AND FISTUL^E

of months. Various injections are recommended for the purpose of
encouraging the growth of granulation tissue, and among the best of
these are glycerin, tincture of iodin, iodoform emulsion, and balsam
of Peru and castor oil in equal parts, or i : 8. The use of a liquefied
bismuth-vaselin paste after the method of Beck ^ has been followed by
successful results in well-walled-off cavities where there is no danger
from pressure or absorption.

So long as a sinus is discharging pus it must be kept wide open, so
as not to offer resistance to the discharge and thus cause the pus to
"back up'* and prevent the cavity from closing in. Crusts must not be
allow^ed to form at the mouth of the sinus and block the exit under the
mistaken idea that the tract is closing in, especially if the abscess is
intra-abdominal, for the pus will collect within the abscess cavity and
after some days or weeks burst out again. If during such a period of
quiescence, in the case of a pelvic or abdominal abscess, scar tissue
has formed at the mouth of the sinus so as effectually to block the exit,
operation may be necessary to reopen the accumulation, or the abscess
may burst into the abdominal cavity or into some neighboring viscus,
as the bladder or rectum, and so find its way out.

If granulation tissue forms about the mouth of the sinus, it must be
kept clipped down with the scissors or burnt down with the silver nitrate
stick, so as to cause no impediment to the outflow. The former is the
better method. Granulations, as a rule, are insensitive. If, as usually
happens in sinuses of long standing, the orifice contracts as a result of
the formation of scar tissue, it must be frequently stretched by inserting
a pair of scissors closed and pulling them out opened, or enlarged by
cutting. If the sinus is so situated that it drains "up hill," that is,
if the abscess cavity is lower than the mouth of the sinus, so that pus
is likely to collect in the cavity from force of gravity, considerable time
may be saved, when practicable, by making a new incision into the
cavity at its most dependent point and allowing the old sinus to close
up.

Sometimes it will be apparent that a sinus of long standing does not
close because the constant and long-continued passage of irritating and
infectous discharges has converted it into a stiff and thick-walled tube
of scar tissue, which will not collapse, and which serves as a very poor
base for the growth of granulation tissue. In such a case, if one is sure
that the original infection has lost most of its virulence, it may be wise

^ Emil G. Beck: Fistulous Tracts, Tuberculous Sinuses, and Abscess Cavities, Jour.
Am. Med. Assoc., 1908, I, 868. Ochsner: Beck's Injection Treatment of Fistulae and Ab-
scesses Following Operation for Empyema, Jour. .Am. Med. Assoc, 1909, liii, 319.

TREATMENT OF SINUSES

to employ a sinus curet and scrape the walls part way through, down
to a well-nourished substratum. It this does no good, the sinus may

be packed with gauze and dissected out entire. In other cases where
the discharge continues profuse over a considerable period of time, or

276 SINUSES AND FISTUL.«

if for any other reason one is led to infer that the degree of resistance
exhibited by the patient toward the specific organism which is respon-
sible for the condition is low, the recently developed science of vaccine
therapy may be brought in to assist us. The organism being isolated
and identified, a stock vaccine may be bought and injected, or the organ-
ism may be cultivated and a vaccine developed (see Chapter LII). If
the infection is mixed, involving two or more species of bacteria, the
treatment becomes more complicated. The results of this form of treat-
ment are sometimes striking.

The cases in which a sinus is kept open by the persistence of the
discharge from a bit of necrotic tissue, a suture, or other foreign body
are comparatively common. As already mentioned, the offending
body may be a splinter of bone, the distal portion of a sloughed-off
appendix, a silk or catgut suture or ligature, or a gauze sponge. Some-
times a stitch, or even a bit of necrotic appendix, may be washed out
through the sinus if a nozzle is used which reaches to the bottom of
the cavity, and the irrigating fluid is allowed to enter under pressure of
5 or 6 feet. A crochet hook is a useful instrument in exploring stitch
sinuses, and with one it is often possible to fish out a ligature which has
become a source of trouble. Another maneuver is to bend sharply
upon itself a strand of silkworm gut, and introduce the loop into the
sinus, twisting it upon itself, in the hope of entangling the recalcitrant
knot of silk or catgut. As a final resource, the sinus may be cureted,
then gradually dilated with uterine dilators, and with a pair of urethral
forceps a minute search instituted over its entire sides and bottom in
the endeavor to loosen and grab the ligature.

In the days when silk was the only material used in the abdomen
and pelvis operators had much trouble from such stitch sinuses. The
material would be contaminated by the surgeon's hands or the tissues
which it was made to tie, give rise to an abscess, which was about as
likely to discharge into the bladder or rectum as through the abdominal
wound. Uterorectal and uterovesical fistulae were by no means rare,
and sometimes the patient had to be operated upon for calculi formed
about ligatures which had worked their way into the bladder. Since
we have gotten into the habit of using absorbable material for our buried
sutures and intra-abdominal ligatures, and have learned better our
aseptic technique, these accidents have become far less frequent, al-
though even now a batch of poorly sterilized catgut may gi\'e rise to a
small epidemic of stitch abscesses.

In the treatment of appendix abscess it sometimes occurs that, for
various reasons, after the pus is let out no more than a hasty search can

BISMUTH PASTE 277

be made for the appendix itself. If the appendix is not found, a reason-
able length of time is allowed for it to find its way out in the discharges.
If this does not happen, and the sinus does not close, it will become
necessary to perform a secondary operation for the purpose of finding
and removing the appendix. In cases where the abdominal sinus
persists, and there is no evidence as to its source, it is well to bear in
mind the possibility of a sponge or other foreign body being left inside
the peritoneal cavity, or the existence of tuberculosis.

A sinus which is discharging at all freely should be dressed once or
twice a day. It should be gently syringed out with a mild antiseptic
and a large absorbent dressing applied. Drainage should be insured
by the employment of a gauze wick or a tube. Ordinarily a fenestrated
rubber tube of the proper caliber, with fairly stiff walls, is to be pre-
ferred; it drains adequately and continuously, from the very bottom
of the cavity, and it is easily and painlessly removed and inserted. It
can be progressively shortened as the cavity fills in from the bottom
with granulations. The part should be kept at rest to insure healing,
and it is sometimes of advantage to apply a judicious amount of pres-
sure, by means of adhesive strapping or the bandage, to aid in the
coaptation of the walls of the cavity and to facilitate filling in. Dress-
ings should be carried on under aseptic precautions, as mixed infections
are ordinarily more diflScult to treat.

Some authors^ note excellent results following the injection of iodojorm
emulsion in chronic sinuses following adenitis, osteomyelitis, mastitis,
tuberculous sinuses of any sort, and, particularly, in tuberculous bone dis-
ease. The emulsion is made up of 10 parts iodoform to 100 parts glycerin.
It is injected under some pressure with a syringe having an olive tip which
will fit tightly into the sinus, and in sufficient quantity to distend the cavity.
Then the sinus is held tightly closed for five to ten minutes, to allow the
iodoform to settle on the walls. Any fluid which escapes after this time will
be pure glycerin. The part should be immobilized during the treatment.

The liquefied bismuth paste of Beck has been widely used, and, where
operative procedures are contraindicated, it will be found to give satis-
factory results in a certain proportion of intractable sinuses. The cures
recorded by various authors range from 29 per cent, (in tuberculous ortho-
pedic cases) to 76 per cent, (in fistula in ano), with an average of 52 per cent.
It acts partly through inducing local leukocytosis and as a weak bactericide,
and partly mechanically by distending the cavities and sinuses, and form-
ing a framework upon which new granulation tissue may be built up. It
is applicable to all sinuses except intracranial ; it should not be used in cases

* Vandini, Gaz. degli Osped., 1910, No. 17; Kausch, Ther. der Gegenwart, 191 1, No. 4.

278 SINUSES AND FISTULA

of fistula, such as biliary and urinary, in acute abscesses of any sort, in tuber-
culous bone or joint disease before the formation of sinuses, or in cases com-
plicated with amyloid degeneration of the viscera.

Two formulas are in use: the soft (i part arsenic-free bismuth subnitrate
and 2 parts sterile amber vaselin) is used in the presence of discharge;
after the cavity is free of pus formula 2 is used (3 parts subnitrate of
bismuth, 6 parts amber vaselin, and i part paraffin). The orifice of the
sinus is cleansed, and the paste, being liquefied by heating to between
110° and 120° F. in a water-bath, is drawn into a sterile blunt-nosed syringe.
The injection is made slowly with the nozzle pressed tightly into the sinus,
until it is estimated that the cavity and its ramifications are filled, or until
the patient complains of pressure. A gauze pad is held over the sinus until
the paste solidifies. Within the thorax, as for empyema, the cavity should
not be distended, 100 grams being the maximum injection, and free drainage
of pus should be provided for. In the presence of considerable discharge
formula i is used daily, or every second day, until the pus disappears, then
formula 2 is used at first every other day, then less frequently.

Treatment by this method may have to be persevered in for several
months; favorable results are not to be expected in the presence of sequestra
or foreign bodies (silk ties, gauze) in the sinus. Two dangers have to be
guarded against: embolism, from rupture of a vessel by the injection and the
introduction of the paste into the general circulation, and poisoning from
absorption of bismuth. Eight fatalities from absorption have been recorded
in about 8000 cases. The symptoms are stomatitis, with the appearance of
a blue line on the gums, and intestinal colic and diarrhea. Serious cases
develop paralysis, delirium, and coma. Prompt evacuation of the cavity
and flushing out with warm olive oil is indicated to avoid this complica-
tion. Mitchell recommends as a simple, efficient, and harmless substitute
a paste made of equal parts of petrolatum and chalk.

The treatment of o. fistula is the treatment of the organ from which
it leads. In general, a fistula will continue to excrete so long as there
remains any impediment to the normal excretion from the gland or
viscus from which it takes origin. In some cases, from the nature of
the primary condition, there can be no hope of restoring the natural
exit, and thus a patient may carry about a renal fistula or a perineal
fistula for the rest of his life. Otherwise, the principle of treatment
is to encourage the discharge through the vice naturales, as by tying a
catheter into the bladder, and so give the fistula rest and allow it to heal.
When this can be accomplished, the fistula will usually be found to heal
rapidly, but sometimes plastic operations are necessary for their final
closure. Fistulae may close temporarily and then reopen, and keep

^ Jour. Am. Med. Assoc., 1911, Ivii, 394.

LYMPHATIC FISTULA 279

alternating thus between open and closed for some weeks or months
before they decide finally to remain closed. Sometimes, on account of
the pain from the pressure of the pent-up secretion behind a temporarily
closed biliary fistula, it will be necessary to reopen the mouth of the
tract with a knife.

LYMPHATIC FISTULA

It occasionally happens that in dissections of the neck the thoracic
duct is accidentally opened, severed, or tied off.^ The integrity of this
lymph-channel, conveying the final products of absorption from the
digestive organs into the blood-current, must be considered vital to
the existence of the organism, and any injury that it may sustain is to
be looked upon as serious.

The thoracic duct, which drains the lymphatics of the entire body
except those of the right head, neck, and arm, comes up into the neck
at the left of the esophagus and behind the left subclavian artery. At
the level of the seventh cervical vertebra it arches outward, goes over
the subclavian artery, and terminates in the left subclavian vein at
its junction with the internal jugular to form the innominate. Its
course is inconstant — in nearly one-half of the cases it divides into two
or more radicles; in half of these it joins again, in the other half it
opens by two or more orifices, sometimes joining with the right lym-
phatic duct.2

Symptoms. — If the thoracic duct is severed and all the chyle
diverted, edema appears about the wound, which opens, and large
quantities of thick, curdy material are poured out. The digestive
organs work to no purpose, and the patient suffers from excruciating
hunger and thirst. The discharge of chyle increases as the amount
of food ingested is increased, but no matter how much the patient
eats, the emaciation and weakness progress. If pressure is exerted
in an attempt to limit the outpouring of chyle, the edema increases, the
patient complains of pain in the thorax, and as soon as the pressure is
relieved there is a profuse discharge of pent-up chyle. The heart's
action weakens as the condition progresses, and loss of consciousness
and, finally, death ensue.

Prognosis. — Death is by no means the necessary outcome of
this accident. Many cases have been reported which have recovered

^Lund (Boston Med. and Surg. Jour., 1899, cxl, 354) reports a case of operative
injury of the thoracic duct following a radical operation for removal of the breast, and
refers to 13 similar cases. The patient recovered.

* Parsons and Sargent, On the Termination of the Thoracic Duct, Lancet, London,
April 24, 1909.

28o SINUSES AND FISTULA

spontaneously after a profuse discharge, lasting some days or even
weeks. When we consider that in nearly half the cases there exist
multiple ducts, it is probable that in these reported instances the surgical
injury involved damage to one division only, and that a second collateral
channel already existed.

Treatment. — If the injury is noted at the time of operation, the
treatment should be the same that one would accord in case of a similar
injury to an arterial trunk; if the wall is only nicked, it should be sutured;
if the duct is cut across, its end should be ligated in the hope that col-
lateral branches exist; if it cannot be reached, a clamp should be applied
or compression exerted by means of a pressure dressing. The implanta-
tion of the cut end of the duct into a vein has been attempted.

In a considerable proportion of the cases the injury is overlooked
at the time of operation and the first sign of its occurrence is the presence
of pain and edema about the wound. The edema may spread up
onto the left side of the face and down the left arm. In the presence of
this edema, suflScient sutures should be released to give free exit to the
chylous discharge. A large absorbent dressing should be applied
without much pressure. Zinc oxid ointment or Friar's balsam should
be applied to save the skin from being excoriated. Everything should
be done to maintain the patient's nutrition until such time as the col-
lateral branches are able to take up their vocation.^ Subcutaneous
feeding should be tried.

FECAL FISTULA AND ARTIFICIAL ANUS

A fecal fistula is a fistula communicating with the bowel and dis-
charging fecal matter. When such a fistula is created purposely by
sewing the cecum, colon, or small intestine to the abdominal wall, it is
called an artificial anus.

Fecal fistula is usually an unavoidable though troublesome compli-
cation of the after-treatment of celiotomies; it sometimes arises from
causes which might have been avoided. Whether or not the surgeon
can be rightly held accountable for the formation of a fecal fistula in a
given case, the patient himself will ordinarily be apt to feel that the
operator is in some way personally responsible for the unclean and dis-
abling condition from which he suffers.

^ For further consideration of the subject see Harvey Gushing, Annals of Surg., June,
1898; Allen and Briggs, Am. Med., Sept. 21, 1901; Unterberger, Ueber Operativen-Ver-
letzungen des Ductus Thoracicus, Beitr. zur klin. Chir., xlvii, Heft 3; v. Graff, Zur Ther-
apie der Operativen-Verietzungen des Ductus Thoracicus, Wein. klin. Woch., 1905, Nr. i;
De Forrest, The Surgery of the Thoracic Duct, Ann. Surg., 1907, xlvi, 705.

FECAL FISTULA AND ARTIFICIAL ANUS 28 1

The most frequent cause of fecal fistula is appendix abscess, either
in the form in which the appendix has sloughed off and the base cannot
be found and ligated, or such a ligature does not hold, or the wall of
the cecum or the neighboring ileum has been rendered necrotic and
friable by the septic process and breaks open at the time of the operation
or later. The ligature of the stump has been known to "blow off" in
clean cases, however, and give rise to a fecal fistula. Fistulae may
appear after operations for the repair of traumatic wounds of the in-
testines and after intestinal anastomoses, where for some reason the
line of sutures has leaked. They may result from slight and apparently
insignificant tears of the bowel in separating adhesions and during the
removal of tumors to which one or more loops of intestine are closely
adherent, even if only the outermost layer or layers of the intestinal wall
are stripped off.

If, in the reduction of a strangulated hernia, the replaced gut, con-
trary to the surgeon's expectations, proves nonviable, a fecal fistula may
result. It may result also from the presence of a foreign body, a stitch
abscess, or from the perforation of a tuberculous or other intestinal
ulcer. It may follow pressure from gauze packing, put in perhaps for
hemorrhage at the time of operation, left for too long a time pressing
on a coil of gut, or from continued pressure of a glass or stiff rubber
drainage-tube. It has been knov^n to follow accidental puncture of
the gut by the needle in sewing up the abdominal wound. In any case
if the point of leakage is not closed off from the general abdominal
cavity by adhesions, or an easy tract of exit appears through the abdom-
inal wound, the case is likely to end in peritonitis.

If an opening in the gut has been left at the time of operation, and
a drainage-tube is m situ, gas and pus of a fecal odor may appear at the
first dressing and fecal matter become evident within twenty-four hours.
Sometimes a fistula does not establish itself for weeks after the operation.
The color and nature of the discharge vary with location of the per-
foration— the higher up in the intestinal tract, the more fluid and the
lighter in color. The discharge from any fecal fistula is irritating to
the skin, but the discharges which come from the higher portions of the
intestines are particularly acrid, and those from the duodenum may even
digest the skin down to the fascia.

Prophylactic treatment consists in avoiding the possibilities which
have already been suggested — particular care should be exercised in
handling tissues which may be friable and in separating adhesions;
anastomoses should not be dropped until they are demonstrated air-
tight, and all rents, even if they go only partly through the intestinal

282 SINUSES AND FISTUL^E

wall, should be well sewed up; and drainage of any sort should not be
allowed to exert too great a pressure or to stay in place for too long a
time.

Once a fistula has established itself, one must first of all see to it
that there is no obstruction to free drainage — all gauze should be re-
moved and the sinus dilated occasionally if it shows signs of closing
down prematurely, or kept open by a rubber tube. The chief danger
at first is from the backing up of feces under pressure. The fistulous
tract should be kept as clean as possible by irrigating it once a day
with a solution of chlorinated soda, using a female glass catheter as a
tip to the douche tube in order to reach its every part. The skin about
the wound should be protected by washing once a day with alcohol,
drying, and painting an area around about 2 in. in diameter with
compound tincture of benzoin.

Healing is encouraged by attempts to divert the fecal contents
through its natural channels. The diet should be moderate, easily
digestible, and leaving as small a residue as possible. To prevent any
back pressure in the intestinal stream the movements of the bowels
should be stimulated by repeated low enemas, but not by cathartics.
The patient should maintain a position in bed which will dispose the
intestinal matter to pass through the regularly ordained channel rather
than through the fistula.

Ordinarily, under this regimen, fistulae from appendix stumps and
other small wounds of the intestine will heal, and any constant diminu-
tion in the discharge, however slight, should encourage perseverance.
If the discharge continues unabated for a considerable period, operative
treatment should be considered, bearing in mind that fistulae sometimes
close spontaneously after existing for six or more months.

ARTIFICIAL ANUS

An artificial anus is made deliberately for the purpose of diverting
the intestinal stream. Sometimes, as, for instance, in malignant cases,
it is intended to serve permanently — usually the formation of an artificial
anus is a temporary expedient.

An artificial anus should be dressed frequently and particularly
good care should be taken of the skin. Some sort of belt or binder
may be devised to hold a pad of gauze against the wound to catch the
discharges. As soon as the bowels begin to resume their function, the
discharge of feces through the artificial anus lessens, and a man may
be about and attend to his affairs if he carries a pad or two of gauze
for a change if necessary. (See also Colostomy, p. 468, for details.)

ARTIFiaAL ANUS 283

Artificial anus does not tend to heal spontaneously. As soon as it
has served its purpose, operation will be necessary for closure. The
usual operation consists in dissecting the loop free from its adhesions
to the abdominal wound, sewing up the intestinal opening, and dropping
it into the abdominal cavity. The earlier this is done after the primary
operation the easier it will be to separate the adhesions.

CHAPTER XXVI

SEPTICOPYEMIA

Septicemia is a toxemia arising from a focus of septic infection;
pyemia is the name applied to the condition in which multiple abscesses
occur in various parts of the body from lodgment and multiplication
of bacteria deposited by the blood-current. In both these forms of
generalized septic infection the bacteria exist in the blood-stream and
may be demonstrated by planting the blood, taken under aseptic con-
ditions, on culture-media; in cases of septicemia, however, the organ-
isms are less numerous in the peripheral circulation than in the capil-
laries of the internal organs, such as the kidneys, liver, and spleen,
and it is, therefore, often impossible to detect them antemortem. As
the two conditions cannot ordinarily be sharply distinguished clinically,
and as they have a common etiology, it will be convenient to consider
them both under the heading septicopyemia.

Any acute inflammatory or suppurative condition which is due to a
microorganism may give rise to a secondary or a systemic infection.
The orgam'sms which are usually met with are the Staphylococcus
pyogenes aureus (common in circumscribed acute abscesses, carbuncles,
etc.), the Streptococcus pyogenes (occurring in spreading superficial
inflammations, diffuse phlegmons, lymphangitis, and erysipelas), the
Bacillus coli commum's (associated with inflammatory and suppura-
tive conditions of the abdominal contents), and, less frequently, the
Micrococcus tetragenus (often found alone or associated with other
organisms in suppurative conditions about the mouth and neck). Meta-
static inflammations and suppurations may follow certain acute diseases,
such as gonorrhea, pneumonia, and t)rphoid, and frequently occur in
tuberculosis; in such secondary foci the corresponding organisms may
at times be isolated.

Secondary infections may occur — (i) through the lymphatics, (2)
along natural channels, such as the urethra, ureters, and bile-ducts,
and (3) by way of the blood-vessels: organisms may be carried along
directly by the blood-current; a septic phlebitis may cause the forma-
tion of a thrombus, which disintegrates as a result of the suppuration

284

PROGNOSIS 285

and forms septic emboli, or there may be a direct extension along a
vein, as in suppurative pylephlebitis. Pyogenic organisms exercise
a peptonizing and liquefying action on blood-clot. As a result, in-
fected particles may be taken up by the lymphatic and venous circula-
tion and carried to the various parts of the body. In this case we
speak of the condition clinically as pyemia or septicometastasis. In the
lymphatic system they cause lymphangitis and abscesses of the glands
of the groin, axilla, and neck. Thrombi reaching the portal system
cause the development of mesenteric and hepatic abscesses. In the
systemic veins the thrombi are carried to the lungs. If they pass
through the pulmonary circulation, those that do not lodge in the
heart enter the arterial current and may be distributed over the body
to the brain, liver, kidneys, etc.

Symptoms. — Locally, skin wounds show marked signs of septic
inflammation, often of the lymphangitis, and inflammation of the
neighboring lymph-nodes. The skin and subcutaneous tissues become
brawny and infiltrated and erysipelas may set in. There may be crepita-
tion from the formation of gas if the bacillus of malignant edema (Bacil-
lus aerogenes capsulatus) is present. If the source of infection is an
operative wound, pus may exude from the stitch holes and from between
the edges of the wound.

The objective symptoms in septicemia are marked — rapid rise in
temperature to 101° or over, the process being initiated by a chill; the
pulse grows gradually more rapid, the tongue becomes dry and glazed,
and the skin hot. As a rule, the temperature-curve is irregular, the
fever is apt to be low in the morning and rise a degree or two toward
evening. It is at its lowest at about seven or eight in the morning,
when it may be even subnormal. The pulse in severe cases reaches
140 or 160 a minute, and as fatal termination approaches it becomes
weak and thready. The respiratory rate runs abo\'e normal. The
patient is frequently delirious as the temperature rises, and at times
may be even maniacal, although he is more apt to exhibit the condition
of drowsiness or stupor. There may be a complicating septic meningitis.
The bowels are usually constipated, although the stools may be watery;
the urine is apt, as a rule, to show albumin and casts; it is scanty in
amount and high colored.

Diagnosis. — Diagnosis may be made absolute by the isolation
of bacteria from the blood.

Prognosis. — Prognosis of septicemia is always grave. If septic
metastases develop, the prognosis, as a rule, is bad. If the site of the
original infection is superficial, where it may be thoroughly cleaned

286 SEPTICOPYEMIA

and drained, the result will be more propitious. The virulence of the
infection and the susceptibility and resistance of the patient must
always form the premises upon which prognosis is based.

Treatment. — ^Free drainage of the original site of the infection
and of all superficial secondary abscesses. One should not hesitate
at amputation of a limb if such a mutilating operation is necessary in
the effort to save life. The general treatment should be supportive
and stimulating, the diet should be easily digestible, made up chiefly of
eggs, milk, broth, cereals, custards, whisky, and the patient should
be fed at frequent intervals. Strychnin and whisky are the best stimu-
lants. The bowels should be kept acting freely by the use of calomel
or salts. Antipyretics are contraindicated on account of their depressing
action. Sponging with cold water and alcohol rubs, with the ice-cap
when needed, form the best means of controlling temperature. In the
earlier stages normal salt solution should be given by rectum. In
critical cases 250 to 500 cc. may be given every four to six hours. In
desperate cases the venous infusion of 500 to 1000 cc. may be given.
Metastatic abscesses should be incised, evacuated, and drained when
accessible. If septicemia becomes chronic, Fowler's solution or elixir
of iron and gentian should be exhibited. The use of bacterial vaccines
has been followed by good results in some cases. (For discussion of
this subject and technique, see Chapter LII.

CHAPTER XXVII

CUTANEOUS RASHES: ETHER RASH, SEPTIC RASH,
ERYSIPELAS, SURGICAL SCARLATINA, DRUG POI-
SONING

Cutaneous rashes and eruptions are likely to be seen occasionally
following operations, especially celiotomies. Usually the operation is
only indirectly responsible for their occurrence. They may take the
form of an urticaria; the eruption may be papular, it may be macular
and resemble measles, or erythematous, like scarlet fever. Often it
will be found that nothing more than a digestive disturbance is respon-
sible for their outbreak, but they may be due to drugs taken internally,
such as morphin, or used externally, such as iodoform, or to irritant
enemas, as of turpentine. Occasionally they are the outward evidence
of so serious a condition as septicemia, and it must not be forgotten
that measles and scarlet fever may themselves complicate convalescence.
While it is true that these postoperative rashes are usually only of passing
importance, they are likely to cause considerable anxiety before they
are identified, and they should never be allowed to go without a diagnosis.

ETHER RASH

During etherization there not infrequently appears on the face,
neck, and chest a bright roseolous rash which marks the height of vascular
excitement. The patches are large, sharply outlined, irregularly shaped,
and asymmetrically placed. They appear suddenly, just about as the
patient reaches full surgical anesthesia, maintain their vividness for
tw^o or three minutes, and then slowly fade. It is most common in
women, and usually affects the area supplied by the superficial cervical
plexus. It is undoubtedly of nervous origin.

No treatment is necessary.

SEPTIC RASH

Associated with symptoms of septicemia there sometimes appears
within the course of a few hours a generalized or limited erythematous
eruption resembling that of scarlet fever. Frequently, particularly in chil-
dren, it occurs without any other evidence of general septic infection,
although its appearance is sometimes preceded or followed by a breaking

287

288 CUTANEOUS RASHES

down and suppuration of the wound. Whether this is cause or effect
cannot be stated.

The eruption occurs ordinarily three or four days after the opera-
tion. It is ushered in by restiessness and malaise, and with its appear-
ance the temperature rises to about 102° F. and the pulse-rate goes up
proportionately. It is usually uniform in its distribution, with a pre-
dilection for the upper half of the body. In mild cases, unaccompanied
by septicemia, it usually lasts two to four days and then begins to fade
out. If the eruption has been at all severe, it is followed by desquama-
tion.

Just how closely this condition is allied to scarlet fever it would be
difficult to say. That it has been, and may be, confused with scar-
latina there can be no question. It differs from this condition as it
ordinarily presents itself in that it appears rapidly, without premonitory
symptoms, such as sore throat and vomiting. The characteristic
"strawberry" tongue of scarlatina is absent. The rash does not appear
progressively on the neck, chest, and face as the scarlatinal rash typically
does. The fever does not run so high, and in some cases at least it is
intermittent. It is not complicated by otitis media or cervical adenitis.
Finally, it is often allied to wound suppuration or general septicemia.

Treatment. — ^Symptomatic and supportive; catharsis as indi-
cated, and treatment of any associated septic condition which may be
allied causally. Until the diagnosis is clear, isolation is advisable. A
powder of zinc oxid and starch may be applied.

ERYSIPELAS

The occurrence of erysipelas after clean operations which have
been performed with due respect for the rules of aseptic technique is
rare. Erysipelas may, however, show itself after operations for the
relief of septic conditions or the repair of wounds accompanied by more
or less extensive destruction of tissues. It occurs particularly in those
whose resistance is lowered by exposure, alcohol, debility, or old age.
The infecting organism is usually the Streptococcus pyogenes, although
it has been recently stated that the Staphylococcus aureus may be the
organism in some cases. Pathologically, the condition is a lymphangitis,
the organism finding its way by some surface lesion into the superficial
lymphatic system, multiplying rapidly and spreading throughout the
lymph-spaces from the point of inoculation by continuous growth.
The organisms may be best demonstrated in the advancing margin of
inflammation.

The onset is usually marked by a chill and gastric disturbance.

SURGICAL SCARLATINA 289

The temperature rises to 102° F. or over and remains at about this
point. The patient is prostrated. In twelve to twenty-four hours he
complains of a burning or itching about the wound, and examination
reveals a contiguous patch of infiltration, elevated, tender, sharply
outlined, and dusky red in color. There is usually an accompanying
serous discharge from the wound. The inflammation advances irreg-
ularly, preserving its raised sinuous border, the color fading out in
the center. This progression is maintained for a variable length of
time — from a few days to many weeks — ^before it gradually clears up.
It usually leaves the patient exhausted and relapses occur in about
10 per cent, of the cases. The prognosis should always be guarded,
on account of the possibilities of gangrene, cellulitis, and metastatic
infection occurring as direct complications, or secondary pneumonia
or nephritis. The mortality may be roughly stated at 10 per cent.;
it is much higher in infants and in the old or debilitated.

Treatment. — ^The patient should be kept quiet and apart from
other patients. He should be well nourished with a sufl&cient, though
light, diet, and brandy or strychnin should be employed if stimulation
is called for. Morphin will often be necessary. The bowels should
be kept moving freely with calomel or salines. Locally, all wounds
should be kept surgically clean. The inflammatory area should be
kept moistened with a refrigerant lotion, such as equal parts of camphor
water and ether, applied every half-hour with a camePs-hair brush.
If the infection is about the face, the eyes should be protected by com-
presses of iced boric-acid solution. If for any reason the application
of the lotion cannot be kept up through the night regularly, a 10 per
cent, ichthyol ointment may be applied at eight o'clock and wiped off
the next morning. In case of abscess formation free incision and
drainage should be performed, without general anesthetic if possible.

SURGICAL SCARLATINA

At this date there can be hardly any question but that scarlet fever
may follow surface lesions, surgical or traumatic. Many cases have
been reported following operation, but some have run an atypical course,
and probably many of these are of the type which we have already con-
sidered under Septic Rash. It must also be borne in mind that a child
may be operated upon unknowingly during the incubation stage. Some
of the true cases of scarlet fever developing comparatively late in con-
valescence are undoubtedly due to contagion from the doctor, a nurse,
or a neighboring patient.

In a few cases that have been closely observed it is highly prob-

290 CUTANEOUS RASHES

able that a surface lesion was the site of primary inoculation on
account of the presence of an areola and lymphangitis about the wound,
the shortness of the period of incubation, the typical course with com-
plications, and contagion from the patient resulting in the occurrence of
the disease in others

Postoperative scarlatina is most frequent in children. It follows
surface lesions, such as burns or lacerated wounds, and operations of
one sort or another, but it has been most commonly reported after
operations about the nose and throat, as for removal of tonsils and ad-
enoids. The treatment does not differ from that generally employed.*

DRUG POISONING

Skin eruptions may follow the use of antiseptics or other local ap-
plications, the internal use of drugs, or the use of enemas.

The commoner drugs which are likely to cause eruptions are atropin
and belladonna, the bromids, chloral, copaiba, the coal-tar derivatives,
such as'antipyrin and acetphenetidin, the iodids, mercury, morphin
and opium, salicylic acid and the salicylates, sodium benzoate, chlorate
of potash, strychnin, and veronal. We have in mind the case of a man
who is poisoned by the slightest dose of mercury in any form, such as
calomel internally or the bichlorid externally, the administration being
followed always by a severe, almost universal, eczema, and we have seen
several instances where a copaiba rash was confused with a secondary
syphilid. While the appearance of the efflorescence caused by each one
of these drugs has certain peculiarities by which they may be some-
times differentiated, they all have points in common which distinguish
them from other eruptions in general and aid in diagnosis.

As a rule, a medicinal rash resulting from drugs taken internally
may be recognized — (i) By its rapidity of development; (2) its symmetry;
(3) the absence of fever; (4) its existence alike on exposed and protected
surfaces of the skin; (5) its tendency to generalization; (6) pruritus,
and (7) the fact of medication with a drug known to cause skin erup-
tions. Any generalized rash which makes its appearance suddenly^
if we can exclude syphilis and the acute exanthems, is likely to be a drug
eruption. They disappear rapidly, as a rule, upon the discontinuance
of the responsible drug.

* Kredel (Wundscharlach, Arch. f. klin. Chir., 1908, Ixxxvii, No. 4) states that in the
Hanover Hospital 28 cases of scarlet fever developed among the patients. In 12 the in-
fection followed an extensive operation and in i a severe burn. The incubation was only
three days in 10 and from five to eight days in the others. He is convinced that the infection
occurred in the operating room, and believes that antiseptic rather than aseptic measures
might be preferable during prevalence of scarlet fever. Van der Bogart (Arch, of Pediat-
rics, Feb., 1909) cites a case of scarlet fever following a wound in the foot.

DRUG POISONING 29 1

The question of personal idioscyncrasy seems to be an important
factor in the occurrence of drug eruptions of all sorts; apart from this,
poisoning is more liable to develop in children than in adults and
in persons who have unsound kidneys.

Cases of local poisoning from the use of antiseptics are uncommon,
but by no means rare. Most of the ordinary agents will excite a local
reaction if applied too strongly or too freely, especially if their action
is concentrated by applying a moisture-proof covering, such as oiled
silk or waxed paper, over the dressing. Ordinarily an erythematous
rash appears under and about the edges of the dressing, bright red in
color, which may itch badly. Sometimes the eruption may spread for
some distance about the wound. Unless the condition has progressed
so far as gangrene, — as it will after the use of strong carbolic acid, —
this local reaction will usually promptly disappear if the irritant is
much diluted or changed altogether for something more mild, and the
skin protected from its action by boric or zinc oxid ointment.

There are only a few of the antiseptics in common use which by
their local application may cause systemic poisoning through absorp-
tion. Of these, the most important are iodoform, carbolic acid, and
its derivative, picric acid.^

Iodoform poisoning' may follow the use of iodoform powder
in large quantity on raw surfaces, the use of iodoform gauze in pack-
ing cavities, and the use of iodoform emulsion or paste in tuber-
culous glands and sinuses and osteomyelitis. As a rule, there is an
areola of inflammation resembling erysipelas surrounding the wound,
and there may be the formation of serous vesicles. The first sign that
things are going wrong is drowsiness. The temperature rises suddenly
to 102° F. or over; there are accompanying nausea and vomiting. Within
twenty-four to forty-eight hours a generalized eruption appears, scarla-
tiniform in type. The pulse-rate rises, and signs of collapse are ap-
parent; the patient is delirious, becomes comatose, and may die; the
urine becomes black and shows the presence of iodin.

Treatment, — All iodoform should be removed as rapidly and as
thoroughly as possible. Any free iodin left behind may be taken up
by scrubbing the surface with moistened starch or irrigating with a
solution of starch in warm water. The patient should be supported
and stimulated, the bowels and kidneys flushed by the use of salines,
diuretics, and water by mouth, under the skin, and by rectum.

^ Amsden (Jour., Am. Med. Assoc, 1910, liv, 2042) reports a case of generalized
maculopapular eruption following the application of aristol as a dusting-powder after
a perineorrhaphy.

292 CUTANEOUS RASHES

Carbolic acid or phenol has a considerable and lengthening list
of fatalities to its credit, although cases of death from its use externally
are at present rare. If enough carbolic acid in solution is applied
over a raw surface to allow absorption in sufl5cient amount, the patient
within a few hours becomes pallid and drowsy, the respiration is
labored and stertorous, and coma gradually develops, followed by col-
lapse; the urine is dark green or black and lacks sulphates.

The treatment of this form of poisoning consists, first, in removing
the source of the absorption, and, second, in the administration of
Glauber's or Epsom salt and general supportive measures.

Poisoning from picric acid is occasionally reported following its
imprudent use in the treatment of burns and minor surgical lesions.
Although a number of cases of mild poisoning have been reported after
topical applications, and even though several suicidal attempts have
been made by taking it internally, it is not known that picric acid has
ever been the direct cause of death. Absorption is readily recognized
by the yellow color which the deposit of this pigment gives to the skin
and mucous membrane. The urine may be yellow, brown, or black.
There is some nausea and vomiting and headache. It is differen-
tiated from jaundice by the presence of bile in the stools. As soon as
the use of the drug is discontinued the symptoms disappear and the
yellow color of the surface of the body begins to fade.

Occasionally the use of enemas will be followed by a skin eruption.
It may be local and patchy, like measles, or generalized, like scarlet
fever. It shows up shortly after the administration of a rectal injection,
in anywhere from four to eighteen hours, and it usually lasts t\vo to
four days. There is no fever. As to its causation, there is some question.
It will follow the injection of turpentine and the use of common yellow
soap in making suds enemas. No treatment is necessary beyond the
use of an antipruritic lotion, such as white wash (carbolic acid, i dr.,
zinc oxid, i oz., lime-water, to make i pt.).

References

Prince A. Morrow, Drug Eruptions, New York, 1887.

Roswell Park, Iodoform Poisoning, Boston Med. and Surg. Jour., 1893, cxx\di, 138.

I. S. Stone, Iodoform and Carbolic Poisoning, Amer. Jour. Obstet., 1902, xlv, 93.

Gottheil, Diagnosis of Commoner Drug Eruptions, Arch, of Diagnosis, April, 1908.

F. J. Shepherd, Eruptions Occurring After Abdominal Operations, Jour. Cut. Dis.,
1909, xxvii, 293.

A. Ehrenfried, Picric Acid and Its Surgical Applications, Jour. Am. Med. Assoc, 191 1,
Ivi, 412; and Picric Acid, a Retrospect, New York Med. Jour., March 25, igii.

CHAPTER XXVIII

RARE COMPLICATIONS: TETANUS, MAUGNANT EDEMA,
PAROTITIS, STATUS LYMPHATICUS, HEMOPHILIA

POSTOPERATIVE TETANUS

In the early days of abdominal surgery it was not rare for patients,
a few days after the operation, to develop symptoms of tetanus, and
these cases frequently proved fatal. Twenty years ago and more the
matter was of sufficient importance to give rise to a considerable litera-
ture. Olshausen * first described it as occurring after ovariotomy, and
he collected 49 cases; Edmund Rose^ in 1897 collected 58 cases;
V. Cackovic,^ 60 cases; Zacharius* adds 18 cases, and W. G. Richard-
son ^ adds 21 more, making a total of 206 cases. Of these, the large
majority have been fatal.

The sources to which the infection has usually been ascribed are
the use of infected catgut • and kangaroo tendon,' the use of gelatin
which has become contaminated by tetanus bacilli,® or contagion from
another patient in the hospital through a nurse.®

It cannot be questioned but that in the majority of reported instances
the infection is referable to catgut.^*^

It was, however, first observed in the cases of Zacharius that the
catgut might be sterile on bacteriologic examination. Richardson ex-
amined the catgut in 14 of his 21 cases and found it negative in every
instance, although in 4 cases a bacillus resembling that of tetanus was

* Krankheiten der Ovarien, Deut. Chin, Lief 58, 1886.

^ Der Starrkrampf beim Menschen, Deut. Chir., Lief 8, 1897.
^ Central, der Chir., 1897, xxiv, 728.

* Miinch. med. Woch., 1908, i, 227.

^ Tetanus Occurring After Surgical Operations, Brit. Med. Jour., 1909, vol. i, 948.

* Gunn, Post-operative Tetanus, Dublin Jour, of Med. Sci., 1909, cxxviii, i.
' Dorsett, Amer. Jour. Obst., 1902, xlvi, 620.

® Haddaeus, Tetanus nach subcutaner Gelatine-Injection, Miinch. med. Woch., 1909,
231.

* Aspell, Amer. Jour. Obst., 1900, xlii, 867.

^^ R. Kleinertz, Tetanus from Catgut, Berlin, klin. Woch., 1909, xlvi, 1654; and
Reuben Peterson, Tetanus Developing Twelve Days After Shortening of the Round
Ligaments, Jour. Amer. Med. Assoc, 19 10, liv, 108.

293

294 RARE COMPLICATIONS

found. It was suggested to him that in the locality in which these
cases occurred sheep ordinarily harbored tetanus bacilli in their in-
testinal tract in large numbers. From this suggestion he deduced the
theory that the tetanus bacilli were not introduced with the catgut,
but that the patient at the time of operation was a host of the bacillus,
and the cases were all to be considered as cases of idiopathic tetanus,
in which the disturbance of opening the peritoneum was enough to
cause the bacillus to become toxic.

This theory of the causation of postoperative tetanus has recently
aroused some interest in this country. Matas, at the meeting of
the American Surgical Association held in June; 1909, read a paper
on the Fecal Origin of Some Forms of Postoperative Tetanus/ and
reported 2 cases which occurred after the patient had eaten copiously
of uncooked vegetables. The result of his careful consideration of this
subject may be summed up as follows: Postoperative deaths from
tetanus sometimes occur in apparently clean cases. The risk of
tetanus infection can be practically eliminated in all operations
except in those regions in which postoperative asepsis cannot be
secured, for example, the extremities and the anorectal region. Post-
operative deaths are not necessarily dependent upon defects of
technique or contaminated materials, such as imperfectly sterilized
catgut: they may be due to the direct contamination of the alimentary
canal and its contents with living tetanus bacilli and their spores
swallowed in uncooked vegetables, berries, and other fruits which
are cultivated in fertile or manured soil; that is to say, soil that con-
tains the tetanus bacilli. He calls attention to the fact that in both
his cases the patients had pre\iously partaken of uncooked vegetables.
All cultivated soil in the temperate and tropic zones contains tetanus
bacilli. They grow more luxuriantly in the soil of the tropics than in
the temperate zone, and, therefore, to a certain extent, tetanus is a
disease of warm climates.

Tetanus bacilli and their spores survive the passage through the
intestinal canal of domesticated animals, particularly the horse and
the cow, and the dejecta of these animals are perfect culture-media for
the bacilli. Of normal adult men, 5 per cent, harbor the tetanus bacillus
or its spores in an active state in the intestinal canal, and 20 per cent,
of hostlers, dairymen, and others intimately associated with domestic
animals show tetanus bacilli in their feces.

Matas concludes that whenever a patient is to be operated on in
any region where fecal contamination is unavoidable, such as in cases

^ Monthly Cyclopaedia and Medical Bull., 1909, ii, 705.

POSTOPERATIVE TETANUS 295

of hemorrhoids, fistula, stricture, etc., antitetanic preparation should
be insisted upon. This consists, first, of purgation for three days
before operation, and, second, suppression of all uncooked food,
especially green vegetables, berries, and fruit, for the same period.
These rules apply particularly to the warm portions of the country
and sections where the tetanus bacilli are known to abound. In cases
of emergency, when dietetic preparation is impossible, lo cc. of tetanus
antitoxm may be injected subcutaneously at the time of operation.

Gelatin has long been known to harbor tetanus bacilli over long
periods, and ordinarily sterilization has been found impotent to destroy
their virulency. If gelatin is to be used for subcutaneous injection, the
bacilli and their spores must be destroyed beyond a question of doubt.
A practical and competent method for accomplishing this purpose is
described by Wandel.^ The gelatin in a neutralized lo per cent, solu-
tion is sterilized in an Erlenmeyer jar, covered with a layer of fluid
paraffin to keep out oxygen. A long glass tube reaches to the floor
of the jar, the upper end being capped with a tube and stop-cock. A
larger short tube in the stopper filled with cotton allows the entrance
of air. The whole is sterilized in a linen bag in steam for forty minutes
at 100° C.^ After cooling, it is kept in the incubator at 31° C, then
sterilized again for thirty minutes as at first, and this is repeated for
fifteen minutes the following day. The gelatin thus sterilized is
poured into sterile vials containing 50 cc, and these are then fused.
Gelatin thus sterilized and preserved can be kept indefinitely.

The treatment of postoperative tetanus is that of trau-
matic tetanus after the development of symptoms. If the source of
toxin supply can be reached, it must be removed or disinfected, if
possible, with carbolic acid. Hutchins^ states on experimental evi-
dence that amputation of an infected limb is of little curative value,
because at the time of the appearance of symptoms the body probably
contains the maximum of toxin. Use of antitetanic serum in this
stage of the disease to neutralize the toxin already circulating in the
system is rarely to be depended upon, but in spite of this it may be
useful to inject 10 to 20 cc. subcutaneously in the neighborhood of the
wound, 10 to 20 cc. intravenously, 10 to 20 cc. into the cauda equina,
and, if the patient's life is in imminent danger, 20 to 30 min. directly
into the spinal cord. The injection is made between the sixth and

* Gelatin in Therapeutics, Therapie der Gegenwart, 1909, 1, 265.
2 Ciuffini states (Policlinico, 1910, xvi. Medical Section, p. 525) that gelatin loses the
property of promoting coagulation if it is heated to 130° or 135° C. for half an hour.
^ Fetschrift fiir Rindfleisch, 1907.

296 RARE COMPLICATIONS

seventh cervical vertebrae.^ Exhaustion should be combated by
proper feeding, which may have to be carried on through a tube, and
by careful stimulation. The patient should be kept quiet in a dark
room. Free diuresis and diaphoresis should be instituted. Water
should be taken copiously. To lessen the high degree of nervous irri-
tability and the constant muscular contractions, some sedative, such as
chloral or the bromids, should be exhibited.

There has been considerable success, so far as diminishing the
reflex symptoms goes, following the subdural injection of magnesium
sulphate, as suggested by Meltzer. This inhibits the convulsive seiz-
ures and produces ascending paralysis, beginning in the lower extremi-
ties when injected into the lumbar spine. Care should be exercised in
computing the dose or it may be followed by paralysis of the respira-
tory center and death. The dose for a male adult should be not more
than I cc. of the 25 per cent, solution for every 20-pound weight. One
injection will inhibit the convulsive seizures for twenty-four to thirty-
six hours, when the dose will have to be repeated. The advantages of
this treatment are: pain is relieved, the patient's strength is conserved,
and the use of depressant sedatives is avoided. The patient may be
fed by mouth. On account of the anesthesia, other measures, such as
local operation and intraneural injection of antitoxin, may be carried
on freely. Fox^ foimd 50 per cent, of recoveries in 15 acute cases,
that is, with an incubation period of less than ten days, treated by
this method. In 2 of these cases more than eight injections were
necessary.

Dr. Willard H. Hutchins, after experience in 6 cases,^ recommends
the use of chloretone for the control of the muscular manifestations.
He asserts that the drug is harmless, easy of administration, and
prompt in action. From 30 to 75 gr. may be given, dissolved in i
ounce of whisky, if the patient can swallow, or through a stomach-
tube, or in I ounce of hot olive oil by rectum. The dose can be re-
peated every twenty-four or forty-eight hours, as indications arise.

^ Rogers, Jour. Am. Med. Assoc., 1905, xlv, 12: As the toxin is centripetal and finds
its way to the central nervous system along the motor nerves, it has been suggested that
there would be an advantage in cutting down upon the nerve-trunks supplying the part
infected and injecting antitoxin into these directly. Success has been reported with this
technique. The recent isolation of tetanus bacilli from enlarged glands by C. A. Porter
and Oscar Richardson (Two Cases of " Rusty Nail " Tetanus with Tetanus Bacilli in the
Inguinal Glands, Boston Med. and Surg. Jour., 1909, clxi, 927) may give an entirely
different aspect to our treatment of the disease, bringing it into the classification with the
septicemias.

2 Therapeutic Gazette, 191 1, xxxv, 730.

^ Trans. Am. Surg. Assoc., 1909, xxvii, 279.

GAS-BACILLUS INFECTION 297

He suggests as probable that the therapeutic effect of the antitoxin is
due to the carbolic acid or tricresol which it contains as a preservative,
and which in itself is strongly recommended by Bacelli.^

The carbolic acid treatment of Bacelli is popular in Italy, where it
has been used with apparently excellent results. Ascoli^ reports ^^
cases, with one death. It consists in the subcutaneous injection of a
I per cent, solution of carbolic acid at frequent intervals until 80 gr.
(adult) have been given in twenty-four hours. American reports do
not show up so favorably. Symmers^ found i6 deaths in 42 cases
where this treatment had been used.

MALIGNANT EDEMA; GAS-BACILLUS INFECTION

The Bacillus aerogenes capsulatus is closely allied morphologically
to the tetanus bacillus. It is anaerobic and its habitat is soil and street
dirt, which might account for its occasional presence on the skin.
Like the tetanus bacillus, it is found in the intestinal tract of man and
animals. Infections with the gas bacillus are likely to follow extensive
lacerations, crushing wounds of the extremities, and compound frac-
tures, and in our experience it seems to be particularly apt to occur
when the wound has been contaminated with grease and dirt from
machinery and shafting or wagon-wheels and car-trucks. Welch*
collected 5 cases in which infection followed hypodermic injections
and subcutaneous infusions of salt solution. Cases have been re-
ported following appendectomy, herniotomy, nephrotomy, operations
about the urethra and uterus, but, on the whole, its postoperative oc-
currence is rare. We have known of its following operation about the
rectum and curettage for induced abortion, and there has recently been
a fatal case following amputation for diabetic gangrene at the Boston
City Hospital. The source of infection in these cases may ordinarily
be presumed to be the intestinal tract, although cases are on record
where the bacilli were deposited by the blood-current in tissues de-
prived of vitality.

The symptoms usually make their appearance within twenty-four
to forty-eight hours after infection. The first sign is a livid or bluish
swelling about the wound, followed rapidly by the occurrence of
gaseous infiltration, which crackles and pits on pressure. A foul,

^ SuH'azione delle iniezione di acido fenico nelle neoralgie, nel tetano e nella tisi,
Lavori di Congressi di medicina interna, Roma, 1888, i, 342.
^ Boll. d. Reale Accad. Med. di Roma, xxiv, iv, 495.
' Amer. Med., Aug. 15, 1903.
* Bull, of Johns Hopkins Hospital, Sept., 1900.

298 RARE COMPLICATIONS

watery, blood-tinged secretion may be expressed, which contains tiny
bubbles. Blebs filled with this secretion appear, and the process
extends rapidly in the form of a moist gangrene, which may involve the
entire limb within twenty-four hours. There is no pain. Profound
prostration ensues, with delirium, and the patient usually dies of
toxemia. This cUnical picture accounts for the name maHgnant
edema, which is sometimes given the condition. Smears from the
exuded serum show the presence of the bacilli.

The treatment must necessarily be immediate and heroic. Free
incision should be made wherever there is infiltration, and moist anti-
septic dressings should be continually applied or the continuous bath
or irrigation employed. On the theory that the bacillus cannot live
in the presence of oxygen, potassium permanganate or hydrogen
dioxid may be used freely, or a stream of oxygen may be carried direct
into the tissues.^ If the infection has involved a limb, high amputa-
tion offers the best hope for recovery, and should be performed before
the patient becomes too depressed to stand anesthesia.^

In a recent personal case, following compound fracture of the elbow,
where amputation was performed at the shoulder through tissues already
edematous, recovery followed wide incision of the tissues, the amputation
stump being left open, and the application of salt and citrate, with sup-
portive measures.

PAROTITIS

Inflammation of the parotid glands occurs not infrequently after
operations, usually, however, after operative procedures on the ab-
dominal and pelvic viscera. It is on record also as following simple
concussion of the abdominal organs.^ It also occurs during rectal
feeding.* It is found to occur more frequently in women than in men.^
It may follow any injury or disease, but is more frequent after in-

* Thiriar, Presse M6d., Beige, 1904, Ivi, 555.

2 Abner Post, Pseudomalignant Edema, Boston City Hosp. Med. and Surg. Reports,
1896, seventh series; Paul Thomdike, Clinical Report of Cases of Infection due to the
Bacillus Aerogenes Capsulatus, Boston Med. and Surg. Jour., 1900, cxlii, 592; J. H.
Pratt and F. T. Fulton, Report of Cases in which the Bacillus Aerogenes Capsulatus
was Found, Boston Med. and Surg. Jour., 1900, cxlii, 599; John Bapst Blake and F. H.
Lahey, Infections Due to the Bacillus Aerogenes Capsulatus, with a report of 10 cases,
Jour. Am. Med. Assoc, 1910. Viv, 1671.

' Kulka, Secondary Parotitis, Wien. klin. Woch., 1908, xxi, 691.

*\\. S. Fenwick, The Prevention of Parotitis during Rectal Feeding, Brit. Med.
Jour., 1909, i, 1297; and Gaultier, Arch, des Mai. de TApp. Digestif., Jan.. 191 1.

•^ Paget, Lancet, 1887, i, 314.

PAROTITIS 299

juries and operations on the pelvic organs than after diseases in any
other part of the body.

In onset and appearance it resembles mumps. The swelling may
be one sided or double, and other salivary glands, such as the sub-
maxillary and sublingual, may also become swollen. The inflamma-
tion usually appears anywhere from five to ten days after the opera-
tion. Its onset is accompanied by a rise in temperature which lasts
for two or three days, together with pain in the affected gland.
Usually the symptoms are not severe. The swelling may disappear
by resolution or the gland may become septic. The temperature,
as a rule, does not rise above 101° or 102° F., except in septic
cases. ^

Suppuration occurs in about one-half the cases following opera-
tion. An abscess will form in the substance of the gland, and unless
treated this is likely to burst into the mouth or burrow a path into the
external auditory canal or down the neck in the pharynx.- A con-
siderable proportion of the suppurative cases prove fatal.

The origin of the parotitis following trauma or operation is still
somewhat doubtful. The association of parotitis with operations
upon pelvic organs is suggestive of the oft-noted occurrence of epi-
didymitis and ovaritis following epidemic parotitis, which speaks for
some association between this gland and the generative organs. Some
authorities consider that toxic agents circulating in the blood are an

* A typical case is well described by P. W. T. Moxom (N. Y. Med, Jour., 191 1, xciv,
■985) : A woman of seventy years suffering from acute appendicitis was treated medically,
with success. The symptoms had practically disappeared by the seventh day (Jan. 3d),
when, late in the afternoon, she awoke from a nap to find her left cheek swollen and painful.

** When seen at 8 p. m. the left parotid was found much swollen and very tender.
The swelling extended around under the left ear; there was considerable postauricular
edema. Temperature per rectum 98.8° F. The following day the swelling had much in-
creased. The gland was very tender and hard, the skin hot and purplish red. Ice-bag
was applied with some relief to the pain, but without much effect on the swelling. The
gland continued hard and much swollen until January 8th, when it became somewhat
softer and ' boggy,' and although no distinct fluctuation could be made out, an inch-long
incision was made into the substance of the gland. Over 2 drams of green, foul-smelling
pus were evacuated. On the following day the right parotid became swollen, hard, and
painful, the skin overlying it red and shiny, and the right eyelid edematous. The follow-
ing day the submaxillary and lingual glands were much swollen, but without pain or ten-
derness. The patient, however, suffered much discomfort from inability to close the
mouth, and from the constant flowing of saliva. With the first appearance of trouble in
the right gland, an ice-bag was applied and the pain and swelling gradually diminished.
Five days later the right parotid was practically normal, and the swelling in the submaxil-
laries and Unguals had subsided. The left gland continued to discharge, at first pus, later
a thin watery secretion until January 25th. Six days later the wound was entirely healed."

2 Bumm, Munch, med. Woch., 1887, xxxiv, 173.

300 RARE COMPLICATIONS

important factor in suppurative parotitis.^ There is far more evi-
dence, however, supporting the theory that germs enter the gland by
way of the mouth. ^

A patient who is kept upon his back and allowed only a liquid diet
or is fed by rectum does not use his jaws in chewing, and, therefore, is
not apt to empty his parotid ducts as he would normally. The secre-
tion of saliva is diminished or suppressed, and the germs present in the
mouth take on an added virulence. They make their way through the
duct into the stagnant gland and inflammation ensues. Parotitis
may also be due to the presence of a decayed tooth, or may follow the
pressure of the fingers of the anesthetist during an operation in hold-
ing forward the jaw.

Reichmann^ reports 3 cases of parotitis occurring in patients under rec-
tal feeding, with i death; Rollestonand Oliver,^ 21 cases, with 2 deaths; and
Gaul tier, ^ 3 cases, of which i was fatal.

Prophylaxis is important. During periods of withdrawal of food
by mouth, and in states of depression, when the patient exists on liquid
foods which require no chewing and make no demand on the salivary
secretions, particular care must be taken to keep the teeth and mouth
clean, and measures must be maintained to keep the salivary glands
functioning. Chewing gum* or sucking a rubber nipple will usually
prove efficacious. Otherwise, the excretory ducts should be mas-
saged several times daily, and their contents expressed.

The treatment of this condition consists in keeping the teeth and
mouth clean and the bowels active, and the use of morphin for pain
when it becomes necessary. Hot fomentations often give relief.

Suppuration should always be suspected if pain is severe and pro-
longed or if the temperature is maintained at 102 ° F. or over. When
suppuration occurs, incision should be made at once, with care that the

* Dyball, Ann. Surg., xl, 886.

2 Soubeyran and Rives, Arch. G^n. de Chir., 1908, ii, 448.

' Archiv. f. Verdauungskrankh., 1905, 133.

^ Brit. Med. Jour., 1909, 2526.

^ Archiv. des mal. de Tapp. digestif., 1910, 20.

* Legrand Kerr (Chewing-gum as a Mouth Cleanser, Am. Med., Oct., 191 1) finds the
use of chewing-gum very desirable in keeping the buccal cavity clean through the mechan-
ical action of the movement of the tongue, as well as in stimulating the flow of saliva.
A fresh piece should be used each time. It is highly effective in its results, and to some
people, particularly children, it is more pleasant than other measures of cleaning the mouth,
which, however, should not be entirely neglected.

STATUS LYMPHATICUS 30I

branches of the facial nerve are not wounded.^ Even if no pus is found,
the incision will usually afford relief. After incision, Bier^s suction
apparatus may be employed with advantage.

So long as the temperature remains normal there need be no uneasi-
ness. Ordinarily, symptoms are slight and of short duration, and the
only disadvantages are the depressing effect upon the patient's mental
condition and his appetite, and the pain which he may suffer. Death
has occurred from secondary cellulitis of the neck and edema of the

glottis.

STATUS LYMPHATICUS

It has long been known that children are more subject to sudden
death during or immediately following an operation than adults.
Sudden death has occurred in children who are apparently in normal
physical condition, even following operations of short duration, such
as tonsillectomy. The fatality has seemed to be independent of the
anesthetic used, and has sometimes occurred when no anesthetic at
all was employed. According to some authorities, this condition is
the most common cause of sudden death during chloroform anesthesia
in cases where the anesthetic is being administered by an expert,
although recently (see p. 112) other explanations have been offered.

Autopsy in some of these cases of sudden death has demonstrated
the.presence of an enlargement of the lymphatic tissues throughout the
body. There is hyperplasia of the lymphatic system in general, en-
largement of the superficial and deep lymph-nodes, especially those in
the neck and the axillae, and enlargement of the spleen. This in some
cases is accompanied by a persistent or enlarged thymus. The associa-
tion of persistence or hypertrophy of the thymus with sudden death
from respiratory interference has been recognized for about three
hundred years, and many surgeons of to-day are coming to be of the
opinion that this gland is the essential factor in what is usually called
status lymphaticus.

The existence of status lymphaticus during life can never be more
than suspected. The fact that the child has enlarged adenoids and
tonsils is not especially significant. If this enlargement is associated
with other evidences of lymphatism, such as general glandular enlarge-
ment or enlarged spleen, one should hesitate before administering an
anesthetic. The condition is known also to be associated with rickets,
and in any suspicious case one should look for enlargement of the area
of thymic dulness. Children who are subject to the disorder are apt
to be anemic, with the pasty complexion and anxious facies suggestive

^ D. F. Jones, Boston Med. and Surg. Jour., 1902, cxlvii, 565.

302 RARE COMPLICATIONS

of cretinism, and they are likely to be subject to attacks of syncope
and dyspnea, of laryngismus stridulus, or thymic asthma. They may
present none of these associated conditions; death after simple opera-
tion may come without warning.

Usually death follows so suddenly upon the first appearance of
symptoms that treatment is of no avail. Artificial respiration should
always be instituted and anal divulsion and cardiac massage resorted
to. If opportunity allows, measures should be taken to support and
stimulate the patient. Adrenalin, camphor, brandy, and atropin may
all be employed, with the hope that they sustain the patient. If there
seems to be mechanical pressure upon the trachea to such a degree as
to interfere with respiration, tracheotomy should be performed.
The introduction of large quantities of fluid by all possible avenues
may dilute an overdose of thymic secretion, which may be the condi-
tion here present.

The function of the thymus gland has not been definitely determined,
though recent experiments by O. Nordman^ and H. Klose^ have thrown
some light upon the subject. Nordman found that removal of the thymus
in young puppies was followed by the death of the animal within one year,,
with dilatation of the entire heart, especially the right half, but without
hypertrophy. He believes the thymus and the adrenals to produce internal
secretions antagonistic to each other. Klose, in similar experiments, found
that following the removal of the thymus in early life symptoms of acid
intoxication set in, presumably from nucleinic acid, and a deficiency of lime
salts, with resulting changes in the brain and bones. Partial removal of the
gland during the stage of activity or complete removal during the period of
involution did not produce permanent injury. Treatment with thymus
extract did no good.

If status lymphaticus is due to oversecretion of the thymus gland, and

if the theory of Nordman, that the secretions of the thymus and adrenals are

antagonistic, is borne out, we would logically be led to put faith in adrenal

extracts in treatment.

References.

R. Park, The Status Lymphaticus and the Ductless Glands, Surg., Gyn., andObst.,
1Q05, i, 140.

R. E. Humphry, Clinical and Postmortem Observations on the Status Lymph-
aticus, Lancet, 1908, ii, 1870.

W. J. McCardie, Status Lymphaticus in Relation to General Anesthesia, Brit. Med.
Jour., 1908, i, 196.

W. H. Roberts, The Status Lymphaticus with Particular Reference to Anesthesia
in Tonsil and Adenoid Operations, Jour. Am. Lar., Rhin., and Otol. Soc., 1908, 507.

^ Archiv. f. klin. Chir., 1910, xcii, 946
* Ibid., 1910, xcii, 1125.

HEMOPHILIA 303

HEMOPHILIA

The occurrence of postoperative hemorrhage has already been con-
sidered under Chapter VI. Sometimes a patient who is subject to
hemophilia is operated upon without knowledge of his condition, and
it is not until after the surgeon notices persistent hemorrhage following
operation that he is led to make inquiry and so arrive at a diagnosis.
Operations of any degree of severity on hemophiliacs are frequently
followed by fatal results. Surgical measures, therefore, should not be
knowingly attempted except when vital necessity exists.^ Before
operation treatment should be instituted to forestall all expected
hemorrhage. Serum or the calcium salts should be administered.

Treatment. — The treatment of the capillary oozing which char-
acterizes hemophilia is frequently tedious and oftentimes barren of
results. It should be followed up most assiduously, and it sometimes
resolves itself into a duel between death and the doctor. Internally,
the patient should be stimulated by a sufficient diet, and iron, ergot,
or thyroid extract may be administered. If the wound is accessible,
it should be cleaned thoroughly down to the bleeding surface, and a
styptic, such as MonselFs solution, tannic acid, or adrenalin in the form
of powder or in solution, 5 per cent, gelatin, or 4 per cent, cocain solu-
tion on pledgets of cotton, should be applied direct and under pressure
to the bleeding capillaries. These applications should be renewed
whenever the oozing of blood is sufficient to warrant it. If firm
pressure can be brought to bear upon the artery which supplies the
part, this may often be efficacious in bringing the hemorrhage to a stop.
For nasal hemorrhage, the spraying of undiluted hydrogen dioxid
into the nose has been extolled. For hemorrhage after extraction of
teeth, freezing the surface with ethyl chlorid spray has been recom-
mended.

Constitutional Treatment, — Calcium chlorid has in some cases been
followed with success by increasing the coagulation of the blood; again,
it has been of Uttle or no value. The same may be said of gelatin by
mouth or subcutaneously. Like gelatin, it sometimes controls the
hemorrhage when applied tightly to the wound in a 2 per cent, solution
on absorbent cotton. Too much calcium will increase the coagula-
tion time rather than diminish it, and it cannot be given over too
long a period, at least without intermissions, without incurring the
same result. In some cases it has been useless. The use of calcium
lactate (see p. 76) instead of calcium chlorid has recently been fol-
lowed by good results, and with it more uniformity and certainty of

* Dahlgren, Hygeia, 1908, Ixx, 481.

304 RARE COMPLICATIONS

action can be expected. It should be given in a dose of about 40
grains. There has been reported success following the use of thyroid
extract.^

The Use of Animal Serum. — It has long been known that
the serum which separates from clotted blood contains an agent which
promotes coagulation. Hayem, in 1882, working on transfusion,
demonstrated that injected serum possessed the power of increasing
coagulability. Weil, while studying hemophilia,^ first made practical
application of this principle. His work forms the basis of our knowl-
edge on the subject.

Weil injected fresh animal sera intravenously or subcutaneously
for the purpose of preventing or controlling hemorrhage. He found,
by clinical observation in 11 cases, that the blood-serum of horses,
rabbits, and, best of all, human beings had the power of controlling
hemorrhagic processes by increasing the coagulability of the blood.
Beef-serum should not be used on account of the toxic symptoms which
are induced. The serum should be fresh, that is, less than two weeks
old, and 15 cc. should be given intravenously or 30 cc. subcutaneously
in adults — half as much in children. It may be repeated after a day
or two without danger, and in hereditary hemophilia he found that
repeated injections were usually necessary. The use of the serum
locally favors clot-formation. He found that the serum was efficacious
in relieving all hemorrhagic conditions, and that definite cures usually
resulted in cases of sporadic hemophilia and acute purpura. Given
in similar dose before operation it acts as a prophylactic.

Weil's observations were confirmed by his countrymen, Eli^agaray^
and Carriere.^ Broca, in Germany, tried the method^ in 3 cases of
hemophilia, using diphtheria antitoxin (horse serum) locally with
success. He decided that the method was a very valuable expedient
in hemophiliac hemorrhage, and suggested that, although it could not
be considered as a cure for hereditary hemophilia, by repeating the
mjections every three months, using sera from different animals so that
the danger from anaphylaxis would be lessened, a hemophiliac could
be practically insured against serious hemorrhage.

LommeP reported success with the method in a boy of four years

^ Rugh, Ann. Surg., 1907, xlv, 666.

2 L'Hemophilie, Pathogenic et Serotherapie, Presse Med., Oct. 18, 1905; Des Injec-
tions de serum sanguin frais dans etats hemorrhagipares, Tribune Med., Jan. 12, 1907.
'Thfese de Paris, 1907.

* MUnch, med. Woch., 1907.
^ Med. Klin., 1907, 1445.

* Zeit. fiir innere Med., 1908, xxix, 677.

HEMOPHILIA 305

afflicted with hemophilia. He used antistreptococcus serum which
was a year old, being the only serum that he had at hand, locally and
in a dose of 20 cc. subcutaneously. He was obliged to give 10 cc. more.
Baum^ used fresh serum after the Weil method in 3 cases of hemophilia
with moderate success. Gangani^ reported partial success in a boy
of four with hemophiUa by the use of diphtheria antitoxin. Complete
success followed the use of fresh rabbit serum. The injection of 10
or 20 cc. he declared should be repeated and pushed beyond the maxi-
mum generally accepted. The fresher the serum the better. The
success which Groodman reports^ with transfusion is undoubtedly due
in part to the thrombokinase suppUed by the serum of the transfused
blood.*

Leary'^ used rabbit serum with success in cases of hemophiUa, post-
operative hemorrhage, hemorrhage of the newborn, uterine hemor-
rhage, typhoid hemorrhage, purpura, and as a prophylactic against
hemorrhage in cases of jaundice before operation. He considers the
subcutaneous method as more desirable than the intravenous on ac-
count of the danger of hemolysis or thrombosis following its injection
into veins.

The rabbit serum can be obtained aseptically by cardiac puncture
without seriously inconveniencing the animal. The chest is shaved
over the sternum and left side. With an ordinary antitoxin needle
a puncture is made to the left of the sternum and about i cm. above
a line drawn transversely at the junction of the sternum and ensiform.
A needle is thrust toward the middle line and slightly upward. The
puncture usually penetrates the left ventricle. Blood to the amount

* Mitt, aus den Grenz. der Med. und Chir., 1909, xxi.

* Gaz. Deg. Osp., 1909, xxx, 753.
' Ann. of Surg., 1910, lii, 457.

* Clinical success with fresh human or animal serum has been reported also by
Beach, Yale Med. Jour., June, 1910; Trembur, Mit. aus den Grenzgeb. der Med. u. Chir.,
1910, xxii, No. i; Sahli, Deutsches Arch. f. klin. Med., 1910, xcix, Nos. 5 and 6, and others.
W. Meyer (Surg., Gyn., and Obstet., 191 1, xiii, 152), at the suggestion of Welch (Am. Jour.
Med. Sci., June, 1910), who commended the use of human blood-serum in hemorrhage of
the newborn, and whose technique he employs, used it in cases of uncontrollable hemor-
rhage following operations on the bile-ducts in the presence of chronic jaundice with
success. The blood may be obtained from relatives or strangers, but the Wassermann
reaction should be taken as a preliminary measure. Tapping both cephalic veins in two
healthy individuals will yield 300 to 400 cc. Thirty to 60 cc. should be administered three
times a day, beginning two or three days before operation, and for two or three days
after. There is practically no limit to the amount which may be used if necessary. Treat-
ment started after operation may succeed, but less favorable results are ordinarily to be
expected.

^ Comm. of Mass. Med. Soc., 1908, xxi, 123.
20

?,o6 RARE COMPLICATIONS

of 30 cc. is slowly withdrawn. It is collected in sterile centrifuge
tubes. After a short stay in the thermostat the clot is separated by
a platinum needle and the material shaken in an electric centrifuge
and the serum drawn ofif.

If diphtheria antitoxin is used for this purpose, it should be less
than two weeks old. The serum supplied in Massachusetts by the
State laboratory is from six weeks to six months old before it is deliv-
ered, because it has to be kept while the animals are being watched for
the development of tetanus and other diseases. The same objection
probably holds in the use of commercially prepared sera.

Nolf and Herry^ advise the use of a 5 per cent, solution of peptone
(Witte), instead of fresh serum, claiming that it is more energetic,
more readily sterilized, and without danger of anaphylaxis. They
have used it successfully in 9 cases, injecting 10 cc. of a 5 per cent,
solution in 0.50 per cent, sodium chlorid. It is sterilized by heat-
ing for one hour at 120° C. For local application they recom-
mend an extract of spleen, lymph-glands, and thymus obtained fresh
from a slaughter-house, and made by triturating the organs with a
little sand, adding to i part of the gland 2 parts of a 0.09 per thousand
sodium chlorid and 0.5 per thousand calcium chlorid solution and
straining. Kottmann and Lidsky^ emphasize the value of the local
application on tampons of fresh animal blood or serum. To obtain
an even more efficient action, they chop and grind fresh rabbit or other
animal liver, soak it in water, filter it through an ordinary cloth, and
apply the turbid suspension directly to the wound.

^ Rev. de Med., 1910, xxx, No. 2.

* Munch, med. Woch., 1911, Ivii, No. i.

CHAPTER XXEX

HABITS AND THEIR RELATION TO SURGICAL CONDI-
TIONS: ALCOHOL, MORPHIN, COCAIN, TEA, TO-
BACCO, SNUFF

Alcohol. — Surgically speaking, there is no habit of worse prog-
nostic significance than the alcoholic; any intemperate person is a poor
surgical risk. Confirmed alcoholics present serious chronic metabolic
changes — cardiac and peripheral arteriosclerosis, enlarged livers, and
impaired kidneys — and unstable nervous systems.

There are two great classes of alcoholics: the constant daily tippler,
with his occasional week-end spree, and the periodic victim of over-
indulgence, who betw^een times is an almost total abstainer. Of the
two, the latter is by far the lesser risk. Other things being equal, his
alcohol does not so seriously lower his surgical resistance. Unfortunately
for him, he frequently meets the surgeon in the midst of one of his sprees,
the unconscious \ictim of an accident. As a rule, his acute alcoholism
does not seriously affect the prognosis of the case. It is an excellent
plan to wash his stomach out, leaving in a generous dose of Epsom salt
and bromids if he is at all unruly. Ordinarily, it is perfectiy safe to
give him ether and repair whatever slight damage there may be. In
severe accidents, aggravated by shock or hemorrhage, the prognosis
in his case is made much more serious by reason of his habit.

The other class is perhaps more often met with surgically, particu-
larly in hospital practice. The surgical trouble is often trivial; it is
the alcoholic habit that makes the case serious. Often, either because
the patient wilfully and to his own undoing conceals his alcoholic history,
or from oversight on the part of the attending physician, or from the
surgeon's failure to appreciate fully the serious after-effects of chronic
alcoholism, the patient is suddenly wholly deprived of his customary
stimulant. His nervous system at once wavers. An unnaturally keen
attentiveness to surroundings, an abnormally active response to trivial
sensations, and a slight tremor of the protruded tongue and extended
fingers are the forerunners of the visionary hallucinations and delirium
by which the nervous system reacts to its deprivation. Delirium
tremens is the price that alcohol demands. To the sudden depriva-
tion of alcohol are added ether anesthesia and enforced rest in bed,
either of which in itself is sufficient often to precipitate an attack.

307

308 HABITS AND THEIR RELATION TO SURGICAL CONDITIONS

Cheever^ effectively sums up the situation in the following paragraph:

"Patients who do not drink do a great deal better than those who
do in every form of accident and injury. The calnmess of the body
and mind is with the temperate. The resistance to shock is with the
temperate. The ability to respond to stimulants promptly is with
the temperate, for the intemperate have already used up their powers
of vital resistance; they have become accustomed to the overuse of
stimulants, and they do not respond readily to them, and you do not
get the benefit from stimulants which you expect. An illustration of
this is seen in etherization; as we said before, it takes a great quantity
of ether and laborious and excitable and protracted etherization to
o\^ercome the drunkard and make him go to sleep, whereas the patient
who is temperate, as a rule, takes it calmly, succumbs to it easily, and
recovers promptly. There can be no doubt, I think, that the con-
tinuous use of alcohol has a deleterious effect on the tissues: hardens
them, thickens them, prevents absorption as readily, dilates the veins,
leads to a slow and labored circulation; in that way delays absorption
and, moreover, produces finally some changes in the brain which in the
end are structural. All these things count against the patient when
he is suddenly brought to meet the strain of a severe accident or a severe
operation."

The treatment of delirium tremens will be considered later. (See
p. 310.) To prevent its development it is always permissible to give
alcohol. In many cases beer and ale, if given from the very start, will
tide a whisky drinker over the critical period. The patient should
be got out of bed into a chair as soon as possible. The exercise of
pushing a wheel-chair about serves to occupy the attention and will
sometimes ward off an incipient case. Etherization should be post-
poned when possible until the nervous system has become steadied.

Morphin. — The morphin habitue ordinarily presents a fair sur-
gical risk, provided the physical condition is good. It is essential, as
in the case of alcohol, that the drug be continued through convales-
cence and the dose gradually reduced. Few cases are more pitiable
than the suddenly restricted morphin fiend. Moreover, the diarrhea,
restlessness, intense misery, and persistent apprehension and wakeful-
ness which follow the sudden withdrawal of morphin constitute a more
than imaginary danger. Morphinism must be recognized as a dis-
ease.

Cocain. — What has been said of morphin applies equally well to
cocain. Before the patient has deteriorated to a marked degree physi-

^ Boston Med. and Surg. Jour., 1893, cxxviii, 253.

MORPHIN 309

cally from the use of the drug the habit should not be a contraindication
to necessary operation. Cocain users are h'kely to suffer from sleep-
lessness, tremors, and hallucinations, together with digestive disturbances
and emaciation. If they are deprived of the drug, there is apt to follow
a profound physical depression. As with morphin, if the opportunity
is allowed, two weeks may be given before operation to the gradual
withdrawal of the drug.

Sudden deprivation of tea or coffee in those who are accustomed to
use them to excess is sometimes followed by the occurrence of a tremor
accompanied by nervous excitation and wakefulness without delirium.
This has been noted to occur also in inveterate users of tobacco, either
smokers, chewers, ^Mippers/' or inhalers of snuff. Both tea and
tobacco are likely to induce functional cardiac disturbances, such as
palpitation and pseudo-angina pectoris, which may compel a more
careful etherization, and, moreover, they may even bring about
organic degeneration in the heart and vessels, which may have serious
significance. Ordinarily, however, the moderate use of tea and
tobacco need cause no anxiety. Deprivation will be followed ordi-
narily by nothing worse than a temporary nervousness and an intense
longing to resume the habit. In so far as it is unwise to attempt to
correct habits of this nature during convalescence, and as the return
to normal is hastened by agencies which promote comfort and a sense
of well-being, it will often be found advisable to gratify to a limited
extent the longings of patients in these matters. One cup of tea or
one pipe of tobacco a day may justify itself by reconciling the con-
valescing patient, in part at least, to his enforced confinement.

CHAPTER XXX

POSTOPERATIVE PSYOiOSES: DELIRIUM TREMENS,

INSANITY, MENOPAUSE

DELIRIUM TREMENS

The condition of maniacal delirium from alcohol poisoning is so apt
to complicate disastrously surgical convalescence that it forms an im-
portant subject for consideration. We meet the condition in one pf
tw^o forms: in the first it is the result of overindulgence — an acute alcohol
poisoning; the other form, which we see more frequently, results from
deprivation; it occurs in those habituated to the use of liquor, even
though several days or weeks have elapsed since they have partaken of
alcohol.

Delirium tremens may be excited by nervous shock from a com-
paratively slight injury.^ It may follow elective operations in those
who are accustomed to alcohol; it occurs most commonly in surgical
practice after operations of necessity, such as compound fractures, etc.

In cases which are operated upon while still under the influence of
alcohol a delirium accompanied by tremor and insomnia may occur
directly after the patient has recovered from the anesthetic. In the
more common form a period of hours or a day or t^^^o is likely to elapse
before the symptoms become so evident as to be recognized. The
patient at first is quiet and subdued, and his condition to a certain degree
resembles that of mild shock. Then there gradually dev^elops a delirium
in which the chief factor is usually fear. The patient suffers from
delusions and hallucinations, which he sometimes succeeds in conceal-
ing from the physician and attendants, and he makes efforts to escape
from the danger which he imagines pursues him. Unless he is care-
fully watched, these attempts may result in injury to himself or others
or he may even escape from the ward in which he lies.

The course of the disease may be divided into three stages: The
fir sty or prodromal stage ^ is characterized by the condition of nervous
apprehension. This usually lasts about twelve hours. The patient,
as a rule, is submissive and extremely anxious to comply with all the

^ Forge and Jeanbrau, Death from Post-traumatic Delirium Tremens, Presse Med..
1909, xvii, 19.
310

DELIRIUM TREMENS 31I

directions which are given him. Whatever he is asked to do he does
with precipitance and sometimes violence. He frequently labors under
the apprehension that he is going to die. His mind is changeable, and
no impression lasts longer than a few seconds. In his fear of death
or danger he forgets pain, and he may get out of bed, tear off his dress-
ings, or walk about on a fractured leg in spite of the admonitions which
have been given him. His hands and tongue are markedly tremulous.
This stage shows itself usually on the second day after operation.

The second stage is that of active delirium. The state of apprehen-
sion occasionally gives way to lapses of intelligence, during which
illusions of sight and hearing and hallucinations of persecution become
evident. The patient becomes anxious and refuses to take food. He
is listless and may lie restlessly quiet for hours at a time, muttering un-
intelligibly to himself, and picking at the bed-clothes and at imaginary
objects in the air. He sees insects and reptiles or other animals in the
corners and on the ceiling. He keeps up active purposeless movements
without intermission until he perspires from weakness and sleep is an
impossibility.

From this stage of active delirium the patient is likely to descend
into a condition of IctiV muttering delirium, and finally stupor develops.
The prostration becomes excessive, pulse soft and weak, and he gradually
sinks into a coma from which he cannot be aroused and death ensues.

Treatment. — If the patient has been operated upon while still
under the influence of an alcoholic debauch, means should at once be
taken after he recovers from the anesthetic to eliminate whatever of the
alcohol may still remain. A stomach-tube should be passed and the
stomach washed out, and two ounces of a saturated solution of Epsom
salt poured into the stomach through the tube. He should be given
water in considerable quantity to drink and potassium acetate in doses
of 15 gr. to further aid elimination through the kidneys. At the same
time he should be sweated by means of a hot-air bath or hot pack. In
order to lessen the desire for liquor, and to forestall an acute gastritis,
he should be given capsicum, 10 minims of the tincture in a glass of hot
milk, every two hours. Alcohol, best in the form of beer or ale, may
reasonably be given in cases of this sort in small quantities. After
twenty-four hours he should be gradually worked up to a normal diet.
If his sleep is interfered with, sedatives should be administered.

If the delirium arises from delayed alcohol poisoning, its treatment
is more complicated and less certain. If the patient can be made to
eat and to sleep, cure is practically sure. To obtain sleep in delirium
tremens the sedatives and hypnotics of the pharmacopeia have been

312 POSTOPERATIVE PSYCHOSES

exhausted. Opium in ordinary doses is ineffectual and in large doses
it may precipitate coma. Chloral and paraldehyd in such doses as
are usually necessary are too depressant, and the same may be said
of sulphonal, though sulphonal, 30 gr. every four hours, to 6 doses, is
often used. Ether by inhalation will give the patient temporary respite,
but the delirium recurs on awakening. Hoffmann's anodyne is a mild
sedative and at the same time a stimulant. The sedative which is
ordinarily employed is the bromids. These are the least depressant
of the active sedatives. Usually they are given in the form of equal
parts of the bromids of sodium, potassium, and ammom'um, on account
of the depressant action of the sodium. This mixture may be given
in doses up to 90 gr. Chloralamid may be given in doses of 20 gr. every
four to six hours. Digitalis was at one time held in high repute, because
it slowed the pulse and quieted the circulation and in this way aided
the system to gain repose. It was formerly given in doses as large as
a dram of the tincture at a time. It was found, however, in some
cases to prove fatal. It is now frequently given in ordinary dosage to
overcome the depressant action of the large doses of sedative which are
ordinarily necessary. Fluidextract of ergot, i dr. repeated every
four hours, has been recommended. Capsicum is valuable when
given for the purpose of stimulating the gastric mucous membrane.
Alcohol in the form of beer or ale is useful as a stimulant, and when
given in limited quantity is justifiable.

When the delirium becomes active, restraint becomes a necessity.
The use of a strait- jacket, or even a sheet tied over the body, is directiy
injurious, and should not be allowed unless it is absolutely necessary.
Under the best form of treatment physical restraint of any sort is usually
not considered. A good nurse should talk with the patient, try to
amuse him and to win his confidence. In this way the patient can be
made to forget most of his fear and he does not exhaust himself by his
endeavors to ward off danger. If he starts to rise, a restraining hand
can be put upon his shoulder and he is readily persuaded to lie quiet in
bed. To be left alone terrifies him. He likes to be in the presence of
people, he likes cheerful conversation, and he is particularly afraid of the
dark. Sleep is to be sought for above all things, and when it comes and
lasts, recovery is almost sure. If it is interrupted, the patient has a
succession of ineffectual short naps and no good results.

Next in importance to sleep is nourishment. If the stomach wiD
tolerate food, the prognosis is good. Usually there is no appetite and
food has to be forced, or the stomach is irritable and will not retain
the food. In the latter condition effervescent waters and small doses of

POSTOPERATIVE INSANITY 313

calomel are of benefit. Ice may be given freely; milk and lime-water,

malted milk, etc., should be tried. If the stomach retains food, the

patient should be given liquids at frequent intervals and in considerable

quantity.^

POSTOPERATIVE INSANITY

The existence of mental disturbances following operation was noted
many years ago. In the sixteenth century Pare remarked that before
an operation the patient must be in a condition of spiritual calm, in
order to avoid delirium and other harmful after-effects. Dupuytren.
(1819) was the first to describe a condition of mental excitation, which
he called delirium nervosum — coming on immediately following opera-
tion. Herzog (1842) described a case of mania following an operation
for strabismus, and Sichel (1863) reported 8 cases after cataract ex-
traction. These reports were followed by many others, all succeeding
operations on the eye. Von Courty, in 1865, described the first case
following ovariotomy, and in 1880 Lossen and Furstner reported a case
after hysterectomy. Since that date there has developed a very con-
siderable literature on the subject.

Occurrence. — Various forms of mental disturbance may follow
operation; genuine insanity may occur, but it is relatively rare. Just
how often psychoses traceable to anesthesia or surgical procedures
occur it will always be diflScult to say, many of them not making their
appearance until weeks or months after surgical recovery. Dewey,
in 5000 insane, foimd only 3 cases of insanity following operation in
persons previously of sound mind. J. K. Mitchell examined 344 pa-
tients, and, excluding all cases where concomitant causes existed, found
31 instances of neurasthenic or mental disorders following operation or
anesthesia. Of these, 94 per cent, were women and 6 per cent, were
men. It is uncommon also in proportion to the total number of
operations, various writers reporting from 0.25 to 0.50 per cent. As
to the nature of the operations which seem to induce insanity, opera-
tions on the genital organs in women or men take the lead, and eye
operations come next, though almost every possible operation has
found a place on the list. Rohe, of Baltimore, in studying 196 cases
of postoperative insanity etiologically, found that the condition fol-
lowed genital operations in 65 cases, cataract operations in 35 cases,
and various operations in 96 cases. The preponderance, as regards
sex, is generally placed at about 4 to i in favor of women. This is
clearly due to the large proportion of gynecologic operations in women
as compared with operations on the genital organs in men, for Sears,

* Cheever, Lectures on Surgery, Boston, 1894, 39.

314 POSTOPERATIVE PSYCHOSES

of Boston, has shown that in operations common to both sexes the
proportion is about equal.

Causes. — A patient suffering mildly from delusions may be oper-
ated upon without her mental condition being appreciated by the
surgeon. It is not uncommon, for instance, for a woman affected with
cyclic insanity to complain of vague abdominal pains, or to suffer from
a variety of symptoms referable to the genital tract. Such a one may
become insane at the application of the anesthetic. Generally speak-
ing, however, operations may be performed on those frankly insane
without detriment, and sometimes even with benefit to their mental
trouble.

It may be considered, in general, that the essential prerequisite for
the development of postoperative insanity in those previously of sound
mind must be a neurotic organization, temperamentally predisposed,
either from hereditary taint or from acquired nervous instability, to
become unbalanced in consequence of an active disturbing factor.
As Weir Mitchell has expressed it, *^We must consider the patient
as a loaded gun, and that the surgeon merely pulls the trigger.''
This determining factor may be psychic — strange surroundings, worry,
vacillation between hope and fear, pain, anticipation of blindness,
sterility, or climacteric. It may be toxic, as the withdrawal of alco-
hol, cocain, or morphin in those accustomed to their use. It may be
traumatic, as head injuries or operations. Old age and arterioscle-
rosis, inanition, and feeble circulation are other predisposing factors.
The nature of the operation, its duration, and severity even, must be
considered of secondary importance.

Besides these preoperative causes, we must consider as important
the toxic effect of the anesthetic, especially if long continued, and
shock, hemorrhage, and collapse. In the postoperative stage we have
to consider pain, enforced isolation, deprivation of light (in eye cases),
deprivation of water, septicemia, acetonemia, and uremia. Finally,
there are various drugs which may induce delirium — iodoform,
atropin, sodium salicylate.

Forms. — There is no special form of mental disturbance to which
the name postoperative insanity can be applied. Clinically, the term
encompasses a variety of psychoses which are related to each other
only in so far as they follow after a surgical operation. The condition
ranges from the transient delirium or mental confusion, which may
follow immediately on the use of any anesthetic — through the drug
psychoses attending the local use of iodoform, the employment of col-
lyria of atropin, or the internal administration of sodium salicylate, all

POSTOPERATIVE INSANITY 315

of which usually subside with the withdrawal of the agent — and acute
confusional insanity, frequently due to sepsis or toxic conditions, which
often lasts weeks or months, and includes premature climacteric in-
sanity in the form of melancholia following the removal of the ovaries,
and premature senile dementia, not infrequently occurring after
genito-urinary operations in the male. The manifestations may be
maniacal, depressive, or paretic. The commonest type is acute
confusional insanity — outbreaks of excitation with confusion and
hallucinations, alternating with periods of stupor, coming on after a
prodromal period of nervous irritability and mental anxiety. Sudden
outbreaks of violence, as in puerperal and alcoholic insanity, occur
uncommonly.

Prognosis. — If the mania has developed slowly in a young person
otherwise of sound constitution, a perfect recovery may be usually ex-
pected, though some patients die of exhaustion. In older persons and
patients suffering from grave organic disease, or weakened by alcohol-
ism or syphilis, the development of a chronic dementia is to be feared.
Recovery, when it takes place, is rapid, and leaves behind only a dim
recollection of the events between the operation and the return to
normal.

Treatment. — In the way of prophylaxis everything should be
done before operation to induce a state of confidence and tranquillity
of mind in the patient, and to lessen the nervous shock of any procedure
which involves the genital or genito-urinary tract. The unpleasant-
ness of the operation should be minimized. The surgeon should main-
tain a constant attitude of optimism and encouragement, and he
should inspire the patient with sufficient confidence so that she will
acquire from him moral support. Especial attention should be paid
if the patient is known to be '^high strung,'' has had attacks of mental
instability, or has a suspicious heredity. In deciding for or against an
operation of choice, the mental condition should be an important
factor. Operations upon neurasthenics should be avoided when
any other treatment will avail; operative procedures may relieve the
symptoms, but the neurasthenia remains just as bad, and it may be-
come much worse.

Treatment should be directed toward relieving any possible causal
condition, septicemia and uremia should be combatted, toxic agents
should be withdrawn. The patient should be kept in bed in cheerful,
airy surroundings; isolation is not desirable. He should be kept clean,
and particular attention paid to forestalling bed-sores. His nutrition
should be well looked to; he should be encouraged to eat, and stomachics

3l6 POSTOPERATIVE PSYCHOSES

and stimulants employed if necessary. The bowels should be kept free
with mild salines. Warm baths will usually suflSce to control restless-
ness and sleeplessness; when hygienic measures fail, opium or hyoscin
becomes necessary, Bromids should be avoided, as being too depress-
ing.

Regis * has reported success with the use of ovarian extract in a
woman who had had her ovaries removed, and A. T. Cabot^ reported a
case of confusional psychosis in which prompt improvement followed
the exhibition of testiculin.

References

Dent, Jour. Mental Sciences, 1889, xxxv, i.

Sears, Boston and Med. Surg. Jour., 1893, cxx^^ii, 642.

C. G. Dewey, Trans. Amer. Medico-Psycholog. Ass., 1898, v, 223.

Roh^, Amer. Jour. Obstetrics, 1898, xxxix, 324.

Hurd, Amer. Jour. Obstetrics, 1898, xxxix, 331.

Englehardt, Deut. Zeitsch. f. Chir., 1900, Iviii, 46.

Schultze, Deutsch. Zeits. f. Chir., 1910, civ, No. 6.

Mumford, Boston Med. and Surg. Jour., 19 10, clxiii, 838.

Lloyd, New Orleans Med. and Surg. Jour., Jan., 191 1.

J. K. Mitchell, Am. Jour, of Med. Sci., July, 191 1.

MENOPAUSE

Mild psychoses analogous to those which sometimes occur at
the climacteric may develop after destructive operations upon the
pelvic organs in women. These manifestations are rarely of sufficient
importance to necessitate treatment. They depend chiefly upon the
apprehension with which most women regard this natural cessation of
function. Many women look forward to the climacteric with dread,
because they have Been or heard of cases of malignant disease or of ner-
vous prostration occurring in others at a similar period. Others are ap-
prehensive of a decrease in attractiveness and an early senile decline.

The symptoms which accompany this artificial menopause are
usually emotional or melancholic, but they sometimes take the form of
nervous instability, accompanied by hot flushes, vertigo, and palpita-
tion. Rarely the condition goes so far as to cause a nervous breakdown
which requires isolation and treatment. Ordinarily, whatever nervous
manifestations arise are of a temporary nature, and disappear as the
patient gets out of bed and about. Sometimes after removal of both
ovaries the patient, if she has previously been thin, will become fleshy.
Usually sexual desire is preserved unimpaired, although this seems to
vary with the patient.^

* Am. Jour. Insan., 1893, 1, 345. * Com. Mass. Med. Soc., 1893, xvi, 657.

'Walthard, Psychoneurotic Climacteric Phenomena, Zeit. f. Gyn., 1908, xxxii, 564;
D. H. Craig, The Menopause, Jour. Am. Med. Assoc, 1908, li, 1507.

CHAPTER XXXI

GENERAL TREATMENT IN CONVALESCENCE

Some surgeons make it a practice to administer tom'c and stimulant
drugs during recovery from operation to hasten convalescence. As a
routine, the habit should be disapproved. Patients come to the surgeon
in a state of more or less profound constitutional depression caused by
their surgical condition, or else they are normal as regards general
health, and present a condition which has caused no constitutional dis-
turbance whatever. In the first case the removal of the depressing
influence should be at once followed by the exhibition of a tendency
toward a recovery of the normal tone and physical well-being; in the
latter case, operation is a mere incident, and, except for the efifects of
anesthesia, the balance of metabolism should not be seriously disturbed.
Ordinarily, a person who expects to be restored to complete health after
an operation, who has not been sick long enough to have lost his impulse
toward recovery, will need no artificial aids except cheerful, comfortable
surroundings and companionship, a suflScient and proper diet, and
plenty of sunlight and fresh air, if these may be called artificial.

The treatment of patients in whom ultimate recovery is not expected,
and those whose spirit has been broken by prolonged illness or repeated
disappointment, will depend on the nature of the case and the personal-
ity of the surgeon. Tonics and stimulants are indicated when they
will impress the patient or sustain or improve his physical or mental
tone. Added to, and better than, these is the moral influence of an
energetic, strong-willed, and trusted physician. Ordinarily, surgical
convalescence is comparatively brief, and the surgeon is not so likely
to have cast in his way that bug-a-boo of the internist — the "chronic.''
Whenever, however, a surgeon becomes convinced that he is losing or
has lost the confidence of a patient who is progressing slowly, and whose
convalescence is likely to be prolonged, he will be wise if he calls a con-
sultant or brings to his aid some other fresh and outside agency, be it
psychotherapy, electrotherapy, hydrotherapy, light or mechanotherapy,
the :v-ray, or massage. Such a move will usually react to the advantage
both of the patient and the doctor, and it should not be too long post-
poned.

317

3l8 GENERAI. TREATMENT IN CONVALESCENCE

The use of morphin in suffering incurables, and the use of proper
medicines in those who have coincident disorders which require medical
treatment, such as malaria or syphilis, is to be taken as a matter of
course. If any other indications develop which require medication,
they should be met. For instance, constipation, nervousness or in-
somnia, loss of appetite, impoverished blood, remembering what we
have already stated, that a proper regulation of surroundings and habit
and sufficient food and sunlight will often render drugs unnecessary.

Among the tonics and stimulants we will consider iron, strychnin,
arsenic, and alcohol.

Iron is frequently indicated to overcome the effects of hemorrhage.
It is best absorbed, in surgical convalescence at least, apparently not
from the liquid preparations, but in the form of ferrous carbonate —
Blaud's mass. Direct measurements of the number of red corpuscles
and of the hemoglobin in an investigation which one of us carried out
in two series of cases showed a distinctly more rapid increase in both
respects on Blaud's mass than on reduced iron or several highly extolled
liquid and proprietary preparations. The Blaud's mass should be
given either in soft pills, not too old, or, better, as a powder in gelatin
capsules.

Strychnin, either in the form of the sulphate, ^V to :fV gr., two or
three times a day, or in the form of tincture of nux vomica, is a standard
stomachic and nerve stimulant, and should be given in appropriate
cases, withheld at night, or the dose diminished if it leads to sleepless-
ness.

Arsenic may be given as the trioxid in doses of j^-jj gr. after each
meal, or in the form of Fowler's solution, liquor potassii arsenitis,
3 to 6 minims, to be stopped at the occurrence of diarrhea or any other
symptom of poisoning.

Alcohol in the form of bitters before meals, or ale or beer, undoubt-
edly has some place in convalescence, but in case of the slightest doubt
as to its appropriateness it should be withheld.^

Out-of-doors and Sunlight. — Nearly all that has been said as to the
value of out-door life and sunshine in surgical tuberculosis, applies, in
our opinion, to the healing of all wounds and to surgical convalescence
in general. The much-vaunted air of the Engadine is, after all, only

' In most of the English hospitals, porter, ale, and stout have been provided ad lib. to
the inmates, the total expenditure for these potables, with wine and spirits, frequently-
exceeding the cost of milk supplied to the hospital. The curious arrangement still per-
sists in some even of the larger hospitals of London of supplying ale, champagne, and al-
coholic liquors to the patients, but classifying such articles as sugar, butter, and tea as
luxuries, to be provided only at the expense of the individual.

GENERAL TREATMENT IN CONVALESCENCE 319

pure air, and we need not cross the ocean to find that. It is obvious
that in the presence of disease of the kidneys, and in possibly certain
other special conditions, care must be taken not to expose the patient
too early to a possible chilling of the skin in the out-door atmosphere,
but in general the respiration and all other vital functions are stimu-
lated by a convalescence spent, so far as possible, out-of-doors. There
is an open-air sanatoriimi at every door, from which any surgeon with
sufl5cient energy and originality can benefit.

A surgical operation should not be looked upon as an experience
in disease, but rather only as an affection of a part — an aggravated sore
finger, as it were, After an operation the patient should, as soon as
possible, be surrounded by an atmosphere of normality, with rather the
spirit of the theoretic soldier who binds up his wounds and proceeds.
The mental attitude to encourage is — the patient has not been sick, he
has been wounded.

It is not a contradiction of this sentiment of returning to normal life
as soon as possible to say that, in the matter of visitors during a smooth
surgical convalescence, the choice and number of visitors should
be decided entirely by the patient, and the duration of their stay by the
attending nurse, if she is a wise woman. Ordinarily, friends need only
be told that it is to the patient's advantage for them to stay away, and
they do so.

CHAPTER XXXII

BED-SORES: CAUSES; PREVENTION; TREATMENT

Decubitus, or bed-sore, is an area of moist gangrene caused by pres-
sure. It is most apt to occur on the backs of patients who are confined
in bed for an extended period, but it may occur wherever pressure is
h'kely to exist unrelieved for any length of time. On the back, it occurs
ordinarily over the bony prominences about the sacrum and on the
buttocks. It may occur also on the heel, over the great trochanter, or
at the edge of a splint, and the pressure of bed-clothes upon the toes
may even be suflScient to cause it. Liability to the occurrence of bed-
sores is always increased in conditions which allow of little or no voluntary
movement on the part of the patient, especially in paralysis. It is
increased by the lack of proper cleanliness or the presence of irritating
secretions, and particularly the state of incontinence of urine or feces.
Crumbs of bread, creases or folds in the sheet or bedgown, bits of string,
pins, or other extraneous objects in the bed will furnish ample cause
for the formation of a bed-sore. The absence of bed-sores in bed-ridden
patients is usually held to be a criterion of good nursing.

The underlying cause of bed-sores is a lessening of the vitality of
the skin by persistent localized pressure. If the nutrition is withheld
from the cells, they slowly die and are cast off in the form of slough.
The first clinical manifestation of a bed-sore is a reddening of the skin.
This increases to a local congestion, which gradually becomes pale and
then bluish. Finally, a line of demarcation forms and the area sloughs
away. This leaves an ulcer with a foul, ragged bottom, which excretes
a thin, acrid fluid. Unless relief is furnished, the ulcer increases rapidly
in size and works its way deeper into the tissues. Sometimes an un-
treated bed-sore will extend so as to involve areas of considerable
size and lay bare, for instance, the entire sacrum. Such ulcers are a
severe drain upon the vitality of the patient and seriously complicate
convalescence.

Any case in which the possibility of bed-sores may arise should be
carefully watched, so that their occurrence may be forestalled. Prophy-
laxis consists in preventing unrelieved localized pressure. The bed-
clothes should be kept clean, dry, and smooth, and no crumbs or ex-
traneous substances should be allowed to find their way under the

320

bed-sores: causes; prevention; treatment 321

patient. The patient's own discharges should be looked out for care-
fully, and if there is any moisture about the genitalia, it should be dried
and the parts powdered. Bandages and splints should be adjusted
from time to time. The patient who is unable to turn in bed should
have his position changed frequendy by an attendant. All bony promin-
ences on the back and points liable to suffer from pressure should be'
massaged and kept absolutely dry and powdered.

In case redness appears over the bony prominences action should
be at once taken to distribute the pressure over a larger area and thus
afford relief. On the back, this can be accomplished by making a so-
called doughnut pad of oakum or tow, wrapped in gauze bandage, and
placing it so that the opening wull come opposite the point suffering from
pressure. The same object can be accomplished by means of the rubber
ring which is inflated w^ith air. If there is pressure on the heel, as in a
case of fracture or paralysis, the pressure can be removed in the same
way. Other points which are liable to become pressed upon, such as
the malleoli, tibia, and head of fibula, in case of splint or plaster-of-
Paris bandage being worn, should be protected by careful padding. In
order to keep the weight of the bed-clothes off the tips of the toes when
they cannot be moved by the patient, a cradle of wire or wickerwork
should be employed, or a lo-inch board on edge between the sheets
along the foot of the bed may be used.

In all cases where patients are badly emaciated, or where the neces-
sity for lying in one position will continue for a long time, they may be
put upon a pneumatic bed, or a w^ater-bed, which distribute the pressure
from the wxight of the patient over a wide area. Patients who are
under treatment for fracture of the hip or thigh can be handled con-
veniently only when lying upon a Bradford (gas-pipe) frame or some
similar device. These patients should be turned over twice a day, and
any region found subjected to pressure should be washed and then
thoroughly dried. It should then be rubbed gently with a soft towel,
so as to improve the nutrition, and, finally, the skin should be powdered
with some emollient powder, such as zinc oxid and starch or stearate
of zinc. A piece of chamois skin placed between the skin and the sheet
will cushion an irritated area and act to prevent friction. The use of
alcohol or spirits of camphor will render the skin more resistant and
less liable to ulceration, and the same is true of the compound tinc-
ture of benzoin. Sometimes a generous dressing of absorbent cotton,
held in place by collodion, will serve to protect a small area of pres-
sure hyperemia, or the skin may be painted directly with collodion or
covered with adhesive plaster.
21

322 bed-sores: causes; prevention; treatment

When the bed-sore has formed, the part should immediately be re-
lieved of all pressure by turning the patient into another position per-
manendy, or by the use of the ring cushion or water-bed. Dry dressings
are to be preferred unless slough occurs, in which case the patient should
be turned upon his face and moist applications frequently applied.
For these dressings, nothing is so good as chlorinated soda and myrrh.
The separation of the slough in deep-lying ulcers is usually tedious, and
it may often be hastened by the use of a digestant, such as enzymol, or by
clipping it away with scissors. Hydrogen dioxid is also of account
in case sloughing occurs. After the slough has separated and the ulcer
presents a granulating surface, skin-grafting, after the Reverdin method,
may be resorted to with advantage. Otherwise some ointment, such
as ichthyol (loper cent.), ichthyol and zinc oxid ointments in equal
parts, or a mixture of equal parts balsam of Peru and castor oil,
may be relied upon. Stimulation, nourishment, and sleep are all
valuable adjuvants in treatment.

CHAPTER XXXIII

FOREIGN BODIES LEFT IN THE ABDOMINAL CAVITY

Although this accident is not a title to greatness, it is said that
every great surgeon has had it happen. It is certain that foreign bodies
have been left in the abdominal cavity much more often than has been
reported — first, because of cases ending fatally without autopsy, and,
second, because surgeons are not likely to publish such experiences.
The most complete recent papers on the subject are by Schachner in
1901 ^ and F. Neugebauer.^

Schachner has collected 155 cases of foreign bodies left in the abdo-
men, including in this number the cases collected by Wilson and Neu-
gebauer. In Neugebauer's collection of cases there are 31 instances of
sponges left in and 19 cases where artery forceps were overlooked and
left behind. Probably every active surgeon, at one time or another,
comes across cases which represent careless technique on the part of
some one else. For instance, we have recently seen a case in which,
four months after a patient left the hospital for a nephrectomy, a
gauze strip a yard long was removed through a small sinus which
had persisted in the scar since the operation. One of us has also re-
moved fragments of glass, remnants of a broken irrigation tip, from a
prostate, and an entire fenestrated rubber drainage-tube from a sinus
which led into a deep-seated ischiorectal abscess. A case is on record'
where a surgeon after a celiotomy noticed that he had lost a seal ring.
The patient some time later was operated upon through the vagina by
a second surgeon, who extracted the ring. Imagine the state of mind
of the first surgeon when his former patient paid him a call for the pur-
pose of restoring his property.

Symptoms. — The symptoms that follow the retention of a foreign
body in the abdomen will depend upon the nature of the body, the
region in which it is situated, and whether or not sepsis is present. If
an instrument has been left behind after a clean celiotomy, it has been
shown by several instances that the patient may suffer very little in-

^ Ann. Surg., 1901, xxxiv, 499.

- Monats. f. Gynak., 1900, xi, 821.

^ W. J. S. McKay, Care of Section Cases, p. 561.

323

324 FOREIGN BODIES LEFT IN THE ABDOMINAL CAVITY

convenience for weeks or months; indeed, it has happened that the
occurrence has not come to light until after an autopsy for some inter-
current affection. Usually, however, sooner or later, the foreign body
sets up an irritation, and becomes the source of an abscess which causes
a fistulous opening, through which it is finally discharged by way of the
vagina or bowel, into the bladder, or e\en through the abdominal wall.
Accompanying this process there is apt to be obscure abdominal pain,
sometimes with symptoms of incomplete obstruction and slight fever.
Rest and a limited diet will bring temporary relief, but the symptoms
are likely to recur soon after the patient gets up and about. There may
occur a sudden exhibition of symptoms which will lead to an immediate
exploratory operation, when the true cause will be disclosed, or else the
symptoms will continue indefinitely with remissions until, after a flareup,
they subside for good and the foreign body will be passed. If the case
is septic at the start, there are immediately evident the symptoms of
general or localized peritonitis or abscess.

Neugebauer, in his summary of the fate of the cases in which forceps
were left behind, shows that 6 died almost immediately after the opera-
tion of sepsis and i after a second operation, performed some months
later for the removal of the foreign body. In three cases the forceps
were expelled spontaneously per anum — i four years, i nine months, and
I ten months after operation. In i case the forceps worked through
into the bladder. In 2 cases they were discharged through abscesses
in the abdominal wall. In i case the artery forceps were foimd in
Douglas' culdesac before closure of the abdominal wound. In 2 cases
the loss of the forceps was noted immediately after the closure of the
wound, and they were recovered before the patient was removed from
the operating table. In 4 cases a subsequent abdominal section was
required for their recovery from three months to two years after op-
eration.

When a sponge or a piece of gauze has been left behind, recovery is
retarded seriously, especially if the case is septic. If the patient does
not die, the presence of gauze will sooner or later give rise to an abscess
or a sinus. In rare instances a piece of gauze has been known to have
been retained without giving rise to symptoms. In some cases the
gauze ulcerates into the bowel and is discharged by rectum.

In 31 cases where gauze sponges were left behind, death occurred in
*]. The gauze was discharged by the rectum in 10 cases, the time vary-
ing from two days to twelve years after the operation. A second ab-
dominal section was done in 4 cases, and in the others the gauze was
discharged through intestinal fistulae. In 2 cases the sponges were

PROPHYLAXIS 325

missed before the wound was closed. In 3 cases the wound was re-
opened before the patient left the table; in 3 cases the wound was re-
opened in twenty four hours; in i a sponge was discharged five months
after operation through an abscess in the abdominal wall. In 19 cases
sponges were discovered at autopsy.

Prognosis. — Neugebauer's collection of cases shows that 58 per
cent, of the patients recovered and 42 per cent. died. Some of the
deaths must be referred, not to the foreign body, but to sepsis. If the
case is a clean one, the retention of a pair of forceps or a piece of gauze
in the abdominal cavity, while a serious accident because of the fistulse
and abscesses likely to be formed sooner or later, it is not to be regarded
as an accident that is likely to lead to an immediate fatal result.

If the foreign body is practically aseptic in its nature, the tendency
is for it to become enveloped in a capsule of fibrous exudate, and the
isolation is still further carried on by adhesions between the surrounding
organs. Thus encapsulated, it may remain quiescent for months or
years, or its presence may lead to suppuration and the foreign body may
be discharged through the fistulous tract, which may communicate with
the surface, the bladder, the bowel, or the vagina. When it enters
the bowel, complete obstruction of the bowel may occur or a fecal fistula
may form. It has happened that a pair of forceps, free in the abdominal
cavity, has, by a sudden movement, been \-iolently driven into a large
blood-vessel and caused the immediate death of the patient, active and
without symptoms, several months after the operation.

Prophylaxis. — No sponges should be at liand during a celiotomy.
For abdominal work gauze should be folded in the form of strips suf-
ficiently long so that an end of 3 to 6 in. may be allowed to hang out
through the woimd. To this end a hemostat should be applied by the
first assistant as soon as the strip has been introduced. Some surgeons
use strips to the ends of which a piece of tape 6 in. long is sewn, and
to this tape the hemostat is fastened. This allows many strips to be
introduced into the abdomen without crowding the wound. As soon
as the strip is soiled it should be thrown on the floor, and the operating
field should be kept free of strips that are not at that moment in use.
No strips should ever be allowed to be cut in t\vo. This interferes with
the sponge count, if the surgeon desires a sponge count, and a cut strip
is always more readily left behind than a strip which is kept entire.
The strict observance of care in these details will render sponge counts
unnecessary.

The importance of exercising proper care in preventing this un-
fortunate accident can be emphasized in no better way than by citing

326 FOREIGN BODIES LEFT IN THE ABDOMINAL CAVITY

a characteristic case.* A surgeon of many years' experience operated
upon plaintiff for ovaritis. The patient did not respond by the expected
recovery, but she grew worse, and thirty days later it was discovered
through a part of the original opening made in the abdomen that some
foreign substance was lying near the surface, which upon being removed
was discovered to be one of the surgical sponges used at the operation.
It was incrustated and saturated with foul-smelling pus. After its
removal the patient improved in health, but there was left a sinus which
it was claimed had developed into a fecal fistula.

"Many of the physicians testifying on behalf of the defendent said
that the best of surgeons left a sponge or some foreign substance in the
bodies of their patients in performing similar operations. It was argued
from this that, as the highest degree of skill and care was not exempt
from the commission of such accidents, a similar lapse by the defendant
was not at least other than ordinary care, but that did not follow; be-
cause all men are sometimes careless does not relieve any man from the
legal consequences of his careless act; but, even then, it was for the jury
to say whether the defendant exercised the degree of care in the case
which ordinarily prudent and skilled surgeons who practise in similar
localities usually exercised in such matters." The verdict — a. judgment
for $3500 for the plaintiff — ^was accordingly confirmed by the Court of
Appeals.

Operation. — If we discover immediately that a sponge or a pair
of forceps has been left behind, we should at once proceed to open the
abdomen, unless the patient is suffering from great shock, when we may
postpone the operation for some hours until the patient has rallied. If
the case has been a clean one and the patient is very weak, we need not
interfere for tw o or three days. If the case is septic, we should act as
soon as possible. If a vaginal examination shows a foreign body in
Douglas's pouch, an incision in the posterior fornix is preferable to open-
ing the abdominal wall.

In infected wounds a retained foreign body of whose presence we are
ignorant must lead to prolonged suppuration without very obvious
cause. Perinephric abscesses and pelvic abscesses, and occasionally
appendix abscess, may give rise to a copious discharge of pus. After
a period prolonged to weeks, if this suppuration goes on without definite
diminution in quantity, or if the excursions of temperature continue,
the existence of a foreign body should be considered. One should,
from day to day, explore the depths of the sinus with a metal crochet

^ Jour. Amer. Med. Assoc, 1909, liii, 1229. Court of Appeals of Kentucky, 118,
S. W. R., 339.

OPERATION 327

hook, and hope therewith to catch into the meshes of gauze or the loop
of silk or other non-absorbable suture if such has been used. If, how-
ever, a definite abscess collect in the depths of a wound, a second opera-
tion, which may frequently be done in the bed imder primary anesthesia,
should open it freely and give opportunity for exploration and removal
of the cause if it be a foreign body.

CHAPTER XXXIV
POSTOPERATIVE HERNIA; ADHESIONS

POSTOPERATIVE HERNIA

After any celiotomy there exists a possibility of the occurrence of
postoperative ventral hernia. It occurs most frequently after median
line incisions, particularly at the lower end of the wound, below the
umbilicus, and just over the pubes, where the pressure of the abdominal
contents is greatest and strain most likely to be felt. It is not infrequent
after operations on the appendix, particularly operations on appendix
abscess, and in cases where the muscle-splitting or McBumey incision
is not used. With the commonly used right rectus incision hernia may
be expected to occur, according to statistics, in about 3 per cent, of un-
drained cases, 12 per cent, where a drainage-tube is left in, and 20
per cent, where the wound is left wide open. Hernia is apt to occur
also in lateral incisions for extensive drainage, as in peritonitis, and it
recurs after operations for hernia, either on account of sepsis in the
wound, poor technique, division of nerves, insufficient musculature,
scar tissue, or imprudent postoperative care. It may be immediate,
resulting from a rupture of the abdominal wound during coughing,
straining, or careless transportation, or it may take months or even
years to develop. It may, however, be fairly estimated that one-half
make their appearance within the first year.

The occurrence of postoperative hernia depends, first, on sepsis,
either within the abdomen or in the wound. Sometimes the surgeon
must assume the responsibility for infection ; at other times suppuration
is unavoidable. Other things being equal, the longer the suppuration
continues, the greater the tendency to hernia. Particularly is to be
condemned the too persistent use of the drainage-tube.

Second to be considered is the abdominal wound. The longer the
incision, the greater the likelihood of postoperative hernia. Median
line incisions are more prone to develop herniae than are right rectus
or flank incisions. Division of nerves causes atrophy of the muscles
which they innervate. An incision in which the various structures are
separated along their own line of cleavage, so that they will come to-
gether more naturally, and so that one layer will buttress the opening
in the next, is ideal from this point of view. Naturally, the median

328

POSTOPERATIVE HERNIA 329

line incision, which traverses only one layer of fascia and no muscle,
and in which reliance must be placed entirely upon the edge-to-edge
union of this poorly healing tissue, and where there is no reinforcing
action of aponeurosis or muscle to take off the strain or keep the
wound closed, is just the opposite. The incision recently introduced
by Pfannensteil has demonstrated its practicability where the median
incision is ordinarily indicated, and, theoretically, it should overcome
the objections of the older methods. It consists of a transverse in-
cision, slightly concave upward, just over the pubes, through skin and
superficial fascia. The aponeuroses are divided transversely, and the
rectus muscle, to one side of the median line, separated vertically.
The contraction of the muscle brings together the cut edges of the
aponeurosis. The technique is frequently modified to mean a trans-
verse skin incision, and then the ordinary right or left rectus incision,
just to one side of the median line. This gives good pelvic exposure,
usually heals rapidly in undrained cases, and with lessened liability
to hernia.

Third, is the matter of wound closure. The peritoneum, even, cannot
afford to be neglected, since,^ after operation, where for any reason the
peritoneum has failed to unite, there may be protrusion of gut im-
mediately beneath the skin without sac formation. It has become
generally accepted that, in sewing up an abdominal wound, homologous
structures should be brought together. This is the basis of our modem
technique, the so-called tier or layer suture. Muscle is united to muscle
and fascia to fascia, and no foreign structure is allowed to interpose.
It is of undoubted advantage, also, if in suturing aponeurosis or fascia
the structures be overlapped \ in. or so, instead of being brought edge
to edge. This gives a broader surface for the exercise of plastic repair
and a consequendy much firmer union. This technique brings together
structures of a like nature firmly but without tension. It has the minor
disadvantage of creating potential dead-spaces be^veen layers. The
great disadvantage of the through-and-through suture is the necessity
of drawing the sutures tightly in order to maintain adequate apposition,
particularly in thick abdominal walls, and the subsequent liability to
suppuration. Noble ^ states that hernia occurs with the through-and-
through suture in about 5 per cent, of the cases, whereas after the tier
suture, in America, hernia occurs in not more than i per cent. If sup-
puration occurs in a wound, hernia may follow, no matter which method

* De Garmo, Abdominal Hernia, Its Diagnosis and Treatment, Phila., 1907.
^ The Abdominal Wound, its Immediate and Afier-care, Amer. Jour. Obst., 1907,
Ivi, 328.

330 POSTOPERATIVE HERNIA: ADHESIONS

we employ; however, the smaller the opening and the shorter the dura-
tion of drainage, the less the likelihood of hernia.

Finally, it is important to consider the etiologic influence of after-
care. It must, first of all, be accepted candidly that scar tissue, even
of aseptic healing, rarely has the strength of the tissue which it is designed
to replace. It is extremely likely to stretch, unless it is bolstered by
adequate muscles, under any form of strain, particularly in the case of
patients of sedentary habits who gain weight rapidly after operation.
It must be remembered, also, that the plastic processes concerned in the
repair of an abdominal incision take place under conditions of unrest
and irregular strain, from respiration, vomiting, etc., not present in many
other parts of the body. In those with ill-developed muscles the scar
tissue yields to the strain of crying, coughing, and defecation, and hernia
results. Whereas, this is less likely to occur in early life, it is quite prone
to take place later on, when fat has accumulated and the general muscular
tone of the body is falling off.^ The modem tendency of getting patients
out of bed early is likely to increase the tendency to hernia. The use
of swathes will be considered in the next chapter.

The commonest type of postoperative hernia is a direct hernia of
the abdominal wall, the ventral hernia, or so-called ^'hernia in the
scar.'* Very rarely one sees a right inguinal hernia following an
appendix operation, probably the result of muscle atrophy from loss
of nerve supply. Femoral hernia may follow operation for the cure
of inguinal hernia, or vice versa: one canal is dilated by the pull on
structures involved in closing the other. Postoperative hernia is
properly to be distinguished from recurrent hernia, which signifies
simply the recurrence of a previously operated hernia.^

Symptoms. — The symptoms of postoperative hernia are usually

^ See Barker, Causes and Operative Treatment of Umbilical and Ventral Hernia, The
Practitioner, 1908, i, 149.

2 Dr. E. Wyllys Andrews has recently reported (Surg., Gyn., and Obstet., 191 1, xii, 190)
2 cases of desmoid tumors following op)eration for hernia. These tumors are found in the
fascia and aponeurosis of the abdominal wall, particularly in the posterior sheath of the
rectus; they are apt to grow inward into the abdomen, so that ultimately they have only
the peritoneum for a covering. Histologically they are hard white fibromata, the result of
hyperplasia of fibrous connective tissue from long-continued irritation or trauma. Most
of the reported cases have occurred in women after repeated pregnancies. Desmoid
tumors should be removed by operation on account of their tendency to increase in size,
and on account of the possibility of malignant changes developing; some of them are un-
doubtedly sarcomatous in nature. E. Benelli (Beitrage zur klin. Chir., 1910, Ixxv, No. 3)
reports 12 cases of bone formation in the cicatrix after celiotomy. Most of the cases were
in men over forty.

POSTOPERATIVE HERNIA: TREATMENT 33 1

never marked, and depend on the site and nature of the hernia and its
manner of occurrence. If the hernia is of gradual development, it at no
time, practically, presents noticeable symptoms, such as pain, although
there is likely to be a more or less constant feeling of strain or soreness.
If the hernia is in the nature of a general bulge, this soreness may be
marked during activity, particularly if the patient wears no support.
If the bowel or omentum comes out through a small opening, such as
that left by a drainage-tube, the condition will simulate that of an in-
guinal hernia, and there may be occasional attacks of sharp, colicky
pain, as knuckles of bowel or omentum get temporarily caught.

Frequently the patient is altogether unconscious of the fact that
he has a hernia. Habitual constipation generally accompanies large
ventral hemiae.

The means of prophylaxis have already been dwelt upon. Summed
up, it consists in making an incision which will allow of as complete a
return to the original integrity of the abdominal wall as possible, and
sewing it up so that this return to normal conditions is encouraged and
facilitated; in shunning possibilities of sepsis, and in guarding the
convalescence so that no strain is put upon the scar until it is ready to
bear it. The advantages of reinforcing the wound by adhesive strap-
ping have already been referred to.

Treatment. — ^A hernia occurring early in the convalescence
should be treated by strapping the edges of the wound closely together
by means of adhesive plaster straps. Straps properly adjusted should
relieve the healing scar of all possibility of further strain, and thus prevent
stretching and consequent thinning out of the scar tissue. As soon as the
patient is up and about, a swathe should be fitted and worn until an
operation is decided upon, or permanendy, if operation is contra-
indicated. No truss or other apparatus should be worn which provides
a pad to exert pressure on the region of the scar, for this will lead to
atrophy and certain increase in the extent of the hernia.

Operation is usually postponed until healing is complete and the scar
has reached its maximum degree of contraction. After this it should
not be put off too long, on account of the tendency for the formation of
adhesions of viscera to the scar, and on account of the increase in size
of the hernia and the resulting increased liability to recurrence.
Mere end-to-end approximation of the freshened edges of the apon-
eurosis which form the ring does not suffice — the fascia must be
cleared back and the edges made to overlap. The flap may be trans-
verse or longitudinal, as best suits the mechanical requirements of the
situation. If there is a redundancy of skin-flap, the excess may be

332 POSTOPERATIVE HERNIA: ADHESIONS

removed by including it in an elliptic incision. In order to better

the chances for healing of the new wound without hernia formation

by relieving the intra-abdominal tension, it is wise to reduce the bulk

of the viscera by removing such omentum as is adherent to the sac

en bloc. This is desirable also if the omentum has to be handled, or is

oozing as a result of the manipulations necessary for separation of

adhesions. The operation, in wide median line herniae, is usually so

planned that the elliptic area of skin, the underlying fat, the sac, and

the tied-ofi omentum which is adherent are removed in one mass.

Catgut only should be used, as primary healing is indispensable;

necessary drainage and stitch abscesses account for most of the cases

of recurrent hernia.

ADHESIONS

The peritoneum has the property of sticking together and forming
adhesions when infected, irritated, or injured. This is the property by
which it responds to protect itself against perforation, to limit septic
processes, and to protect the organism against general infection. The
peritoneum serves the purpose most intelligently; for instance, when
it has tried in vain to prevent perforation of a gastric or intestinal ulcer,
by reinforcing the viscus at this site, it limits the abscess which results
by forming a circumscribed pocket for it to pour into, and after a time
provides for its oudet by directing a second perforation into the intes-
tine or externally. Accordingly, we frequently rely upon this function
of the peritoneum for aid in overcoming disease processes.

This useful property has, however, another aspect. Adhesions
may arise after clean operative procedures in cases where, to the
surgeon^s understanding, they can serve no useful purpose. In other
cases, where they have been of valuable assistance, they may persist
after their usefulness is ended and interfere with the normal function of
the viscera to such an extent that the patient, freed from his primary
trouble, may have to be operated upon for relief from his adhesions.
Moreover, adhesions may stretch into bands under the influence of
the intestinal activity, and they are always a potential cause of acute
obstruction.

The chief source of postoperative adhesions is infection; this may
vary from a mild inflammation to a virulent sepsis, but, generally speak-
ing, the greater the degree of suppuration, the more extensive will be
the adhesions. Imperfect hemostasis may cause adhesions; the blood
which oozes out clots and organizes. Another important source is
the leaving behind of raw surfaces, without peritoneal covering, either
from accidental tears or necessary stripping of the peritoneum. Opera-

ADHESIONS 333

tive irritation acts similarly, by causing a necrosis of the delicate endo-
thelial layer which constitutes the peritoneum. This irritation may be
chemical, as by the use of antiseptic solutions in washing out, or me-
chanical, from injudicious use of retractors, rough or excessive manipu-
lation of viscera, unnecessary sponging, the use of dry gauze, the undue
exposure of the viscera to dry or cold air, and the use of unprotected
gauze drainage. Gauze, indeed, is frequently used when we are
desirous of encouraging and training adhesion formation to serve our
purposes in septic cases.^

Wherever the peritoneum is irritated, cut, inflamed, or denuded
from whatever structure it invests, there is an immediate outpouring of
more or less bloody lymph. This coagulates and becomes organized
into granulation tissue, which finally becomes fibrous. Any organ or
structure which comes into contact with the area so covered with
exudate or granulation tissue is extremely likely to become adherent to
it within a few hours, particularly if it has itself undergone similar
inflammation or injury. Thus, the omentum practically always be-
comes adherent to an abdominal incision during the process of healing.
This is salutory, in so far as it prevents the formation of adhesions
directly between intestine and scar, and it is usually intentionally
promoted by bringing down the omentum to cover the intestine before
closing an abdominal incision.

Adhesion formations of this type tend to elongate and stretch
under the influence of the normal motility of the organs which they
connect. Sometimes the bands which result are firm enough to be
the source of danger from intestinal obstruction. Operations in the
lower peritoneal cavity and pelvis are more likely to be followed by
acute obstruction than operations on the stomach and gall-bladder,
for it is into the lower portion of the peritoneal cavity that the intes-
tine naturally gravitates. The omentum, moreover, may become
adherent at several points, leaving loops through which knuckles of
intestine may be wedged and caught. Bands usually tend to atten-
uate and gradually disappear, apparently under the influence of peris-
talsis, which should be started early after operation. Sometimes there
is a massive outpouring of exudate instead from some generalized cause,
and deposits of fibrin cover intestine and parietes in thick layers, which,
organizing, unite each to each, and bind together the viscera in a mass
of adhesions. This matting together of intestines is less likely to be

* Dry gauze is stated (E. H. Richardson, Bull. Johns Hopkins Hosp., 191 1, xxii, 283)
to adhere to peritoneum in twenty minutes so intimately that when it is pulled away it
brings the endothelial layer with it.

334 POSTOPERATIVE HERNIA: ADHESIONS

followed by obstruction than is the band formation, largely because
the normal bowel relations are in a measure preserved, and it likewise
tends to attenuate and may in time disappear entirely.

The formation of adhesions, and their elimination when once
formed, seems to depend in a certain measure upon the individual
peculiarity of the patient. In some peritoneal cavities we find that
very slight provocation has been followed by the formation of extensive
or even universal adhesions, and sometimes, on the other hand, we
find very slight adhesion formation after serious bacterial inflamma-
tion. In the same way in some persons extensive adhesions will ap-
parently take care of themselves and give no trouble after operation,
and in others mild adhesion formation after a clean celiotomy may
cause symptoms of so aggravated a type as to make necessary surgical
interference.

The operation which most frequently gives rise to trouble from
adhesions is appendectomy. It is practically impossible to perform
an operation upon the appendix or gall-bladder, for instance, with
the assurance of complete bacteriologic sterility. In interval cases
the adhesion formation is slight; in acute or septic cases the intestines
may be matted together, and the lower end of the ileum may be tied
to the inner side of the cecum and so angulated or compressed as to
interfere seriously with its functioning. Similar results may occur
after operations in the female pelvis, if care is not taken to float the
intestines out of the pelvis before sewing up. Another frequent
source of origin of postoperative adhesions is operation upon the gall-
bladder or bile-passages. Bands are likely to constrict the ducts so as
to interfere with normal drainage or to limit the functions of the gall-
bladder. Adhesions after gastro-enterostomy may be the cause of
protracted bilious vomiting.

The symptoms arising from postoperative adhesions may be
either insidious or fulminating. While it is true that intestinal adhe-
sions may exist and the patient suffer no impairment of health, never-
theless they are the frequent cause of digestive disturbances, ill-defined
or sharply localized abdominal pain and soreness, and sometimes acute
intestinal obstruction.

In the insiduous form the symptoms at first are slight and they may
appear only at intervals. The patient complains of soreness in the in-
testines or about the region of the scar. She is usually constipated, and
finds that ordinary cathartics do not relieve, and sometimes, after a
dietary indiscretion, the bowels will be completely inactive for a week or
so and then move again with fair regularity. She is apt to experience

ADHESIONS 335

an unusual amount of pain or distress with the menstrual flow, of a
griping or colicky nature, even if the operation has not involved the
pelvic organs. In many cases the patient gets more or less accustomed
to her new state, and gradually, in the course of time, the symptoms
wear away as the adhesions attenuate and disappear. Not infrequently,
however, a condition of neurasthenia develops, and the morbid interest
of the patient in her own symptoms magnifies them until she becomes
a neurotic, ill-nourished invalid.

In contradistinction to these effects of partial obstruction or im-
pairment of function, as the intestines or viscera are distorted or con-
stricted by the pull of adhesions, is the strangulation which sometimes
occurs from the constriction of a loop of intestine imder or about an
adhesion band. Acute obstruction may occur at any time from a few
weeks to many months after the operation. It is usually preceded by
some of the indefinite symptoms just noted, but it may appear out of
a clear sky — as, for instance, in a patient upon whom we recently oper-
ated for strangulation of the gut in a loop of omentum tw^elve years after
the uneventful recovery from an abdominal operation.

The symptoms are those of acute intestinal obstruction from any
cause. They depend to some extent upon obstruction of the current
of gas and feces, but probably to a greater degree to obstruction of
the circulation. Thus, a patient with obstruction may nevertheless
continue to pass small quantities of semifluid feces and gas. The
characteristic symptoms are acute pain with colicky exacerbations,
and more or less generalized, but often referred to the epigastrium, and
tenderness, at first directly over the seat of the trouble, but later rather
difiicult to localize on account of spasm of the abdominal muscles;
there are nausea, vomiting, distention, at first to be noted just above
the seat of the constriction, spasm, which is ordinarily less marked than
in peritonitis, and general pallor and sweating. The first enema or two
may bring away feces if the bowel below the point of obstruction was
fairly full before the strangulation began, or if the lumen of the intes-
tine is not entirely closed off at the point of constriction. The temper-
ature is not elevated at first and may be subnormal. The pulse is
normal or somewhat increased.

Prophylaxis* — The matter of prophylaxis is an important part
of abdominal technique, and the lines which are to be followed at the
time of operation have already been suggested. The English sum these
up under the expressive phrase, ''toilet of the peritoneum.^^ They may
be restated categorically, thus:

Employ aseptic rather than antiseptic technique, avoid the use of

336 POSTOPERATIVE HERNIA: ADHESIONS

chemicals for any purpose, and use only warm normal saline for flushing
out.

Operate under conditions of warmth and moisture which will as
closely simulate those of the peritoneal cavity as possible; keep all
exposed or delivered viscera protected from the air by gauze pads kept
warm and moist by hot saline solution.

Protect such parts as are not involved in the operation by walling
off with pads of moist gauze.

Allow no rough retraction, no inconsiderate handling or sponging
of the intestine, or needless or ungentle manipulation.

Use moist or hot dry strips and sponges within the abdomen.

Suture the peritoneum carefully and avoid the use of the cautery.

Cover the ends of pedicles, appendix, and hysterectomy stumps so
far as practicable by sewing the peritoneum together over them in such
a manner as to leave a smooth peritoneal surface behind.

Leave no large surfaces denuded of peritoneum; if no other means
of relief offers, cover in by means of an omental flap or graft.

Remove all blood-clot; if oozing is anticipated after sewing up,
provide for its stasis or outlet.

Drain only when necessary, use only a sufficient amount of gauze
to serve the purpose, and, except where contact with peritoneum is
intended, protect it by rubber tissue.

After the Trendelenburg posture, rearrange the coils of intestine in
their natural positions.

Before sewing up draw down the omentum under the abdominal
wall.

Various methods have been commended, largely on an experimental
basis, as means of preventing the formation of postoperative adhesions
within the abdomen, between brain and dura, and about tendons. While
some have been shown to be of doubtful value, and no single agent has
demonstrated its assured fitness for this purpose, the observations are worthy
of record.

On the theory that active peristalsis ^prevents or limits the formation
of intestinal adhesions, D. C. Craig^ has recommended the subcutaneous
injection of salts of physostigmin (p. 177). Heile,^ with the same end in
view, advises the injection of 50 to 100 cc. of warm castor oil, preferably
emulsified with a little soda and water, directly into a high loop of the
small intestine, before closing the abdomen, in cases of diffuse peritonitis.

1 Am. Jour. Obstet., 1904, xlix, 44Q.

2 Central, f. Chir., 1909, xx.wi, 1073.

ADHESIONS 337

The use of antifibrin, phosphorus, and peptone to prevent coagulation of
exuded serum and the consequent agglutination of apposed raw surfaces,
of thiosinamin or fibrolysin to soften or dissolve adhesions, and of the
iodids to promote absorption of the newly formed connective tissue, have
all had their advocates.

Muller originated the plan of leaving the abdomen full of salt solution,
with the purpose of floating the coils of intestine and so preventing the
app>osition of raw surfaces. The solution, however, merely floats the loops,
but does not separate them, and it absorbs too rapidly to permit of much
growth of endothelium before they come again in contact with the parietes.
VogeP declares it ineffectual. E. Marvel- regards a solution of adrenalin in
normal saline as of value in preventing plastic exudate.

Distention of the abdomen with gases has recently been advocated.
T. Weiss and L. Sencert^ state that oxygen injected in continuous stream
into the abdominal cavity through a small buttonhole in the anterior wall
stimulates the cardiovascular and respiratory systems, arrests absorption
of septic fluids, promotes healing, and prevents the formation of adhesions.
The gas comes out, bringing with it pus and fluids, through various drainage
holes. The use of carbon dioxid gas has already been mentioned in con-
nection with the Henderson theory of the causation of shock.

Lubricants have been employed for various years by many men with
the expectation that raw surfaces would be protected thereby until sufficient
time had elapsed for the regeneration of their normal endothelial covering.
The use of sterile olive oil was first made by August Martin.* J. B. Blake,
of Boston, concludes,^ as a result of an experience with its use in 14 operations
on animals and 7 on human beings, that *^ oil, absolutely sterile, may be
used in the peritoneal cavity of patients in moderate quantities, i to 4
drams, without danger, general or local; that it remains in the peritoneal
cavity for periods of from five to fifteen days and p)ossibly longer; that its
presence tends to prevent early and direct adhesions of denuded or inflamed
peritoneal surfaces, and, therefore, that its use, under the above precautions,
is indicated and is moderately effective in sometimes preventing and usually
diminishing the formation of postoperative peritoneal adhesions.^' Vogel*^
has reported good results with a mucilaginous solution of gum arabic (gum
arabic i part, normal saline, 2 parts; filter and sterilize) injected through
a tube just before the abdominal wound is closed, and others have confirmed
his report. Sterile vaselin has been commonly used, and is well spoken of.^

^ Deut. Zeit. f. Chir., 1Q02, Ixiii, 2q6.
- Jour. Am. Med. Assoc, 1907, xlix, 986.
•^ Rev'ue de Chir., iqio, xli, 563.
* Ellis, Proceed. Path. Soc. of Phila., 1906, ix, 178.
"* Surg., Gyn., and Obstet., 1908, vi, 667.
'^Op. cit.
E. H. Richardson, Bull. Johns Hopkins Hosp., 191 1, xxii, 283.

338 POSTOPERATIVE HERNIA: ADHESIONS

Other substances which have been recommended are agar, gelatin, lanolin,*
prepared animal fat,^ and Glimm's method of injecting 30 cc. of sterile
10 per cent, camphorated oil into the abdominal cavity.^

In contradiction to these reports, however, stand the researches of
M. Busch and E. Bibergeil.* They have experimented with clean olive
oil, solid paraflSn, anhydrous lanolin, liquid paraffin, gum arabic, agar, and
gelatin, and they conclude that it is impossible to prevent contact between
abraded and injured surfaces of peritoneum and the consequent production
of adhesions by means of mucilaginous or similar substances left in the ab-
dominal cavity. Some of the materials, such as lanolin, paraffin, oil, and agar
they assert cause irritation of the peritoneum, while non-irritating solutions,
such as gum arabic and gelatin, are too rapidly absorbed to be of any me-
chanical advantage. They had no better results with the prophylactic use
of physostigmin and fibrolysin.

Non-absorbable protective membranes of various sorts have been used.
The painting of collodion over raw surfaces was suggested by Stern, ^ but it
has been discarded. Similarly, xylol and a solution of gutta-percha in chlo-
roform have been used. A thin silk protective has been advocated by C.
Lauenstein,^ as well as thin sheets of rubber fabric. The filmy coagulum
produced by aristol acting on lymph has been employed, as well as a gelatin-
formalin coagulum, but with poor success. M. C. Harris,^ however, has
had good results from the use of silver-foil after operations on the brain, and
Ellis^ has demonstrated the value of films of celloidin wrapped about
tendons to prevent adhesion to their sheath.

Non-viable animal membranes have had more or less enthusiastic ad-
vocates. Thin goldbeaters' skin (the peritoneal coat of the cecum of the
ox) was recommended by Duschinsky.^ From this developed the use of
shark's peritoneum, the peritoneum of oxen (Cargile membrane), and a
finely woven cloth of catgut. The experiments of A. B. Craig*^ and Ellis
show that little reliance can be based on this method ; theoretically, such sub-
stances are foreign bodies, and might be expected to provoke rather than
prevent adhesions.

The method which promises the most, in the limited field where it can be
employed, is the use of living animal membrane, either in the way of an
autogenous graft of omentum or by plastic operations on the peritoneum, or

* Gellhorn, Surg., Gyn., and Obstet., 1909, viii, 509.
2 Crump, Surg., Gyn., and Obstet., 1910, xi, 491.

^ Hoehne, Miinch. med. Woch., 1909, Ivi, 2508.

* Archiv. f. klin. Chir., 1908, Ixxxvii, 99.
'' Beitrage z. klin. Chir., 1889, iv, 653.

* Archiv. f. klin. Chir., 1890, xlv, 224.

^ Jour. Am. Med. Assoc., 1904, xlii, 763.

* Op. cil,

® Inaug. Dissert., Munchen, 1898.
^^ Ann. Surg., 1905, xli, 801.

ADHESIONS 339

the use of material from a freshly killed animal. Omental grafts adhere and
establish a good blood-supply within twenty-four hours. If transplanted
onto fixed surfaces or viscera which have weak peristalsis, as stomach or
bladder, they are likely to adhere to neighboring loops; accordingly, they are
used to best advantage on the sma-ll intestine, to cover weak points, raw areas,
and suture lines. For the same purpose Richardson^ recommends taking
one leaf of the adjacent mesentery, freed up through an incision parallel to
the bowel, and sewing the freed edge to the margin of the area to be covered.
This rotates the bowel somewhat in its longitudinal axis, but it causes no
kinking or occlusion. If the leaves cannot be separated, the whole thickness
of the mesentery can be similarly used. In case of great loss of peritoneal
substance in the pelvis from pelvic abscess, tumors with adhesions, etc.,
Summers^ transports the sigmoid flexure across the pelvis and sutures it to
the lateral walls of the excavation, across the fundus of the uterus, or, if the
uterus is gone, to the bladder, in such a way as to cover over all the raw sur-
faces. Drainage is had in cases of total hysterectomy through the vagina,
otherwise from under sigmoid and out of lower angle of wound. He claims
that this technique prevents the spread of infection and postoperative in-
testinal obstruction.

Treatment. — ^The non-operative treatment of adhesions consists
in the early and consistent use of gentle laxatives and a carefully selected
diet. This should be digestible to the point of leaving little residue,
which nught clog the narrowed and imperfectly acting gut. It should
be finely di\ided and well masticated. Byford^ has obtained relief
from symptoms through active exercise, probably through the stretching
and attenuation of the adhesions which result. He cites one case which
was permanently cured by horseback riding on a roughly gaited horse.
In cases where this is not practicable or advisable, massage and elec-
tricity may be applied to the abdomen with advantage. (See Chaps.
XXXVII and XXXVIII.)

Operative treatment becomes imperative in cases where non-operative
methods give no relief, when pain and spasm become severe, or when
symptoms of acute obstruction appear. In the ordinary case the sur-
geon should not wait for the obstruction to become absolute, for by
this time beginning necrosis of the bowel is already frequently in evi-
dence and resection may be necessary.

The incision should be made nearly over the obstruction, if this can
be localized, otherwise in the median line, below the umbilicus. Care
should be taken in incising the peritoneum lest adherent intestine be

' Op. cit.

2 Surg., Gyn., and Obstet., 191 1, xiii, 125.

'Ibid., 1909, viii, 576.

340 POSTOPERATIVE HERNIA: ADHESIONS

punctured. Recent delicate adhesions may be separated by sponging;
if they are broad enough to contain vessels of size, they should be tied
off. Adhesions a year or more old usually are poorly supplied with
\'essels, and, if not too large, may simply be divided at their points of
origin and the intermediate portions removed, lest a long end left free in
the abdomen contract fresh adhesion. Broad adhesions leave behind
large raw areas which should be protected in any suitable fashion. If
the intestine is kinked by a band, it usually straightens out as soon as
the band is divided. If it is obstructed by close adhesion to the parietal
peritoneum, it is best to cut out the peritoneum and leave it attached
to the bowel, covering over the raw surface left behind by bringing the
peritoneal edges together. This plan must also be employed as far as
possible in case the intestine is matted together. Raw surfaces which
cannot be protected in other ways should be covered with portions of
omentum.^

^ F. B. Lund, Remarks on Intestinal Obstruction by Bands Following Operations on the
Peritoneal Cavity, Boston Med. and Surg. Jour., 1902, cxlvi, 565; J. C. Webster, The Pre-
vention of Adhesions in Abdominal Surgery, Surg. Gyn. and Obst., 1909, viii, 574.

CHAPTER XXXV

ABDOMINAL SWATHES: THEIR USE AND ABUSE

It has until recently been considered the proper thing to recommend
that a fitted abdominal swathe be worn one to twelve months after all
abdominal sections,^ and that trusses or specially adapted swathes,
containing pressure plates, be applied after all operations for hernia.
The practice is rapidly becoming more and more restrfcted.

If an abdominal incision is made with proper regard for anatomic
mechanics, and is closed with efficient deliberation, and the approxima-
tion of the wound-edges is then supported by strips of adhesive plaster
carefully applied and maintained during the plastic period of healing
— namely, twenty-one to thirty days — a solid and resistant scar is to be
expected. With median line incisions, in fat, flabby-muscled individuals,
and in the presence of sepsis, further support may be necessary. Other-
wise, it may be contended that an abdominal swathe has a positively
deleterious effect in so far as it encourages atrophy of abdominal muscles
through disuse. Abel ^ shows by statistics that the abdominal swathe
has nothing to do with preventing the formation of hernia.

The arguments advanced by those who favor the routine application
of the swathe without special indication are varied. They hold that
the presence of a swathe serves to remind the patient of the fact that he
has a weak spot in his abdominal wall, and that he will accordingly
refrain from straining himself by lifting and muscular overexertion.
The swathe is said to guard the scar against the extra tension resulting
under conditions such as constipation and respiratory affections, and
during physical effort. Finally, it is stated that the public has become
so accustomed to the idea of wearing a swathe after abdominal operation
that any surgeon w ho neglects its use will lay himself open to the serious
criticism of his patients in case postoperative hernia does develop.

Wounds heal by the process of scar-tissue formation. After about
ten days the line of incision shows under the microscope as young vascu-
lar connective tissue. In the course of weeks and months this red scar
tissue gradually contracts and loses its vascularity, becomes more

^ Kummer (Corres. f. Schweizer Acrztc, 1901, xxxix, 361) insists that an abdominal
bandage be worn for three months after a celiotomy.
^ Archiv f. Gyn. u. Chir., hi, 656.

311

342 ABDOMINAL SWATHES

fibrous in character, and changes permanently into white scar tissue.
Skin and peritoneum proliferate quickly and heal rapidly by the forma-
tion of new similar structures; connective tissue, fat, and muscle
repair more slowly by the formation of connective tissue; fascia and
tendons repair very slowly by means of connective- tissue formation.
Whenever circumstances allow, it is theoretically advisable carefully to
approximate homologous structures, so that scar contraction will unite
firmly muscle to muscle and fascia to fascia, restoring in this way to a
greater extent the integrity of the abdominal wall. Septic wounds
require a longer time for healing than do aseptic, and repair by the
formation of much larger amounts of connective tissue, resulting in
larger scars.

Postoperative swathes were devised to support the abdominal wall
until the firm white scar was fully formed, in an endeavor to prevent
hernia during the process of healing, and to overcome the tendency
to the formation of a thin, wide scar. It must be borne in mind that a
swathe is to all intents and purposes a splint, and a splint causes atrophy
of the muscles it supports and whose activity it limits. It is not to be
denied that there are cases which are benefited by swathes and are
protected from the occurrence of hernia, but the indications are gradually
becoming more limited, and the ill effects are safeguarded by suitable
exercises for the abdominal muscles to preserve their tone and to increase
their development. The majority of cases, depending on the character
of the wound and on the muscular development of the individual, do
perfectly well without a swathe and almost never show postoperative
herniae.

In the McBurney or muscle-splitting incision the only cutting done
is in going through the skin and peritoneum; the muscles and fasciae
are torn apart in the direction of their fibers. The result is that the
structures fall together naturally, requiring but few sutures. Such a
wound needs no support; as soon as retraction ceases, each layer as-
sumes almost its former integrity, and so buttresses every other layer
against strain that the patient may be allowed up in three days, or even
earlier in a small wound, without support or risk, provided that adhesive
plaster strips are used.

The right rectus incision, while not perfect mechanically, is well
designed in that it brings the center of the injured rectus muscle over
the wound in the deeper layers and supports it against strain. A patient
with such an incision does perfectly well without a swathe. Occasion-
ally herniae are reported after these two incisions, but investigation
practically always reveals the fact that the blame can be placed on sepsis,

THEIR USE AND ABUSE 343

too long an incision, or unpractised technique. Incisions above the
level of the umbilicus are subject to no great amount of intra-abdomi-
nal pressure, and, if properly closed, practically never require support.

Incisions in the median line, where there are no muscle-fibers, heal
slowly and entirely by connective tissue. It is safer to insist that such
cases, particularly if drained, wear a swathe and take supplementary
exercises for about six months. By that time the scar is as firm as it
will ever be, and the further support of a swathe is useless and even
detrimental. A case has recently come to our notice of a young woman
who is wearing a swathe six years after operation simply because she
has never been told she could go without it.

Abdominal wounds which have been drained, or allowed for sepsis
or some other reason to heal by granulation, should be supported by
swathes for six months. Advocates of the McBumey technique declare
that this is usually unnecessary in their muscle-splitting incision.
However, it must be borne in mind that in a McBumey incision
which has been drained for any length of time, say, forty-eight hours
or over, the different layers fail to fall together into close approxima-
tion, and the intervening space has to fill in with granulation tissue.
In the case of abdominal wounds which, by reason of emergency, have
had to be sewed up by through-and-through sutures, or left widely open
for a time, fitted swathes should be worn until the surgeon is satisfied
that the scar will not give way. For this class of cases it is far better to
wear the swathe a lifetime if the patient is one who, should hernia ap-
pear, would not be willing or in condition to have it treated surgically.

In addition to the character of the wound, we must give considera-
tion also to the physical development of the individual. Just because
a patient is fat is not a sufficient reason for applying a swathe. Under
the fat there may be good firm muscles capable in themselves of pre-
venting hernia. Fat patients generally, however, are inclined to have
flabby muscles, strained by the large accumulation of intraperitoneal
fat. Such cases demand, first of all, exercises for those muscles, and
the exercises will also tend to diminish the fat; a swathe may often be
worn with advantage during this process. Moreover, in a fat per-
son a swathe imparts a sense of security and satisfaction that will give
confidence to undertake and continue exercise. In a man whose ab-
domen is approximately the size of his chest at expiration, or smaller,
a swathe is hardly ever to be considered necessary.

Women ordinarily stand more in need of abdominal support than
men during wound healing, on account of their naturally less muscular
development, decreased still further, frequently, by the wearing of

344 ABDOMINAL SWATHES

corsets and by repeated pregnancies. In a well-developed woman with
small abdomen who has not worn corsets no swathe is necessary under
ordinary circumstances. In a woman used to wearing corsets no
swathe can serve so well as the present-day straight-front corset,
laced from below upward. The corset should be advised, if support
is necessary, as soon as the tenderness of the scar will permit its being
worn. In a woman with pendulous, flabby abdomen, a fitted swathe,
with perineal straps, or a specially made corset, may be prepared
for the purpose of relieving the scar of strain and the weight of the
abdominal contents. Cases operated on for malignant disease which
show any signs of cachexia should wear swathes in order to support
their weakened muscles. Cases undergoing an operation which
materially reduces the intraperitoneal contents, either by the removal
of the fluid, cysts, or masses of omentum, should wear swathes until
the abdominal walls have readjusted themselves. Any case subject to
chronic cough of any nature, and the old or feeble, should wear a swathe.

The question of swathes following hernia operations is worthy of
special consideration. Many varieties of swathes have been devised
for use after operations for inguinal and femoral hernia. In order to
relieve tension on such wounds the thigh must be kept flexed on the
body, slightly adducted and inverted. No swathe yet devised will
do this with any degree of comfort to the patient. The patient should
be kept in bed until satisfied that the scar is firm, usually about three
weeks, and then he should be allowed to get up, with instructions not
to bend backward or to the well side and not to straddle. In this way
he will avoid nearly all undesirable strains. As epigastric and umbilical
herniae nearly always occur in fat people, and the operative scar is
necessarily in the median Hne, such cases should wear swathes. Opera-
tions for ventral and postoperative herniae should be followed by the
use of swathes.

The matter of the ki^id of swathe to employ, when one is decided
upon, is not to be settled off-hand. Like most apparatus designed as a
substitute for or to reinforce normal physical function, the swathe is a
makeshift. Many forms have been designed sufficiently complicated to
suit the most ingenious mind, and depending in principle on minor de-
tails usually of no great importance. These are marketed under various
names. It must, however, be understood, first of all, that no one type
of swathe, whether or not it represents the copyright hobbies of some
enthusiast, will do for every case. The surgeon should have clearly
in mind what purpose he expects the swathe to serve. Most hospitals
have relations with a clever woman who is adept in designing and fitting

THEIR USE AND ABUSE

345

;eons. In

swathes in accordance with the instructions of th'
special cases, at least, swathes should be specially fitted.

Ordinarily, simple and inexpensive swathes of the types pictured
(Figs. loi, 102, 103) maybe purchased which will serve every purpose.

The less the complications and the fewer the straps and buckles, other
things being equal, the better. A swathe should be washable, and if it
contains no or little elastic webbing, so much the better. It should sup-

346 ABDOMINAL SWATHES

port and not constrain the abdomen, by exerting a constant lift on the
suprapubic bulge. If the swathe is likely to slip up, it should be held
down by perineal straps or leg-binders.

When the swathe is applied, the patient should be clearly informed
as to how long it is expected that its use will be necessary. He should
understand also the dangers of swathe wearing, for nothing encourages
inguinal hernia more than body movements with a swathe improperly
applied, for instance, tight about the waist and loose below. A swathe
which constricts the abdomen but does not support it will do far more
harm than good. The use of exercises has already been dwelt upon.
The surgeon should see the patient at intervals to satisfy himself that
the swathe is properly worn and the directions carried out.

CHAPTER XXXVI
ARTIFICIAL LIMBS; POSTOPERATIVE FLAT-FOOT

ARTIFICIAL LIMBS

In the operative treatment of wounds the surgeon is ordinarily
actuated by the principle that all viable tissue should be saved. The
only exception to this principle should be in cases involving amputation
of limbs. Due consideration must here be given to the important
matter of efficient prosthesis. It is true oftentimes, for example, that
saving too long a tibial stump means inconvenience and discomfort
when the patient is ready later to wear an artificial leg. It is import-
ant, therefore, in performing amputations to be governed by the ex-
perience of those who have to do with the making and fitting of arti-
ficial limbs.

Amputations through the tarsus, such as the Chopart and Faraboeuf,
are usually not highly satisfactory. The tarsal bones which remain
are liable to be pulled out of place, and oftentimes the heel is so retracted
by contraction of the tendo Achillis that the scarred surface is drawn
under the leg in such fashion that it becomes the bearing point of weight.
On account of its unevenness it is usually intolerant of pressure. This
retraction also so lengthens the leg that a compensatory elevation of the
sole of the shoe on the other foot must be employed. The only efficient
artificial limb for this sort of amputation is one having a leg, the front
half of which is made of aluminum, and the rear half, which encloses
the calf and the aluminum shell, of leather. As an ankle articulation
would be cumbersome, it is better to have instead a stiff ankle and a sole
made of rubber. This appliance should be so fitted that the weight
of the body is borne by the calf of the leg, not by the end of the stump.

Amputations about the ankle-jointy the Syme*s and the Pirogoff , which
have flaps formed of the resistant tissues of the heel, usually provide
stumps which, though clumsy, are capable of weight-bearing. If,
however, the cicatrix extends over the bearing point, or if the stumps
are tender, they do not allow of end-bearing, and legs must be planned
which allow of no pressure on the extremity but distribute the weight
over the lower leg. The leg ordinarily applied is one similar to that
already described. If fitted with a mechanical ankle-joint, it is usually
cumbersome and uncomfortable.

347

348 ARTIFICIAL limbs; postoperative flat-foot

The amputation at the point of election between the ankle and
the knee is the amputation of both bones, which gives a stump from
6 to 8 in. long. Generally speaking, in operations above the ankle the
longer the tibial stump the better, but stumps which reach close to
the ankle are usually, in the majority of cases, not capable of bearing
pressure, because the flaps are poorly nourished, and are, therefore,
slow in healing, and are extremely liable to ulceration if subjected to
pressure. This is due partly to poor collateral circulation in the lower
third of the leg and partly to the absence of muscle in the flap. Ulcera-
tion frequently necessitates re-amputation. Moreover, these stumps
are usually hypersensitive. Long tibial stumps are likely to be en-
larged or bulbous at the tip, which interferes with the use of a socket.

Tibial amputations short of 4 inches are of practically no use in
throwing the lower leg forward in walking. In addition, they are
likely to become atrophied or contracted. The fibula, which is prac-
tically subcutaneous as a result of friction, may be excited to perios-
titis, and sometimes re-amputation above the knee is the only relief
from the soreness or infection. Amputations, therefore, in the mid-
dle third of the leg are the most likely to give good results, both
from the point of view of the surgeon and the maker of limbs. The
fibula should be sawn off slightly shorter than the tibia, and the front
of the tibia should be beveled off.

The legs which are suitable for such an amputation consist of a
lower leg or socket made of willow covered with parchment, a foot
made of willow, felt, or rubber, with or without an ankle-joint, and a
thigh socket made of leather, to lace about the thigh and connect with
the lower leg by means of side irons hinged at the knee. Various
modifications are provided and lauded by the several manufacturers,
but none are essential, and a simple well-made leg, without pretended
'' improvements,'^ can usually be relied upon.

The following p)ersonaI letter is from a patient whose leg was amputated
at the point of election. It is given entire, because it presents the subjective
attitude of one artificial-leg wearer. The writer is a man of keen intelligence
and good mechanical ability:
Dear Dr. Crandon:

In regard to the artificial leg business, it has been my experience that
the different manufacturers all have a story to tell trying to convince one that
theirs is the only real thing. All these patent ankles and different appliances
simply give them something to talk about.

" The first limb I had was what they call a slip-socket, which was made of
leather. It is a very heavy, cumbersome leg, and the slip-socket I do not con-

ARTIFICIAL LIMBS 349

sider of any benefit. The only thing for me to do is to select a good, honest,
painstaking leg manufacturer and one who has patience to see that you are
suited. I consider a wooden leg the most satisfactory, inasmuch as it is
lighter and not so cumbersome, being smaller in cumference, and will hold
its shape much better than any leather preparation, which, as you will
readily see, will change if it is subjected to moisture and then heat, which
they all are.

" I suppose any artificial limb would be a disappointment to a person at
first, but after one gets accustomed to wearing it, they soon find out that it is
not altogether in the limb, but rather the unnatural feeling which a person
has, and, of course, the stump being tender, there is nothing made that a
person can put on and wear without more or less inconvenience at first.

^' I am getting along first-rate, and as I look back I think I have done
as well, if not better, than can be expected. I have been able to drive my
own car all summer without any inconvenience — in fact, have just returned
from a trip through the White Mountains.

** In regard to circulars or catalogues, I should read them all critically
and be slow to decide.''

Not infrequently in cases of tibial amputations the knee-joint
becomes contracted, either as a result of the primary injury or from
neglect in exercising the leg during the period after the stump has
healed and before the leg is finally applied. If a stump becomes
contracted at right angles so that it cannot be fully extended, or in
case a stump is so short that it is of no value in flexing the knee-joint
of an artificial leg, it is allowed to remain contracted, and the stump
then becomes a knee-bearing stump, and a leg is constructed so as to
receive the knee in the flexed position. This appliance is unsightly and
complicated. Ordinarily, a stump of proper length can be brought to
full extension either by manipulation or by the use of an artificial leg
which has been properly adapted. This may be accomplished by
applying a leg which is fitted with a lacing attachment that passes over
the rear of the stump in such a way as to exert constant pressure.
This appliance tends to stretch the contracted hamstrings progres-
sively, until at last it can be removed and the ordinary socket worn.

Amputation through the knee-joint may give a useful stump if
properly performed. In order to bear weight the flap should be thick
and the scar high up and out of the way. The condyles should not be
scraped or otherwise disturbed, and the patella should be either removed
or else firmly fixed in the depression between the condyles. Such a
stump will have a nodular end and may be clumsy in appearance, but
it will usually be capable of end-bearing without sensitiveness or pain.

In amputations of the thigh the same principles should govern the

350 ARTIFICIAL LIMBS; POSTOPERATIVE FLAT-FOOT

operator as in the case of tibial amputation. Thigh stumps, like those
of the tibia, are not capable of bearing weight upon their extremities,
as a rule, and, therefore, reliance must be placed upon the socket.
Amputations which are too close to the knee do not allow sufficient
room for the mechanical knee-joint with which these legs are supplied.
For this reason it is found that the most suitable point for amputation
is at the junction of the middle and lower thirds. Thigh amputations
which leave a bony stump short of 5 in. in length usually are inadequate
from a functional point of view, on account of insufficient lever-
age. For this reason, in cases of amputation above the point of elec-
tion the perfection of the flap should be sacrificed to the length of the
bone.

Thigh stumps, like those below the knee, are subject to contraction,
provided the use of an artificial leg is too long postponed. This con-
traction is, however, usually overcome with slight difficulty after the leg
is applied. The legs are made like those already described for tibial
stumps, except that the socket is fitted to the thigh and the knee is
supplied with a spring which allows of flexion in walking so as to
simulate the natural gait. An appliance is fitted to the knee, which
holds it in the flexed position when the wearer is sitting. The
socket is held on by a band of webbing which goes over the opposite
shoulder.

After amputation through the hip, legs are supplied similar to those
just described, with a few modifications. The socket is wide and shallow,
and has a broad, rounded edge, so that the wearer is practically sitting
upon it. It is held in place by a broad belt and suspender.

In all amputations in general there are details which should never
be overlooked. Of these, the most important is the position of the scar.
If the stump is to be end-bearing, that is to say, if the extremity, as in
the case of the amputation at the ankle- or knee-joint, is to take the
weight of the leg, the scar should be out of the way in front or behind.
If the stump is to be a conical one, as in the case of amputations of the
tibia and thigh, the scar should be so placed near the extremity that it
will not be subjected to pressure or irritation from the socket. The
presence of sharp edges or spicules of bone or corners which are not
rounded off will make themselves disagreeably felt after the stump
has atrophied with use. The slightest pressure will cause irritation
of the skin over such points and usually leads to ulceration, which does
not heal up permanendy until the bone is properly trimmed. Nerves
should always be drawn down and cut off short, so that they will retract
into the tissues. If they are caught in the scar, they will give rise to

ARTIFICIAL LIMBS 35 1

amputation neuralgia or other serious symptoms. Sometimes the cut
ends will proliferate and form neuromata, which are accompanied by
hallucinations of sensation in the absent limb, and usually necessitate
re-amputation.

The flap should be so well planned that it will be well nourished.
It should contain tissue enough to amply protect the bony stump, but
the tissue need not be thick, because it must shrink to its maximum
before the socket can be worn to the best advantage. It is best to have
this shrinkage accomplished and the desired conical shape attained
before the leg is fitted, as this will save the trouble and expense of suc-
cessive refittings of the leg-socket as the stump shrinks in use.

This shrinkage may be accomplished by keeping the stump tightly
bandaged from the time the skin is healed. The bandage may ad-
vantageously be made of cotton flannel, and it should be applied in case
of a tibial stump from the tip to the knee, and in case of a thigh amputa-
tion from this extremity to the body. Unless this is carried out, the
stump will be soft and flabby. If it is properly attended to, the stump
will become tough, solid, and resistant, and will gradually diminish in
size.

Instead of the bandage, we can make use of a leather appliance called
a stump-corset. This is molded to fit the stump, and is made to lace
up so that graduated pressure can be applied and the desired end at-
tained. Ordinarily, under this treatment the patient is ready to be
measured for his leg within a fortnight after the wound has healed, so
that he can be up and about on crutches. To prevent contractions the
stump should be exercised and given proper massage and manipulation
until the limb is ready. If the stump undergoes further shrinkage in
the socket, a new socket may be supplied, or, if the shrinkage is slight,
it can be compensated by wearing thicker socks.

Artificial hands may be fitted to a forearm which is amputated at
or above the wrist, or, if part of the hand remains, artificial fingers can
be supplied. For amputation at the middle of the forearm an appliance
may be fitted which will allow of motion at the elbow. It is held in
place by a broad strap, encircling the arm above the elbow. The
thumb of the artificial hand may be made to grasp by means of a cord
which goes over to the opposite shoulder.

In amputations above the elbow the socket is made so as to go over
the shoulder, and it is held in place by a strap about the body. Cords
may be fitted to control motion at the elbow and thumb. Stumps on
the upper extremity are not required to bear weight, but insomuch as
friction from the socket comes upon the sides of the stump, it is advisable
to have the scar at the extremity.

353 ARTIFICIAL LIMBS; POSTOPERATIVE FLAT-FOOT

POSTOPERATIVE FLAT-FOOT

After a severe operation or in a patient for any reason much debili-
tated, on putting the feet first down to the floor and attempting to walk,
the feet, ankles, and legs arc liable to swell. Cold spraying, massage,
and flannel bandages will help to make this stage pass quickly.

Many patients after a se^'ere surgical experience, especially if the
stay in bed has been long, will rise at first with their muscles and
ligaments so atrophiefi ihat symptoms of a weak or " flat " foot will
immediately appear. This is especially seen after fractures, partic-
ularly if the foot has not been held at right angles to the leg and well
ad ducted.

This condition of muscle atrophy, through disuse or improper use,
is indeed the common etiology of so-called flat feet, and for it the fol-
lowing exercises are recommended:

I. Stand stiff-kneed, the feet 3 or 4 inches apart, parallel or slightly toeing
in, the toes making a grj-sping effort. This is the correct standing posture
(Fig. 104)-

II. Standing with knees "broken" or slightly bent forward, the knee-
caps turned outward to simulate bow-!egs, the feet as before, parallel or
slightly toeing in, the toes grasping. This is a position such as the gorilla
or the ourang takes. It is a perfectly stable, strong posture. The weight of
the body a^ the next step is tiiken in this position is not thrown suddenly and

POSTOPERATIVE FLAT-FOOT 353

wholly on the arches of the feet, but the load is taken up and distributed
in the spring action of knees, ankles, and feet (Fig. 105).

nr. The legs are missed, the feet placed parallel, 2 inches apart, the
weiglit equally divided between the feel. This jiosturc, maintained one

minute and then reversed, brings into jilay all the muscles of balance (Fig.
106).

354 ARTIFICIAL limbs; POSTOPERATIVE FLAT-FOOT

IV. Sland on one foot placed straight forward, the other fool curled
around behind the standing angle. Balance in this position without other
support for a minute, first on one foot, then im the other (Fig. 107).

These exercises barefooted, or in correct shoes, should be taken for two
r three minutes, five to twenty times a day; in other words, whenever the

■Weak, OiT-TOEiNt; Po<iHBE, Calleii " L*dv-i

opportunity presents for a moment, until the springy, balancing posture and
gait of childhood are recovered.

POSTOPERATIVE FLAT-FOOT

355

The shoe, to allow for this correct standing and walking, must have
the following characteristics (Fig. 109):

It shouLd be light in weight, soft and flexible in shank and all other parts,
and the low, flat heel should be rendered balancing and unslaMe, best by the
use of soft rubber, either for the whole heel or for the outer front corner. The
construction should be such ihat in size and shape the shoe shall not pinch
the extended foot, bearing all the weight of the body, and the inner sole so
made that the font shall not, after a short lime, sink down in the middle of

Ovfid, Ihin leilhcr. imslihk h«l, lleiihk sli^nk, " fiH.I-5har*«l " l.isl.

ihe plantar region as into a trough. The upper should be high enough in front
to allow the freest toe-flexion, and over the middle of the foot, to let the dorsum
of ihe foot raise itself as the toes grasp the sole. The counter should be low,
to allow free motion at ankle. There should be no "fit" in the usual sense
of the word, but yet enough fitness for the particular toot for a loose lacing
to prevent slipping at the heel.

The shoe should always be an Oxford, allowing for freest play of the ankle-
joint. It is no more reasonable to bind a high shoe round the ankle than
to put a leather support on the knee-

CHAPTER XXXVII

MASSAGE: FRICTION, PERCUSSION, KNEADING, AND

REMEDIAL MOVEMENTS

Massage, in a broad sense, is the systematic manipulation of parts
of the body whereby the nervous, circulatory, lymphatic, and mus-
cular systems may be stimulated, exudates absorbed, waste matter
taken up and eliminated through the proper channels, recent adhe-
sions broken up, and the tone of the body as a whole improved.

Nervous System. — In cases where there is a partial or entire
loss of nerve force or where the nerv^es are sluggish, as in the para-
plegias, neuralgias, and neuritis, unless there is great hypersensitive-
ness, massage acts as a stimulant.

Circulatory System. — Massage acts first as a vasoconstrictor,
later, as a vasodilator. It mechanically pushes the venous blood
along, which, in conjunction with the dilatation of the arterial and
capillary systems, lessens the resistance to the blood-stream, and there-
by decreases the effort necessary on the part of the heart muscle; at
the same time more blood is sent into the parts under treatment, the
superficial circulation improves, and the skin is made to functionate
more freely.

Muscular System. — It is known that a muscle will begin to
develop signs of atrophy rapidly when not in use, where it is im-
mobilized, where the nerve force is lessened, or where the circulation
is obstructed. When properly stimulated, however, by muscular
exercise, or, where this is not possible, by the use of massage, atrophy
of the musculature is prevented, or if it has already occurred, it im-
proves rapidly. The individual fibers become firmer and larger and
new fibers are also formed.

An analysis of the manipulations employed in massage demon-
strates that there are fundamentally four procedures: friction, per-
cussion, kneading, and remedial movements. These may be applied
separately or in combination or sequence, and with more or less force,
as indicated.

356

PERCUSSION 357

I. FRICTION

Friction, or effleurage, is a light introductory movement used in the
beginning of all manipulations, slow stroking with palmar surface of
the fingers, the flat hand, heel of the hand, or thumb, governed by the
location and condition for which treatment is given. The effect is to
aid the forward movement of the lymphatic and venous circulations.
It is soothing and slightly stimulating, and it may be useful in the
removal of serous exudates, as edema following fractures, cellulitis,
and such conditions.

The strokes may be circular or in straight lines, corresponding to
the long axis of the limb. In either case the pressure during the up-
ward strokes should be slightly the stronger, and the return should be
hardly more than a grazing of the surface. The strokes may be ap-
plied at the rate of 90 to 180 per minute, depending on the length; and
they should not be strong enough to bring more than a blush to the
skin.

11. PERCUSSION

Percussion, or tapotement, may be defined as the administration of
a series of sharp blows with the hands, delivered in rapid succession,
all the joints of the hand, wrist, and elbow being held flaccid. It is
used over muscular masses, and may be applied in several ways: (i)
With the ulnar edge of the extended hand, ''hacking'*; (2) with the
ulnar border of the hand half-closed, ''beating"; (3) with the ulnar
border of the hand, with the fingers so separated that they will strike
together with each blow; (4) with the tips of the fingers held closely
together, the hand being half-closed; (5) with the backs of the ends of
the fingers held loosely ; (6) with the flat palm of the hand, " slapping " ;
and (7) with the palms lightly flexed, so as to form a cup-shaped de-
pression which compresses the air.

Generally speaking, a muscle should be percussed transversely to
the direction of its fibers. The blows should be delivered alternately
with the right and left hands, and the percussion should be rapid,
from 200 to 600 blows per minute. The delivery should be active and
springy, with a quick recovery, not solid or sluggish.

Percussion is very stimulating. The superficial arteries are con-
tracted by gentle percussion, while they are dilated by strong percus-
sion. When applied over tendons and muscles in certain regions it
causes sharp reflex muscular contractions. Overstimulation and nerve
exhaustion may be caused by too prolonged or too strong percussion,
and unless carefully used it will leave the muscles lame and sore. It

35^ MASSAGE

increases the functional activity of the skin, improves the circulation,
and promotes the nutrition and development of wasted muscles, as
in the jKiraplegias and certain of the urthritides. It should never be

used where there exists a tonic contraction of any muscles or group of
muscles.

Vibration. — Vibration is sometimes included under tapotement.

PERCUSSION

360 MASSAGE

It is performed with the hand held tup shaped, with the finger-tips
touching the subject held tightly, but not rigidly, and with a series
of very rapid and vibratory motions imparted to the lingers by the
contraction of the forearm muscles. Vibration is usually done by
machine, unless by skilled operators, who can govern the force with
more accuracy than can be done by any machine.

Vibration stimulates the nervous, circulatory, and lymphatic
systems, as well as deep-lying muscles, and is especially useful in any

condition where the nerve power is diminished, as in paraplegia and
neuralgia. It should not be used over inflammatory surfaces.

III. KNEADING

Kneading, or petrissage, is one of the most important elements of

massage. It consists in picking up the tissues under treatment with

the base of the fingers and thumb and kneading the parts, a small

portion at a time. It may be either superficial or deep. As the term

ifle.ine the Iwl. The

362 MASSAGE

implies, superficial kneading is applicable to the skin, which is picked
up and kneaded by alternately tightening and relaxing the grasp, care
being necessary not to grasp the parts with the tips of the fingers to
avoid pinching. Deep kneading consists in picking up a muscle or a
group of muscles, or rolling or kneading between the hands, or pressing
on the underlying bone. Fist kneading, in which the fist is used to
compress the tissues, is especially useful in the abdominal region.
Wringing, where the hands grasp the tissues and wring them in
opposite directions, is useful only on the extremities.

Superficial kneading stimulates the nerves of the skin and in-
creases its functional activity. It is indicated particularly in local
edema following injury, fracture, local sepsis, etc. Deep kneading
stimulates the deeper nerves, aids the venous and lymphatic circula-
tion, and promotes the absorption of inflammatory exudates. It
breaks up adhesions and relieves venous congestion, thus producing
an active hyperemia, stimulating and stretching the muscles, pre-
venting contraction, giving tone, and strengthening them. The heart
is relieved of some of its work by the pushing on of the venous and
lymphatic streams.

IV. REMEDIAL MOVEMENTS

Remedial movements are divided, according to the amount of work
required of the patient, into: (i) Passive movements; (2) assistive
movements; (3) active movements; (4) resistive movements.

Passive movements consist of motions produced wholly by the
operator, where the subject makes no effort at active muscular move-
ment whatsoever. One hand of the operator supports a part, while
the other hand produces motion. This is useful in very recent frac-
tures, dislocations, or sprains.

Assistive movements, as the name implies, consist in helping the
patient make the motions, allowing him only to do a small part at
first, gradually increasing the amount of work, until such time as
he may have arrived at the point where he can safely perform the
active movements.

Active movements are those in which the patient slowly moves the
member through a part of the arc of motion at first, gradually increas-
ing until the whole arc is completed.

Resistive Movements. — In these the operator resists the patient's
action of a muscle, at first slightly, increasing gradually, in this way
strengthening the motor power. Resistive treatment may be carried
out by Zander machines (Fig. 119) if one is near a city where they are

REMEDIAL MOVEMENTS

363

The one ,

jnth.

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rUl.er,»bkhn,ay'

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3^4 MASSAGE

installed. They may be carried on at home if one has the time and
patience, all movements of this sort being simulated by the hands with
fully as good results.

Some operators require the use of a lubricant, as cold cream, for
work on the deeper structures. Coid creams have as a base petroleum
oil, which stimulates the growth of hair, and as this is objectionable
to most patients, it should not be used. If anything is required,
talcum powder is cleaner and more desirable. If cold cream is used,
it should be thoroughly removed with dilute alcohol after each treat-

ment, and wiped dry with a soft towel. Where superficial treatment
is required, no lubricant at all should be used.

There are certain general rules which should be followed in carry-
ing out these procedures. The patient should be disposed comfort-
ably and without restraint in a cool, well-ventilated room. ,The
operator should be near enough to get the most definite and energetic
action, and yet not so near that his movements will be in the least
cramped. He should begin his manipulations slowly and gently.
increase them gradually to the fullest speed and force desirable, and
then gradually lessen them. He should cover the greatest e.xtcnt
of surface with his hands and lingers which the conformation of the

GENERAL RULES 365

part and the nature of the manipulation allow, so as to get the widest
effect with the least effort, and to save time. The direction of all
the procedures employed in massage should be centripetal: from
extremities to trunk, in the direction of the return circulation, and,
generally speaking, from insertion to origin of muscles. Gentleness
should be cultivated above all else; crude operators are prone to be-

lieve that the efficacy of massage depends upon the force which they
expend in accomplishing it.

The question of the dosage involves the form or forms of proce-
dure to be employed and the frequency with which they are applied,
the length of time to be given to the manipulation, and the intervals
proper between treatments. All this has to be measured by the
indications, and by the skill and experience of the operator. A well-
trained and experienced masseur can accomplish more in less time
and with less effort than the amateur, and to better advantage.

366 MASSAGE

Nevertheless, the comparatively crude manipulations of the nurse
or attendant may become, if properly supervised, of considerable aid
during surgical convalescence, and should by no means be despised.
In cases involving any important question of dosage, an expert should
be called in.

CHAPTER XXXVIII

ELECTROTHERAPY; X-RAY THERAPY; RADIUM

Historic. — The first application of electricity to medicine was
made during the early part of the eighteenth century. Static electricity
was the only form then known. Its use was entirely empirical, and
appears to have been suggested by observations of its effect upon persons
who took electric shocks to gratify curiosity. De Haen, of Vienna, was
the first to make extensive employment of electricity as a therapeutic
agent,^ publishing his observations in 1756, although others had pre-
viously reported isolated cases. In 1758 Benjamin Franklin introduced
electrotherapy into America,^ treating a number of paralytics without
much success. Another well-known layman who was interested in
this subject about the same time was John Wesley, who, in 1759, wrote
a treatise on it.^

The use of electricity extended and soon became wide-spread. The
number of patients who were treated by it was prodigious, and the re-
ported cures were indeed miraculous. After the first misguided and
exaggerated enthusiasm had subsided, investigations by leading physicians
threw discredit upon the therapeutic value of electricity, and its use was
for a time relegated to quacks and imposters. A more rational view
soon prevailed, however. Writing in 1780, Cavallo* says: "But at
prefent a much better acquaintance with the fcience of electricity than
philofophers had about thirty or forty years ago, has pointed out the
real effects of that power upon the human body in various circum-
ftances, and has fhewn how far we may confide in it; eftablifhing,
upon indifputable facts, that the power of electricity is neither that
admirable panacea, as it was confidered by fome fanatical and interefted
perfons, nor fo ufelefs on application as others have afferted; but that
when properly managed, it is an harmleis remedy, which fometimes in-
ftantaneoufly removes divers complaints, generally relieves, and often
perfectly cures various diforders."

* Beard and Rockwell, Medical and Surgical Electricity, New York, 189 1, eighth
edition, 200.

^ Kassabian, Electro-therapeutics and Rontgen Rays, Phila. and London, 1907, 31.
^ John Wesley, The Desideration: or Electricity made Plain and Useful by a Lovei
of Mankind and of Common Sense, 1759.

* Cavallo, An Essay on the Theory and Practice of Medical Electricity, London, 178a

367

368 electrotherapy; x-ray therapy; radium

At first very strong shocks were given, but it was soon discovered
that these were no more effective than weaker ones and were even pro-
ductive of harm. Electricity was tried in almost every conceivable
medical or surgical condition, but its field of application soon became
fairly clearly defined, at least among the more enlightened members
of the profession, and, except that we now no longer use static elec-
tricity upon abscesses or in tonsillitis, it has not changed greatly up to
the present.

With the discovery of animal electricity by Galvani, in 1790, and
the invention of the Voltaic pile, ten years later, the continuous current
began to be used in therapeutics, and, after the work of Faraday in 183 1-
1832, the induced current also received wide employment in medicine.
These were, however, used empirically and indiscriminately until
Duchenne, in 1850, laid down the principles for the scientific use of
local faradism, and it was not until even later that Remak, of Berlin,
applied the same principles to the use of the galvanic current.

Steady progress from this time on was made in the rational applica-
tion of electricity, but with no great impetus until the discovery of the
Rontgen rays in 1895, ^^^ ^^ I^&^t therapy by Finsen two years pre-
viously, ushered in an era of rapid development, to which the recent
discovery of the therapeutic possibilities of radium has added an im-
portant factor.

In the after-treatment of surgical conditions electricity in its various
forms has as definite and useful a place as in general medicine. It is
not a panacea, but when intelligently used to meet definite indications,
it is invaluable. These indications, the form of electricity to be used,
and the technique of its applications, will be briefly set forth in the fol-
lowing pages:

INDICATIONS

Relief of Pain. — Pain may be divided technically into — (a) Habit
pain; (b) pain due to congestion or stasis; and (c) pain due to cicatricial
pressure.

(a) Habit Pain. — It is a well-known fact that frequently pain that
has existed for some time prior to an operation will persist to almost
the same degree postoperatively. Where we find no cause for such
pain we are forced to call it a habit pain, though with refinements in
methods of diagnosis the number of so-called habit pains is constandy
growing less. In a true habit pain some mechanic or electric method
of treatment offers the quickest possibility of relief. Where we can
determine the ner\^e supply involved, vibration, applied to the appro-

congestion; pain 369

priate nerve-center in the spine until inhibition is produced, is the first
choice. This treatment should be given for ten to twenty minutes,
and should be repeated often enough to "bridge the pain"; that is,
so as to render the patient free from pain, which may mean daily treat-
ments, or treatments every second, third, or fourth days. (See Vibra-
tion.)

Other cases may be relieved by the incandescent or the arc light;
the superficial hyperemia which is produced will cause analgesia of the
part, plus the effects of increased nutrition. If the blue light be used,
there is produced a local anesthesia of the nerve-endings as well as local
ischemia, due to stimulation of the vasoconstrictors. (For technique,
see Light Therapy.)

At times the positively connected sponge of the direct (gahanic)
current, saturated with a 20 per cent, solution of cocain hydrochlorid,
placed directly over the painful areas, the negative pole being placed
indifferently, using large, well-moistened pads with a current strength
of from 5 to 50 ma., will be found of advantage. The main object of
treatment is to keep the pain under control, so that the chain of habit
may be broken.

(b) Pain Due to Congestion cr Stasis, — Frequently, for example after
a resection of an ovary, there remain behind large and varicosed blood-
vessels, which, distributing the same supply of blood to the part as
before operation, will cause the same pain and feeling of weight to
persist. Here the static wave current, by producing deep-seated mus-
cular contractions, by its apparent power of restoring muscular tone,
and by its analgesic effect on nerve-endings, is the treatment par excel-
lence. A metal plate of block tin, large enough to cover the sacral and
lumbar portion of the back, should be connected by a wire to the positive
pole of a static machine; similarly, another strip of metal sufficiently
large should be placed over the abdomen and this plate also connected
to the positive pole. The further technique is given under the head of
the static wave current. Treatments should be from fifteen to thirty
minutes every other day.

At times, though painful, the indirect static spark, by producing
deep-seated muscular contractions, will give the same effect. The
sparking should be applied over the area of pain, single not multiple
sparks being employed, and continued until all pain is gone. At first
daily treatments should be used.

{c) Pain Due to Cicatricial Pressure. — Those who have seen even a
keloid disappear under the Rontgen rays know what great power of
absorbing scar tissue the rays have. A tube which shows the bone of

370 electrotherapy; x-ray therapy; radium

the hand black is the best one to use, and it should be employed for
eight minutes at a distance of lo to 12 in. from the skin, measuring from
the central anode of the tube. For the first four treatments every third
day will be enough, and then every five to eight days, until the pain
has ceased or a slight dermatitis has developed.

A hard, constricting cicatrix may be replaced by a soft, pliable scar
by means of metallic electrolysis. The technique is — connect with the
negative binding post of the galvanic plate a needle, or needles, inserted
J in. into the periphery of the scar. A sponge electrode the size of the
hand is bound anywhere on the patient, and a current of 2 to 15 ma. is
allowed to flow until the tissue around the needles is completely bleached.
This requires from one to tv\^o minutes, and is to be repeated until the
scar is completely surrounded by a ring of these bleached marks. Co-
cain cataphoresis will render the operation nearly painless. No anti-
septic or cerate dressing should be used afterward. Repeat in a week
if necessary.

Atrophy of the Musculature Due to Disuse.— This is one
of the most important indications for postoperative electrotherapy.
Here the induced current (faradic) should be employed, using the rapid
interruption, and current strength enough to produce gentle but decided
contractions of the muscle or muscles involved. One pad should be
placed over the spine while the other should be gendy stroked over
the muscles for ten to fifteen minutes every other day. This may be
followed by massage or vibratory stimulation, using the large round
rubber vibratrode for five to ten minutes; or the sinusoidal current,
employing the same technique as in the induced current, may be ad-
vantageously used. The advantage of the sinusoidal current is, first,
that it is much more agreeable to the patient, as it is symmetric and
regular in its intermittency; and, second, by means of a low-priced
suitable controller it can be taken from the alternating commercial
light service.

Nerve injuries may be divided into three classes: {a) Pressure
neuritis; {b) operative injury to nerve; and (c) severed nerve.

(a) Pressure neuritis is due to pressure sustained by a nerve during
a prolonged operation. If no reaction of degeneration be present, the
resulting paralysis may be treated similarly to atrophy of the muscula-
ture due to disuse. If there be a diminished reaction to the induced
current (faradic) and no pain is present, high-tension faradism may be
used for five minutes, followed by interrupted galvanism (60 to 100
interruptions a minute), the negative sponge being stroked over the
affected muscles while the positive is firmly affixed over the spine. If

ANKYLOSIS 371

pain IS present, the positive sponge of the direct current (galvanic)
should be gently rubbed over the nerve- trunk, care being taken not to
use the interrupter nor to cause muscular contraction by breaking the
contact of the sponge with the skin. If the pain is excessive, the posi-
tive sponge may be saturated with a 20 per cent, solution of cocain
or the indirect static spark employed for five minutes.

If a complete reaction of degeneration be present, the positive sponge
should be used as above, without interruption if pain is present and
with interruption if there is no pain. A current of 2 to 20 ma. for ten
to thirty minutes, repeated every other day, is sufficient. If the pain is
severe, the positive sponge may be bound on the part, as the mere act of
stroking may cause increased pain, and, for this reason, massage or
vibratory stimulation, if used at all, should be tried guardedly. The
high-frequency monopolar vacuum tube (exhausted to a blue vacuum)
and light, incandescent or arc, are at times also useful in palliation of
pain.

(b) Operative injury to nerves should be treated as above, the treat-
ment varying with the amount of the reaction of degeneration and the
pain present.

(c) Severed Nerves, — If the cut ends are nearly approximate, union
may take place, and they should be treated as a complete reaction of
degeneration with pain. If the approximation is not present, no result
will be obtained.

Adhesions and Ankylosis. — This subject may be considered
under the headings: (a) Joints; {b) contractures of fingers or toes; and
{c) adhesions elsewhere in the body.

{a) Joints, — After operative work on the joints pain and limitation
of motion, due to adhesions or ankylosis, may be a prominent feature.
This may ordinarily be speedily relieved by the following method:

First, baking the joint with superheated dry air, which, inducing
an active hyperemia, relieves the pain and causes increased absorption
of exudates (for Technique, see Superheated Dry Air), followed by
stretching of the joint by massage and manual manipulation, or vibratory
stimulation while the joint is on the stretch, using the ball vibratrode
and as great an excursion of stroke as the patient can tolerate. If there
is increased pain after this procedure, the indirect static spark, the static
wave current (wrapping a sheet of foil around the joint), or the monopolar
high-frequency vacuum tube may be used from ten to fifteen minutes.
Treatment should be repeated every third to fifth day until relatively
free and painless motion is obtained.

{b) Contractures of Fingers or Toes, — A saturated solution of sodium

372 electrotherapy; oc-ray therapy; radium

chlorid on the negative sponge of the direct current (galvanic) should
be placed over the contractures, with the opposite side resting on the
positive sponge and a current of lo to 30 ma. driven through the part
for fifteen to twenty-five minutes, the object being to soften the tissues
through the resolvent effect of the chlorin atoms or ions liberated by
the negative pole saturated with sodium chlorid. Massage and stretch-
ing by means of the vibrator should follow. Repeat every other day
unless the skin becomes too tender.

(c) For adhesions in the abdomen there is a slight chance, by the
use of the x-ray (remembering the possibility of producing sterility),
by the sodium chlorid cataphoresfs described abo\'e, or the gentle vibra-
tion, to relieve the condition, though ordinarily adhesions sufficient to
cause much in the way of symptoms call for operative interference.

I/OW Vital States. — In addition to proper hygiene and diet,
and tonic treatment where indicated, static insulation, the static wave
current, or the arc light may be used every other day for fifteen to thirty
minutes to increase the hemoglobin and number of red corpuscles.
For exhaustion the high-frequency monopolar vacuum tube, or the static
wave current with the metal electrode down the spine, is useful. (See
Postoperative Neurasthenia.)

Postoperative Neurasthenia. — In this condition the treat-
ment is general and symptomatic. If there is any toxic basis for nervous
exhaustion autocondensation, by its apparent stimulation of the sympa-
thetic nerve system, will cause increased elimination (as may be proved
by urinary examination), and will engender a feeling of well being.
Exhaustion on the slightest muscular exertion will call for general
faradization (which see) and general vibratory stimulation. For head-
ache and sense of pressure in the head the static wave current with a
metal strip along the spine for tv^'enty minutes, followed by a positive
static breeze for ten minutes, will afford much relief. For a tender,
irritable spine, the arc light, the static wave current, the high-frequency
monopolar vacuum tube, or a long sponge connected wnth the positive
side of the galvanic plate, the negativ^e over the abdomen, 10 to 30 ma.
for twenty minutes, may be employed.

For the various paresthesias the faradic wire-brush or the high-
frequency monopolar vacuum will be indicated. For insomnia use the
static wave current, the positive head breeze, or the incandescent or
arc light over the spine. For mental exhaustion employ the high-
frequency monopolar vacuum tube along the spine and over the head for
fifteen minutes with a current strength as great as the patient can toler-
ate, followed by the positive static head breeze for ten minutes. For

a:-RAY FOR CANCER 373

fermentation use the static wave current with a large metal plate over
the abdomen, repeated every second or third day for twenty to thirty

minutes.

High Blood-pressure and Sclerotic Changes in the Ar-
teries.— Where there is a high blood-pressure and there is no chronic
interstitial nephritis, the blood-pressure may be steadily and apparently
fairly permanently reduced by autocondensation with 200 to 400 ma.,
flowing for tu-enty to thirty minutes. The treatments should be repeated
every third day until a normal pressure has been reached. Cases so
treated have remained normal for over tvvo years. The more moderately
increased pressures may be reduced by applying the high-frequency
monopolar vacuum tube over the spine and the solar plexus for ten to
fifteen minutes.

This reduction in pressure is apparently due to the stimulation of
the sympathetic nervous system. The immediate drop is due to stimu-
lation of the vasomotors, and the permanency to the increased elimina-
tion due to the sympathetic stimulation.

After Operations for Malig^nant Disease. — ^Whatever one's
opinions may be regarding the use of the Rontgen ray before resorting
to operation in malignant disease, there can be little doubt that it forms
an often valuable and effective means of dealing with recurrent growths
and of preventing recurrences. At the symposium upon the therapeutic
value of the Rontgen ray in surgery, held at the meeting of the Amer-
ican Surgical Association in 1902,^ its postoperative use was advocated
by Williams, Bevan, Coley, Rodman, Pfahler, and Johnson for both
these indications.

Holding^ has analyzed 148 cases from the literature of inoperable
or recurrent malignant disease treated by the Rontgen rays and found
that ^2 per cent, were "apparently cured" (meaning complete disap-
pearance of the growth, but without five years having elapsed), 58 per
cent, were improved, and only 10 per cent, not benefited. Of the
entire number, 16 were recurrent carcinoma ta, and of these, in 13 the
growth disappeared entirely, and in the remaining 3 marked improve-
ment was noted.

Although the widest employment of the rays has been in carcino-
mata, they have also been well tried out in sarcomata. Coley,^ whose
experience with the treatment of sarcomata, both by the mixed toxins
of the streptococcus and bacillus prodigiosus and the Rontgen rays,
has been extensive, states that the rays have caused disappearance of

* Trans. Amer. Surg. Assoc, 1903, xxi, 208.

^ Albany Med. Ann., 1903, xxiv, 94. ^ Ibid., 215.

374 electrotherapy; ot-ray therapy; radium

the disease in some cases where the toxins alone have failed, but that in
each of these, however, the growth soon returned, whereas a consider-
able number cured by the toxins remained well after a period of years.
He states that the poorest results of the Rontgen rays have been in the
spindle-cell sarcoma, in which variety the best results are obtained by
the toxins. Therefore, he advocates the combined use of these two
agents in the hope that the rays may accomplish what is left undone
by the toxins.

In tuberculous lymph-nodes the Rontgen ray has been apparently
of decided therapeutic value in some cases when used in conjunction
with the general measures for the treatment of tuberculosis. Sinuses
have been reported to heal rapidly under its use.

Keloids frequently disappear with rapidity under Rontgen-ray treat-
ments, leaving a fine white line, soft and pliable, which in the course of
time closely resembles the surrounding skin.

ELECTROTHERAPEUTIC TECHNIQUE

Static electricity is exhibited in three forms: {a) Wa\'e cur-
rent, {h) Spark, {c) Head crown breeze.

(a) Wave Current, — Patient on insulated platform; spark balls of
machine together; negative pole grounded; positi\e pole connected
by a wire to tin-foil firmly placed against the bare skin of the part to be
treated (if around a joint, bind with bandage); machine started at not
more than 200 revolutions a minute, and spark balls gradually pulled
out to the point, just short of causing pain to the patient. Treatments
every second or third day; duration, fifteen to thirty minutes. Any
prickling sensation means that the foil is not in close approximation to
the skin and may be overcome. by having the patient press that point
against the skin.

{b) Spark, — Patient on insulated platform; spark balls of the machine
wide apart; negative pole grounded; positi\'e pole connected by metal
rod to platform; the other ground wire (connected to gas-pipe or water-
pipe) connected to ball electrode, which is brought near enough to patient
to cause a spark to leap forth. Single sparks (as multiple sparks are
poorly tolerated) should be given over as wide an area as possible until
pain is relieved. Treatments repeated on any return of pain.

{c) Head Croum Breeze, — Patient seated in a comfortable chair on
an insulated platform; negative pole grounded; positive pole connected
with metal rod to platform or held by patient, the other ground con-
nected by wire to metal head crown, which should be suspended at such

GALVANIC CURRENT 375

a distance above the patient's head that he feels a strong breeze with
just a suggestion of tingle. Treatments repeated as often as needed
to relieve condition. Time of treatment, ten to thirty minutes.

High Frequency. — (a) Autocondensation. (b) Low vaccum
tubes.

(a) Autocondensation. — To one pole of the d'Arsonval current of
the American type of high-frequency machine a long metal rod is con-
nected, which is held in the hands of the patient. The other pole is
connected with a metal plate, which is insulated from the patient by
two sheets of rubber and a felt cushion or mattress at least 3 in. in thick-
ness. The best result is obtained by having the patient reclining on
a rattan couch free from metal nails or screws. With a hot-wire meter
in the circuit, from 200 to 400 ma. of current is turned on for ten to
twenty minutes. Repeated every third day.

(b) Low Vacuum Tubes, — Tubes exhausted to a blue vacuum are
best for relief of pain. Ordinarily they are connected by the monopolar
method and are applied over the bare skin, as thereby a greater degree
of current can be tolerated by the patient. If a strong counterirritant
effect is desired, they can be applied through the clothing. As strong a
current should be used as the patient will stand, unless the erythema
of the skin becomes too marked. The local action is decreased nerve
irritability, followed bv local anesthesia, increased action of the sweat-
glands, hyperemia of the skin, increased temperature, and liberation of
free ozone in the tissues. Duration of treatment, five to fifteen minutes;
frequency, every second, third, or fifth day. If the vacuum tube sticks
to the skin, a little talcum powder will allow it to be moved freely over
the surface. If the patient complains of pricking or tingling afterward,
this may be relie\'ed by the application of cold cream.

Direct Current (Galvanic). — With the direct current polarity
is all important. As large pads as possible should be used, well moistened,
as thereby a greater amount of current can be employed with less dis-
comfort to the patient. The treatment in general is, wherever there is
pain or complete reaction of degeneration, use the positive pole, while
if there are no pain and no polar inversion, the negative pole is indicated.
For the introduction of medicinal solutions into the tissues we find that the
acids and acid radicles, being electronegative, should be placed on the
negative pole, while the bases and alkaloids, being electropositive, should
be placed on the positive pole; thus, for example, if we wish to introduce
cocain hydrochlorid, the cocain would be placed on the positive pole;
if we wish to introduce the chlorin atoms of sodium chlorid, or the iodin
atoms of potassium iodid, the negative pole should be employed. If

37^ electrotherapy; x-ray therapy; radium

there are no pain and no reaction of degeneration in the paralyzed
muscle, the faradic current may be used, while if there are a partial
reaction of degeneration and no pain, and interrupted galvanic, 60 to
100 interruptions a minute, is best.

The direct current has a decidedly nutritional effect on the nerve
tissues, and hence should be employed where we desire increased nerve
nutrition or stimulation.

I/ig^ht Therapy. — For therapeutic purposes two forms are ordi-
narily used: (a) Incandescent light and (b) arc light.

(a) Incandescent Light. — This may consist of a cluster of lights
under a polished metal reflector or a single light of 200 to 500 candle
power. The main effect from either is the heat-production and stimu-
lation of the tissues by the radiant light-rays. The heat and the resulting
active hyperemia are the main factors to be considered. The technique
is as follows: The exposure should always be made over the bare skin.
The patient is best treated in a recumbent position, the light being
suspended overhead. The light should be gradually brought down
nearer the surface until tolerance of a considerable degree of heat has
been established. Sw^inging the light from side to side will prevent any
burning from focusing the light-rays on one point for too long a time.
Stroking the flesh with the hand will achieve the same result. Treat-
ment should be continued until the pain has ceased or until the patient's
temperature has reached over 100° F., or until the pulse-rate has in-
creased to 120. The treatment should be repeated as frequently as neces-
sary to relieve the symptoms, whether it be every day or once a week.

(b) Arc Light. — The arc light has a spectrum analogous to that of
the sun, and is especially rich in ultra-violet rays. Except for the cost
of operation and the closer personal attention required, it is far superior
in every way to the incandescent light. The technique is as follows:

(i) The Whole Arc Light. — Exposure made on the bare skin; light
at a distance of 18 to 36 in., depending on the tolerance of the patient
to the heat; time of treatment, five to fifteen minutes on each part
exposed; maximum of treatment, twxnty-five minutes. Applications
from every day to over a week, dependent on pain.

(2) Blue Screen. — Here a screen of blue glass is interposed between
the light and patient and the technique is similar, only we do not need
any great amount of heat, as the effect we wish to produce is a local
ischemia and anesthesia. The blue screen has a strong sedative effect,
and will produce a local anesthesia sufficiently strong to allow one to open
small furuncles painlessly. The vasoconstrictors are stimulated, and
consequently a more vigorous circulation is established through any

VIBRATION 377

region where stasis has been present. A striking example of its anes-
thetic properties is in orchitis, when, after fifteen minutes' exposure,
examination may be made without pain. Granulating surfaces which
are indolent and painful heal rapidly and with a great decrease in pain.

(3) Red Screen, — Technique similar to that of blue screen. The
red screen has strong stimulating powers and acts as a direct nerve-
irritant and stimulant.

Superheated Dry Air. — The source of heat may be alcohol,
gas, or gasoh'ne, and a special baker is provided for the different joints.
The main object is to raise the temperature to from 350° to 450°, with
its consequent very active hyperemia and dilatation of the superficial
blood-vessels. This intense heat and increased circulatory activity is
accredited with certain bactericidal powers also.

The technique is as follows: The joint should be entirely bare and
then wrapped with several thicknesses of Turkish toweling, and in this
condition placed inside the baker. Any point which may become ischemic
from pressure should have an extra fold of Turkish toweling, so as not
to become burned. The ends of the baker are well covered and the
heat gradually increased until 400^ or 450° is obtained, or to the point
of tolerance of the patient. This should be continued from fifteen to
thirty minutes. As in the incandescent light, the pulse, temperature,
and general feelings of the patient are the guide as to the length of treat-
ment, and arteriosclerotics should be watched carefully. This may be
repeated every third or fifth day, and, after every treatment, if there is
any ankylosed condition in the joint, it should be stretched by means of
the vibrator or by massage with manipulations.

Vibration. — For successful vibratory treatments a vibrator having
either the lateral or gyratory stroke is essential. The percussive
stroke is of very limited value. We can hope to accomplish one of two
main objects with vibration — either stimulation or inhibition. The
latter is the result of excessive stimulation. In all \ibratory treatments
it is desirable to apply the vibratrode directly to the bare skin and to
have the patient recumbent, as thereby much better relaxation is secured.
For general vibratory stimulation the patient should remove all tightly
fitted clothing, and the remaining clothing should be so arranged that it
will be easy to get at the various parts of the body. It is better to have
a loose gown which ties up the back than to use a sheet. For general
stimulation the patient should lie on the table, back up, arms hanging
down at the sides, head turned to one side. Now bare the back, and
apply vibration with a medium stroke and as much pressure as the
patient can stand, between the transverse processes of the vertebrae.

378 electrotherapy; jit-ray therapy; radium

for fifteen to thirty seconds at each point, using the ball vibratrode.
Then, with the flat brush vibratrode, go over the arms and legs, back
muscles, chest, and the abdomen. If constipation is a feature, con-
tinue the vibration over the course of the colon and over the epigastrium
to stimulate the solar plexus, and longitudinally across the abdomen
to stimulate the small intestine. For inhibition the vibration should
be applied for a longer period — one to three minutes — over the appro-
priate nerve centers in the spine. Treatments should be repeated daily if
necessary. Similarly, stimulation or inhibition may be applied locally
m the treatment of strains, sprains, or contusions, and, as already
described under Adhesions, for postoperative joint conditions.

Induced Current (Faradic).— This is useful for muscle stim-
ulation, and, as we saw when discussing the direct current, it may
be used to prevent further atrophy, provided there is no reaction of
degeneration. It has been considered that its polarity was theoretic
only, but some experiments recently made seem to show that there is
considerable polar action. It should be used by placing one sponge
indifferently and stroking the affected muscles with the other. One
form of treatment of great value, but unfortunately little used, is the
so-called general faradization. Its technique is to have the patient
thoroughly undressed, with both bare feet resting on a copper plate
which has been wet with a little warm water, and with a sponge con-
nected with the other pole of the faradic coil to apply the current over
all parts of the body, paying special attention to the top of the head,
the ciliospinal center (seventh cervical), and the solar plexus. The
object is to put all parts of the body under the effect of the current.
The spine should be treated for five minutes, the muscles of the back
for three, each extremity for two, the abdomen for four, and the chest
muscles for t\vo. Treatments should be repeated every third day and
sufficient current strength used to cause agreeable muscular contrac-
tions.

Sinusoidal Current. — This is an alternating current absolutely
symmetric in character, and consequently more agreeable from a
patient's standpoint. It may be employed by taking it directly from
the alternating street current, interposing a resistance, so that the
patient can receive a graduated quantity. Because of its pleasant
character it is used in England in preference to the Faradic or induced
current. The technique is the same as for the induced current.

The Rontgfen Ray. — Since any surgeon about to purchase an
x-ray outfit would naturally consult one of the several text-books de-
voted to this subject, it does not fall within the scope of this work to

RADIUM FOR CANCER 379

discuss such apparatus. The general principles of the use of the :x:-rays
in surgical after-treatment we shall, however, describe briefly. The
method of procedure inaugurated by Dr. Williams, at the Boston City
Hospital, is as follow^s: After operation for malignant disease the treat-
ment by the Rontgen rays is commenced as soon as the patient can be
transported to the :r-ray department (i, e., in from ^vo to seven days).
The scar and the region of the neighboring glands are exposed to the
rays for from five minutes to one-half hour, depending upon the size
of the area to be exposed — the larger the surface, the longer the exposure.
The rays are transmitted through an aluminum screen. The distance
of the patient from the tube is determined by means of Dr. Williams'
fluorometer, by which the point at which the rays are of greatest strength
is found, and the surface to be exposed is placed at this distance, usually
about i8 in. from the tube. Treatment three times a week is kept up
for at least two months. If at the end of this time there is no sign of
recurrence, it is discontinued, but the patient reports once a month for
one year and then every three months up to five years for observation.
At the slightest sign of return of the disease treatment is reinstituted.

When a recurrence has already taken place, treatment should be
commenced at once. The area involved is exposed for a short time
(five minutes or longer) and the reaction is noted. This reaction con-
sists in swelling, exudation, crust formation, and some softening of the
pathologic tissue. In some instances there is only a slight redness of
the surface. If there is more than a slight reaction, it is allowed to
subside before the second exposure is made, and the duration of the treat-
ment is shortened. On the other hand, if there is no reaction, or only
slight reaction, the next exposure is made in two or three days, and its
duration increased. In this way the frequency and length of the treat-
ments are determined in each individual case. Growths will usually
begin to show improvement within two weeks. Treatment is con-
tinued until all evidence of the disease has disappeared and then stopped,
but the patient is kept under close observation and treatment reinstituted
if there is the slightest sign suspicious of recurrence.

Radium. — ^The use of the radiations from radium salts as a substi-
tute for the jc-rays was first suggested by Dr. William Rollins, of Boston.^
In the development of the therapeutic use of radium Dr. Francis H.
Williams holds the leading place. The action is exactly similar but
much superior to that of the rc-rays, which, where available, it has en-
tirely supplanted in the treatment of small, easily accessible growths. In
growths occupying a large area the :r-rays alone, or in combination

^ Williams, Communications of the Mass. Med. Soc., 1908, xxi, 263.

380 electrotherapy; jc-ray therapy; radium

with radium, are indicated, and the x-rays alone in the case of malig-
nant disease of the internal organs. The general principles for the
employment of the x-rays as regards indications for, reaction from,
and frequency of exposure, apply also to radium.

The high cost and the inability to secure radium of sufficiently
high radio-activity has prevented its general use. In brief, the results
may be said to be brilliant on epithelial tumors of the skin and in
nevi, in warts and moles, and in a certain number of myeloid sarcomas/
while in epidermoid cancer of the lip, tongue, tonsil, inside of the
cheek, esophagus, stomach, rectum, and uterus the results have been
nil.

From a tube of radium three kinds of rays are given out — the
alpha, beta, and gamma — of which the alpha is very feeble in avail-
ability and power, though it may bum the skin.

The greater part of the available rays of radium are the beta, which
carry a negative charge of electricity, are capable of being deflected
by a magnet, and are able to penetrate deeply into the lung tissue.

The gamma rays carry no electric charge and are able to penetrate
deeply into tissue, even through considerable thicknesses of metal.
The beta and gamma rays are the ones used in treatment. The safer
beta rays irritate the skin and have little penetration, hence they are
filtered out by the interposition of thin sheets of lead.

As with x-ray, radium seems to have an inhibitory eflfect on cell-
life. Seed exposed to radium for a sufficient time will not germinate.
Bacteria on the surface of Petri plates exposed to radium will be killed.
The technique is simple and is governed by the highness of the radio-
activity of the radium employed. The higher the radio-activity the
less the exposure needed.

The method of application of radium is the following: 50 mg. (a
little less than i gr.) of pure radium bromid contained in a capsule,
covered with a sterilized rubber cot for sake of cleanliness, at the end
of a handle at least i ft. long, is moved about close to the surface to be
treated for from two to fifteen minutes, according to the size, beginning
at the least affected portion, but applied longest to the most active
spot of disease. The radium must be kept constantly moving and
not held still over any one spot. Several such applications are made,
and then a visit in two or more weeks is in order to determine the
amount of reaction produced. Where the growth is very extensive,
radium may be used on the worst part and then the entire surface
exposed to the x-rays.

^ R. Abbe, Radium's Contribution to Surgery, Jour. Am. Med. Assoc., 1910, Iv, 97.

CARBON-DIOXID SNOW 38 1

The disadvantages of radium are the small surface from which the
rays proceed and its enormous cost.

Carbon-dioxid Snow. — This has acquired great and deserved
popularity because of the ease with which carbonic acid gas can be
obtained, because of its cheapness and the simple technique required,
the ability to control the reaction, and the superior cosmetic effect
produced.

The technique is simple: The gas is released from the carbonic
acid tank into a specially modeled perforated mold, here it is col-
lected in the form of a snow, which is compressed by a metal plunger
into a crayon of ice and snow with a temperature of 72° C.

This ice crayon is held by means of chamois skin in the fingers,
and the end of the crayon is shaped to any desired size by placing it in a
metal cone, where the rapid withdrawal of heat from the metal causes
a shrinkage in the crayon corresponding to the inner diameter of the
cone.

The crayon is applied over the lesion from five to fifty seconds, the
length of time and the pressure employed depending on the depth to
which it is best to freeze. For example, a deep-seated nevus, rich with
blood-vessels, would require the maximum time and pressure, while
the removal of powder granules from the face, the extreme minimum.

Immediately on removing the crayon a white depression is seen,
which rapidly fills in, and in a few minutes the treated area swells
and a wheal is formed, which attains its maximum in twenty-four
hours. The serum may then be let out of the vesicle, and a crust forms
which should not be disturbed until it suppurates of its own accord
in ten to twelve days. A pale pinkish cicatrix is seen which rapidly
fades, and is soft and pliable.

The pathology of the reaction, according to W. A. Pusey,^ "is the
production of a relatively deep, sharply defined inflammatory reaction
in living tissue by sudden intense freezing,'' a reaction which can be
controlled from stimulation to destruction with the production of an
interstitial sclerosis, to an immediate destruction of masses of dis-
eased tissue in the skin. The dermatologists have taken advantage
of this, as shown by the numerous cases reported treated by this
method. Five cases will show its range of applicability:

Case /.—Mrs. C, aged eighty. Epithelioma of forehead the size of a
silver dollar, treated for two months with x-ray with slight improvement.
Carbon-dioxid snow applied over the entire area for eight seconds at a

^ Med. Rec, N. Y., 1910, Ixxviii, 691.

382 electrotherapy; jc-ray therapy; radium

sitting, each section receiving three apph'cations at a treatment. After
four such treatments, covering a period of six weeks, it has completely
healed and has remained so up to date (three months).

Case 2. — Miss B., aged eighteen. Burned about neck and chin by gaso-
line explosion. Neck and chin a mass of irregular, constantly contracting
cicatrices, bobstay from point of chin to sternum. After four applications
of carbon-dioxid snow chin covered with a smooth pliable scar, bobstay
entirely removed.

Case J. — Infant D., aged three months. Nevus of wrist. Carbon-
dioxid snow applied for thirty seconds. Two months after site of nevus
could be made out with dijficulty.

Case 4, — Mr. R. Face sprinkled with powder granules, Carbon-dioxid
snow applied with small pointed crayon over site of each granule, using slight
pressure for four seconds. Slight wheal formed and powder granule was
removed with crust ten days later. Skin apparently normal. Tattoo-
marks can be removed in the same way. There is some tingling after ap-
plication, such as would be felt in the ears after exposure to cold. Rarely
there is pain for one to two hours.

Case 5. — Mr. B. Hands and face burned with a:-ray, with here and there
formation of nodules, which scab and discharge. Scabs curetted ofif and
carbon-dioxid snow applied for fifty seconds, with complete healing, though
with some scarring.

CHAPTER XXXIX

PREPARATION OF THE PATIENT

It may seem somewhat out of order in a book on postoperative
treatment to go into details in regard to the matter of the preparation
of the patient for operation. The importance of preparation and the
immense influence which proper or improper preparation exerts, how-
ever, on the course which the patient will follow after the operation
seem sufficient excuse.

The literature which deals with this subject gives an immense variety
of detailed advice and instruction. Each individual surgeon is likely
to be persuaded that this or that particular procedure has been the
essential in his successful practice. The rules laid down differ so widely
that one must conclude that the only good rules are general ones, de-
duced from the experience of many men, applied and varied by common
sense to suit each case. In discussing this matter of preparation, then,
it is not here meant to be arbitrary, except in matters of principle, but
the general directions here given may be followed by one who has yet
to develop his own peculiar experience, w^ith the assurance that every
detail will bear the pragmatic test, namely, that "// works.'^

It is a trite observation that every surgeon of a general hospital,
particularly where there is a large accident clinic and other emergency
work, cannot fail to notice that, taken by large, the emergency cases,
operated as they are without preparation beyond that immediately
preceding operation, seem to do about as well after operation, in the
way of comfort and complications, as the patients who have been through
a long course of preparation. We have noted this so many times that
we are led to believe that that part of preparation which includes pre-
operative starvation and routine catharsis is often overdone, that
starvation weakens and increases the liability to shock and acetonemia,
that many patients unused to cathartic medicines suffer irritation of
the intestine and notable general depression from their use. Such
preparation, moreover, renders more likely the occurrence of intestinal
paresis, with distention and nausea, than no preparation at all. Nor
does there seem to be any reason, in theory or practice, why a patient

383

384 PREPARATION OF THE PATIENT

more or less starved and purged should better endure the strain of
operative treatment than one who is well nourished. On this point
Ochsner^ says: "As a rule, long-continued preparatory treatment
leaves the patient in a much less favorable condition for a surgical
procedure than a very short and simple preparation, which serves to
put the kidneys, the skin, and the alimentary canal in condition favor-
able to elimination of the waste products. . . . His strength is
not impaired by confinement, and his nervous system has not suffered
by looking forward to the operation for a long time. Some years
ago I had an opportunity to observe the effect of waiting for a number
of days, and sometimes for several weeks, to allow the patient to get
into a more favorable condition for operation, and I am positive that,
as a rule, the practice is bad.''

CATHARSIS

For the Elective Operation.— The patient is told to take a
slightly increased dose of his usual cathartic morning or night, the
day before, if he has the cathartic habit. If customarily he has not
required cathartics, he should take from 3 to 10 gr. of extract of
cascara sagrada at bedtime the second night before operation. If the
patient is of the type that yields more kindly to morning salts, he
should be directed to take one or two Seidlitz powders, or i to 3 dr.
of effervescent sodium phosphate, or a dose of some natural or artificial
aperient water on two or three successive mornings instead. The night
before operation a simple enema of soapsuds (strong soap) should be
given. None should be administered on the morning of operation
unless the case calls for surgery of the rectum.

For the Emergency Operation.— Frequently, to aid in arriv-
ing at a diagnosis in emergency abdominal conditions, an enema has to
be given. In case this has not been done, and provided there is no
surgical contra-indication, an enema should be administered, if time
permits (and usually there is ample time while preparation of room,
instruments, and other things is going on). This is desirable, if for no
other reason than because by it we can start our operative convalescence
with a clear lower bowel, hardened masses of feces being much easier
to remove before operation than after; and, furthermore, if the patient
must be stirred up, it is more desirable to do it before operation than
after. The enema to be chosen in abdominal cases should be either
the compound turpentine, the milk and molasses, or the warm glycerin.
(See p. 172.)

* Clin. Surg., 1902, 13.

DIET 385

DIET

For the Blective Operation. — It is obviously undesirable in
all abdominal cases to have much stomach or intestinal contents present.
In preparation, therefore, the patient should, for three or four days
before operation, have sufficient food to keep up a feeling of normal
strength and no more; the diet should be limited in quantity and variety
and should consist of simple, easily digestible material. The diet list
should not contain milk, woody vegetables, or any other food which
leaves a voluminous residue. Throughout the day before operation
strong broths — beef, chicken, or mutton — ^w^ith, possibly, a little wine
and water, should be given. On the morning of operation, at any time
preceding two hours before the starting of anesthesia, black coffee,
plain tea or sherry, or whisky and water in small quantity, may be given
as a stimulant to body and spirit. Exception will have to be made to
this rule, of course, in case of operation on stomach or duodenum.

The diet in emergency operations cannot, of course, be controlled.

Experience seems to show that a considerable increase in water-
drinking for some time before operation is desirable. The urine is
increased thereby, and, to a certain degree, the excretion of body waste
must be increased also. Baths contribute to this same end. A thor-
oughly clean skin must be an asset in elimination after operation. The
day before operation, then, the patient is to be given a warm tub-bath
or a thorough sponge-bath if unable to leave the bed. In women, where
no contraindication — such as virginity — exists, a vaginal douche of 2
to 4 quarts of hot water, containing i drachm of sodium bicarbonate to
the pint, should be given.

An attempt should be made, if time and circumstances permit, to
have the teeth and mouth clean, even if the services of a dentist are
necessary. There can be no question but that a clean mouth lessens
the probability of postoperative parotitis. We believe also that, as
postoperative throat and lung complications are better understood,
stricter attention will be paid to mouth cleanliness. In the study of
a recent epidemic of noma^ the following conclusions were reached :

" Any uncared for mouth, particularly in a sick child, may contain bacillus
fusiformis and spirochaeta gracilis. In such a mouth these organisms may be
found without ulceration or in the lesions which have been described as sto-
matitis gangrenosa, Vincent^s angina, and noma. Any of these conditions,

* Crandon, Place, and Brown, Boston Med. and Surg. Jour., 1909, clx, 473.
25

386 PREPARATION OF THE PATIENT

including the extensive gangrene and sloughing of so-called noma, may be
different stages of the same disease, which may be, therefore, considered as
not necessarily a specific disease, but the successful ingress of mouth bacteria
into tissues rendered non-resistant by uncleanliness and preceding disease."

Examination of the tirine, chemical at least, should be made
in all cases, not that the presence of certain urinary abnormalities
would preclude a necessary operation, but that a knowledge of the
condition of the avenues of elimination should be had in anticipation
of any postoperative complications. The twenty-four-hour amount
of urine should be known also, if possible.

Geraghty Test. — The importance of the routine preoperative
urinalysis for renal impairment has already been stated. Certain
other tests have been devised for the purpose of estimating that of
which no urinary analytic method gives us definite information,
namely, the functional capabilities of the kidney. Of these, the
best known have been the methylene-blue, indigo-carmin, rosanilin,
and phloridzin tests.

An accurate determination of the functional power of the kidney
is of value to the surgeon in many ways. The decision as to the
advisability of operating in the presence of renal impairment from
chronic disease will be aided by finding whether or not the damaged
organs may be expected to bear the temporarily increased load which
the operation will throw upon them. In considering a nephrectomy,
for instance, the surgeon's responsibility will rest much more lightly
if he knows not alone that there is another kidney, but that it is sound
enough to do double duty.

GERAGHTY TEST 387

Recently a method has been originated by Rowntree and Geraghty*
which, though reasonably simple in technique, offers a degree of accu-
racy not obtainable with any of the others. It has been used by care-
ful observers in a sufficient number of cases to make it safe to draw
certain preliminary conclusions. It consists in the hypodermic in-
jection of a fixed amount of phenolsulphonepththalein, noting the
time which passes before it first appears in the urine, collecting the
urine for an hour after its first appearance, and by simple color com-
parison determining the percentage of the dose given which is present
in the urine.

Phenolsulphonephthalein is a soluble red powder, giving in alkaline solu-
tions a brilliant purplish color. It is not toxic, and in slightly alkaline solu-
tion it is not irritating. Administered subcutaneously it normally appears
in the urine within a few minutes, and practically all the drug given is
eliminated through the kidneys in two hours. The length of time necessary
for excretion enables us to draw conclusions as to the ability of the kidney as
an excretory organ.

The patient to be tested is catheterized, and the catheter left in the
bladder. Six mg. of the drug in alkaline solution (ampoules containing 6 mg.
per cubic centimeter can be obtained) is then injected intramuscularly. The
catheter is allowed to drip into a test-tube or other receptacle containing a
few drops of a 25 per cent, solution of sodium hydroxid. The interval
between the injection and the time of the first appearance of color in the
test-tube is carefully noted. The urine is then collected for one hour, its
quantity is made up to i liter by the addition of water made distinctly alka-
line with sodium hydroxid, and a portion is filtered for comparison with a
standard solution containing 6 mg. per liter. For this purpose one can use
the Dubosc colorimeter, or the modified Hellige hemoglobinometer, both
expensive, or one can make up, as suggested by Cabot and Young,^ a rack
holding a series of ten test-tubes containing solutions of 5, 10, 15, and 20
per cent., etc., of the drug, up to 50 per cent., and, using a similar test-
tube for the sample, compare its color directly with these. The standard
solutions are practically permanent if they contain an excess of alkali, and
the test-tubes are stoppered and sealed with paraflin. The reading by this
improvised scale is correct to within 2 per cent, of the Dubosc reading.

An accurately graduated syringe is necessary. The patient can drink
water as he desires at any time before or during the test. Blood in the
urine will interfere with the color; in this case the urine should be boiled to

* L. G. Rowntree and J. T. Geraghty, Jour. Pharm. and Exp. Therap., 1909, i,

579.

* Boston Med. and Surg. Jour., 191 1, clxv, 549. See also Goodman and Kaisteller,

Surg., Gyn., and Obstet., Jan., 191 1; Eisenbrey, Jour. Exp. Med., Nov., 191 1.

388 PREPARATION OF THE PATIENT

coagulate the blood, and then filtered. Highly concentrated urines affect
the color, changmg it to orange; if necessary, new standard solutions must
be made up for comparison, using the patient's normal urine instead of
water.

To test separately the functional capability of each kidney, catheters
are passed into one or both ureters for a few inches, left in place, the injec-
tion made, and the urine separately collected. There are several sources of
error: (i) The presence of the catheter may occasionally cause reflex
anuria, with consequent delayed excretion. (2) There may be leakage
about the urethral catheters; to prevent this the largest catheter practicable
should be used, having a " whistle '' tip, and the amount of urine in the
bladder after the removal of the catheters should be figured in. (3) Blood
not uncommonly appears toward the end of the hour from congestion of the
ureter caused by the catheter.

The following table of findings is based upon the article of Cabot and
Young, and an unpublished paper by Dr. H. B. Loder:

Normal individuals show the characteristic color in from five to fifteen
minutes; from 38 to 60 per cent, is excreted in the first hour, and from 15 to

25 per cent, in the second hour.

Acute Nephritis. — Severe cases show a marked diminution of the per-
centage excreted in the first hour.

Chronic Nephritis. — The time of appearance is delayed, even to forty-
five minutes, and the first hour's excretion may fall as low as 10 per cent.
A very low or persistently falling percentage is evidence of impending
death.

Cardiorenal Cases, so-called. — This test enables the observer to decide
whether heart or kidney affection is the more important element. Cardio-
vascular cases, on the contrary, exhibit practically normal renal function.

Obstrtcction from prostate shows delayed appearance (average about
twenty-two minutes) and slowed excretion (average output in first hour about

26 per cent.). If the findings improve under treatment, constant drainage,
forced fluids, and an appropriate diet, the kidneys are sho^\Tl to be not hope-
lessly damaged. Ether operation is contraindicated in any case showing
an output of less than 20 per cent, during the first hour; such cases have been
found to develop uremia with uncomfortable frequency.

Obstruction from Chronic Stricture. — The findings are not far from nor-
mal, averaging fifteen minutes for appearance, and 37 per cent, for first
hour's output.

Surgical Diseases of the Kidney. — The diseased kidney shows delayed and
diminished output, in relation apparently to the amount of tissue destroyed.
In cases of unilateral disease the test will give evidence of the functional
power of the kidney to be left behind, and in a case of bilateral surgical dis-
ease it will show the relative working value of the two kidneys.

FIELD OF OPERATION 389

Preparatory stimulation, in the form of drugs, tonics, and
massage, must vary with each case; they may be the deciding factors
in the outcome.

The value of a complete history and thorough physical examination
cannot be overemphasized. Such a routine may seem irksome and
footless, but by it facts of the greatest clinical importance are brought
out, often enough to make the value of complete acquaintance with the
patient unquestionable. Another advantage derived from complete
examination, as Ochsner* says, is that — ''If the surgeon knows that all
his cases are to be examined thoroughly by an equally competent col-
league or assistant, he is not so prone to become careless in his personal
examination as his work accumulates.^' Complete examination again
and again brings forth a possibility we are apt to forget, namely, that a
patient may have simultaneously two diseases.

FIELD OF OPERATION

Except for the warm bath the night before, it is undoubtedly better
not to prepare the field until immediately before operation. This is
true for the following reasons: (i) Shaving or scraping may cause
minute wounds in which the native bacteria of the skin will develop
over night. (2) The heat and moisture which are present under a
preparatory dressing may Be'enough to cause the pouring forth and
propagation of skin bacteria from pores and hair-follicles. On the
morning of operation all hair in the vicinity of the proposed wound should
be removed by careful shaving or by the application of a depilatory
paste.

Depilation vs. Shaving. — Arbitrary decision as to the relative
values of shaving and depilation of the field of operation cannot be made.
Some surgeons, notably Robert T. Morris, are strongly in favor of
removal of hair by caustic applications. Shaving long before the
operation — the day before, for example, as is done in many hospitals —
is imdoubtedly bad practice. As just stated, minute wounds are
sure to be made by the nurse or orderly who does the shaving, because
of the contour of the parts to be shaved, the delicacy of the skin,
and the shrinking movements of the patient. These minute wounds on
many patients will show signs in twelve hours of mild inflammation,
small hyperemic areas in which staphylococcus albus is to be found.
If, in addition, the old method of moist applications over night in prep-
aration has been used, the spread of this infectious process will be en-

* Clin. Surg., 1902, 13.

390 PREPARATION OF THE PATIENT

couraged. If shaving, therefore, is to be done, it should be done only
just before operation. Most of the depilatory pastes are germicidal as
well, and, therefore, are to be commended.^

An efficient depilatory, simple to prepare, is that of Boudet:

Calcii causUci pulveri (fresh unslaked lime) lo.o

Sodii sulphid ^ (crystals) 3.0

Amyli (pulverized starch) lo.o

These ingredients are separately pulverized, mixed, and kept in a
bottle dry When needed for use, enough water is added to form a thin
paste. This is spread on the part to be denuded about | in. thick by
means of a wood or glass spatula. At the end of five minutes the paste
is washed off with sterile water, after which the usual preparation
proceeds.^

Then follows the important part of the preparation, namely, the
scrubbing with soap and water. Short of positively injuring the skin,
the scrubbing can hardly be overdone. Except in regions such as

* A complete list of formulas may be found in Paschkis, Cosmetik fiir Aerzte, Wien,
1905, pp. 256, 257.

* Barium sulphid may be used equally well.

•Robert T. Morris, Amer. Jour. Surg. Gyn., June, 1903, xvi, 179:
**When the depilatory has just been wiped away from the skin after about five minutes*
application, the melted hair and superficial loose epithelium comes away, together with
any dirt that lies within the area acted upon. The skin is then as sterile, apparently, as
it would have been after the labor and prolonged methods of preparation, and we have
entirely avoided the disturbance caused by shaving. The time-saving element in itself
is of consequence. I have taken the hair from an entire leg in less time than it would have
taken to shave a tenth part of it, to say nothing of the fact that the leg was all ready for
operation without further antiseptic preparation. We can plaster the depilatories evenly
over the skin without regard for their entrance into the open wound, as the germicidal
influence of the sulphites will counterbalance any irritating effect.

" The manufacturers of depilatories advertise them as harmless. This is not true.
They are about as capable of harmful influence as are carbolic acid and bichlorid of mer-
cury, and need to be used with as much care as we employ with these two standard anti-
septics. In removing the hair from the vulva, for instance, the mucous membranes of
the labia are sometimes irritated by the depilatories unless we first brush the mucous
membranes with a little sterile oil for protection from plastering the whole vulva with the
paste. On the skin of some patients the depilatories have the effect of taking off small,
superficial patches of epithelium, so that one will often need to brush these spots with
sterilized oil. Nurses are apt to dislike the staining of the nails from the action of sul-
phids when preparing a patient for operation, but one can, with a little care, avoid staining
the finger-nails.

" On the whole, however, the use of germicidal depilatories is such an advance over the
older methods of preparation of the skin of the patient that I believe it to be the coming
method, and my nurses and assistants would not like to go back to the troublesome methods
that are as yet in conmion employment.*'

Harrington's solution 391

scalp, axilla, pubes, hands, or feet, the scrubbing-brush should not be
used; it is too harsh. The person who does the preparation should
have his own hands thoroughly cleaned by a soap-and-water scrub, and
may, indeed, well wear sterile gloves. For preparation of the field
strong soap containing pulverized pumice may be used, or any strong
soap wrapped in one layer of gauze to give it a rough surface, vigorously
scrubbing it up and down and round, following some systematic plan
of motions. At the same time, at intervals, as directed by the scrubber,
a second assistant pours, from not too great a height, hot tap or sterilized
water from a pitcher. By this means the dirty, soapy water is continu-
ously being washed off and the same water is hardly used twice. Dip-
ping the scrubbing hand back and forth into a basin is a slack method.
Instead of wrapping the soap in gauze, a handful of cut gauze and tincture
of green soap may be used. In any case, enough actual lather should
be raised to indicate that all the grease in the soap and on the skin has
been saponified. The soap is now thoroughly washed off with con-
tinued libation of sterile water. A small amount of ether may now be
used if the surgeon thinks best to remove any fat or grease which has
been left on the skin. Whether this step is taken or not, 70 per cent,
alcohol is next applied and thoroughly scrubbed all over the field, using
a sterile sponge of gauze. Assurance is made doubly sure if at this
stage Harrington's solution is used.^ An alcohol saturated pad is now
left over the site of incision while the sterile sheets, towels, and other
coverings are being placed over the patient. This is removed by the
surgeon at the moment of incision.

In the scrubbing particular attention should be paid to the region

* Dr. Charles Harrington, of Boston (Trans. Amer. Surg. Assoc, 1904, xxii, 41, et seq.),
made a careful comparative study of all the antiseptics used at present, and as a result
of that study devised a mixture which, on experimentation, proved to combine the greatest
germicidal action with the least irritation :

Corrosive sublimate 0.8 gm.

Commercial alcohol (94 per cent.) 640.0 cc.

Hydrochloric acid 60.0 cc.

Water ■. 300.0 cc.

This mixture contains corrosive sublimate, i: 1250, in a solution made up of 6 per cent,
hydrochloric acid and 60 per cent, absolute alcohol. Sixty per cent, alcohol will destroy
staphylococcus aureus in four minutes; 10 per cent, hydrochloric acid is equally efifective,
and 1 : 1000 corrosive sublimate will kill it in three minutes. Why a combination contain-
ing all these substances, but with lesser proportions of the acid and salt, is so much quicker
in its action than any one of them alone, is an interesting question of physical chemistry.
But such is the fact. After giving the hands an ordinary wash and soaking in the solution
two minutes, all culture tests, ev^n under the nails, are st^rUe.

392 PREPARATION OF THE PATIENT

of the umbilicus, which is to be very thoroughly washed with a cork-
screw motion, to the folds under pendulous breasts, and to the groins,
especially if the abdomen is pendulous. If the skin in any of these
areas is eczematous, the operation should be postponed, if possible,
until the condition has been cleared up. If the operation must go on,
and these areas come at all within the field, they should, for the time
being, be sealed with absorbent sterile gauze and the whole covered with
collodion. This also applies to blistered areas where escharotics, plas-
ters, or hot-water bags have caused breaks in the skin. If operation
is imperative through such area, the region may be scraped with a curet
and just before operation painted twice over with tincture of iodin.
Then, in addition, a whole sheet is placed over the area and incision made
through sheet and skin. Whatever is thereafter inserted into the wound
does not rub over this questionable area of skin.

This method of preparation by soap and water scrubbing remains
as efficient as it ever was, but experience of the last two years seems
to have brought forth a method more simple and, at the same time,
more efficacious, namely, the use of tincture of iodin.

J. E. Cannady^ reported his technique of preparation wherein he
follows the usual scrubbing by the sponging over with tincture of
iodin. The method as now employed, laying emphasis on the fact
that the skin should not be wet with water before the iodin, was first
proposed by A. Grossich.^ Gibson^ and many other writers have
reported experiences with it. A. Bogdan^ has contributed further
to the subject by adding benzine to the preparation.

Noguchi* imdertook extended experimental and clinical investigations
into the value of the method as described by Grossich, and recommends
it highly from both the bacteriologic and clinical standpoints. The phar-
macopeal tincture should be used, as more potent than any dilution or
combination. An excess should be avoided, as it may cause trouble.
The operation may be started two minutes after one coat has been
applied, to allow for drying. It should be rubbed in gently. A second
coat is of little, if any, advantage. The use of soap and water as a pre-
liminary, or for shaving, is of no disadvantage, provided that the skin is
dried before the application of the iodin. By this method, however, all
of the bacteria of the skin are not destroyed, and for that reason some

* Jour. Am. Med. Assoc., 1906, xlvi, 1102.
*Centralbl. fUr Chir., 1908, xxxv, 1289; 1910, 737.
*Ann. Surg., 191 1, liii, 106. ^

*Centralbl. ftir Chir., 191 1, xxxvii, 73.
^Archiv. f, klin. Chir., 191 1, xcvi, 494.

TINCTURE OF lODIN 393

prefer the older technique in cases where absolute asepsis is a desidera-
tum, as in operations exposing joint surfaces. It should not be used in
operations for thyrotoxicosis, and its applicability to operations on mucous
membrane and for skin-grafting has not yet been determined. Occasion-
ally a susceptible skin will show some acute eczema following the appli-
cation, and this is particularly likely if adhesive plaster is applied. The
wound heals as readily as with other methods, and the scar is usually
insignificant. On the whole, according to Noguchi, the iodin method is
better as a means of disinfection of the operative field than any previ-
ously employed.

The improved technique of preparation of the field of operation now
stands as follows: When feasible the whole body, or at least the field
of operation, is thoroughly washed with soap and water the day
before operation. Shaving may be done at this time. On the day
of op)eration water should not touch the area involved. If shaving
must be done, it should be done dry. The patient, thoroughly anes-
thetized, is on the operating-table in position for operation. An area
much larger than the mere field of operation is thoroughly wiped over
with benzin, using two or three gauze *' wipes." This clears off all
grease and coarse dirt from the skin. Care must be taken not to let
benzin run down on dependent parts, such as the back, in an abdom-
inal operation, lest from lying wet with benzin a burn result.

The benzin dries quickly and the area is next wiped over with
gauze saturated in tincture of iodin. Some of it should be poured into
the umbilicus in abdominal cases. This coating of iodin dries spon-
taneously and should not be covered in with towels until quite dry.

The method is simple, inexpensive, and more certain in its surgical
cleanliness than soap and water. In the preparation of areas hard to
clean or already much lacerated by injury this method is at its best.
Blistering or actual bums are seen only in cases of especially sensitive
skin, notably in blondes, but should not appear oftener than i in 300
cases. Gangrene of toes in lacerated wounds first treated with iodin
has been observed.^

A valuable note recently published by Tinker and Prince* calls
attention to the fallacy in the belief that clinical results alone are a
test of the value of any method of skin disinfection:

I. The skin of people accustomed to habits of reasonable personal
cleanliness is not apt to be badly infected. This was shown in the

* Hindenberg, Mtinch. med. Woch., 19 10, Ivii, 1465.

*Surg., Gyn., and Obst., June, 191 1, p. 530: Fallacies Regarding Skin Disinfection
with Special Reference to Iodin Method.

394 PREPARATION OF THE PATIENT

Russo-Japanese War, when soldiers, it is said, were required to take
a full bath and put on clean clothing before going into battle.

2. The ordinary bacteria with which we come in contact under
ordinary conditions are of a low-grade virulence. The bacteria on the
floor and ordinary objects are too cold, lack moisture, and are not
surrounded by suitable culture-media. This explains why many men
are able to get fairly satisfactory results in surgery with relatively
faulty aseptic and antiseptic technique.

3. Common, slightly resistant bacteria ordinarily giving wound
infection are used in the laboratory in testing the value of any anti-
septic. Thus, Staphylococcus aureus and albus, Bacillus coli and
pyocyaneus are killed by many weak antiseptics. This fact makes it
possible for a surgeon to get clean wounds from 90 or more cases out
of 100. Although the resistant spore-forming bacteria are relatively
infrequent, it should be evident that our methods must he so reliable
that resistant spore- forming bacteria j such as Bacillus tetanus and B.
anthrax, shall be certainly destroyed. J. Lionel Stretton^ reports a
death from tetanus after iodin preparation occurring in a series of 300
clean cases.

It seems to us, therefore, according to our present light, that
preparation of the field of operation should include:
(i) A thorough bath the day before, if possible.

(2) Gauze scrubbing with benzin after patient is arranged on
operating-table.

(3) A thorough application of tincture of iodin, to be allowed to
dry five minutes.

(4) The application of a gauze pad soaked in Harrington's solution
over the line of incision, to be left in place at least two minutes.

PREPARATION OF SPECIAL AREAS

Scalp. — For all scalp wounds, removal of wens, and such minor
matters, if surgeon and patient are wilUng to give up enough time for
thorough scrubbing, little if any shaving need be done. The scrubbing
must be thorough, however, with strong soap and a brush, the hair
carefully separated in the region to be treated, and the work then
carried on through a hole cut in a towel or sheet. The benzin-iodin
method is quicker and as efficient. If no shaving has been done,
a cocoon dressing cannot be applied, but an alcohol or Harrington
solution pad will have to be put on after sewing.

For all operations on the skull itself complete shaving of the head

* Brit. Med. Jour., 1910, i, 1350.

PREPARATION OF SPEQAL AREAS 395

must be done, because, if for no other reason, one can never tell how
extensive an operation may be necessary. It is always easy, however,
to induce the patient to allow shaving by telling him that the cosmetic
effect of complete removal of the hair is better than partial shaving.

The Region of Beard and Eyebrows. — ^The beard or mus-
tache, when the operation involves these regions, might better be en-
tirely removed, but even to this rule there may be exceptions, and a
perfectly clean operation may be done, if the reasons are sufficient,
through a bearded area.

It will rarely be necessary to shave the eyebrows, inasmuch as the
hair is so short and so sparse that it should be perfectly cleanable, and
the absence of an eyebrow, even for a short time, is a rather important
cosmetic matter to a sensitive person.

For a mastoid operation a zone of scalp behind the ear, i
to I in. in width, should be denuded of hair.

All other hairy areas of the body should be entirely denuded
of hair in preparation for any operation.

Mouth. — Though complete asepsis of the mouth is probably not
attainable, much may be done. Most of the cleaning, however, is me-
chanical, since antiseptics of sufficient strength to be efficient cannot
be used with safety. If it is possible, the teeth should be thoroughly ,
cleaned by a dentist and bad teeth either filled or removed. An excel-
lent antiseptic to be applied to gums at the line of contact with the teeth,
the commonest site of mouth infection, is the following:

R. Zinci iodidi ) .. «

lodi / ^5"*

Glycerini q. s. ad 5ij.

This is applied with a brush or cotton-stick intimately round the base
of each tooth. The mouth should be washed by the patient every
hour or two for two days preceding the operation. At the time of
operation the whole mouth may be scrubbed out by the surgeon with
boric acid, 4 per cent., or full strength liquor antisepticus, or some
such cleansing fluid. Gargling is good as a mouth-wash, but abso-
lutely without value for the pharynx, as may be proved by any one
who will gargle with a staining fluid and then examine the mouth.
The stain will not go, as a rule, beyond the anterior pillars.

The nose similarly should be cleansed by the surgeon at the
moment of operation.

Vagina, Cervix, and Genital Region.— Here, too, the most
valuable cleansing is mechanical. On the table a douche should be

396 PREPARATION OF THE PATIENT

given, thoroughly distending all the folds, then the whole cavity scrubbed
out with soap and water and gauze, the manipulations not being too
rough. Another douche follows.

Few women know how to take an efficient vaginal douche. Most
nurses know little about it, and many doctors let their directions end,
"Take a hot douche morning and night," without any details.

^rm

> ■ •■ • y *• »

Fig. 122. — Vaginal Douche.

Hammock of canvas suspended on metal side-bars in bath-tub, designed to give proper elevation of pelvis.
The shoulders arc supported on the lower cross-piece, the buttocks on the higher, and the feet may conve-
niently rest on the rim of the tub at its lower end.

Most women take a douche sitting, in which position the walls of the
vagina are entirely pressed together by the weight of the viscera. The
cleansing fluid under these conditions cannot at all distend the folds
and the douche must fail more or less in its purpose. Some women
take douches lying on the bed-pan. This is a better position, but e\'en
taken in this way, the woman is likely to be partly reclining on three or
four pillows till the body is really inclined downward toward the but-
tocks, with the same compression of the vagina. The fluid wets her
clothing, the bed, and the floor, and does not reach the parts for which
it is intended.

A vaginal douche should always be taken lying on the back, with
the buttocks raised at least 6 in. above the level of the shoulders. Such
a position may be obtained by a specially devised hammock which
may be hung in a bath-tub ^ (see Fig. 122), or, more simply, the douche
may be taken lying on the floor with a douche pan, but under the douche
pan a pad or pillow of rubber or stork-sheeting, filled with excelsior,
the whole suflicient in height to lift the buttocks well above the level
of the shoulders. In this position the vagina bellows out, the fluid
injected distends it thoroughly, comes in contact with every part, and
insures all the benefits of moisture, heat, and medication to vagina,
cervix, and pelvic floor.

Rectum. — On the table, under anesthesia, is the time for rectal
cleansing, and then only after eight or ten minutes have been taken to
slowly and thoroughly dilate the sphincter ani to a thoroughly paretic
condition. Under these conditions irrigation with salt solution, with

* Boston Med. and Surg. Jour., 1908, clix, 795.

PREPARATION OF SPECIAL AREAS

397

the tube inserted not over 6 in., thoroughly cleans rectum and ag-
moid.

Bladder and TTrethra. — So many of the operations in this
rei;ion are for obstructive conditions of the urethra, it is frequently not
pOFsibJe to wash out either bladder or urethra, A\'hcre it is possible
it should be done with Harm boric-acid solution, 2 per cent., in and out
several times.

Hands and Feet. — These regions with thickened skin, so much
more exposed than other parts to sources of infection, should be pre-
pared for operation by lonj^-repeatcd soaking in hot soapy water, or,
better still, soapy water with the addition of a little chlorinated soda
(liquor soda; chlorinat.T) . Hands or feet, soaked for half an hour
e\-ery four hours the day before operation, or, in any case, bvo periods
before, can have all the overthickened, macerated epidermis then
scrajjed otT. The benzin-iodin method or iodin alone poured into a
fresh accidental wound immediately will insure against all infections
except tetanus and anthrax. Harrington's solution alone destroys
these infertions. Pero.tid of hydrogen is also valuable.'

, Nuw Orlw

. .\k<l. J<™

PART II

CHAPTER XL
OPERATIONS ON THE HEAD AND FACE

SCALP WOUNDS

Aseptic Wounds. — ^The primary gauze dressing of a large wound
may be removed on the third day and, if there appears to be no sepsis,
a cocoon substituted. On the eighth or tenth day the cocoon and the
stitches are removed.

Septic Wounds.— If, after the first hventy-four hours, there is
considerable throbbing, pain, or increasing tenderness, it is probable
that some grade of infection is present. The dressing should be re-
moved, perhaps a stitch or two removed to let out retained serum, and
wet dressings applied. A culture may be taken. Infection of scalp
wounds sometimes is fulminating in character. The appearance of
edema about the eyes or behind the ears, together with headache, vertigo,
and perhaps delirium, should be looked upon as an indication of grave
import. In such cases the wound should be laid freely open and other
drainage wounds made. (See Septic Wounds, p. 257.) The general
treatment of septicopyemia (see p. 284) — bed, ice-cap, wet dressings,
stimulation, and, in appropriate cases, vaccine therapy — should be
begun at once.

Septic Wounds with Necrotic Bone. — Scalp wounds going down to
the bone, when septic, are characterized by a profuse purulent discharge,
due, in frequent instances, to the presence of necrotic bone. When this
process of necrosis occurs, it will continue from ten to sixteen weeks
and end by the separation of the superficial plates of dead bone, which
is followed by prompt healing. Probably very little, if any, time is
saved by operative attempts to remove the dead bone before it is ready
to separate.

TREPHINING AND BRAIN OPERATIONS

It is assumed that the dura has been sewed over the brain so far as
possible. Drainage is best made with rubber dam. This serves to
carry away the steady ooze of blood and serum which takes place

398

TREPHINING AND BRAIN OPERATIONS 399

at the operative site during the first tw^enty-four hours. Its removal
then is advisable in order that the normal intracranial tension may be
gradually restored. This tension in septic cases, with careful hemostasis,
is never sufficient to interfere with primary healing, and, at the same
time, it exerts a salutory pressure on the brain, which tends constantly
to extrude through the wound, and helps also to prevent direct adhesion
between the scalp and the dura or brain beneath it by the formation
of soft connective tissue.

In cases of osteoplastic resection by the DeVilbiss cranial bone-
gouge, or by any other method which has for its purpose the preservation
of the bone-flap, prolonged suppuration is the only sign by which we
can conclude that the bone-flap is not alive. Secondary operation
becomes necessary.

Trephined cases may have several pillows almost immediately after
ether recovery, but should be kept in bed and restrained from all mus-
cular effort for two weeks. Straining at stool should in particular not
be allowed.

Complications and Sequelae. — (i) The anesthetic may not he
well taken, "If there is no contra-indication, \ gr. of morphin before
operation is desirable, since the amount of anesthetic will be then cut
down. The morphin also contracts the arterioles of the brain and
diminishes bleeding. In unconscious cases, of course, neither the
morphin nor anesthetic is needed. If the shock is not profound, and
there is no other good reason against chloroform, this anesthetic should
be used — first, because, contrary to ether, it produces cerebral depres-
sion, and, second, because there is less vomiting. Anesthol is taken well
in cerebral cases." ^

(2) Postoperative hemorrhage may appear, often, apparently, started
up by vomiting. If it is from cerebral vessels, litde can be done beyond
packing; if from the dura or sinuses, a secondary operation must be
done at once to control the bleeding; if from the diploe, it may be con-
trolled by plugging with bone wax or the hot drippings of a candle.

(3) Shock may be profound, and should be combated on general
principles.

(4) Edema of the lungs is likely to follow long anesthesia.

(5) Hernia Cerebri, — ^This may occur {a) immediately, during the
operation, where there exists much intracranial pressure which it has
not been possible entirely to relieve. It may appear (6) later, as the
result of an intracranial collection of serum or pus. If such a collection
is then drained and the pressure relieved, the brain may be held in with

* Jacobson and Steward, i, 314.

400 OPERATIONS ON THE HEAD AND FACE

a piece of sheet silver or lead. Actual hernia of the brain should, of
course, be distinguished from false hernia, which is due to a so-called
red softening of the brain, or is composed of granulation tissue. Real
hernia of the brain, if it is not reducible under slight and sustained
pressure, should be treated by resection of the entire mass at the end
of t\vo or three weeks. False hernia cerebri should be treated like
granulation tissue, cut off at once, and further growth checked by pres-
sure and caustics, if necessary, while epidermatization is being en-
couraged.

(6) Infection is particularly liable to occur in brain cases, partly
because of the traumatic etiology of a large proportion of conditions
necessitating operation upon the skull, and partly because of the diffi-
culty of establishing and maintaining complete asepsis during a cranial
operation. If general symptoms manifest themselves immediately, it is
either a diffuse encephalitis or a meningitis and proves rapidly fatal.
Most free drainage and general treatment for septicopyemia are the only
resources. Many cases may now be cited of successful operative
treatment of apparently hopeless meningitis.* After drainage is
established, saline infusion of 500 cc. should be done two or more
times six to twelve hours apart.

REMOVAL OF THE GASSERIAN GANGLION AND OTHER NERVE

RESECTIONS

The wounds after these operations should all heal by first intention.
Prolonged stay in bed is uncalled for. Pain may appear in correspond-
ing parts on the other side of the face and demand sedatives for the first
few days.

Paralysis of the eyelids calls for protection of the conjunctiva at first
until the eye learns to roll itself under cover. The conjunctiva should
be washed out with 2 per cent, boric-acid solution or sterile water every
hour or t^vo. Drooling from the paralyzed corner of the mouth irritates
the skin, but control of the mouth to a degree to prevent escape of saliva
is soon resumed.

EXCISION OF THE UPPER OR LOWER JAW

Packing of iodoform or other kind of gauze which was put in at the
md of the operation should be removed at the end of t\venty-four hours.
The patient is best kept, after ether recovery, in approximately a sitting
position, to facilitate drainage downward and forward. The cavity

^ G. Krebs, Therap. Monats., Berlin, 1910, xxiv, No. 5.

TUMORS OF THE PAROTID 4OI

should be washed out with an alkaline antiseptic, or, if not too pain-
ful, it may be better cleansed by means of gargling on the part of the
patient himself. Food should be given through a tube for the first
few days.

Complications and Sequelae. — (i) Prolonged shock may ap-
pear, though it is rare. This is to be treated in accordance with the
principles already laid down. (See p. gi.)

(2) Hemorrhage, — If it resists the use of adrenalin or ice, packing
should be tried; if necessary, the wound must be opened and the bleeding
point found and plugged or tied. •

(3) Sepsis, — Some degree of infection must always occur; it may
amount to an erysipelas. This complication calls for the usual treat-
ment. (See p. 288). If the tumor removed was sarcoma, erysipelatous
infection is welcomed. (See Chapter LIU.)

(4) Bronchopneumonia very often appears, especially in aged patients,
from inhalation of blood, pus, or food, and is not infrequently the second-
ary cause of death. Preventive treatment is the most important — namely,
careful antiseptic preparation of the mouth before operation and great
care in preventing choking and cough during feeding. The mouth
and wound should be thoroughly cleansed by irrigation and with gauze
and forceps at least every four hours and after each meal.

(5) Recurrence of the Tumor, — Attempts should be made to prevent
recurrence of the tumor, depending upon the type of new-growth present.
At the present writing, our only resource in sarcoma seems to be the
Coley serum (see Chap. LIU); in carcinoma, A;-ray therapy (see p. 378).

If the excision, after thorough healing, seems to lead to the hope that
success has been attained in its object, the problem of apparatus to fill
out the contour of the face and to provide for chewing is one that the
surgeon must refer to dentists skilled in such work.

TUMORS OF THE PAROTID

If none of the greater radicles of the duct have been cut, the wound
or wounds should heal by first intention. The stitch or stitches may
come out with perfect safety on the fifth day. The patient may be up
as soon as the effects of the ether are over.

Complications and Sequelae.— (i) Facial Paralysis, — ^The
facial nerve may have been cut by mischance or it may have been cut
necessarily to allow of removal of the growth. After-treatment consists
only in protecting and cleaning the conjunctiva of the paralyzed eye
until it is accustomed to the new conditions. Later, nerve anastomosis
may be indicated (see p. 628).

402 OPERATIONS ON THE HEAD AND FACE

(2) Parotid Fistula. — Sections of the gland may be temporarily
isolated by operation, and within a week or ten days — perhaps some-
what longer — reestablish drainage by their normal ducts. If, after a
sufficient interval, it becomes evident that a definite fistula has formed,
a seton of coarse twisted silk is put into the fistulous opening, through
the cheek into the mouth cavity, and tied in a loop out through the
mouth. From time to time this is pulled through until the opening is
well established into the mouth. It is then removed; the edges of the
skin wound are freshened and sewed up.

ENUCLEATION OF THE EYE

Immediately following enucleation there is considerable hemorrhage
for a minute or two. As a rule, this gradually ceases; it may, very
rarely, be necessary to use pressure at the apex of the orbit. There
is ordinarily but littie bleeding after four or five minutes. The orbital
cavity must be irrigated at once with sterile water, normal salt solution,
or with a 3 per cent, solution of boric acid, until all clots of blood are
removed. Clean up the eyelids and surroundings, and then introduce
about i dr. of some simple antiseptic ointment inside the eyelids. This
prevents the secretions from gluing together the lid margins. Over the
closed eyelids apply numerous layers of sterile gauze cut in small
squares, making in all a pad about li in. thick, extending from the
brow to the cheek, and from the nose to the temple. This should be
held in place by a 2-in. monocular roller-bandage, applied snugly but
not tight enough to produce discomfort.

The following day the patient may sit up out of bed. The bandage
is removed, and the margin of the eyelids cleansed with small sterile
gauze sponges or cotton balls wet in a 3 per cent, solution of boric acid
and then redressed in the manner described above. More or less re-
action in the form of ecchymoses and swelling of the lids will be observed
at this time, although in a few cases it is hardly noticeable. It is usually
a litde more marked when a glass or gold sphere has been implanted
in Tenon's capsule, but all signs usually disappear in about two weeks.

The dressing should be changed once daily, preferably in the morn-
ing. The bandage may be omitted in three or four days after simple
enucleation, and in six or seven days when a sphere has been implanted.
After this period, cleanse the cavity and lids with a solution of boric
acid three times a day and apply an ointment to margin of lids at bed-
time.

Remove the silk conjunctival suture in six or seven days; after this the
patient may be discharged from the hospital. Occasional cleansing

OTHER PLASTIC OPERATIONS ON THE FACE 403

with a solution of boric acid to remove any secretion which may form
is the only subsequent treatment necessary. A single eyeshade may be
worn for cosmetic effect until a glass eye can be fitted. This may be
done as soon as the wound has healed and the discharge ceased and
all swelling has disappeared. As a rule, it is better to wait three or
four weeks before having the artificial eye fitted.

Rarely a button of granulation tissue forms at the center where the
cut edges of the conjunctiva meet. This should be snipped off with

scissors.

CANCER OF LIP

For small growths the ordinary V-operation is closed in a vertical
line, in case there is much tension, by two through-and-through sutures,
besides the necessary number of silk or silk-worm gut for approxima-
tion of the edge. The woimd is cleaned and painted twice over with
compound tincture of benzoin and a cocoon. The wound should be
dressed daily, inside and out, by painting with benzoin. No cocoon
is necessary after the third day. The silver tension sutures should
not be removed until after the seventh day.

Of all the plastic operations for cancer of the lower lip, where the
removal of the entire lower lip is necessary, we like, best of all. Grant's.^
This operation, where two sliding lateral flaps are used, needs two
tension sutures in the middle line.

OTHER PLASTIC OPERATIONS ON THE FACE

It is somewhat difficult to deal with this matter solely from the
point of view of after-treatment, since common sense must dictate the
specific treatment for special cases. In general, however, by position
or by the application of plaster straps, all tension must be kept off
the sutures so far as is possible. The wound itself might better be not
closed in by any dressing, but rather left exposed to the air, and fre-
quently cleaned with alcohol or painted with the compound tincture
of benzoin or some such application.^ The stitches will have served
their purpose in most instances by the sixth day, and should be re-
moved then in order to avoid forming stitch scars.

Hemorrhage must be thoroughly stopped, since a relatively thin
layer of blood-clot may prevent a plastic flap from adhering. Firm

* Jour. Am. Med. Assoc, 1905, xlv, 962.

* Antiseptic Varnish:

Iodoform or aristol (thymol iodid) ] . . aa i part

Glycerin J

Tinct. benzoin, comp 4 parts.

404 OPERATIONS ON THE HEAD AND FACE

pressure, therefore, for an hour or hvo, even if it has to be apph'ed con-
tinuously by a nurse's hand, may be necessary. Too much detailed
care can hardly be given in these important cases. From the beginning,
when, as Treves^ says, "Each flap must be gently handled, carefully
adjusted, and most tenderly and precisely sutured, '' up to the sixteenth
to the twenty-first day, during which time there must be no tension,
strict cleanliness must be maintained. During the early restlessness
after operation and during sleep it is safest even to overdo the applica-
tion of harness, straps, or other apparatus to prevent sudden movements
which may disturb the flaps.

Skin-grafting. — Where this procedure has been used, in addition to
plastic flaps, for special care see p. 633.

^ Oper. Surg., 1892, ii, 3.

CHAPTER XLI
OPERATIONS ON THE MOUTH, NOSE, AND PHARYNX

HARE-LIP

The difficulties of feeding a child after this operation have been
somewhat exaggerated. After the operation a piece of gauze or some
antiseptic varnish (see p. 403), or both, is applied over the wound, and all
side-pull on the wound is prevented by a dumb-bell-shaped piece of zinc
oxid plaster. The crinolin covering adherent to that part of the plaster
which crosses the lip itself is so left that the plaster does not stick to any
part of the lip, but only to the cheek. The upper lip is necessarily so
crumpled together by this plaster application that sucking would be
impossible, even if it were best for the lip for other reasons. The child
must be fed, then, with a small spoon, put well into the mouth. The
mother's milk should be drawn and given if possible. The child is
first given water, just as any ether patient would have it, but if it is
weak on account of poor general condition or from shock, the milk
should be offered within three hours of the operation. Bottle-feeding —
a large nipple is advantageous — may be resumed in three days; breast-
feeding at the end of ten days, the breasts being kept active during the
interval.

Sutures should be removed, in part, as early as five days — all by
ten days. At the moment of their removal all tension on the lip must
be prevented, and a new butterfly plaster applied at once, as before, in
order that the newly formed scar shall not be subjected to strain and
widen. This butterfly is worn up to three weeks.

Complications and Sequelae.--(i.) Asphyxia,— In the younger
infants this calamity, unless carefully guarded against, may frequently
occur. It cannot be better described than in the v;ords of Mr. Jacob-
son;* "One point of great importance is not alluded to in surgical
works, and that is, that in some cases of hare-lip death from dyspnea
may take place very soon after operation, Thus, where the cleft has
been a large one and the upper lip when restored is tight, where it over-
hangs the lower, if the nostrils are flattened and partly closed by the
operation, owing to the tension of the parts, so littie breathing space

* Loc. cit.„ 410.

405

406 OPERATIONS ON THE MOUTH, NOSE, AND PHARYNX

may be left that temporary interference with respiration may occur,
with grave and even fatal results before the breathing can be accom-
modated to the altered circumstances and before the parts dilate and
stretch."

(2) Many children die after this operation, particularly the young
ones. For that reason it is probably best, despite the clamors of the
parents, to postpone the operation for this deformity until the child is
from six to nine months old. This rule, of course, does not hold if the
child cannot well nourish itself on account of the deformity. Many of
the infants that die under this operation are of the marasmic type that
rarely live, operated on or not.

(3) Hemorrhage may be serious, especially in a weak infant. Prop-
erly placed stitches should hold the coronary arteries. Apart from
the primary dangers of hemorrhage any considerable collection of clot
under the lip or between the edges leads to non-union. The fauces may
even fill up with blood-clot, and, unless the child is watched carefully,
death ensues from suffocation.

(4) Bronchopneumonia is liable to occur, as in any infant after
etherization, and particularly after mouth operations.

CXEFT-PALATE

A small injection of morphin may be given immediately after the
operation, but no food should be allowed for three hours, only a little
ice being given to suck. For the first forty-eight hours diluted milk
or barley-water only should be allowed, nutrient enemas being given
if needful; all feeding is done with a spoon; the child is weaned. After
this yolks of eggs, arrowroot, broths, soups, and, in about ten days,
light food of other kinds if the child is old enough. The hands should
be secured for the first few days. If the patient^s temper and intelligence
allow it, the mouth may be regularly washed with boric acid or salt
solution. In any other case it is best to leave the wound quite alone.
The nurse should devote herself to preventing the child from crying and
to keeping the patient amused. Whenever it is possible, the child should
be taken into the fresh air after the first tw^o or three days. "There
should be no hurry to remove the sutures, which, if not of silk, may
remain for seven or ten days in the soft, and an almost indefinite time
in the hard, palate. No one should be allowed to look at them either
early or often. It is well for the operator to keep out of the child's
notice for the first ten days." It is now a well-established custom, in
America at least, to operate upon these infants within the first six
months, as soon as the child has a hold on life.

CLEFT-PALATE 407

"To make this subject of after-treatment at all complete a few words
must be said about the improvement of speech after the cleft has been sur-
gically cured, and the occasional need of an obturator. Even after a com-
plete closure of the cleft much awkwardness of speech is liable to remain,
this being, of course, most marked the older the patient is. Parents are often
greatly to blame for the little trouble they will take to further the success of
the surgeon^s efforts, and this refers in many cases to those who have not the
excuse of ignorance and toilsome life of the poorer classes. They too often
act as if, because the cleft is closed, no further responsibility rests with them.
Again, the patients being usually children, without thought as to the future,
and satisfied with the improvement in their deglutition, present many diffi-
culties. Not only has the child to be taught the right way of using its organs
of speech, but wrong habits, especially nasal and guttural tones, have to be
unlearned. This is only to be brought about by means of systematic lessons
and practice gone through regularly day by day for months and even years.
No plan will be found better than that recommended by Mr. W. Haward,
Clin. Lect., 'On Some Forms of Defective Speech.'^ The instructor should
sit directly facing the pupil; the pupil is made to fix his attention thoroughly
upon the face of the teacher, and to copy slowly his method of articulation.
This should be displayed by the teacher in an exaggerated degree, every
movement of the lips and tongue being made as obvious as possible to the
pupil, and the more difficult sounds or movements prolonged for the purpose.
Thus, for instance, suppose the word * sister' were to be practised, the teacher,
having filled his chest with a long inspiration, would open his lips and draw
back the angles of the mouth, so that the pupil could see well the position of
the tongue against the teeth; he could then prolong the hissing sound of the
*s' and, finally, separating the teeth as the sound of the *t' in the second syl-
lable issues, allow the pupil again to see the position of the tongue as the word
is ended. Or, for another example, take the word 'lily.' Here the teacher
would separate the lips and teeth, so that the tongue would be seen curved
upward, with the tip touching the hard palate; the word would then be pro-
nounced with a prolongation of each syllable, the teeth and lips being kept
open, so that the uncurling of the tongue and its downward movement are
clearly seen. So, again, in teaching the proper method of sounding such
words as *wing' or 'youth,' much aid is given by keeping the lips somewhat
separated, so that the relation of the tongue and palate can be made manifest.
The pupil must be made to fill his chest,^ and then to imitate as closely as
possible every movement and sound of the teacher; and this may sometimes
be assisted by making the pupil feel with the finger as well as observe with
the eye the relative movement and position of the teacher's tongue and pal-
ate. There should be no other person in the room to distract the pupil's atten-

^ Lancet^ 1883, i, iii.

^ Opening the mouth \sddely and learning to keep the tongue down on the floor of the
mouth are two points to be early and strenuously insisted upon. The patient should prac-
tise them before a looking-glass.

408 OPERATIONS ON THE MOUTH, NOSE, AND PHARYNX

tion. It is best to continue the exercise for a short time only, and to repeat it
frequently, rather than fatigue the child by a long lesson; and it is a good plan
to take an ordinary elementary spelling-book and to mark the words which
the pupil finds most difficult to pronounce,* so that these may be especially
practised.

^ ^ With regard to the question of obturators and vela, in cases where it has
been found impossible to close a very wide cleft, or where it is evident that even
after a successful operation the palate will be so tense and short as to be
quite unable to touch the pharynx, and so shut off the nose from the mouth,
an obturator may be required."'

This matter should be referred to a dental surgeon of experience.

Complicatioiis and Sequelae. — d) Vomiting, if excessive or
if by chance something solid comes up, may cause the wound to separate
and the operation to fail.

(2) Tension may cause sutures to cut through and let the wound
separate. The only treatment of this naturally is preventive, and is,
therefore, a matter to be considered at the operation.

(3) Hemorrhage after operation is very rare in children, but must be
watched for in adults.

(4) Sepsis, curiously enough, merely from mouth bacteria, may be
disregarded, but infections of such nature as arise from scarlet fever,
measles, or diphtheria are serious, and will usually result in at least
partial failure of the operation. At the slightest appearance of a suspici-
ous membrane in the mouth diphtheritic antitoxin should be given, even
before a bacteriologic report can be obtained.

(5) Diarrhea. — This complication may appear as a part of the
shock of operation or it may be due to any of the usual causes. The
bowels should be cleaned out with small doses of calomel or with castor
oil, and the food should be modified and sterilized according to the age
and condition of the patient.

For a masterly article on Cleft-palate and Hare-lip the reader is
referred to a monograph under that title by W. Arbuthnot Lane, M.S.,
F.R.C.S., of Guy's Hospital, published ^ in London in 1908.

EXCISION OF THE TONGUE, PARTIAL OR COMPLETE

The chief problems which arise after this operation are, to keep
the mouth clean and to nourish the patient. The practice of Jacobson ^
before this operation is excellent. He teaches the patient to wash the

* Especially those containing the letters t, b, d, k, g, s, z, and I (Rose).
^ Jacobson and Steward, The Operations of Surgery, 1902, i, 444, 445.
^ Med. Pub. Co., Limited. ^ Loc, cit., p. 467.

RANULA 409

mouth thoroughly with some antiseptic, such as carbolic acid i : 80,
boric acid, or some of the alkaline antiseptics. The patient also "gets
used to feeding himself with a drainage-tube attached to a feeder spout
and passed by himself to the back of his throat."

At the completion of the operation the cut surface is painted with
compound tincture of benzoin or a solution of zinc chlorid (gr. x-3j).
The patient is given ice to suck, and nourishment is given as necessary
in liquid form through nutritive enema. If the patient has learned how
beforehand, he will be able, after the usual post-ether nausea has passed,
to feed himself by the feeder-tube passed to the back of his throat. The
mouth and wound must be inspected and thoroughly cleaned at least
every three hours during the daytime. The patient must be made to sit
up as soon as possible and his position must be continually altered.

Complicatioiis and Sequelae. — (i) Bronchopneumonia and lobar
pneumonia are the great causes of failure after this operation, the former
due to direct inhalation of infected material. Care of the mouth, the
sitting posture, and general early activity are the preventive measures.

(2) Hemorrhage. — Early hemorrhage is rare. Secondary hemor-
rhage is unusual if the mouth has been kept clean. Arterial bleeding
in the conscious patient can only be controlled by the immediate applica-
tion of hemostatic forceps and all the patient's courage will be necessary
to endure their remaining in situ,

(3) Edema oj the glottis may follow during any of the first days from
extension of infection, and must be met by scarification, intubation, or
tracheotomy.

(4) Suffocation may be caused by the stump of the tongue falling
back against the epiglottis. This is so liable to occur that it is probably
best always, at the end of the operation, to leave a stout silk loop sewed
through the stump hanging 2 or 3 in. out of the mouth.

RANULA

"In operating for the relief of ranula the object to be attained is
either to establish a new communication between some portion of the
ducts of the sublingual glands involved and the cavity of the mouth or
the complete removal of the entire gland. The simplest method to re-
establish a connection between the ducts of the gland and the cavity
of the mouth is through the use of a seton. By applying a large-sized
silk suture transversely across the ranula, and tying this loosely so that
it does not have a tendency to cut away the intervening portion of the
mucous membrane, one can frequently secure the growth of epithelial
cells in these openings and the cavity of the mouth becomes continuous.

4IO OPERATIONS ON THE MOUTH, NOSE, AND PHARYNX

After this has occurred, at both the point of entrance and exit of the
suture a new suture may be introduced through the same openings and
tied more tightly, so that the intervening tissue may become absorbed
slowly. The opening formed between the cavity of the ranula and
the mouth will thus become continuously lined with mucous membrane
and presendy a permanent opening will be established. This, however,
will not occur in every case, and it may become necessary, later, to remove
a considerable portion of the tissue between the cavity of the mouth
and the ranula." *

In our experience the silk seton through both sides of the tumor gets
foul from mouth contents and secretions, induces inflammation, and
tends to cut itself too rapidly to establish a permanent duct or ducts.
Better than silk, therefore, is an ellipse of silver wire, or, better still,
because it is stiffer, gold wire, may be used. A piece of gold wire is
passed through and bent into the shape of an ellipse and the ends need
not be twisted. Motion of the tongue moves the wire enough to establish
openings, but does not cause the wire to cut through.

ALVEOLAR ABSCESS

Incisions of the gum tend to close rapidly. Closure may be delayed
by means of iodoform wick or packing, which is rarely indicated, or
by the simple procedure of dipping the knife-blade in 95 per cent,
carbolic. Ordinarily, syringing or irrigating is never required unless
there is present septic periostitis or osteomyelitis (hydrogen dioxid
should not be used). If the constitutional symptoms persist, these are
to be thought of as well as empyema of the antrum of Highmore.

If the incision is within the mouth, as it should be whenever possible,
the patient should be supplied with some pleasant mild antiseptic, such
as liquor sodii boratis compositus (Dobell's solution) or liquor anti-
septicus alkalinus, and instructed to rinse the mouth out every two
hours, at the same time exerting gentle pressure on the cheek over the
tumor to assist in drainage. Lying on a hard pillow upon the affected
side will act similarly. With these precautions it will very rarely be
necessary to reopen an abscess.

The tooth which gives origin to the abscess can usually be determined
by tenderness elicited by pressure on its crown. If it is in bad shape,
it should be removed. If the dentist advises, it should be sterilized and
filled, if necessary.

In case of a sinus through the check, which heals with a disfiguring
scar, a tenotome should be passed under the scar to separate it from

* Ochsner, Clin. Surg., 1902, p. 318.

PARAFFIN PROSTHESIS FOB DEFORMITY OF THE NOSE 4II

the underlying bone or tissue, and paraffin injected to restore the contour
of the face. Long-standing sinuses — internal or external — usually sjjcak
for a sequestrum. If internal, the dentist can usually relieve them. If
external, the source of the discharge is hkely to be in the maxilla itself,
and radical measures should be taken to remo\'e necrotic bone.

PARAFFIN PROSTHESIS FOR DEFORMITY OF THE NOSE AND

OTHER PARTS

The danger most feared in this procedure, particularly if the jiaraffin
be used hot, is the immediate one of embolism, followed by thrombosis
of the ophthalmic vein, with consequent blindness. Nevertheless, in
all the literature there are only three cases.' This possibility should
always be considered when advising this operation. When the calamity

occurs, there is no treatment. When cold paraffin (melting at 115° F.)
is used, however, screwed in by the ingenious syringe of Dr. Beck, as
modified by V. Mueller & Co., of Chicago, the danger is at a minimum
— so small that we do not hesitate to advise the operation in cases of
notable deformity.

After the injection the injected mass is molded into the desired
shape and a compress, wrung out in iced witch-hazel, laid over the nose
at intervals for the first twenty-four hours or longer. There is some
reaction in the way of swelling and tenderness which, unless true sepsis
develops, should subside after forty-eight hours. If the wound or the

' Harmon Smith, Laryngoscopy, El. Loui?, rgoS, \viii, 798.

412 OPERATIONS ON THE MOUTH, NOSE, AND PHARYNX

paraffin cavity becomes infected, as a rule, it will not heal until the last
bit of paraffin is either forced or curetted out. The operation should
not then be attempted again for at least three months.^

Sometimes this method leaves an obvious foreign body which is
more noticeable than the original deformity. On this account the
procedure should not be used unless there is a definite and serious cos-
metic indication.^

NASAL POLYPI AND SPURS

Adhesions. — Special care should be observed in operating within
the nose to prevent adhesions, which are the result of two wounded sur-
faces coming into apposition. This condition may occur after the most
painstaking technique, on account of the extreme narrowness of the nasal
chamber. The nose should be examined by the surgeon daily, and any
tendency to adhesions carefully noted and the apposing surfaces sepa-
rated with the nasal probe. After drying the surfaces collodion may be
painted on and aristol blown over the raw mucous membrane. In some
cases a strip of gauze, covered with thin rubber dam, may be laid between
the septum and the turbinate, or an intranasal tampon, made from
Bernay's sponge, may be found of great service. This dressing should
be changed daily until healing has taken place. If possible, packing
in the nose after an intranasal operation is to be avoided, as it has a
tendency to check the natural drainage and favor sepsis. It is advisable
to place in the vestibule of the operated side a small plug of aseptic
absorbent cotton, thereby protecting the wound from impurities from
the atmosphere. This may be changed from time to time and left out
altogether after twelve hours. It is preferable not to use washes in the
nasal chambers for several hours after an operation, as bleeding is sure
to follow from disturbance of the cut surface by dislodging of clots.
At the end of twelve hours Dobell's solution, or liquor antisepticus
alkalinus, may be used, diluted one-half with warm water.

Nasal Hemorrhage. — This is a frequent after-result of intra-
nasal surgery. It is always advisable to define clearly the location
from which the bleeding arises, whenever this is possible, and not to
pack the nose except as a last resort. Cold towels should be applied
externally, and cracked ice may be used in the mouth and several small
pieces placed in the nose. Absolute rest should be insisted upon and
all coughing and sneezing avoided. If simple measures do not stop the

^ This subject of expulsion of foreign bodies has been carefully studied by H. V.
Baeyer, Beit. z. Klin. Chir., Tubingen, 1910, Ixx, 350.

2 F. Strange Kolle, Subcutaneous Hydrocarbon Prostheses, New York, 1908.

ANTRUM OF HIGHMORE 413

bleeding, the nose may be packed with sterilized sauze soaked in ad-
renalin, or a cigarette pack made with sterilized cotton or gauze, with
a thin dental rubber layer outside to prevent, temporarily, adherence to
the mucous membrane.^ In most cases it is only necessary to pack
either the anterior or middle portions of the nose, but in a few excep-
tional cases it is necessary to pack the posterior cavity. This may be
best done after so shrinking the turbinates with a 4 per cent, cocain in
1 : 1000 adrenalin solution, so that as much room as is possible may be
gained to allow thorough and careful work. Several long strips of
sterilized gauze are carried backward, through the anterior nares, with
Hartman's long-bladed nasal forceps, to the posterior space (where
it is advisable to have the finger as a guide to prevent the packing coming
in contact with the pharyngeal wall) and the nostril is firmly filled with
the gauze. This packing should not be allowed to remain in the nose for
a longer period than twenty-four to forty-eight hours. In removing
the packing great care should be exercised to prevent renewed bleeding.
If rubber dam or Cargile membrane has been used, there is no tendency
for the shreds of gauze to adhere to the mucous membrane. With the
plain gauze dressing it should be thoroughly wet with dioxid of hydrogen
and removed slowly and carefully.

Packing the postnasal space is undesirable on account of possible
sepsis or infection of the middle ear through the Eustachian tubes. If
hemorrhage demand such a procedure, it is best done, not by means of
Bellocq's cannula, but by passing a soft- rubber catheter through the nose
and into the mouth, and tying to this one end of a piece of suture material,
to which a tampon is attached. This is drawn through the nose and
the tampon rests in the postnasal space. The other end of the suture
material comes out of the mouth and is tied to the nasal end and rests
over the ear. The nares is packed anteriorly if necessary. This plug
should not remain in situ longer than twenty-four hours, and, after
removing, the parts should be cleansed with Dobell's solution diluted
to one-half strength.

ANTRUM OF HIGHMORE

After a radical antrum operation (opening both through canine
fossa and lower meatus) the gauze may remain in place for forty-eight
hours, and be then removed arid the antrum washed out by a glass
syringe and rubber tube or catheter passed into mouth wound, the wash
coming out through the nose. DobelPs solution, one-half strength,
some other alkaline preparation, or normal saline solution may be used.
This procedure should be repeated daily until no trace of pus can be

' M. D. Stevenson, Jour. Am. Med. Assoc., 19 10, liv, 1864.

414 OPERATIONS ON THE MOUTH, NOSE, AND PHARYNX

seen. After one week the cavity should be inspected and probed to

find if any areas of diseased mucous membrane or carious bone exist.

If it is desirable to allow the wound in the mouth to remain open, it

should be repacked and the wick changed every second day. WTien

the mouth wound closes, the washing, if more is necessary, is done

through the inferior meatus. If necrotic areas of bone are found, they

should be gentiy curetted, after applying 5 per cent, cocain in i : 1000

adrenalin solution, and then touched with 50 per cent, silver nitrate

solution. Any associated or secondary atrophic rhinitis or polypoid

condition of the nose must be coincidentally treated.

Destruction or injury of the superior dental nerve, with resulting

death of three or more teeth, should not occur after a careful operation,

unless there be an anomaly in the situation of the nerve with relation to

the canine fossa.

FRONTAL SINUS

Cold compresses should be applied constantly to lessen postoperative
edema and ecchymosis. External dressings should be changed in
Uventy-four hours and the covered eye bathed with saturated solution
of boric acid. The drainage-tube should be left in position for forty-
eight hours, and after its removal the sinus should be syringed with
Dobeirs solution, one-half strength. The tube should be replaced and
the treatment repeated daily for two weeks. After this, if the pus has
disappeared, the tube may be left out. If necessary, a silver tube may
be used, which should be worn until every trace of discharge has ceased.
If the sinus has not been packed, it may be washed out in twenty- four
hours with warm normal saline solution or saturated solution of boric
acid.

For some time patients may complain of diplopia if the pulley of
the superior oblique muscle has been interfered with. This gradually
passes off in a week.

A certain amount of numbness on the forehead upon the affected
side may occur. This also disappears in a short time.

The discharge may cease in a few weeks, or it may take months to
complete the cure. If unsightly scars or depressions persist, parafl&n
prosthesis may be employed.

REMOVAL OF ADENOIDS

The patient should be made to lie on the side, and should be care-
fully watched for the vomiting of blood, which is sure to occur. Should
the bleeding be excessive, as it may be if the curet has cut into the
mucosa, or has left pieces half cut off, or if the child is a bleeder, or if

REMOVAL OF ADENOIDS 4 IS

the growth is malignant, the patient should be sat up and an applica-
tion of i: looo adrenalin solution made to the site of operation. If
three or four applications of this do not stop the bleeding, a tampon of
gauze, with a piece of silk tied around the middle, may be prepared, a
nasal forceps passed through an anterior nares, the mouth-gag placed
in position, the silk attachment on the tampon passed with the finger
into the postnasal space, seized then by the nasal forceps, and the silk
drawn out through the nose, thus bringing a tampon of appropriate size
into full pressure in the postnasal space. MonselPs solution is another
styptic which may be used.

Occasional oozing, small in amount, may continue so long that, at
the end of ten or twelve hours, the child is largely exsanguinated. For
this the nurse must be on the watch, and measures such as those given
are then to be taken. Many instances of death from particles of adenoid
tissue or blood in the trachea have been noted, though, perhaps naturally,
few have been reported.*

The patient should be in bed one to three days, or longer if there is
fever, and should not go out-of-doors in wet or very cold weather within
a week after the operation.

Ice-cream and cracked ice relieve pain, and a mild embrocation,
such as oleum gaultheriae and linimentum saponis, equal parts, may be
applied to the muscles of the neck if stiffness occurs. A laxative should
be given twenty-four hours after the operation, to clear the stomach and
bowels of any blood that may have been swallowed and not expelled
from the stomach by vomiting. The diet should be limited for the first
twenty-four hours to cold liquids or semisolids. Eisenzucker tablets
(saccharated red oxid of iron) of 3- or 5-gr. doses are agreeable to children,
and should be used when anemia exists.

Nasal ol^struction in many cases seems greater for a few days than
before operation, due to the swelling and inflammation of the naso-
pharynx. Nose-breathing should improve in from four to seven days,
but the vicious habit of mouth-breathing, especially in older children,
can be corrected only by repeated admonition, which almost amounts
to *^ nagging," during the day, and possibly by the use of a four-tailed
chin bandage to hold the mouth shut at night.

Complications and Seqnelae. — (i) Bronchopneumonia from in-
halation of blood or vomitus.

(2) Sepsis, shown by excessive purulent excretion and possibly by
general symptoms. This is best treated by irrigation through the nose
into the mouth with some alkaline antiseptic, such .as DobelPs solution,
half strength, liquor antisepticus alkalinus, or normal salt solution.

^ Jacobson and Steward, 1,372.

41 6 OPERATIONS ON THE MOUTH, NOSE, AND PHARYNX

(3) Earache, due probably to infection through the Eustachian tube,
either directly during operation or by unwise use of the nasal douche.^
This is less likely to occur if the fossae of Rosenmiiller have been thor-
oughly cleansed out with the finger during operation. The ice-bag or
hot water should relieve this in most instances. Paregoric or Dover's
jK)wder will best relieve severe pain. If the drum membrane bulges,
paracentesis should be done early.

In some cases after removal of the adenoid tissue the catarrhal deaf-
ness does not clear up without treatment. In these cases a few Politzer
inflations are necessary. In more chronic cases the turbinates may
require cauterization, either with the actual cautery or some chemical
cautery, of which trichloracetic acid is the best.

(4) The cervical lymph-nodes may swell and become painful. They
usually do not suppurate, and the condition calls for no treatment beyond
the application of an ice-bag or a hot-water bag if that seems more
soothing.

(5) The possibility of the appearance of diphtheria immediately
after operation should always be kept in mind.

(6) Deformities of the chest may be to some extent overcome in
young patients by proper breathing, gymnastics, and out-of-door exer-
cises, the causal condition having been removed.

(7) A thick, stuffy, and nasal quality to the speech may remain for
some time after the operation, especially in children who have had
nasal obstruction for some time. This may be overcome by lessons in
proper voice production.

(8) In some cases a mouthy voice, improperly called "nasal," may

be due to slight temporary paresis of the muscles of the palate, brought

about by their being stretched at the time of operation. This usually

quickly disappears and the voice becomes natural. If there is a paretic

condition of the soft palate, small doses of strychnin and cold gargles

should be tried.

REMOVAL OF TONSILS

This operation in the adult, from the point of view of suffering and
of possible complications, is a serious one; in the child, it is much less so.
The same general directions for the after-treatment hold as for the
operation for the removal of adenoids. Locally, relief from pain is
best obtained by the use of ice constantly applied and by insuflflation
on the site of operation with orthoform powder. This may be done
every half-hour if necessary. Gargling increases the pain; the use of
lozenges is not advised because the necessary swallowing causes
pain.

TUMORS OF THE TOXSIL

417

Hemorrhage. — Bleeding may continue from the moment of oper-
ation (see p. 89), or may take place as a true secondary hemorrhage
any time up to the tenth day. If adrenaUn or Monsell's solution
fail to check it, the tonsillar fossa; should be examined carefully with a
strong reflected light, and the anterior pillars retracted to see if the
bleeding point can be detected. In some cases the base of the tonsil
or ragged edges of tonsillar tissue have been left, and after a thorough
removal the bleeding ceases. If a bleeding vessel can be seen, it
should be grasped with a hemostatic forceps and a suture applied.
Sometimes the mere twisting of the forceps on the vessel wilt stop the
bleeding. If these measures fail, the tonsil hemostat may be used, and.

as a last resort, the pillars of the tonsil may be sutured together (see
Fig. 126), and, if unsuccessful, the external carotid must be tied.

Diet. — Anything that the patient desires he may take, but ex-
perience shows that liquids or semisolids very cold are the least irri-
tating forms of nourishment. Cold water, orange -album in. custard,
sherbet, and ice-cream are to be recommended. The pain on swallow-
ing will last from four to ten davs.

TUMORS OF THE TONSIL

If the removal has been solely through the mouth, the same care is
taken as in operation on the tongue. (See p. 408.) If, in addition, there
is a wound in the neck, with drainage from the pharynx, drainage
gauze should be kept in not more than twenty-four hours, after which

4l8 OPERATIONS ON THE MOUTH, NOSE, AND PHARYNX

drainage should best be allowed to maintain itself, provided the wound
is kept thoroughly clean. The dressing should be replaced as often
as it is wet; the skin about the wound should be painted with compound
tincture of benzoin to preserve it from maceration. Feeding should
be done by esophageal tube for between two and three weeks. "The
patient's feeding himself should be forbidden as long as any attempt
at this causes choking or coughing, owing to the danger of fluids enter-
ing the air-passages" (Jacobson). The patient should be up and out
of bed as soon as possible.

PERITONSILLAR ABSCESS

It is assumed that no surgeon will be content with mere incision
of the abscess of quinsy sore-throat. If, through the incision, the ex-
ploring finger breaks down all dividing walls and all cell-like accessory
cavities, making the abscess into one, drainage will take care of itself.
The tip of a glass syringe may be introduced through the wound every
two or three hours after ether recovery, and the cavity thus washed out
with warm myrrh or some alkaline antiseptic solution. This should
be done for twenty-four to seventy-two hours, only when the patient is
awake. Gargling does no good and is very uncomfortable.

The patient may take for nourishment whatever he can swallow
without too much pain. Usually semisolids at room temperature, such
as mush, blanc-mange, curds, and jellies, are swallowed the easiest.

Complications and Sequelae. — (i) Septicopyemia may result
in patients much reduced or in cases inefficiently opened. Diphtheria
may be present coincidentally or may appear during convalescence.

(2) Delayed or secondary hemorrhage should never occur, unless
due to anatomic anomaly.

RETROPHARYNGEAL ABSCESS

Most of these cases are in children under five years of age. It is
assumed that the operation has been a vertical pharyngeal incision on
one or both sides; that the incision has been very free; that, as in the
case of peritonsillar abscess, all septa have been broken down by the
finger; that the operation has been done in the Rose position.

The mouth should be opened wide and inspected every few hours
to see that drainage is free; that the wound has not sealed up and pus
collected within it. Washing out the wound is not necessary, but every
effort should be made to keep the mouth thoroughly clean.

Complications and Sequelae. — Bronchitis or bronchopneu-
monia make the commonest complication. The most important treat-

RETROPHARYNGEAL ABSCESS 419

ment is, naturally, prevention by having the operation done in such
position that no pus is inhaled and by subsequent mouth cleanliness.

Whether acute or chronic, retropharyngeal abscess is extremely likely
to cause edema of the glottis and sufiFocation. An ice-collar is a good
prophylactic against this danger. If the incision is made through the
mouth and drainage is ineflScient, an external incision along the posterior
border of the stemomastoid may be made.

Septicopyemia may occur and generally with fatal result. The usual
general treatment applies.* (See Chapter XXVI, p. 284.)

* M. A. Goldstein, The Larj^ngoscope, St. Louis, igo8, xviii, 46.

CHAPTER XLII
OPERATIONS ON THE NECK

TRACHEOTOMY

After this operation the patient should be put in the position in
which he can breathe best. This should be determined by experiment
in a given case. Most cases, however, breathe best reclining at about
45°, with the head somewhat back. The tape which holds the tube
in position must be tight enough to hold in the tube during coughing,
but should not be so tight as to constrict the neck, for this not only
induces the natural discomfort of venous congestion in head and face,
but tends to cause the lower end of the tube to press against the
inside wall of the trachea. Some patients at first or during the night
may find relief in an atmosphere laden with hot-water vapor (so-called
steam). Where the coughing is continuous, where the secretion from
the tube is very thick and stringy, where the patient continually gets
cyanotic, in spite of the tube being clear, steam should always be tried.
For the purpose of confining the vapor, any of the usual devices for
holding mosquito-netting over the bed may be used, or a special one
may be made by tying four uprights to the legs of the bed; over such
uprights a sheet is dropped as a canopy, leaving an aperture into which
the vapor may be carried directly from the mouth of the tea-kettle
over an oil-stove, or through a pipe, a steam radiator, or any other
device which may be at hand. Such apparatus is most often necessary
where intubation has failed in diphtheria and tracheotomy has been
necessary.

Ordinarily the room should be kept at 65° to 70° F. Over the
mouth of the tracheotomy-tube should be placed 5 to 10 layers of gauze
wet with boric acid or some such mild antiseptic. This wet gauze
serves to moisten the air inspired, and to make it less irritating to the
bronchi. The amount of gauze should not be enough to interfere
with free breathing. The inner tube must be removed and cleaned as
often as necessary — probably every hour or two at first. A solution of
sodium bicarbonate will best clean the secretions off the tube, though
if an aluminum tube is used, it must not be washed in alkalis. If re-

420

TRACHEOTOMY 42 1

moving the inner tube does not relieve obstruction, a long, narrow feather
(such as that from a hen's wing) should be inserted deep into the outer
tube and removed with a twisting motion. A nurse should always be
present and waking for at least the first twenty-four hours after tracheot-
omy. At the same time, it should be remembered that the care-taking,
especially cleaning of the tube, may be overdone, just enough to prevent
the child getting sleep, the most important remedy.

Feeding is sometimes a difficult problem. As after all operations,
at all times, unless there is a definite reason, these cases should not be
wakened for feeding. On the other hand, swallowing at first, before
the patient is used to the tube, may be so uncomfortable that it is difiicult
to induce the patient to take sufficient nourishment. Liquid feeding
through the mouth should be tried. If it fails, nourishment may be
carried on by nutrient enemas or by esophageal tube; the latter method
is so apt to frighten small children that it should be avoided whenever
possible. (For details of Esophageal Feeding, see p. 148.)

Removal of the Tube. — In general, this should be done as early
as possible. Not only is there danger of ulceration of the trachea from
pressure of the inner end of the tube, but the longer the person uses the
tube, the more difficult is it for him to resume breathing by the natural
passages.

'^ Conditions Which Impede the Removal 0/ the Tube. — (i) Prolonged
formation of membrane. The longest possible period for this is probably
about ten days. Patience and support are the main indications In the
treatment here. (2) The larynx is crippled like any other inflamed
part. (3) The air-tube is closed by granulations, usually above the
cannula. More common than these is obstinate swelling of the mucous
membrane. Here the tube must be removed and astringents and
caustics carefully applied from below, with the aid of an anesthetic if
necessary. (4) Closure of larynx by deep ulceration cicatrizing after
detachment of membrane. In such a case, with the aid of an anesthetic,
the larynx must be opened up by probes of increasing size and laminaria
tents introduced from below, and later on by the use of AlacEwen's
tubes. (5) Paralysis of the dilating cricoarytenoidei postici or spas-
modic action of the closing muscles, arytenoidei or cricoarytenoidei
lateralis, from fear, excitement, or during effort.* (6) The commonest

^ In a case in which one of us had jjerformed tracheotomy, and was watching the child
for the first few hours after the tube had been dispensed with, most urgent symptoms
came on during the slight straining which accompanied an action of the bowels, the
patient falling off the night-stool onto the floor apparently lifeless. Artificial respiration
restored the child, and the case did well.

422 OPERATIONS ON THE NECK

cause of inability to dispense with the tube is probably due to the rapid-
ity with which the larynx falls into abeyance when a child is allowed
to breathe through a tracheal cannula, the patient at this age being not
intelligent enough to understand the importance of dispensing with the
tube, and perhaps too young to care to talk, or, if older, not realizing
the need of again using its voice while all its wants are supplied. With
the above condition are coupled a nervous dread of having the tube
removed and paroxysms of temper and struggling which rapidly produce
embarrassed breathing. Any organic mischief, such as adhesions in
the larynx, is, I think, extremely rare, and granulations above or below
the tube are more often talked of and given as a reason for inability to
dispense with the tube than really seen" (Jacobson and Steward, p.
490) . Where repeated efforts to get the child to resume natural breath-
ing fail, the O'Dwyer cannula should be inserted, unless there is organic
obstruction to this procedure. The O'Dwyer tube should also be
removed experimentally every day or two, with the idea of dispensing
with it as soon as possible. But even when laryngeal breathing is
restored without the tube, the child must be closely watched, especially
at night, and the tube inserted at a moment's need.

Complications and Sequelae. — (i) He7norrhage. -^lmmed\3,to
hemorrhage is usually venous, the result of the congestion of asphyxia,
and stops as soon as breathing is well established. No particular
effort need be made to stop it. Occasionally, an artery in the thyroid
isthmus is cut and must be tied. Hemorrhage after some days may
come from ulceration of the trachea from pressure of the tube; pre-
ventive measures should make this impossible. The tube should be
only long enough to enter the trachea and curve around until its axis is
parallel with that of the trachea. A tube long enough to reach the
sternal notch may ulcerate into the arch of the aorta. The tube should
be as large and as short as possible. It should be of the same size
throughout, without tapering. The inner tube should project a little
bevond the outer one. The collar of the tube should stand out as little
as possible from the neck.

(2) Sepsis of the Wound, — Such a wound is never entirely aseptic.
The collar of the tube should be held from the wound by a few layers
of gauze split to straddle the tube. The wound should be kept sweet
with compound tincture of benzoin, eucalyptus vaselin, or some other
antiseptic emollient.

(3) Emphysema. — This complication is usually the result of a faulty
operation. Either the incision in the trachea is not in the same plane
with that in the soft parts, or the incision in the trachea is too small for

LARYNGOTOMY 423

the tube and immediate efforts at breathing pump the soft tissues full
of air.^

(4) Ulceration of the Trachea. — ^This is due to a cannula which is
too long or which has a wrong curve. This condition is to be suspected
if the expectoration after three or four days is streaked with blood, or if
the outer tube, on examination, shows a black patch on the anterior
aspect of the lower end. If the tube is still needed, it should be trimmed
or a different one tried.

(5) Suppuration may rarely take place in the mediastina. This is
indicated by the signs and symptoms of profound torpidity, labored
breathing, and substernal pressure and pain. The only treatment is a
well-performed operation, such as trephining of the sternum.

LARYNGOTOMY

The vertical incision in the pharynx above the tube should be left
unsutured, with a slight packing of antiseptic gauze in it. The foot of
the bed should be raised for the first t\venty-four hours, to overcome the
tendency of the drainage to run down into the trachea. The usual care
of the tracheotomy tube should be maintained. (See p. 420.) Feeding
should be carried on by nutrient enema or esophageal tube unless the
latter is particularly painful or obnoxious to the patient. Solid food
should be taken very early, since it frequently may be well taken by
natural means even better than by liquids. The sutures holding the
end of the trachea and of pharynx to the skin must be removed if they
are non-absorbable at about the fifth day, as they tend to become folded
under and diflScult to reach.

The question of a permanent apparatus which shall serve as an
artificial pharynx in these cases is a complicated and special one. In
general, such an appliance consists of two arms, one going down, the
other up, with a common exit at the site of the operation wound. In
such a tube various ingenious valve-like arrangements are provided to
allow of respiration and speech.

^ Mr. Jacobson {loc. cit., 493) quotes the conclusions of Dr. Champneys as follows:
(i) ** Emphysema of the anterior mediastinum, often associated with pneumothorax,
occurs in a certain number of tracheotomies. (2) The conditions favoring this are division
of the deep cervical fascia, obstruction to the air-passages, and inspiratory efforts. (3)
The incision in the deep cervical fascia downward should not be longer than needful;
it should on no account be raised from the trachea, especially during the inspiratory efforts.
(4) The frequency of emphysema probably depends much on the skill of the operator,
especially in inserting the tube. (5) The dangerous period during tracheotomy is the in-
terval between the division of the deep cervical fascia and the efficient introduction of the
tube. (6) If artificial respiration is necessary, the tissues should be kept in apposition with
the trachea, and any manipulations performed without jerks. * *

424 OPERATIONS ON THE NECK

Complications and Sequelae.— (i) Shock may be very great,
apparently analogous in nature to that frequently seen following the
slightest laryngeal operations. (2) The usual tracheotomy dangers,
with relation to blocking of the tube, etc., exist. (3) Bronchopneumonia.
This danger, due to inhalation of septic matter, blood, and food, is great,
and is present for at least the first t\vo weeks. (3) Sepsis, possibly
extending deep into the neck or into the thorax, can be met only by
constant care.

INTUBATION: INDICATIONS, TECHNIQUE, AFTER-TREATMENT

When laryngeal stenosis becomes acute, and from the symptoms
it is evident that the patient's life is in danger from asphyxia, immediate
operative relief is necessary. In such cases outside of a hospital tracheot-
omy would ordinarily be the only operative procedure possible. In a
hospital intubation may be considered, particularly if the cause is
suspected to be laryngeal diphtheria, or, in other acute cases, if some one
skilled in intubation is at hand. Where there is no immediate urgency,
intubation may be chosen if the patient's condition contraindicates the
shock and loss of blood which may be consequent to tracheotomy. In
the case of gradually increasing obstruction resulting from new-growth,
tracheotomy is unquestionably the better choice. If there is any ques-
tion of aspirated foreign body as the cause of obstruction, intubation
is most decidedly to be avoided. If the case be appropriate for either
intubation or tracheotomy on the grounds as stated, and the patient is
an adult, the difficulty of intubating adults would incline one to trache-
otomy rather than intubation.

In the operative treatment of obstructive laryngeal diphtheria, in
hospitals where constant super\ision by nurses and physicians ex-
perienced in the technique of intubation is the rule, the choice between
tracheotomy and intubation would ordinarily be in favor of the latter.
The statistics since the advent of antitoxin show that this agent has
reduced the mortality in both these methods of procedure. At the
South Department, Boston City Hospital, the intubation mortality for
the last three years has averaged about 20 per cent. In the fever hospitals
of London, where tracheotomy is the operation of election, the mortality
has been about 35 per cent. While it is difficult to make comparison
of cases operated in different countries, the consensus of opinion in
this country, based on statistics of mortality and experience in the con-
duct of cases, is that intubation should be the operation of election in
laryngeal diphtheria.

Under the following conditions, however, tracheotomy may be

intubation: indications 425

elected: First, when no one experienced in the technique of intubation
is available; second, in the home, where constant skilled supervision is
impossible; third, in the case of some adults having extensive swell-
ing of tissues of the neck, when experience would indicate that intuba-
tion might be difl&cult or even impossible. Tracheotomy becomes the
operation of necessity in any case when, for one reason or another,
intubation fails to relieve or when the tube cannot be introduced on
account of the stenosis.

Indications for Operation in I^aryngeal Stenosis. —
There are all grades of laryngeal stenosis. In the extreme type the
symptoms and signs are so obvious and urgent that relief by operative
procedure will not be delayed. The patient presents a picture of never-
to-be-forgotten agony from air-hunger. He tosses about in the bed in
vain effort to obtain sufficient air. The skin is dusky and covered with
perspiration, the mouth opened, the ala nasi dilating and contracting,
the sternocleidomastoid muscles in a state of spasm, the supraclavicular,
substernal, and intercostal tissues retracted at each attempt at inspira-
tion. Expiration is quite as difficult as inspiration, and the abdominal
muscles become hard and contracted in their efforts to aid the diaphragm
in expelling the air through the narrowed larynx. Aphonia may be
complete or attempts at phonation may result in short, high-pitched
squeaks; the cough as commonly heard is short, rasping, and "croupy."
Beyond this stage of cyanosis there is apt to be one of unconsciousness
imless operation is performed. The exertion has been so great that the
heart has failed and we have a state of pallid asphyxia, the patient
pulseless, the jaws set, and the musculature generally in the state of
spasm; then comes relaxation, and death rapidly ensues. If the patient
is first seen in this grave condition, intubation, reinforced by hypodermic
stimulation, artificial respiration, and oxygen, will often cause him to
regain consciousness, with eventual recovery.

Other acute conditions besides diphtheria which may cause sud-
den stenosis of the larynx should here be mentioned. In peritonsillar
abscess associated with extensive swelling edema of the glottis may occur
and require operative interference. The same may be said of severe
types of tonsillitis. Enlarged cervical glands may produce constriction
of the trachea and operative relief be necessary. In the latter case
tracheotomy is apt to be indicated; in the others, intubation should be
considered.

Technique. — The patient should be wrapped in a blanket and
taken to the operating room. Here there should be laid out for instant
use instruments and accessories calculated to meet any emergency.

426 OPERATION-S ON THE NECK

Several intubation tubes of each size should be kept attached lo as
many introducers, a tracheotomy set, oxygen, solutions for hypodermic
stimulation, and a sterile syringe should be at hand.

The intubation instruments follow closely in their dcsif^r those
originated and perfected by O'Dwyer, and are very satisfactory in use.
The so-called improvements over these instruments are usually the
opposite. The tubes are of metal, either nickel or gold-plated, or of
rubber molded about a small metal lube. The metal tubes are less
fragile than the rubber and are consequently more commonly used.
The rubber tubes are preferable in cases where the period of intuba-

tion is for one reason or another prolonged, and where the hea\-y metal
tube might eventually produce pressure necrosis. The tubes are molded
in such a manner as to produce no undue pressure al any point, and at
the same time are equipped with a flange to prevent slipping into the
larynx, and a fusiform enlargement, at about the middle, in order that
they may be less easily expelled from the larynx when the patient coughs.
They are made in several sizes according to the age of the child for
which they are intended. Some manufacturers mark, on each tube
the limits of age between which the tube is applicable; others provide
a metal scale by which this information may be obtained. The common
sizes are for the ages of one to two years, two to four, six to eight, and

intubation: technique 427

ten lo twelve, and several adult sizes, the latter generally of rubber.
Each tube has extending the full length of its lumen a hinged piece of

metal termed the obturator, and from which the tutie is easily disengaged
when it is inserted into the larynx. This obturator, with the tube upon

it, fits into the so-called introducer, which is merely a metal handle for
the manipulation of the tube. There is a small hole drilled through
the head or flange of each tube, through which a loop of silk thread is

428 OPERATIONS OX THE SECK

passed. This silk loop should be the full length of the handle, or about
6 inches.

The extractor is a metal instrument with a tapered and curved beak
which fits into the lumen of the head of the tube, and when the beak is
expanded by pressing the lever, the tube is firmly engaged and may be
extracted. The gag may be seen in the illustration. Tubes of shorter
dimension than those described are often useful and may be had on
special order. Others with a built-up flange or head are sometimes use-
ful where there is much edema in the tissues abn\-e the \-ocal cords.

The patient is laid upon the operating table and is wrapped in a
blanket, the arms held to the side, the blanket being pinned about the

neck and over the body tightly, so that the arms and legs are fixed.
Underneath the neck should be a sand-bag. The back of the head
should rest near the edge of the table. The table should be heavy and
without casters. A nurse stands at the patient's left, ready to restrain
and prevent any movement; the operator stands at the right, and at the
end of the table is the first assistant, who is to steady the patient's head
and hold the gag. He inserts a wooden gag between the teeth, opens
the mouth sufficiently to introduce the metal gag, and with this widely
separates the jaws. The plates of the gag should be wrapped with
adhesive plaster and should rest on the molar teeth. The introducer is
grasped by the operator in his right hand, the silk thread is passed over
his little finger, and his thumb is pressed against the upper surface of

intubation: after-treatment 429

the handle. The forefinger of his left hand he inserts into the mouth,
hooks forward the epiglottis, and with the finger-tip touches the vicinity
of the right arytenoid cartilage. The back of the finger would approxi-
mate the posterior wall of the pharynx, and the side of the finger would
be about on a line with the vocal cords. In the brief time during which
the finger is being inserted, the introducer, with the tube affixed, is intro-
duced into the mouth in the median line and the end of the tube is made
to follow the forefinger as a guide. The end of the tube slides over the
epiglottis, and, guided by the forefinger, reaches its tip and is directed
against the vocal cords. The handle of the tube is then elevated so that
it is in a vertical position or slightly beyond vertical. This brings the
tube about in a line with the direction of the larynx. The tube should
then be disengaged by the forefinger, and thus the tube is loosened from
the obturator. The tip of the forefinger on the head of the tube pushes
it gently into the larynx, at the same time releasing the tube from the
obturator The introducer is removed from the mouth, and at the
same time, by means of the forefinger, the tube is pushed further into
the larynx until the head is well seated.

The loop of silk thread is carried to the corner of the mouth, passed
over the left ear, the gag removed, and the patient at once set upright.
If the tube is in the larynx, the patient at once coughs in a peculiar man-
ner, breathes easier, cyanosis and other signs of dyspnea disappear. If
the tube is not in the larynx, instead of improvement in the condition
the breathing is apt to be worse; the cough will still be high pitched,
and the patient may even collapse. If by chance the tube is in the
esophagus, the string will shorten as the tube goes down. There should,
however, be no question as to the location of the tube, since the examina-
tion by the forefinger should have given information as to whether or
not the tube is properly in place. The child should be w^atched care-
fully for a few minutes, and if the breathing is comfortable and easy,
should again be placed in a recumbent position, the gag reinserted,
the forefinger of the left hand placed upon the head of the tube in the
larynx, the silk thread held with the right hand, cut by an assistant, and
removed.

It is not uncommon to have the breathing immediately cease when
the tube is inserted. This may be because the tube is not in the larynx,
but this question among experienced operators rarely comes up. It
is usually caused by the aspiration of a piece of membrane into the tube,
which, of course, should be at once removed and cleaned. Often, after
the tube is removed, the patient may, after a series of spasmodic coughs,
eject large pieces of membrane. The breathing may in this way be so

430 OPERATIONS ON THE NECK

much relieved that it will be unnecessary to reinsert the tube. On the
Other hand, reinsertion may be very urgent, and it is well always to have
two or three tubes of each size at hand, that in such an emergency there
shall be no delay such as might be caused by cleaning a tube.

Again, it may happen that the tube is pushed into a mass of mem-
brane and secretion and does not pierce it. This is a grave condition
and respiration stops. If the tube is removed, the chances are that
considerable loosened membrane will be coughed up, and upon rein-
sertion of the tube breathing may be much easier. In such a case the
tube is apt to plug, and repeated intubation and extubation may be
necessary.

Further, the tube may loosen a flap of membrane from the w^all of
the larynx, which will act as a valve against the end of the tube, allowing
inspiration, but preventing expiration. Suspecting this, a short tube
of the French type may be tried.

In certain uncommon cases the tube may fail to relieve, because the
membrane not only covers the trachea, but reaches into the finer branches
of the bronchi, or there may be, in addition to moderate amount of mem-
brane, a capillary bronchitis. In either case intubation w^ill fail, trache-
otomy will be performed, and no improvement from either will result.
Such cases rarely get well and require maximum doses of antitoxin
from the start.

Occasionally where the passages of the nose are occluded by mem-
brane and edema, and likewise by swelling of the tonsils and the ad-
jacent tissues, the anterior atrium of the pharynx is practically occluded,
and dyspnea arises resembling closely that produced by laryngeal ob-
struction. Intubation in this case will obviously not relieve, and trache-
otomy may have to be resorted to unless, after swabbing the throat as
free as possible from secretion, mouth-breathing is restored.

After-care.— The after-care of intubation cases is extremely im-
portant. Such cases should be grouped together so that they can be
constantly watched, for it is not uncommon for a child to cough up its
tube at almost any time and for immediate reintubation to be necessary.
If the tube is coughed and swallowed, such a complication is of no
serious consequence. In case there is much loose membrane and the
tube is repeatedly obstructed, it may be well to leave the silk thread, so
that the nurse may extract the tube in case it is suddenly blocked and
the child lacks expulsive cough of sufficient force to expel the tube. If
the child repeatedly expels the tube, a larger size may be used, or to
avoid a series of emergencies, tracheotomy may be necessary.

Gradual occlusion of the tube may occur from the accumulation and

intubation: after-treatment 431

drying of secretion in its interior. This may be suspected if the respira-
tory murmur gradually becomes higher pitched and the abdominal
muscles harden at each expiration, even though the color remains good.
The nurse should be taught to recognize this condition, so that tlie tube
may be removed and cleaned before serious dyspnea results.

Feeding. — Feeding (see also Chapter XIII, p. 148) in intubation
cases is rarely a serious problem unless the tube is retained consider-
ably longer than in the average case. Ordinarily, bread and milk, cus-
tard, soft-boiled eggs, etc., are swallowed with very little discomfort.
The patient often coughs excessively. Semisolid foods are apt to pro-
duce less cough than liquids. The most serious complication not
directly connected with intubation is bronchopneumonia. The treat-
ment should be carried out, eliminating drugs so far as possible. The
most favorable thing that can happen is that the patient cough up the
tube and no longer require it.

At the end of four days, however, if this does not occur, the tube
should be removed, although it may be necessary immediately to re-
introduce it. The arrangements of the patient are the same as
for intubation. The extractor is grasped lightly and the beak follows
forefinger to the head of the tube. As it touches the metal the impact
will be felt, and the beak is moved about cautiously until it drops into
the opening of the tube. The lever of the extractor is then pressed, thus
firmly engaging the beak in the tube. The tube is elevated from the
larynx, the forefinger being placed beneath the head or flange of the
tube to prevent it slipping from the extractor during removal, and the
whole withdrawn, carrying the tube upward and forward in the arc of
a circle. If the child breathes well during the first twelve hours, the
tube will ordinarily not require reinsertion.

Retained Tubes. — It sometimes happens that the patient re-
peatedly develops signs of stenosis whenever the tube is removed, in-
definitely repeated reintubation has become necessary, and, finally,
it is found that the tube must be worn continuously or intermittently.
Fortunately, such cases are rare, perhaps i per cent, or less of the total
of intubated cases. The immediate cause is, in the vast majority of cases,
the contraction of scar tissue at some point where it obstructs the breath-
ing. This scar tissue is in the site of an ulceration, produced by pres-
sure of the tube, or by the diphtheritic membrane, or at the point of
some trauma, due to faulty technique. The latter should be preventable.
To eliminate pressure necrosis the tube should be removed in all cases
at the earliest possible moment, even though it has to be reintroduced
at once. The mortality in the retained tube cases is commonly due to

432 OPERATIONS ON THE NECK

bronchopneumonia. If the patient lives, intermittent intubation must
be practised for a long time, with the hope that eventually the tendency
of the scar tissue to contract will be overcome.

ESOPHAGOTOMY

If the wound in the esophagus is at all clean cut, such as after the
removal of a foreign body, the wound should be closed with chromic
catgut and the neck wound dramed down to these sutures, best, probably,
with rubber dam or a soft-rubber tube, held in place by a stitch holding
it to the skin. Secretion from the wound is likely to be a form of a pro-
fuse, thin, yellow discharge with a yeasty smell. The wound, therefore,
calls for frequent dressings. For the first seven days it is probably
best to feed the patient by nutrient enemas, giving only a little ice
or hot water by mouth. If the enemas are not held and nourishment is
urgently needed, the patient may be fed by stomach-tube.

Complications and Seqnelae. — Sepsis. — These wounds are
always infected and frequently present large sloughs and vile discharge.
In some cases as a result of operation, and in all cases where the
foreign body has already ulcerated through, the mediastinum is in-
fected and may pour forth large quantities of foul pus. Immediate
through-and-through drainage must be established or a fatal result
ends the case shortly. A soft-rubber tube with many fenestrations
in the lower 3 inches of it should be inserted through the neck
wound down alongside the esophagus as far as it will go. A flexible
uterine sound within the tube will make this deep insertion feasible.
The patient should be in bed with the foot so elevated that mechanical
drainage is favored. The wound must be thoroughly wiped out,
every hour if necessary, and kept dressed with salt and citrate solu-
tion twenty- four hours, later, with weak chlorinated soda, myrrh wash,
or tincture of iodin.

ESOPHAGEAL DIVERTICULA

Whether the diverticulum has been treated by amputation and
suture or by inversion by means of a string/ rubber-dam drainage is
left in down to the esophageal wound. The second day the drain is
removed and the wound is wiped out with tincture of iodin, and
thereafter similarly every day.

Proctoclysis is maintained forty-eight to seventy-two hours if
bearable. Sups of hot water are given every two hours on the second
day. Beginning the second day after ether-nausea is passed, a small

^ Mayo Clinic Papers, 19 10, 37.

PARTIAL THYROIDECTOMY 433

stomach-tube is passed for the purpose of feeding. If this pro-
cedure is very distressing or induces retching, feeding may be carried
on for the first five days by rectum.

PARTIAL THYROroECTOMY

Anesthesia. — Dr, Halsted^ says: "I am not convinced that very
light general anesthesia with ether, skilfully given by an expert anes-
thetist for only fifteen or twenty minutes, is less safe, even in the gravest
cases, than local anesthesia plus the prolonged operative period and
its attendant nerve strain. In operations for exophthalmic goiter the
general anesthesia should be administered only by an expert.

"A nurse trained in the pre- and postoperative care of cases of
Graves' disease should be in charge, and the patient should have a
private, quiet room. We have knowledge of no analogous disease and
of no toxemia comparable to that which follows operation upon people
afflicted with hyperthyroidism. It is, therefore, particularly difficult
for the uninitiated to realize how critical is the condition of so many of
these patients until, as a demonstration, a death has been experienced.

"Water. — As so impressively pronounced by Dr. Mayo at his
clinic, saturation of the patient with water must be accomplished in
one way or another. The surgeon must not accept excuses that water
could not be given by mouth because it hurt the patient, to swallow,
and not by the intestine because the guttatim injections were expelled,
unless the patient is uncontrollable; in such event proper resort to
subcutaneous infusion must be had.''

C. H. Mayo^ says: "After the operation the patient is given i quart
of saline slowly per rectum. This is repeated twice within the next
twelve hours. Should intestinal relaxation be present, we consider
the salines of sufficient importance to give them subcutaneously in all
severe cases. The precordial ice-bag may steady a rapid heart; atropin
checks excessive perspiration, and morphin quiets restlessness. Death
from operation seldom occurs after the first twenty-four hours.''

As to chilling or freezing the neck before and after operations for
Graves' disease, Dr. Halsted remarks, "It had not occurred to me at
first that excessive cold applied to the neck in these cases, particularly
after operation, might delay the processes of repair and absorption and
thus bridge over the period of greatest danger — the two or three days

* William S. Halsted, M. D., and Herbert M. Evans, S. B., Ann. Surg., Oct., TQ07,
xlvi, " The Parathyroid Glandules: Their Blood-supply and their Preservation in Op>er->
ation upon the Thyroid Gland."

2 Surg. Gyn. and Obst., 1909, 602.

OPERATIONS ON THE NECK

succeeding operation. Its employment was \ery imperfectly tested in
tliree instances, but in all with beneficial results, it seemed to me,
although one of the patients, desperately ill before the operation, did
not recover. In no instance, unfortimately, did we succeed, with the
inadeciiiate appliances at our disposal, in doin^ much more than sliijhtly
coo] the surface of the skin. In one case, thirty-six hours after opera-
tion, the pulse, which had been steadily rising until it reached i8o,
dropped 30 beats a minute within one and one-half hours of the
application of the cold. In another, a good night's sleep, the first in

weeks, seemed to be attributable to the application of cold to the neck.
It is quite possible that harm rather than good might be done by inef-
fectually ap|)lied ice-bags. They might serve as a poultice if, for example,
swathed in protecting flannel, or if negligently attended to. The danger
of reaction, too, must be constantly borne in mind — the reaction follow-
ing either a brief or a prolonged use of the cold. Therefore, no time
should be lost in changing the packs, and ultimately the cold should
gradually be withdrawn. I doubt the ability of the rubber ice-bag to
produce a degree of cold suiHcient for the very ill cases, or the non-
conducting rubber should, perhaps, be so thin that rents would hardly
be avoidable. In some cases a degree of cold low enough almost to
freeze the skin might be necessary. Possibly to be considered as a
method of treatment for desperately ill cases is an unclosed wound
constantly irrigated with water of the desired temperature.

" I am convinced that the toxemia is not simply due to the ab-
sorption of the thyroid secretion. Otherwise, might not the gravest
cases of exophthalmic goiter be safely treated by total excision of the

HYPERTHYROIDISM

435

^- ft >** ^

JUa,

thyroid gland ? It is my belief that the toxemia incident to wound
healmg is badly borne by the subjects of hyperthyroidism. On sev-
eral occasions, soon after thyroid lobectomy, I have seen prompt and
great improvement follow the liberation of a dram or even a few drops
of reddish serum from the wound. Moreover, the typical postopera-
tive toxemia may, it seems, follow operations of other kinds upon
patients afflicted with Graves' disease. Absorption takes place con-
tinuously during the process of repair, even in wounds which are ^dry'
and healing throughout by first in-
tention. Thus it seems to me quite
reasonable to hope that something,
perhaps much, may be accomplished
by the adequate employment of
cold. The entire neck, fore and
back and sides, and from chin to
chest, might be made so cold in the
serious cases as to arrest for a time,
more or less completely, the process
of absorption and possibly of heal-
ing.

'' Furthermore, if absorption from
the wound is, even in a measure,
responsible for the toxemia so badly
borne, the area of the wound sur-
faces must be a factor influencing
the result, and, if so, there would be
in this an indication for as small a
wound as feasible in certain cases.
A vertical skin incision to avoid re-
flection of a flap might be tested,
and less complete division of the
muscles at their attachment to the
hyoid bone might suffice for the lib-
eration, in the manner described in

this paper, of the superior pole. The operation of ultraligation might
thus be effected through a hole just large enough to permit the delivery
of the lateral lobe of the thyroid gland.''

Complications and Sequelae. — (i) Hemorrhage. — Bleeding
may be so general, so difficult to localize, and so difficult to control by
hemostatic forceps that one may be forced at the operation, or at any
time during the first forty-eight hours after operation, to pack the capsule

Fig. 133. — Thyrotoxicosis.

Right (the larger) lobe and isthmus of thyroid
tumor removed. Pulse 216 at end of operation.
Rogers-Beebe serum and also bromid of quinin used
during convalescence. (See also Figs. 131, 132.)

436 OPERATIONS ON THE NECK

with gauze and, possibly, even to sew, temporarily, the capsule over
the packing. To wet the packing with adrenalin (i : looo) makes it
more efficient.

(2) Much handling of the gland during its removal may, apparently,
squeeze into the wound an amount of thyroid secretion sufficient to
cause symptoms of thyroidism} For this reason, rubber-dam drainage
should always be used at the lower end of the vertical part of the
wound.

(3) Injury to the Recurrent Laryngeal Neroe, Asphyxia, Aphonia, —
The inferior laryngeal nerve may be wounded in the operation, or
injured by pulling or contusion during operation, or may be later com-
pressed by the scar. It may already have been injured before opera-
tion. The cricothyroid branch of the superior laryngeal may suflfer
any of these injuries. Dyspnea and aphonia arising from any of these
causes need not always be permanent.^ Any of these nerve injuries

* •* * I take it that squeezing the gland may help to liberate secretion contained in the
follicles, and that the same may escape into the wound from the lymphatics in the dinded
capsule around the severed isthmus, the iNTnphalics being the normal channel for absorp-
tion of the secretion. If the condition from which these patients suffered is to be regarded
as thyroidism, and not, as Mr. Horsley has said, alhyroidism, then every possible source
of contamination of the wound with thyroid secretion should be avoided. I cannot rec-
ommend that the safe grasp of the gland should be altogether given up; but I believe that
it may be rendered harmless by first ligating the isthmus, and exercising caution in the
operation, handle the gland carefully, and at once, on the barest suggestion of the train of
symptoms referred to, open up the wound, irrigate it, and fill with dr\', aseptic, absorbent
wool.' In the first of the two cases related by Mr. Paul in the paper mentioned above,
which ended fatally just two and a half days after the operation, the wound at the necropsy
contained fluid of a very watery character. Believing that the grave symptoms were due
to absorption of thyroid secretion, Mr. Paul, when his second case began to show symptoms
which were a repetition of the first, about twenty-four hours after the operation, (opened
the wound and filled it with a dry salicylic wool. This was followed by a marked improve-
ment, but only for a time. During the second night after the operation the j)atient 'be-
came worse than ever; the temperature was 104.8° F., the pulse almost uncountable, the
respirations 36. I removed the plug of wckjI, and found it saturated wath watery dis-
charge, replaced it with dry wool, and left instructions that it was to be changed as often
as it became moist, which proved to be about every two hours. The following day she
was better in every way. The day after the temnerature was only just above normal,
and continued so until convalescence was established, but the pulse and respirations wore
down more gradually.*

** While I never squeeze the gland, but limit the handling of it to shelling it out from
adjacent imjxirtant structures, and while I have never seen the watery secretion described
by Mr. Paul, the course of the case has, on three or four occasions, so closely resembled
that described by Mr. Paul, that I cannot doubt the explanation which he gives of this
insidious and sometimes fatal complication is the correct one" (Jacobson and Steward, i,

532).

2**Inawoman, aged twenty-five, suffering from suffocating dyspnea, the operation
was followed by aphonia, which lasted for three months, and by complete paralysis of the
cords. The operation was performed with great care, and there is no reason to think that

PARTIAL THYROIDECTOMY 437

are liable to occur where the tumor is large, is very closely adherent,
very broad -in its base, when it extends around the trachea and esopha-
gus, or when it is malignant.

(4) Collapse of the Trachea, — This is rather a complication during
operation than after it. It may be due to a real defect of the rings
posteriorly, or may be due solely to great pressure of the tumor toward
the middle line during enucleation. To speak of it is to suggest im-
mediately its treatment.^

(5) Sepsis. — Infection of the thyroidectomy wound is likely to de-
velop, particularly where the tumor dips down behind the sternum,
because of the difficulty of adequately draining this region. Careful
and frequent dressings are, therefore, indicated.

(6) Myxedema {Athyroidism, Cachexia Slrumipriva). — This condi-
tion, following thyroidectomy, has now received adequate explanation
through the researches of Halsted, and the first treatment of it is
necessarily preventive, namely, to avoid removal, with the tumor, of
the parathyroid glandules.

(7) Tetany {Tetania Parathyreopriva). — Tetany following the
extirpation of a simple goiter was first described by Nathan Weiss,^

either of the recurrents was cut, but it is possible that they were bruised or stretched;
however, in four months the cords regained movement and the voice was fully restored.

" In the second case, aged twenty, a hard, mobile tumor, the size of a walnut, was at-
tached to the isthmus by a narrow pedicle, and the gland itself, though apparently some-
what hypertrophied, was not prominent, but, when exposed, it was found that the tumor
had a broad attachment to the isthmus, and that the two lobes of the thyroid were greatly
hypertrophied, closely embracing and compressing the trachea; it was, therefore, thought
desirable not only to remove the tumor, but also to dissect out the whole gland. When
recovering from the effects of chloroform, the patient was suddenly seized with cyanosis
and threatening asphyxia, and though she partially recovered, on the next day there were
aphonia, dysphagia, and uninterrupted dyspnea, and she died asphyxiated in the evening.
Both recurrent laryngeals had been cut, and the upper end of the left one was included in a
ligature.

"In June, 1894, this being my fifteenth case of removal of the isthmus and one-half
of the thyroid, I met with this complication, which was, however, not permanent.

" The patient was aged thirty-five, the subject of an ordinary solid bronchocele, of large
dimensions, the right lobe being 7 inches long. The voice was decidedly weak before the
operation, but while this presented no difficulties and was not accompanied by any cyano-
sis, dyspnea, etc., it was followed by marked aphonia, the voice being almost reduced to
a loud whisper. The right vocal cord was now found to be motionless. Complete re-
covery had taken place when the patient was last seen in April, 1895. I have recently
(February, 1899) ^^^ ^^^ patient again, on account of a Colles fracture. Her voice is
good, though a little weak. Since 1895 she has been following her occupation as a cook."
(Jacobson and Steward, i, 533, 534-)

* T. C. Witherspoon, Surg., Gyn., and Obst., 191 1, xii, 185.

2 Volkmann's Samml. klin. Vortr., 1880, vii, 1696.

438 OPERATIONS ON THE NECK

He ascribed the condition to the congestion resulting from the liga-
tion of numerous vessels during the operation. A. v. Fisberg^ be-
lieved it due to too extensive removal of the parenchyma.

F. Pineles,^ in 1906, clearly demonstrated that tetany is the result
of injury or removal of the parathyroid glands, and does not occur if
the parathyroids are avoided in doing the operation. A review of the
32 cases reported in the literature is to be found in an article by X.
Delore and H. Alamartine.^

Theodore Kocher* states that tetany occurs much more com-
monly after extirpation of the thyroid for Graves^ disease than for
simple goiter.

Tetany develops from a few hours to four weeks after operation.
The seizures are characterized by tonic flexions, chiefly of the wrist and
fingers, sometimes by convulsions. The lower limbs, face, and dia-
phragm are not commonly affected. In severe cases there is high
fever, dyspnea, and the signs of profound intoxication (vomiting,
diarrhea, albuminuria).

This complication is not, as a rule, fatal. When death does occur
it is the result either of contracture of the diaphragm, spasm of the
bronchi, or intoxication of the medulla. More commonly the case
becomes chronic and goes on with occasional muscular spasms, formi-
cations in the extremities, a little dyspnea, tachycardia, and hyper-
excitability to electric and mechanical stimuli. If all the para-
thyroid tissue has not been removed, hypertrophy of the remaining
portion may take place and recovery ensue.

The treatment in the acute stage consists in the administration of
morphin, bromids, or chloral (5 gr. an hour for five doses). In the
subacute and chronic stages little can be done. Thyroid extract is
valueless. Recently, Lowenthal and Wiebbrecht^ and E. Bircher®
have reported cases successfully treated with Freund and Redlich's
parathyroid extract, which is prepared from the parathyroids of
cattle in a manner similar to thyroid extract. The value of this
treatment has yet to be determined.

The only treatment of this lamentable complication that is known
to be of value is the surgical implantation somewhere in the body,

* Beitr. z. klin. Chir. Festschr., Billroth, 1892.

* Archiv. f. klin. Med., 1906, Ixxxv, 491.
' Revue de Chir., 1910, xlii, 540.

* Cor.-Blatt. f. Schweiz. Aerzte, 1898, xxviii, 545.
^Med. Klinik., 1907, iii, 1012.

* Ibid., 1910, vi, 1 741.

SPECIFIC CYTOTOXIC SERUM FOR THYROTOXICOSIS 439

the rectus abdominis being a convenient place, of human or animal
parathyroid glandules/

The prophylaxis of tetany consists in the careful avoidance of
the parathyroids in the performance of the operation. The sub-
capsular ligation of the thyroid vessels, with or without partial thy-
roidectomy, as described by C. H. Mayo,- seems best fitted of all
operative procedures to preserve these important structures. W. S.
Halsted and H. M. Evans,^ in an admirable article, have shown that the
parathyroids lie usually behind the thyroid gland and are just extra-
capsular. Both the superior and inferior parathyroids are supplied by
branches arising usually from the inferior thyroid artery, but occa-
sionally from an anastomotic arch between the superior and inferior
thyroids. Thus, it is seen that if the posterior capsule of the gland is
preserved, and the thyroid arteries ligated with great care to avoid
interference with the blood-supply of the parathyroid bodies, tetany
following the extirpation of goiter will be prevented.

Specific Cytotoxic Serum for Thyrotoxicosis.^— The serum
is made by inoculating rabbits or sheep with the pure proteids from
the human thyroid gland.

The serum is always given by hypodermic injection, and we have chosen
the arm as the site of injection because it is more convenient for the patient
and because the local reaction causes less trouble in this region and may
be treated more readily. The upper arm just below the deltoid should be
carefully cleaned and the injection made subcutaneously, but not intramuscu-
larly, in order to avoid too rapid absorption. In 95 per cent, of the injections
the local reaction consists only of an area of hy])eremia and slight indura-
tion which may be somewhat tender on pressure for a few hours. It quickly
clears up, and in thirty-six to forty-eight hours the arm is perfectly nor-
mal. The indurated area may in some instances be three or four inches in
diameter, and occasionally the w^hole arm has become edematous from the
shoulder to the finger-tips. Such a reaction is unpleasant, but fortunately
it is a rare complication, and if the arm is wrapped in a wet dressing, the re-
action subsides without unpleasant after-effects. The exact nature of the

* W. H. Brown (Ann. Surg., 191 1, liii, 305) artificially produced a parathyreopriva in
a dog, cured it by implantation of one parath\Toid, later removed this body Trom the dog
and the animal died within twenty-four hours in tetany. In other words, these para-
thyroids are essential to life and their loss can only be made good by their reinstatement.

2 Surg., Gyn., and Obst., 1909, viii, 602.
' Ann. Surg., 1907, xlvi, 489.

* John Rogers and S. P. Beebe, The Treatment of Thyroidism by a Specific Cyto-
toxic Serum, Mutter Lecture, College of Physicians, Philadelphia, Dec. 13, 1907.

440 OPERATIONS ON THE NECK

reaction in any given case cannot be foretold because the matter of personal
idiosyncrasy of the patient is an exceedingly important factor. It is best,
therefore, to start with a small dose and to determine the nature of the re-
action in each case before the full therapeutic dose is attempted. As has
already been stated, the very acute toxic cases take the serum better than
the mild cases, and with them it may be best to keep hot applications on the
arm for half to three-quarters of an hour after the injection, and gently mas-
sage the area about the point of puncture. Unless some quite unusual con-
dition results, no further treatment is necessary, for the condition subsides
promptly. If a second injection is made before the reaction from the first
has subsided, a more decided reaction is produced in the second instance
and the area of the first injection is again excited. Thfe local reaction is,
therefore, of value as a guide in the determination of dose and frequency of
administration. The two arms should be used alternately as the site of
injection.

The general reaction likewise shows considerable variation. In a large
percentage of cases there is no disturbance whatever; there may be, how-
ever, a slight rise in temperature, accompanied by nausea, some restless-
ness, and perhaps some increase in the tachycardia. Rarely the patient may
vomit and all the symptoms of the disease be temporarily exaggerated. If
the serum is given too frequently or in too large doses, both the local and the
general reactions become more severe. The serum must never be pushed
in the presence of a progressively increasing reaction. Serious consequences
may arise if this precaution is not observed. If, during the course of treat-
ment, an unusually severe reaction has been obtained, it is best to allow a
somewhat longer interval before the next injection, and at the same time to
reduce the dose.

The relation which the specific treatment bears to the surgical treatment
is naturally of much interest. The list of 141 patients includes 8 who have
had some surgical procedure for the condition. To summarize these cases, 5
patients tried serum first without benefit and later died as a result of opera-
tion; two were operated on before the serum treatment with good result and
were later treated successfully with serum for a recurrence of the disease, and
the last was benefited considerably by serum treatment preliminary to a com-
pletely successful operation. As far as these figures go it would seem that
if a case cannot be benefited by serum, it may be dangerous to operate; and
also that, if an operation is likely to be successful, serum may also be success-
ful. It appears to be true that the type of case which can be completely
cured by operation is a type favorable for serum treatment.

Conclusions, — This work is the first attempt to treat disease in the human
subject by means of a specific cytotoxic serum, and our conclusions, subject
to revision as experience increases, are as follows:

I. The serum has a specific effect in neutralizing the toxic action of the
thyroid secretion.

EXaSION OF LYMPH-NODES OF THE NECK 44 1

2. As a therapeutic agent it gives results which cannot, in many cases, be
attained by any other medical means.

3. Not all cases presenting symptoms of thyroidism can be treated success-
fully with serum, because not all cases are purely hypertrophic in origin.

4. The rapid amelioration of symptoms in the acute toxic cases, similar
in most respects to the well-accepted instances of neutralization of toxin by
antitoxin, is a weighty argument in favor of believing the symptoms to be due
to the toxic effects of hyperthyroidism.

5. The beneficial results of combined treatment, especially in the older
cases, indicates a dysthyroidism as well as hyperthyroidism as a factor in the
production of symptoms.

EXCISION OF LYMPH-NODES OF THE NECK

After extensive dissections, the first dressing may be covered with a
layer or two of plaster-of-Paris bandage for immobilization. If there
were no pus spilled in the wound, it should heal by first intention. If
the wound has been contaminated with pus, it may be closed, except
for a small space at its lower end, and drained with a rubber-dam or
spiral drain, but if the cavity is clean and dry at the end of operation,
it may be merely packed with iodoform or formidin gauze. This
packing or drain is usually left in place three to five days. At the end
of that time the drain is removed, the cavity swabbed out with full-
strength tincture of iodin, the skin about the wound being protected
with ointment, and the cavity may be packed again, but, better still,
exposed without any covering to direct sunlight for as many hours as
possible each day.

Tonsils and adenoids should be removed at the time of neck opera-
tion if possible. Syrup of iodid of iron should be started at once and
continued in maximum doses for at least a year, combined with general
good hygiene.

Injury to the Spinal Accessory Nerve, — A portion of the nerve may
be necessarily removed in a large mass of lymph-nodes, and this mis-
fortune may befall any patient in the hands of the most skilful surgeon.
The nerve emerges from the posterior edge of the stemomastoid muscle
at about its middle. This nerve may be identified by its position in
the outer border of the trapezius at the top of the supraclavicular
triangle. If the nerve injury is recognized, repair can be done at
once, usually with good results. Unsutured, an atrophy of the trape-
zius and a dropping of the shoulder are likely to follow. If not recog-
nized at once, a secondary suture operation should be undertaken as
soon as may be.

442 OPERATIONS ON THE NECK

Pulmonary tuberculosis is connected with tuberculous nodes of the
neck less frequently than has been thought, thus, E. S. Judd^ reports
649 patients operated upon for this condition in fifteen years, of which
19 have since died of pulmonary tuberculosis, and 9 of tuberculosis
elsewhere; 10 of the patients had phthisis at the time of operation.

The cannula designed by Briggs is often valuable in the case of
isolated abscesses in regions where cosmetic results cannot be disre-
garded. It consists of two surfaces of silver, curved laterally, bent
outward, and joined at the angle. The cut through the skin being
made {\ inch), the knife is pushed into the abscess. Upon its with-
drawal the cannula is inserted as in Fig. 134. When the joint is reached,
the external arms are closed. This re\erses it. The internal arms
open, dilating the tissues in the vicinity of the cut and retaining the
cannula within the cavity, while the external arms come together and
make a tube (Fig. 135). A projection at the end of each external arm
prevents it from falHng into the abscess-cavity, and it is fixed in situ.

Fig. 134- Fig. 135.

Figs. 118, 119. — Briggs' Self-retaining Drainage Cannula (Enlarged).

It is removed by seizing one of the external arms and withdrawing
it until the hinge is reached, when, by spreading, it is again as in
Fig. 118, and easily slides out. This cannula can be cleaned and ster-
ilized, and giv'es free, continuous, and, if necessary, permanent drain-
age through a skin-cut of barely \ inch. It reduces the cut to an
undoubted minimum, gives surgical drainage, and leaves the least
possible resultant scar.^

INCISION AND EXCISION OF CARBUNCLE OF THE NECK

If a crucial incision only is made, the wound then calls for the
general treatment of a septic wound.

^ Mayo Clinic Coll. Papers, 1910, 523.

' F. M. Briggs, Boston Med. and Surg. Jour., 1895, cxxxii, 433.

MASTOIDITIS 443

If the more modern methofl of complete excision of the carbuncle is
emplo\'ed, the problem becomes within twenty-four hours merely that
of a large granulating wound. Such a wound should be cleaned twice
a day at least, this being one of the
places where hydrogen dioxid works
well. Small suppurating jraints or bits
of slough in the margin of the wound
must be carefully removed and the
region disinfected. The dressing con-
sists of a pad, wet for the first three or
four days with salt and cilrate, and later
with glycerin or balsam of Peru laid
within the wound. The dressing is held
on by means of a bandage, the ujiper
margin of which is held up and pre-
vented from gaping from the neck by fh-. ns,— CAKBiNfi.FOFTHE nkk,
pinning it to a tape skull-cap, as in bypiiir TLuv^JsL^d.^si:'''^^■^'tll'L^lLu^^

Fig. 136. -f^..'^ -■"■■' 8..r.."« of .lr«.i„. f.„ .hc

General treatment counts for much
in these cases. The patient should be out-of-doors from the first, if
it is feasible. General stimulation shoukl be free and close attention
paid to elimination. To ))re\-ent recurrence serum treatment may !je
resorted to. {See Chapter LIT.)

BRANCHIAL CYSTS APJD SINUS
These epiblastic remains may appear in positions corresponding to
any one of the four gill-clefts, from the level of the cars to the root
of the neck. Eradication usually calls for extensive dissection. Even
after such dissection, however, at the end it may be found necessary to
leave a portion of the epithelial lining, to be destroyed later by successive
cauterizations. In any case, it is attempted to heal these wounds by
granulation. They are, therefore, packed at first and are treated as
aseptic granulating wounds. They may take months to heal.'

MASTOIDITIS
Ordinarily, shock is slight after a. mastoid operation and pain is
usually not severe enough to demand an anodyne. If it does occur
during the first twenty-four hours, the external dressing should be care-
fully examined to see if the pinna has been twisted, and reapplied.

444 OPERATIONS ON THE NECK

After twenty-four hours, if pain is present, the skin-flaps should be
examined for possible infection or swelHng and tension of the sutures.
Sutures should be removed if too tense. The patient may complain
of a soreness or stiffness of the muscles of the neck on the operated side,
due to partial or complete separation of muscular attachments from
the mastoid tip. This condition quickly subsides, but it may be neces-
sary to strap adhesive plaster o\*er the neck to assist in keeping the
muscles at rest.

The length of time that the first dressing should be left undisturbed
depends on several conditions. If the temperature remains normal
or but slightly elevated, pain absent, and the dressings dry, sweet, and
clean, the wound should not be disturbed for five or six days after the
operation. Saturation of the dressing with exudate or blood, causing
foul odor or great stiffness, is a cause for early change of dressing.

Extreme gentleness should be exercised when removing the gauze from
the wound. If the dressing has to be removed before the sixth day, it
is apt to be adherent and cause pain if force is used in removal. Welting
the gauze will so dislodge the adherent threads that their removal causes
no pain. After the fifth or sixth day the dressing is usually wet from
the excretions and may be removed without pain. Irrigation of the
woimd at the first dressing is seldom necessary. All dry blood or excre-
tion should be softened and removed by wet pledgets of cotton. Boric
acid should be insufflated into the wound cavity, sterile strips of gauze
applied loosely, and a roller bandage applied over the fre.sh dressing.
The subsequent dressings may be made every tiventy-four to forty-eight
hours, depending on the amount of discharge.

The open mastoid wound heals by granulation, and the gauze
dressing should be used to prevent the wound closing too soon, as a

MASTOIDITIS

445

sinus may result, leading to a diseased cavity. The granulations should
be small and firm. If otherwise, they should be curetted or stimulated
with balsam of Peru or, if necessary, with the nitrate of silver pencil.
If unhealthy granulations develop on the edges of the incision in the
skin, and partly close the entrance into the cavity, they should be curetted
until entirely removed. If eczema develops about the skin during
convalescence, it may be due to the
use of iodoform gauze, and soon dis-
appears after plain sterile gauze is sub-
stituted.

To avoid formation of scales and
small crusts about the auditory canal or
in the vicinity of the mastoid antrum,
Wright's citrated saline solution may be
used several times a week.

After a week, and in some cases on the
fourth or fifth day, the patient may sit up
in a chair and walk about the room. In
radical cases the patient should stay in
bed for one week, and longer if the dura
or lateral sinus has been exposed.

Healing may be complete within a
month. In some exceptional cases a
shorter period is sufiicient, or a much
longer period may be required.'

Complications and Sequelae. —
(i) Thrombosis of Laterals Sinus and In-
ternal Jugular, — This may follow acci-
dental opening of sinus during operation
(Fig. 138), or may result from advance
of the infection. If redness, tenderness,
or induration are observed along the de-
scending line of the internal jugular, immediate operation should be
done to tie the vein proximal to the clot.

(2) Cerebral abscess (epidural or subdural) is suggested by continuing
fe\er without adequate apparent cause in the wound, intense headache,
nausea, vertigo. Extensive operation is imperative if this diagnosis is
reached.

* Hammond, Jour. Am. Med. Assoc, 1906, xlvii, p. 1645.

M.lfr-

• ■

Ihaono^iiUttmtaiA Att«<>«<iii.

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r»v.vi. t, if fciijki

mEIiEEEtfibHctiifi^^:ij*

Ui
Q.

ui
v>

:>
a

2
0

107'
l«'
lOT'

'Of-

»03*
lOl*
101'
100'

130
|2«

llff
ICO

80
70
60
=yF
f5

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10

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20
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10

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Fig. 1.^8. — Mastoid Abscess.

Lateral sinus opened, packed with iodo-
form gauze. Xo apparent infection of in-
ternal jugular. Immediate drop of temf-«r-
ature when sinus-packing was removed.

CHAPTER XLIII

OPEEtATIONS ON THE THORAX

AMPUTATION OF THE BREAST

Ukcomplicated, if it has been possible entirely to cover in the area
with skin-flaps, the after-care of this operation should be only that of
a simple incised wound. The best dressing after the complete operation
is the double swathe — the first around the thorax, high in the operated
axilla, the second swathe outside the affected arm, wide enough to be
folded over the shoulders. This binds the arm to the side, gives good
pressure on the dissected axilla, and at the same time fixes the arm

(Figs. I ^q. 140). In many cases there is so much oozing that it seems
best at the end of operation to insert a rubber-dam drain through the
posterior part of the axillary flap. This drain should be removed at the
end of twentv-four to forty-eight hours. These patients may suffer
greatly from thirst, due to loss of blood. They should sit up on the
day after operation, unless the prostration of shock or hemorrhage for-
bids. Stitches out on the tenth day.

Complications and Sequelse.— (i) Skin-grojling.—l'iimnTy

EXCISION OF BENIGN Tl-IIORS OF THE BREAST 447

skin-grafting at the time of operation is being done constantly more and
more, as surgeons observe that most local recurrences are in the skin.
For treatment of the wound which has been grafted, see p. 633. On
the other hand, the best cosmetic efforts should be made which are
consistent with thorough removal.'

{2) Embolism, arising in the axillary or subclavian vein, is always
a fearful possibility. This is practically always fatal.

(3) Injury to the thoracic duct has been repeatedly observed. (See
p. 279.)

(4) Secondary hemorrhage, due nearly always to sepsis, is seen
now constantly less often. If outside pressure fails to arrest it, a few
stitches are removed and packing is tried. This failing, however, the
flap must be turned back with all precautions and an effort made to
catch and tie the bleeding vessel.

(5) Recurrence in the Scar. — The advisabiHty of immediate treat-
ment of these scars by exposure to the x-ray or carbon-dioxid snow
should be considered. fSee pp. 378 and 381.)

EXCISION OF BENIGN TUMORS OF THE BREAST

These cases should present only a small incised wound, made pre-
ferably at the periphery of the breast, where the scar will not show.

lijdpl i™

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Firm pressure should be maintained for four or live days to prevent

the cavity filling with blood or serum. Stitches are taken out in eight

I J. Wiener, .\m, Surg,, iqoq. I. 85;.

448 OPERATIONS ON THE THORAX

to ten days. If it has been possible to make a beveled incision, the
wound can be held to^elher by plaster straps, and there will be no
stitches to remove and practically no scar to be found.

ABSCESS OF BREAST

Xo amount of good after-treatment will make up for an inefficient
operation in this aSection. Drainage wounds, it is fair to say, are fre-
quently insufficient in size, and are not made at the places best adapted
for drainage. The cavity should never be curetted. It should be
distended by gauze packing (plain or chemically treated) at the time
of operation. This should be removed at the end of one or two dajs,
depending on the indication given by temperature or pain. The pack-
ing has now made the irregular cavity into a unit, .^t the first dressing
the cavity may be filled with glycerin or balsam of Peru and a small
wick or soft-rubber tube inserted. At each subsequent dressing the
wound is wiped out with gauze, the same emollient and stimulating
preparation as before poured in, and a small drain used. Salt and
citrate dressings with judicious use of Klapp's suction cups,' with or
without vaccine therapy, may cause rapid subsidence of the process.
.\ll the time a tipht sivathe and the position of the body are to be used
to favor thorough drainage. Extensions of the process must be met by
further incision, A thoroughly infected breast may be drained by a
circular Incision one-quarter to one-third of the circumference of the
base of the breast, breaking down all cavities into this incision. The
• R. L. (ie Normandie, Busloii Meii. ami Surg. Jour., 1909, cli, 601.

EMPYEMA 449

same after-treatment is used. Large suction cups may be obtained for
the application of the KJapp treatment of passive hyperemia to the
breast if indications arise.

The patient should sit up as soon as possible, and e\ery means,
physical and psychologic, should be used for legitimate stimulation.
In cases of small abscess, and in cases where the patient, within a day
or two, gets distinctly better, the flow of miik may be maintained in the
other breast and nursing shortly resumed.

A soft-rubber bobbin or spool, a tube from 1 to i V inches long, on each
end of which is a lip or flange (Fig. 144), is the best apparatus for main-
taining free pleural drainage. It is self -retaining, reaches through the
parietal pleura, and no further. The inner end, unlike tiie common

drainage-tube, does not reach and injure the lung. If a fenestrated
drainage-tube is used, a safety-pin at right angles through the outer
end will prevent the tube from slipping into the pleural cavity {Fig.
144)-

It seems best not to wash out the pleural ca\ity, though some surgeons
do it. It is apparent that each time the washing fluid is jiassed in the
same hydraulic conditions as in the original empyema are reestab-
lished for the moment, and then drained off. This alternation must
be to a degree shocking. A very voluminous dressing of sterile pads
should be applied and held by a swathe. These pads require changing
usually within the first hour, and perhaps every two or three hours in
the first twenty-four. After that, the amount of drainage may become
rai>idly less. The patient should be placed in bed with the drainage

45°

OPERATIONS ON THE THORAX

hole down; that is, he is placed on the affected side with a slight inclina-
tion backward, the first criterion in posture, however, being the position
in which breathing is least difficult. The tube must frequently be
probed with a sterile instrument or finger to see that it has not become
plugged with fibrin or blood-clot, and should Ix' kept in position in any
case about a week, and if drainage is then profuse, still longer.

These patients should be carried almost immediately out-of-doors and
best sitting up. If adeijuate protection and nursing can be provided, they
should sleep out-of-doors. Lung e.^ercises, such as deep breathing and
blowing fluid from one bottle to another (Fig. 145), should be started
as early as the end of ihe first week. In a patient who is at all intelligent,
as soon as he has the strength a tube may be sealed (Fig. 146) in the

wound (say at the end of two weeks), ant) in the end of this tube the
patient himself, from time to time, perhaps live or six times a day,
inserts an ordinary suet ion -syringe bulb and pumps (Fig. 147) from
the pleural cavity both air and pus, thus partially establishing a vacuum.
This procedure favors lung exjiansion and is a great aid to rapid con-
valescence.' The Bier hj-peremic cup is of great value, used daily
/rom the time of removing the tube till the sinus is healed.

The duration of drainage in these cases varies with the condition
of the patient, the amount of pleura! or lung disease, and the surround-
ings. Dust-free air. as in the country or at the seashore, together with
maximum sunshine, are the best tonics.

Complications and Sequelae.-d) Lack of Free Drainage.—
If the characteristic fluctuations of the chart persist after operation
'C. E. Tennant. Am. Suri;., ipio, li. 84.

EMPYEMA 451

(see Fig. 22, p. 63), an encapsulated empyema, not drained by the
operation, is to be suspected. Sometimes a finger can be introduced
through the wound to break up the adhesions and so drain such a cavity;
at other times, a second opening must be made. The possibility of

empyema on the other side, although rare, must always be ke])t in
mind. Should this arise, immediate operation might best be attempted

in the negative pressure cabinet. It may be conservative to carry the
operation along for a time by aspiration of the second side until the
lung on the first side has expanded somewhat.

452 OPERATIONS ON THE THORAX

Encapsulated empyema, which is not reached by operation, apart
from the chance of death from toxemia, may at any time rupture into
a bronchus or through the diaphragm into the peritoneum or into an
adherent colon.^

(2) Sepsis in the wound is ahvays present, and is of h'ttle importance,
unless the pus burrows into the layers of the chest-wall. This is more
liable to happen if the opening has been made so far back toward the
tip of the scapula as to go through the latissimus dorsi. Any such
spread of infection must be drained.

(3) Subcutaneous emphysema may occur if the inner end of the tube
slips, or the tube gets plugged and, at the same time, there is a wound
in the lung sufficient to allow air to be forced into the pleural cavity with
each inspiration.

(4) Cardiac Dilatatimi, — Collapse and death due to this condition
are most likely to occur at the moment of escape of pus during the opera-
tion, particularly in left-sided empyema, when the heart has been dis-
located toward the right and suddenly assumes its normal position.
Pre\entive treatment is, of course, the most important. The pus in
left-sided operation, with dislocation of the heart, should be allowed
to escape slowly, the cardiac condition being followed closely at the
same time with stimulants at hand.

(5) Necrosis of Rib. — The cut ends of the rib or, in simple pleur-
otomy, the edge of rib exposed, may become necrotic, beginning with
destruction of its periosteum. No active measures of treatment should
be undertaken until the empyema itself has practically stopped dis-
charging. At such a time — namely, eight to thirteen weeks — the dead
bone surface will probably separate itself and then heal OAer.

(6) Cerebral abscess is spoken of as a possible complication of em-
pyema. There is, apparently, little in the literature to support this
view. In abscess of the lung, however, we find a not infrequent asso-
ciation with cerebral abscess.

(7) Chronic Sinus and its Sequelce. — Where failure to heal seems
to depend upon failure of the lung to reexpand, treatment by valve or

1 One of us recently saw a case of this sort with Dr. W. W. Harvey, of Boston. The
right chest had been fiat to percussion, but an hour later became tympanitic, and at the
same time great relief of all symptoms appeared, accompanied by a thin yellow diarrhea.
Three days later a new collapse occurred, with profuse discharge from the trachea of thin,
yellow, foul-smelling material and symptoms as of drowning. At the same time distention
of the abdomen appeared, increasing, apparently, with almost every breath. Autopsy two
hours later showed an encapsulated empyema, ruptured, first, through diaphragm into
transverse colon, and, second, into a large bronchus. Every deep inspiration, favored by
valve-like action of the torn lung, served to blow up the colon.

EMPYEMA 453

suction apparatus is indicated (Fig. 147). This is especially of value in
the more chronic cases. Emil Beck's bismuth paste (see p. 277) gives
good results also. Paste No. i is injected every day while active
suppuration continues, enough to keep the cavity filled, and held in
by a gauze plug. No. 2 is used to fill the sinus after pus ceases to
form. The general septic condition is relieved almost at once, the
discharge becoming sterile in a short time. Bismuth poisoning is very
rare, but may occur. Such poisoning is treated by injection into the
cavity of olive oil at 110° F., which dissolves the paste and facilitates
its escape.*

Deformity of the chest is usually temporary and yields to treat-
ment, but long-continued discharge from the cavity is not infrequently
followed by chest deformity and scoliosis of a severe type, permanent
and sometimes extremely severe.

(8) Actinomycosis. — Ochsner says: ^*In the United States empyema
caused by an infection with the ray-fungus is not so very uncommon,
and should constantly be borne in mind as one of the possibilities,
especially as the treatment must be entirely different in case actinomy-
cosis is present. This condition can be recognized by the presence of
little yellowish flakes in discharge from the empyema which contain the
characteristic ray fungus, easily demonstrated by microscopic examination.

**In cases suffering from actinomycosis it is important to bear in
mind the fact that this disease is curable by the administration of very
large doses of iodid of potash. Small doses are of little benefit. It
seems necessary to saturate the blood thoroughly with this drug in
order to destroy the parasite- The method consists in the administra-
tion of 60 to 90 gr. of iodid of potash in a glass of warm milk an hour
after meals, three times a day, followed by a pint of hot water. In this
way the drug can be given in these large doses without causing any
marked disturbance. It is used for three days in succession, then the
patient is permitted to rest for the same period of time, when the ad-
ministration is again repeated. After about six weeks of treatment
these cases usually recover perfectly unless an undrained abscess be
present. In such case some of the parasites seem to remain where the
drug does not reach them, and from that point a reinfection may
take place; consequently, it is wise to repeat the treatment a number
of times after permitting the patient to rest for a month or two, when
he has arrived at what is considered a complete cure.''

' A. J. Ochsner, Ann. Surg., 1909, 1, 151.
2 Clin. Surg., 1902, 272.

454 OPERATIONS ON THE THORAX

ABSCESS OF THE LUNG

The abscess cavity, draining through the external wound, should
be washed or wiped out with tincture of iodin^ unless too much coughing
is caused by it, or menthol and eucalyptus, or some mild antiseptic and
deodorant, often enough to control the bad odor. A soft tube must be
maintained to the very depth of the cavity to insure healing from the
bottom. The external opening tends to heal before the lung cavity is
obb'terated. If this happens, bronchitis or bronchopneumonia follows
at once.

THORACOPLASTY
(Estlander's Operation; Schede's Operation)

After this operation, which is supposed to favor the collapse of the
firm chest-wall enough to obliterate a pleural cavity into which the
lung will not expand, there are no special directions for the care of
the woimd. The wound is packed with gauze, and the cavity which
remains is sponged every day or two with full-strength tincture of iodin,
which acts in these cases almost as a specific. This operation is not
usually performed until every effort is made to aid the lung to expand.

For details as to recent progress of lung surgery under positive and
negative pressure, reference is made to:

Samuel Robinson, Ann. Surg., 1908, xlvii, 185; Jour. Am. Med. Assoc., 1908, li, 803;
Trans. VI. Intemat. Cong. Tuberc, 1908, 73. Samuel Robinson and G. A. Leland, Jr.,
Surg., Gyn., and Obstet., 1909, 255; Willy Meyer, Ann. Surg., 1910, Hi, 34; F. Sauerbruch
and S. Robinson, Ann. Surg., 1910, li, 320.

OPERATIONS ON THE PERICARDIUM

A punctured wound of the pericardium, as from a trocar for relief
of effusion, is sealed at once with cotton and collodion. Where pus is
present, with the trocar as a guide, a free incision is made and drainage
maintained through a soft-rubber tube held, to prevent slipping in or
out, by a stitch through it and the skin. The inch or more of tubing
which is within the pericardium should be fenestrated, and after the
dressing is applied drainage of the cavity may be materially aided by
keeping the patient lying face down as much as possible.

Cardiac stimulation should be used fn these cases only for reason,
for it should be constantly in mind that the heart may be doing its best.

GUNSHOT AND STAB WOUNDS OF THE CHEST

"In the treatment of gunshot or stab wounds of the chest it is, first,
important to determine whether there is dangerous bleeding from the

GUNSHOT AND STAB WOUNDS OF THE CHEST 455

intercostal vessels or from the internal mammary artery. The former
can easily be exposed, clamped, and ligated. The latter, being located
near the sternum, between the costal cartilages and the pleura, is in a
position in which it is difficult to ligate without fear of causing pneumo-
thorax by opening the pleura. The fact that this vessel is given off from
the subclavian artery makes the hemorrhage very formidable, and the
fact that it is located behind the costal cartilages makes a hemorrhage
into the pleural cavity more likely than an external hemorrhage. In
case of bleeding from the internal mammary artery it is necessary to
bear in mind the fact that the costal cartilage can be easily cut with an
ordinary scalpel and that the external wound ig of no importance, con-
sequently a large external wound should be made over the costal carti-
lage of the next rib about the point of injury; this cartilage should be
carefully cut away for a distance of at least an inch over the point at
which it crosses the artery, and then a fine stitch should be passed
around the artery and tied. The danger from trying to perform this
operation through a small external wound is very much greater than it
is if ample space be secured by making a large external wound.

"The hemorrhage from these two sources having been disposed of,
the next important point is to secure, as nearly as possible, complete rest
of the chest-walls. This can best be accomplished by applying a plaster-
of-Paris jacket, extending from the lower border of the ribs up over both
shoulders. The patient will immediately begin to breathe by using
the diaphragm alone, and the irritable hacking cough will in most cases
subside, and, therefore, the patient will stop pumping blood from the
lung tissue into his pleural cavity. If empyema follows through an
infection caused by the injury, it should be treated according to the
method which has already been detailed.

"This point should be borne in mind above all things — that under
no condition should a wound of the thorax be examined with a probe,
because probing is one of the chief sources of infection. If plaster of
Paris is not available, or if the patient does not seem sufficiently strong
to bear its application, a protecting cast can be constructed in a few
minutes by winding long strips of rubber adhesive plaster, from 2 to
3 inches in width, about the entire chest, beginning at the border of the
ribs and working upward until the whole chest and shoulders are covered.
Several layers of this plaster may be applied to advantage. It is sur-
prising how quickly a patient, who has not been able to rest for a moment
on account of the irritation due to the motion of his chest-walls, will
become quiet and fall asleep after one or the other of these jackets has
been applied. Cases which have so far advanced that the danger of

45''

OPERATIONS ON THE THORAX

new hemorrhage is over, but in which the blood in the pleural cavity
is not absorbed, should be aspirated through a trocar or drained by
open incision or treated Hke an empyema." '

If the symptoms are not those of hemorrhage, the wound is to be
cleaned and sealed. Mechanical rest and morphin arc used to dimin-
ish the respiratory excursion and to lessen the chance of secondary
hemorrhage.^

'Ochsner, Clin. Sutg., 1901, pp. 277, 278.

' See also A. Vander Veer, Ann Surg., igog, 1, 158.

CHAPTER XLIV
OPERATIONS ON THE ABDOMEN

OMPHALITIS

This condition varies from a simple inflammation, following ec-
zema of the navel, up to a large abscess. Occasionally a case ap-
pears in which the urachus has persisted. In any case, elliptical
excision of the umbilicus is indicated down to its base, but, if possible,
not into the peritoneum. The cavity remaining is wiped out with
tincture of iodin and packed with plain or medicated gauze.

Complications and Seqnelae. — (i) Extension of the injection
may follow along the suspensory ligament of the liver and result in a
large abscess appearing after a protracted course of fever. This ab-
scess is situated on the under aspect of the liver and comes toward
the surface external to the gall-bladder. It must be drained.

(2) Urinary Fistula, — ^A persistent urachus may have given rise
to the omphalitis, coming to the surface perhaps late in life, as do
bronchial cysts. In a case of this kind, perhaps a week or a month
after operation, immense quantities of pus will be seen in the urine,
without renal or cystic symptoms. This may persist two or three days
and then cease, but at the same time a continuous leak of urine will be
discovered at the navel wound. These two conditions may alternate
indefinitely. After a reasonable time (two to four weeks) if the
fistula does not close, a radical operation, seeking to dissect out the
remains of the urachus, should be made.

(3) Umbilical hernia is a possible after-effect, unless the wound
after healing is kept reinforced by straps or corsets for at least three
months.

GASTRO-ENTEROSTOMY

'' On being placed in bed a glass female douche point is passed just
above the internal sphincter and attached to a gravity bag filled with
half-strength normal salt solution. The elevation should not be greater
than 6 inches. A small stream passed into the rectum is easily absorbed
without irritation. One or two quarts are taken up in an hour. The
patient is then placed in a semisitting posture. Beginning at sixteen to

458 OPERATIONS ON THE ABDOMEN

twenty hours, an ounce of hot water is given every hour; this is rapidly
increased, and in thirty-six hours the usual experimentation with liquid
feeding is instituted. Rectal feeding is unnecessary/' ^ The patient
may get up on the fourth to tenth day, according to his strength.

Recent investigations^ have established the fact that a gastro-
enterostomy opening will not functionate unless there is some obstruc-
tion to the normal oudet at the pylorus. This is due to the fact that
the pylorus is situated at the most dependent part of the stomach, that
peristaltic action directs the stomach-contents toward the pylorus, and
that peristalsis tends to close the anastomotic opening. If there is tem-
porary closure of the pylorus from spasm, as in cases of gastric ulcer,
the gastro-enterostomy opening will remain patent until the normal
acidity of the gastric juices has been attained.

After every competent gastro-enterostomy, bile and pancreatic
secretion will be found in the stomach, in amounts depending on the
style of operative procedure and the sufficiency of the opening. In
cases of permanent closure of the pylorus, this finding will persist, and,
so far as present observations go, it does not seem to interfere appreciably
with gastric digestion and nutrition. If it disappears, it means that
the pylorus is resuming its function, under the encouragement of the
neutralized hyperacid gastric juices.

Complications and Seqnelae. — Peritonitis is rare with a sur-
geon skilled in the technique. If it develops, the wound must be opened,
the cavity wiped out, and drained at site of operation and elsewhere if
it seems best.

Delayed hemorrhage should be equally unexpected.

Acute intestinal obstruction or gastric dilatation may occur from
kinks or adhesions. In a case of Bloodgood's^ a loop of jejunum was
found caught in the fossa of Treitz.

Persistent vomiting, not obstructive, persisting partly from habit,
may be a serious sequel of operation. The treatment varies from
stomach starvation to giving the patient whatever he wants. A case
of ours vomited everything until she demanded and got broiled beef-
steak.

If the vomiting does not stop, and bile is found in the vomitus, the
surgeon must conclude that a vicious circle has been established, where-
by, on account of a kink or valve fold at the enterostomy site or ob-

^ W. J. Mayo, Five Hundred Cases of Gastro-enterostomy, Ann. Surg., 1905, xlii, 641.
' See especially W. B. Cannon and J. B. Blake, Ann. Surg., 1905, xli, 711, and W. B.
Cannon, Boston Med. and Surg. Jour., 1909, clvi, 720.
' Ann. Surg., 1903, xxxviii, 806.

GASTRO-ENTEROSTOMY 459

struction beyond, all the bile and pancreatic juice is flowing back
through the gastro-enterostomy into the stomach. In the early days
of the operation, when a long loop (9 in.) was used, this was frequent.
At present, with the jejunal loop of minimum length or with the Roux
operation, this is less likely to occur. The only treatment is a second-
ary operation to modify the first.

Jejunal and Gasirojejunal Ulcer, — The possibility of such ulcera-
tion following this operation should always be in the surgeon *s mind.
A very thorough research on the subject has been made by Herbert
J. Paterson, of London.^ He reports 2 cases and has collected 61
others. Of these, nearly one-third were found in the line of anas-
tomosis, due, therefore, probably to technical failures in the operation
itself. For example, one case shows the ulcer to be the result of an
impacted Murphy button; another, of a retained silk suture; a third
shows infected hematoma in the suture line. He summarizes the
views as to the causes of these ulcers after gastro-enterostomy thus:

I. Hyperacidity, normal flow of bile and pancreatic juice.

II. Normal acidity or hypersecretion, normal flow of bile and pan-
creatic juice.

III. Normal acidity, diminished flow or diversion of bile and pancre-
atic juice.

IV. Normal acidity, normal flow of bile and pancreatic juice. Toxic
agent other than HCl.

V. Infective processes.

Research on the first two of these causes has been made bv Dr.
Charles Bolton.^ He says: "It appears that any strength of HCl above
the normal can act as a protoplasmic poison for the gastric cells and
will add its quota to other devitalizing influences and assist in bringing
aboiit self-digestion.''

It is true that it has been asserted that the inner row of stitches in
the anastomosis on animals seems to have little influence on the healing.
The mucous membrane around the margin sloughed, leaving an ulcer
which covered over in about three weeks. If this were true on the human,
every case is followed by a gastrojejunal ulcer. Mr. Paterson believes,
in our judgment rightly, that in humans primary union is possible through
the sterilizing of the gastro-intestinal tract in preparation and the com-
pletely aseptic technique. He is supported in this belief by the fact
that microscopic examination from recent anastomoses have not shown
such sloughing. He holds, further, that *' regurgitation of bile and

* Ann. Surg., 1909, 1, 367.

2 Trans. Royal Soc. Med., Dec, 1908, Path. Sect., p. 54.

460 OPERATIONS ON THE ABDOMEN

pancreatic juice, which takes place into the stomach after simple gastro-
jejunostomy, must be favorable to the union of the apposed surfaces by
diminishing the acidity of gastric contents as they pass through the
opening." He declares that in 24 per cent, of the recorded cases jejunal
ulcer has followed operation of the Y-t}^pe (Roux operation). Pater-
son's conclusions on the subject seem worthy of quotation.

" The necessity for prolonged after-treatment in cases of gastrojejunostomy
has perhaps not received the attention which it deserves. My rule is to
advise all patients whose gastric contents have been hyperacid before gastro-
jejunostomy, to avoid meat in any form for six months at least, and until
such time as examination shows that the gastric acidity is subnormal. The
immediate relief which is experienced by patients on whom gastrojejunostomy
has been performed, tempts them to indulge in food unsuited to the condition
of the gastric mucosa. In most cases in which gastrojejunostomy is neces-
sary, the mucous membrane is chronically inflamed, and many months
must elapse before it is restored to a healthy condition.

*^ Some surgeons, in their dread of jejunal ulcer, have maintained that
gastrojejunostomy is contraindicated in gastric ulcer with hyperacidity,
except when the ulcer is near the pylorus and is causing symptoms of obstruc-
tion. Others have even suggested that unless there be gastric stasis, gastro-
jejunostomy is useless in the treatment of gastric ulcer. I believe this teach-
ing to be retrogressive. For some years I have been advocating the view
that gastrojejunostomy is not a drainage operation.

** The success which follows this operation in cases of gastric ulcer is due,
not to drainage, but to the physiologic effects of the operation in diminish-
ing the acidity of the gastric contents, and this diminution follows gastro-
jejunostomy irrespective of the situation of the ulcer."

Wm. J. Mayo^ rep>orts 1141 gastrojejunostomies, in which, so far as
knowledge could be obtained, not a single case developed true jejunal ulcer-
ation, and he adds: " Nor have any such cases come to our clinic where
gastrojejunostomy had been performed by any other surgeon."

GASTROSTOMY

In this operation, whatever type has been used, either the simplest
or one of the complex ones, in which an attempt is made to establish
the valve-like opening, it is well to leave a tube tied in through the gas-
trostomy at the end of operation in order that for feeding the first few
days the abdominal wound need not be disturbed. This tube of soft
rubber, held from slipping for the time being by a single catgut stitch,
comes out of itself at the end of a week or ten days. After this a funnel
or stomach-tube with funnel is passed into the gastrostomy opening at

^ Coll. Papers, 1910, 61.

GASTROSTOMY 46 1

each meal time. Through the opening then is introduced at the ap-
propriate time first the usual postoperative diet, very rapidly increasing
to the full limit of the patient's digestion. If the esophageal obstruc-
tion has been so complete that the patient suffered severely from thirst
before the operation, half a pint of warm normal salt solution may
be poured into the stomach through the feeding-tube at the end of the
operation, and this should be repeated every half-hour until the thirst
is satisfied. If he has been able to drink before operation, he may be
allowed to do so aftenvard if this causes no distress; otherwise, fluid is
to be given through the feeding-tube only. After a time the absence
of irritation may cause the obstruction to be less complete, and then the
patient again will be able to take liquids by mouth. The ideal prepara-
tion of food for a gastrostomy is in the patient's mouth, and there are
many instances in the literature reported of patients who chew their
food, subject it thereby to salivary digestion, and by their enjoyment
of it stimulate gastric digestion. They then eject the food, well chewed,
into the funnel, whence it passes, if the opening is big enough, directly
into the stomach.

" Almost invariably these patients gain rapidly in weight and strength,
because the enforced rest of the stomach and intestines has usually
placed these organs in a condition in which they can thoroughly digest
an abundance of food. I have repeatedly obser\'ed these sufferers gain
sufficiently in strength in a few weeks to enable them to do hard manual
labor, which they continued to do until the carcinoma had implicated some
other important organ, either by invasion or by the formation of metas-
tases.

"It is, of course, necessary to explain to the friends of the patient
that this operation cannot result in a cure of the disease, but that it can
simply give temporary relief. This relief, however, is so great, and
the risk in obtaining it is so slight, that it is an operation which can be
very strongly recommended. Aside from the distress due to hunger,
and especially to thirst, patients afflicted with obstruction of the eso-
phagus suffer pain but slightly, consequently the relief given by this
operation is relatively very complete.''^

In benign stricture of the esophagus a bougie should be passed at
least once a month during the remainder of the patient's life, in order
to prevent a late contracture, which may otherwise come on so gradu-
ally that the patient does not recognize it until so far advanced that
it is diflicult to dilate it again.

*Ochsner, Clin. Surg., 1902, pp. 179, 180.

462 OPERATIONS ON THE ABDOMEN

Complications and Sequelae. — I. Intense pain on the intro-
duction of food into the stomach. Several instances of this have been
noted, but it seems as if in each case the cause may have been lack of
fine division or grinding of the food or the too rapid attempts to take
full diet after many weeks or months of starv^ation.

II. Acute gastritis is really an exaggerated form of what has just
been noted. It is an acute gastric indigestion following lack of careful
gradation in extending the diet list after long fasting.

III. Inanition and Exhaustion, — The operation may be postponed
until the patient is in such a state that he is too weak to rally.

IV. Sepsis may appear after any such operation either in the form
of a general peritonitis or as localized abscess bet^veen the stomach and
the liver, or on the other side behind the spleen.

GASTRECTOMY

This operation, after the results of hemorrhage and shock have been
met, presents only the problem of feeding. If the loss of blood has
been considerable, transfusion may be done, and in practically every
case saline under the breasts is to be used. Food is given on the
second or third day with much less hesitation than formerly. For
example, Ehrlich^ recommends the following diet: First day, tea,
red wine, broths; second day, bouillon with bits of meat; following
days, chopped chicken, beef, lamb, potato soup, eggs; seventh day,
ordinary diet, but made up of things easy to digest.^ W. J. Mayo's
recommendation, however, is more conservative than the German
method, and we believe it to be safer. He^ maintains the patient
in a semisitting position and continues proctoclysis at least twenty-four
hours. If there is much debilitation he gives 10 to 15 minims of cam-
phorated oil hypodermically every four hours for several days. A
nutrient enema is given every twelve hours for the first three or four
days. Hot water may be taken by mouth from the first unless it
induces vomiting.

Total gastrectomies take their nourishment in small amounts at
short intervals; thus, the case of Schlatter* took food every three hours
at first, and in the fourth week was taking a full variety of food. Eight
months after the operation this case was eating like any healthy person.

* R^v. Frangaise M^d. et Chir., 1905, 761.

^ A. Monprofit, La Gastrectomie, Paris, 1908, 119.
' Coll. Papers, 1910, 116.

* Beit. z. klin. Chir., 1898, xix, 757.

PYLOROPLASTY 463

Gradual increase in the amount leads, apparently, to a dilatation of the
region near the union of esophagus and duodenum.^

Complications and Sequelae. — (i) Constipation, — For a time,
at least, there is a greatly diminished gastric digestion, and a consid-
erable quantity of material usually digested in the stomach is, there-
fore, passed on to the intestine without alteration. The resulting con-
stipation is usually not of long duration.

(2) Diarrhea may appear for exactly the same reason.

(3) Stasis, — When feeding is first begun after operations near the
pyloric end of the stomach, motility of the stomach may be so much
diminished that stasis with decomposition of food will appear. This
should be suspected if there is a distressed feeling or sensation of weight
in the stomach region or vomiting of fetid material. Indeed, sometimes
high fever may be the only symptom. For this the stomach should be
washed out. The tube should be passed very gently, and after it enters
the stomach region, the water pressure should be very low. Nothing
approaching distention should be permitted.

(4) Persistent Vomiting. — Vomiting which continues after ether re-
covery may indicate blood or secretion in the stomach-pouch, and may
be relieved by very gentle lavage.

(5) Infection. — The possibility of this ranges from infection of the

abdominal wound up to general peritonitis, and calls for no treatment

not already outlined.

PYLOROPLASTY

Finney 2 quotes Robson as follows:

'' Concerning Points in Favor of Pyloroplasty. — (i) Regurgitation
of bile into the stomach is prevented.

(2) Secretion of hydrochloric acid, when it has been excessive,
becomes normal.

^ Dr. Harvie, of New York (Ann. Surg., March, 1900, p. 344), reports a case of gas-
trectomy where duodenum and esophagus were united by direct suture. The patient
was a woman, aged forty-six, who had had gastric symptoms for eighteen months before
operation. On examination a rounded tumor could both be seen and felt. The opera-
tion was rendered difficult by adhesions both in front and behind the stomach, practi-
cally the whole of which was infiltrated and thickened. The entire stomach was removed
and the cut surfaces of esophagus and duodenum united by means of sutures. The
entire time consumed, from the first incision until the abdomen was closed, was one hour
and five minutes. There was little or no loss of blood. Subsequent progress was most
satisfactory, nourishment being given by the mouth on the eighth day. The patient left
the hospital six weeks after the operation after taking a dinner consisting of roast beef,
mashed potatoes, ice-cream, cup of coffee, and one glass of milk. (Quoted by Mr. Jacob-
son, vol. ii, p. 326.)

2 Johns Hopkins Hosp. Bull., 1902, xiii, 157.

464 OPERATIONS ON THE ABDOMEN

" (3) If the secretion of hydrochloric acid has been diminished or
absent before operation, it remains m statu quo after operation.

'' (4) If there has been primary gastric atony, peristalsis is but little
improved.

*' (5) This function improves rapidly, or reaches perfection, if the
muscular contractility has been normal or increased and when the
obstruction was due to fibrous stenosis or pyloric spasm.

" (6) In all such cases evacuation of the stomach is accomplished in
its physiologic period, except in rare cases, and these only in the first
months after operation.

" (7) Capacity of the stomach always decreases, but rarely becomes
as small as normal.

*' (8) The pylorus recovers tone.

'^ Points of Difference Between the Results of Pyloroplasty and Gastro-
enterostomy.— (i) The absence of regurgitation of bile, and hence
absence of any biliary influence on the gastric secretions.

" (2) The function of the stomach is not accelerated, hence the diffi-
culty the stomach has in reaching its normal size.

^' (3) Slight or negative result obtained by pyloroplasty in abstract
from primary gastrectomy compared to the positive results from pos-
terior gastro-enterostomy.''

Finney now continues:

"Accumulated experience has proved that it is unnecessary and
often harmful to put patients through a long course of preliminary
treatment. Cleaning the mouth and teeth carefully with antiseptic
washes and the administration of sterile food only will quickly render
the stomach-contents innocuous. The treatment carried out in all my
cases was as follows:

"For two or three days before the operation the mouth and teeth
^^ ere carefully cleaned with carbolic solution and only sterile liquid food
and water administered. The stomach was irrigated night and morning
just before operation with boiled water. No food at all was given by
mouth for twelve hours preceding operation. Cultures were taken from
the stomach-contents in three of the cases and two were found to be
sterile. The abdominal wound is closed without drainage. Nothing
is given by mouth for the first thirty-six to forty-eight hours. Enemata
of salt solution and coffee are given every five hours for the first twenty-
four hours, after which time nutrient enemata are alternated with the
salt solution. Water in small quantities is allowed early. On the second
or third day albumin in teaspoonful doses is administered, and, if borne
well, broths and milk are rapidly added.

" Patients are not required to lie flat on the back, but are encouraged

PERFORATED GASTRIC ULCER 465

to turn, and even allowed to be propped up in bed very soon after
the operation/^

Jianu^ reports 2 cases of edema of the legs following operation for pyloric
obstruction. The urine showed chlorin retention: before operation the diet
was of milk (chlorin poor) ; after operation the diet was chlorin rich. The
edema resulted from the retention of chlorin before the system could adjust
itself to excrete the increased amount.

GASTROPLICATION

This operation is to be done only in the very rare cases of so-called
idiopathic dilatation of the stomach accompanying gastroptosis.
Since these cases will usually yield to lavage and general health im-
provement, the operation is not frequently performed.

Farquhar Curtis^ says: **If the surgeon should chance to overlook

some cause of pyloric obstruction, his patient will be sure of cure if he

survives the operation, whereas gastroplication will be useless if pyloric

obstruction exists.'^

PYLORECTOMY

Whether direct suture of the first portion of the duodenum to the
stomach has been made, or closure of the cut ends with gastrojejun-
ostomy, the shock is profound, and the principal attention during early
after-treatment is directed to meet this condition. Beyond that, the care
is practically the same as in gastrojejunostomy. (See p. 457.)

PERFORATED GASTRIC ULCER

In these cases, even though the operation has been performed within
a very few hours after the perforation, drainage is to be employed.
This drainacje is not established so much because of actual infection
of the peritoneum, but the mere escape of gastric contents sets up an
irritation which reduces the resistance of the peritoneum and gives
every favorable condition for the spread of an infectious process. Tube
drainage, preferably of the spiral type, should go down to the site of
the closed ulcer, and also' to the region of the right kidney and over
behind the spleen. If the effusion of gastric contents has been general,
it will probably be wise also, through a suprapubic incision, to drain the
pelvis. These cases, if the perforation has been found and closed, may
be given water at the end of twelve to eighteen hours; in small amounts
at first, lest vomiting appear.. At the end of twenty-four hours feeding
by rectum should be begun. A nutrient enema (see p. 140) should be

^ Wien. klin. Woch., 1910, xxiii, 994.
* Ann. Surg., 1900, xxxii, 49.

466

OPERATIONS ON THE ABDOMEN

given every eight hours with a mild soap-and-water cleansing enema
two hours before the morning nutritive. As in the case of all drainage,
the watchful '' let alone " policy is here also to be followed. The wicks
are to be started about the fourth day and extracted on the sixth or
seventh day, although at any time before then it may be necessary to
remove the wicks if there is apparently any retention of pus behind
them. With the extreme danger of residual abscess in some fossae, or up
under the dome of the diaphragm, continued drainage should be main-
tained until the temperature is normal and the pus has practically dis-
appeared. Klapp's suction-bulbs or syringe (see p. 267) may be used

with advantage. Feed-
ing by stomach should
be postponed four to six
weeks if the rectum will
endure nutritive enemas
for so long a time. The
starving stomach during
this period, particularly
as ulcerated stomachs are
usually hyperacid, may
be the source of attacks of
heart-burn, repeated per-
haps several times daily
to a distressing degree.
Sodium bicarbonate h dr.
in one-half cup of water,
will give temporary and
sufficient relief to the
symptom, and may be re-
peated many times with
no bad effects. Practice

Fig. 148.— Perforation of Pyloric Ulcer. aS tO time of beginning

Operation eight hours later. Stomach-contents diffused throughout StOmach-f Ceding after
abdominal cavity. No septic reaction. . . . • i i

perforation varies widely.
For example, Dr. Jos. A. Blake * remarks on a case of perforated ulcer
as follows:

U.L.

JHaanotis p0Tforat«d Pylorl

[c~uic«r«

iZLmJf^'lS

•f

«ll

-«

AAA^^

OlSCAsr.

/»

■r

•i
<»

1^1

C«.

CO.

«tt

K
bi
0.

2
0

a
c^
w

107*
!«•
lOS'
'Of*

•

4«

r-t

4»

■^

101'
IO(f

Try
»♦•

176

•

•*

*■

•*

¥9

^—

-9

110

ICO

80
70

bo
30

2S
20
IS

—

" Albumin-water was given on the day after operation. On the third day the patient
was given whole milk that had been coagulated with rennet and the curd then beaten
with an egg-beater and pressed through cheese-cloth, there then being no possibility of
large curds forming in the stomach. This form of milk, devised by Dr. Walter Mar-
tin, has been used with great success in several postoperative stomach cases, and is far
more palatable than peptonized milk."

*Ann. Surg., 1908, xlviii, 130.

PERFORATED GASTRIC ULCER

467

When full diet is resumed after operation for perforated gastric
ulcer, we allow the following liberal diet, the list including all things
which the patient may eat. The important rule should be not what
he eats so much as his method of eating. We direct that the food shall
be taken dry and that each mouthful shall be chewed till it is fluid.
The quantity will then regulate itself: too much will not be eaten.

Diet-list After Heaung of Gastric Ulcer, to Avoid Recurrence.

Soups:

Buttermilk,

Wine whey,

Purees and creams:

Cream,

Caudle,

Barley,

Bailed milky

Broth with egg.

Rice,

Pasteurized,

Pea,

Potato,

Butter.

Puddings:
Blanc mange,

Tomato,

Vegetables:

Cup custard.

Asparagus,

Starchy:

Junket,

Celery.

Rice,
Peas,

Rice.

Thick soups:

Lima beans,

Ice Cream:

Vegetable,

Potatoes,

Vanilla,

Noodle,

Baked,

Chocolate,

Julienne,

Boiled,

Fruit flavors.

Vermicelli,

Mashed.

Fish soups.

Water Ices:

Green Vegetables:

Orange,

Fish:

Tomatoes,

Lemon,

Broiled,

Stewed,

Sherberts.

Boiled.

Baked,

Lettuce.

Cake:

Oysters:

Plain.

Raw,

Bread:

Panned,

Stale,

Jellies:

Broiled,

Toasted,

Lemon,

Stewed,

Pulled,

Wine,

Scalloped.

Zwieback,
White flour.

Fruit.

Meats:

Sugars:

Boiled,

Cereals:

Cane-sugar,

Stewed,

Corn meal,

Honey,

Roasted,

Hominy,

Molasses,

Broiled,

Arrow-root,

Confectionery.

Hashed,

Tapioca,

Beef,

Cornstarch,

Fruits:

. Mutton,

Farina,

Oranges,

Mutton chops.

Sago,

Melons.

Lamb,

Macaroni,

Lamb chops.

Spaghetti.

Stewed:
Apples,

Poultry:

Special:

Peaches,

Chicken,

Beef-juice,

Pears,

Turkey,

Clam-juice,

Plums,

White meat,

Scraped beef,

Apricots,

Squab.

Beef -tea.
Albumin -water.

Cherries.

Eggs:

Milk toast.

Nuts:

Soft boiled.

Toast-water,

Peanuts.

Poached,

Barley-water,

Scrambled,

Gruel,

Beverages

Omelet.

Irish moss,

(on empty stomach only):

Flaxseed tea,

Cocoa,

Milk-punch,

Grape-juice,

Milk:

Eggnog,

Mineral waters.

Unskimmed,

Koumiss,

Skimmed,

Wine whey.

468 OPERATIONS ON THE ABDOMEN

PERFORATED DUODENAL ULCER

In cases op)erated on within ten hours the peritonitis is here as in
gastric perforation, also largely irritative and chemical rather than
septic. We prefer to err on the side of conservatism and, temporarily
at least, drain down to the site of the sutured perforation.

The after-treatment is identical with that of gastric perforation

(vide supra),

COLOSTOMY

This subject is a difficult one to discuss solely from the point of view
of after-treatment, since so many possible conditions and complications
may be present, depending frequently upon the great possible variety
of operations.

If the operation has been a deliberate one, that is to say, not an
emergency, or if the emergency is so moderate that it has been decided
to do the operation in two stages, the bowel presenting at the wound,
whether left or right, may be opened by a small puncture of the knife,
or burnt through with the Paquelin cautery, without anesthetic, any
time after six hours. The skin round the wound should be painted
with compound tincture of benzoin or smeared with zinc oxid ointment,
or both. A small pad of gauze or absorbent cotton will do for a dressing
while the patient is still in bed. When the patient gets up, special devices
must be used to maintain cleanliness.

The method above employed — namely, sewing the gut to the peri-
toneimi — is far from being the best practice at present. The use of
the Paul tube is much to be preferred.

The glass tulles are made in two sizes. That used for the colon measures
4] inches in length by ?, inch in diameter, has a double rim at the bowel end

and a single rim at the distal end, and is bent at a
right angle. The tube for the small intestine (Fig. 149)
is as light as is consistent with sufficient strength.
It measures 3^ in. by i in., and is bent at a right
angle at the distal end. In either case, the end with
the double rim is introduced into a small incision
made in the loop of the intestine, drawn out, if
possible, and safely cut off with aseptic gauze pack-
iG. I4Q.-PALLS UBE. ^^^ ^ pursc-stfing suture of linen thread or silk is

sewed into the wall of the gut. An incision is made within the circle of the
suture. The tube is then inserted and .secured by tying the purse-string.
The loop bearing the tube is now dropped back into the peritoneal cavity.
Feces from the tube are received through a rubber tube, and conveyed into
a bottle hung on the side of the bed. Two objections have been made to

* Brit. Med, Jour., 1891, ii, 118.

COLOSTOMY 4^9

the use of ihesc tulics. Ont\ tliat it is difTic-ult to insert the tube without
letlins the feces escajje uver Uie wound. This is certainly true when the
intestine is distended and the feces lluid. If, however, the locii to he opened
is emptied intii an adjacent Iwwel, and lcm{X)rarily ciamped if possil)le, the
introduction iif the tube is greatly simplified; otherwise, the operator may
safely trust to drawing oul the lM)wel as much as possible and isiilating it with
gauze. The other objection is that the ligature may cut h> way through ti»)
quickly, " espei'ialiy if the !)(>wcl is much congested. Thus the tube may hn
loose in two or three days; but it not infrequently remains for a week firmly
adherent. ]iartly because some of the circulation becomes reestablished behind
the ligature, and partly owing to the copious exudation of lymph, which covers

the bowel to the very end, quite concealing the ligature. The use of a
purse-string suture to fix the tube in the bowel, and the prevention uf
undue tightness in tying in the tube, will help to lessen this trouble,"''

The Paul tube comes out with gentlest traction or even by itself
at the end of five or six days, leaving a well-formed and controllable
artificial anus. If now a small and efficient device be applied, such
as that effected by H. B. Jackson (see Fig. 151. p. 473), this opening
can be kept under good control, particularly if the muscles have been
opened by the muscle-splitting or McBurney type of incision. Another
method, also simple, is the use of a small pad, conical in shape, held in
position by a truss. If the wound is iow, particularly in a more or
less prominent or pendulous abdomen, a well-fitted spring truss,
exerting only slight pressure, will serve well.

' Jaoobson and Stc^warcl, 11. 226.

470 OPERATIONS ON THE ABDOMEN

If the opening in the bowel is too large, the mucosa may prolapse,
exposing a moist, excoriated, bleeding, cauliflower-like mass on which
it is difficult to keep any dressing. If the opening in the bowel is too
small, repeated dilatation by the finger or some opener of the glove-
stretcher type may be necessary.

Feces beyond the colostomy, whether it be right or left side, may be
cleared out from time to time by enemas passed through a small catheter,
provided the stricture or disease for which the operation was done is not
absolute. If this is not feasible, into the distal bowel should be passed,
through the colostomy, either a thorough rapid salt-water irrigation,
or, if this does not suffice to cleanse the gut, any one of the approved
irritative enemas (p. 172). By this method the gut may be efficiently
cleaned throughout.

Complications and Seqnelae.— Where this operation has been
done for obstruction due to malignant disease, death may follow despite
treatment from exhaustion and toxemia — (i) due to the absorption of
toxic matter due to the obstruction and to the shock of operation, par-
ticularly if there has been much pulling on the gut; (2) due to peritonitis
from extravasation of feces or to actual suppuration. " Often it is not
due to the operation, but to the want of it at an earlier stage. Thus,
the distended bowel may have given way just above the obstruction;
often it is that weak spot, the cecum, which is found perforated after
the stress of distention''^; (3) due to bronchopneumonia, such as may
be looked for in any aged patient who has had ether. If this operation
has been done for acute peritonitis (an excellent procedure), and if all
goes well at the end of ten days, the patient may be given an anesthetic
in bed and a few No. i chromic catgut sutures taken in the rent in the
cecum. If the patient's condition is good, there is no advantage in wait-
ing longer.

Small intestine may escape between the drained gut and the edges
of the wound during a fit of coughing or straining. This must be
thoroughly cleaned and returned, best under an anesthetic, but still in
bed. When omentum protrudes, it should be left, but it should be
fastened to the skin by sutures and cut off in two or three days. Bowel
sewed to the abdominal wall under tension may tear away from its at-
tachments and begin to empty itself into the peritoneum. This calls
for immediate and thorough operation. The small intestine may
strangulate between the edge of the colon and the parietes. This may
happen at any time, near or remote, after the operation, particularly

* Jacobson, i, loi.

COLOSTOMY 471

in case of a median enterostomy, a very dangerous procedure, to be
done only under greatest urgency.

A doctor, keen observer and ingenious, suffered from general peri-
tonitis for which, among other things, cecostomy was done. He made
a good recovery, the fecal fistula remaining open, however. It re-
mained open nearly a year, largely because the doctor was too busy to
take the time to have it closed. The following is his story from the
subjective point of view:

The routine care of a colostomy wound presents several features
not generally encountered in ordinary open wounds. The amount of
the discharge is great, particularly repulsive, and is likely to be very
irritating to the skin, either from putrefactive products or from free
digestive ferments. Then, too, the wound is likely to remain open so
long that the patient frequently assumes the upright posture, and may
even become an active individual before the hole in his side closes.

It is then essential that, immediately after a^olostomy has been per-
formed, particularly if it is located high in the colon, or the contents of
the bowel are putrefying, or in any way seem likely to become the source
of irritation, an effort must be made to protect the skin. Accordingly, until
the dermal resistance has been determined, the dressing must be changed
whenever soiled, even if it be as often as once an hour. Of the remedies
generally used to prevent irritation of the skin, tinctura benzoinatus com-
positus is probably the best. At the first dressing it should be painted
on over a generous area about the wound with a camePs-hair brush,
the skin having been previously cleansed with alcohol and dried. One
coat dries quickly and is nearly as effective as two, but if the second is
applied, it must be dried ten to fifteen minutes before the dressing is
applied, else the latter will stick to the benzoin and the additional pro-
tection will be nullified. A coating of benzoin will often last a number
of hours, frequently as many as twelve, but it should be renewed when-
ever it begins to come off. If the skin is unirritated or unbroken, the
application of the benzoin is painless, but if either condition prevail,
or any of the benzoin enters the wound, an intense burning sensation,
lasting fortunately but a minute or tvvo, immediately supervenes. This
disagreeable feature, however, can be shortened to a few seconds by
briskly fanning the field as soon as the application is made. If these
two precautions are carefully observed, there should be little difficulty
in keeping the skin from becoming irritated. If, however, for any reason
it becomes so sore that it is deemed best not to apply the benzoin, a free
use of zinc oxid ointment, or, better still, an ointment such as the fol-

472 OPERATIONS ON THE ABDOMEN

•

lowing, together with extreme caution in quickly removing the discharge,
will soon relieve this distressing condition:

" 1^. Zinci oxidi oj

Bismuthi subnit 5ij

Amyli 5iv

Ung. aquae rosae ^ oij-

Often allowing the skin to be exposed to the air while covered with
ointment seems materially to assist in quieting irritation.

When the intestinal contents are normal, the skin will generally
maintain its integrity with only a little ointment smeared on at the time
of dressing, but it should be borne in mind that with any tendency to
diarrhea, intestinal putrefaction, or if cathartics are used, the skin
breaks down (probably in the latter case from digestive action) with
marvelous rapidity. I recall a case of cecostomy which had been get-
ting on well for a long time w^here the skin became nearly raw within
three hours of taking a dose of castor oil. It might be proper, how-
ever, to add that in this case the intestines contained little or no food, so
that it was pure intestinal secretion that was poured out.

The problem of the control of the discharge is often somewhat
difficult. Within a few moments enough material may be poured out in
successive gushes to soak through or escape from under a large dressing,
to the great annoyance of the patient. While he is in bed, the annoy-
ance is comparatively slight, as he may be surrounded by such dress-
ings and clothing as can be easily removed, but when he assumes an
upright posture, it will be found well-nigh impossible, even with an elastic
belt, to hold a dressing to the side firmly enough to keep the intestinal
contents, if it be at all liquid, from running down between the skin and
dressing before it is absorbed by the latter. Furthermore, if the dress-
ing is held firmly against the abdominal wall with nothing but a swathe
or elastic belt, it will slip and pull sufficiently with respiration and
the various movements of the body to irritate the edges of the wound,
perhaps already more or less inflamed and eroded by the discharge.
Both of these difficulties may be overcome in a large measure by the
following device:

Take three pieces of zinc oxid adhesive plaster, 2 to 3 in. in width
and about 3 in. long, and sew on the back two heavy dressmakers'
hooks, about f in. from one end of each strip. Place these strips,
a, 6, c (see Fig. 151), radially about the wound, so that a shall be di-

^ A better preparation is made by substituting white petroleum oil for the almond oil
called for by the U. S. P.

COLOSTOMY

473

rectly below and the hook ends of each plaster shall be about li to 2 in.
from the opening. As any discharge that reaches the plasters soils them
and tends to work them loose, it is well to stick on a guard strip of plas-
ter, rr, i to f in. wide, and lapping onto the ends of the plasters a, b, c.

These may be removed frequently without disturbing the main
plasters, and thereby saves considerable time to the attendant and dis-
comfort to the patient. If, when the main plasters are removed, they
are first moistened with ether, they will come off without pulling and
consequently without pain or injury to the epidermis.

The plasters having been placed, a dressing can be put on over
the wound, filling the space between the hooks, and a lacing passed from
the hooks on plaster a to each of the hooks on plasters b and c. This
will serve a triple purpose — to hold the dressing next the wound without

Fig. 151 — Diagram to Show Akrangement of Adhesive Plaster Strips Used in Maintaining a

Dressing in Ambulatory Colostomy Cases.

a, b, c. Squares of plaster to which are scwii dressmakers' hooks, .v, x, x, giiard strips to prevent moisture

working under main plasters.

slipping, and sufficiently firmly along its lower border to check the dis-
charge from running down rapidly, and so escaping absorption from the
large dressing of absorbent cotton placed over and below the dressing just
described, and which is held in place by a swathe, with or without an
elastic belt. Finally, in case there is no obstruction of the bowel, and
it is desired that the wound should close, this form of dressing is par-
ticularly advantageous, inasmuch as it draws the edges of the wound
together, thereby assisting in the healing. In such case, if the in-
testinal contents are normal, the plasters should be brought nearer
the wound and as much pressure placed over the opening as the tissues
will bear. Four strips of plaster instead of three, placed opposite each
other, will be found more effective for this purpose.

As to the care of the wound itself, little is required that is not

474 OPERATIONS ON THE ABDOMEN

required by other open abdominal wounds. After the tube has been re-
moved or has come away, a sterile dressing should be used for a few days,
after which plain gauze and absorbent cotton are all that are needed.
Granulations may require trimming down either with scissors or caustic.
If, when the wound has closed down to a fistula, it is packed at each
dressing with the ointment previously mentioned (which at body tem-
perature remains firmer than most ointments with a petroleum base),
the edges are less likely to become sore, and the discharge does not seem
to make its escape as readily as when no ointment is used. This latter
statement, of course, has reference only to those cases where there is no
obstruction.

From what has been said about loose and irritating discharges it
will be evident that the diet must be so arranged as to be easily di-
gested, and a moderate degree of costiveness will give rise to less local
disturbance than will the opposite condition of the bowels.

In conclusion it may be said that the successful treatment of a
cecostomy wound requires much patience on the part of the physician
and patient, and constant intelligent attention on the part of the at-
tendant. Given these, the patient, so far as the wound itself is con-
cerned, may be kept tolerably comfortable and may even lead a moder-
ately active life.

JEJUNOSTOMY

This is a very rare operation, and has the disadvantage of causing
leakage high in the alimentary tract, with escape of digestive fluids
of the greatest importance to nutrition. It has been done for cancer
of the stomach where other operations are impossible.*

The operation is performed in two stages: after the gut has become
firmly adherent to the abdominal wound it is opened, three or four
days after the first operation, and the patient is fed by funnel into this
opening. The feeding is done by giving a meal of about lo ounces
every four hours, half of it being directed upward toward the duodenum,
the other half downward toward the ileum.

INTESTINAL END-TO-END ANASTOMOSIS, OR CIRCULAR ENTEROR-

RHAPHY

The tendency in this operation is constantly toward less apparatus
and more simplicity. The choice of operation at the present day lies,
perhaps, between ConnelPs method- of direct suture. Murphy's button,^

^ E. Hahn, Deut. med. Woch., 1894, xx, 557.
^ Jour. Amer. Med. Assoc, 190 1, xxxvii, 952.
^New York Med. Record, Dec. 10, 1892.

ABSCESS OF LIVER 475

and Mayo-Robson*s* bobbin of decalcified bone, with every advantage
in favor of the first if time permits.

Enterorrhaphy by circular suturing must be admitted to be the
ideal operation from its simplicity, the entire absence of any special
apparatus, and the fact that no foreign body is left behind to give
trouble. Comparison between Murphy's button and other methods of
resection in the series of 226 cases of resection of intestine for gan-
grenous hernia, collected by Gibson,^ is, on the whole, to the advantage
of Murphy's button; for in the 63 cases in which Murphy's button was
used, there were 14 deaths, or 22 per cent., while in the remaining
163 cases, in which various other methods were used, there were 44
deaths, or 27 per cent.

The after-treatment varies litde from that of gastro-enterostomy
(p. 457). A wick is left going down to the site of the intestinal wound.
This is removed on the third day. Water is given from the first.
Rectal feeding is begun at the end of the first twenty-four hours and
continued to the end of sixty hours at least. If there are then no
signs of general or local infection of the peritoneum, liquid diet, § to
2 ounces every two hours by day, are begun and rapidly increased in
amount if no complications arise. While the rectal feeding is main-
tained, the bowel should be cleansed daily (p. 140); when feeding by
mouth is resumed, the bowels should be moved by enemas only till the
fourteenth day.

Complications and Sequelae. — (i) Sepsis or gangrene at point
oj union may show itself either in a general peritonitis or as a localized
abscess at the site of the intestinal operation, with possibly a fecal
fistula (p. 471).

(2) The Button May Not Pass, — If no symptoms arise, this need not
disturb doctor or patient. The button may make difliculty in passing
the external sphincter; it may cause obstruction in the gut and call
for intervention. It should come away by the fourteenth day. If
it does not pass, nothing but symptoms of obstruction would warrant
further operation.

ABSCESS OF LIVER

After the abscess-cavity has been thoroughly opened, a large gauze
wick is packed into it, other wicks draining the fossa below the liver
and walling off the general peritoneal cavity. The wound is covered
with a large sterile gauze dressing and the patient kept on the right

* Brit. Med. Jour., 1896, i, 451.

* C. P. Gibson, Ann. Surg., 1900, xxxii, 486, 676.

47^- OPERATIONS ON THE ABDOMEN

side in bed to encourage free drainage. The outer layer of gauze is
reinforced whenever it becomes necessary. The wicks are removed
on the fourth day and replaced, being changed daily thereafter, and
shortened at each dressing. They are left out when the discharge from
the wound ceases to be purulent and the sinus has closed to a depth of
3 in. When there is a discharge of bile, the edges of the wound must be
kept smeared with some protective salve, such as stearate of zinc oint-
ment. The stitches, if any, are removed on the tenth day.

The general principles of after-treatment to be followed do not vary
in the main from those in any celiotomy. These patients are always
extremely sick, and stimulation forms an important part of the after-care.
When recovery takes place, the stay in bed will depend largely upon the
patient's condition, seldom being less than four weeks. The patient
should be kept in bed until the temperature has been normal at least
a week and until the sinus has well closed down.^

Complications and Seqnelae. — Septicopyemia is extremely com-
mon and usually fatal. Peritonitis or empyema and septic pneumonia
may have developed before operation from rupture of the abscess either
into the peritoneal cavity or through the diaphragm. The treatment
of these complications is described in the appropriate sections.

Secondary hemorrhage may occur and necessitates repacking the
wound in the liver with a firm gauze pack. Failure to open up all the
abscess-cavities in the liver is probably the most common complication
and the most frequent cause of death after this operation. This is
usually unavoidable. All that can be done at the time of operation is to
explore the abscess-cavity as thoroughly as possible and try to open all
pockets. If after operation there is still elevation of temperature which
shows no downward tendency, it is at least worth while thoroughly to
explore the sinus again and endeavor to find an unopened abscess.

A biliary fistula frequently develops, but spontaneous closure is the

rule.

HYDATID CYST OF THE LIVER

The operation for this condition may be done in one or two stages.
If the latter, the liver over the tumor is sewed to the abdominal wound,
and the tumor is then, or three days later, incised and drained. Hemor-
rhage from the cyst wall, at the first moment of relief of tension, is met
by packing. The cavity will have to be packed firmly and may take
many months to heal. It may well be wiped out every two or three days
with full strength tincture of iodin.

If the operation is completed at one sitting, the cyst is opened and

» A. B. Herrick, Surg., Gyn., and Obst., iqio, xi, 472.

GALL-BLADDER AND BILIARY PASSAGES

477

drained and its lining removed so far as possible. The cavity is packed
with sterile gauze, and another gauze wick is passed into the abdomen
below the liver to wall off this region. These wicks are both removed
on the fourth day and replaced by a single wick into the cyst cavity.
The dressing is then done daily, the gauze drain being shortened each
time. When discharge from the sinus is reduced to a minimum, and its
depth does not exceed 3 in., drainage is omitted. Stitches are removed
on the tenth day.

The general principles of after-treatment are the same as after any
celiotomy. The length of stay in bed will depend upon the rapidity
with which the wound closes — usually about three weeks.

Complications and Sequelae. — Infection is to be met by free
drainage. Secondary hemorrhage is to be controlled by packing the liver
wound firmly with gauze.

Biliary fistulae close spontaneously, and require only that the skin
about the wound be kept in good condition by smearing it twice or three
times a day with 10 per cent, stearate of zinc ointment.

GALL-BLADDER AND BILIARY PASSAGES

Bevan's incision (Fig. 152)^ is, in our experience, by all odds the
best, the most favorable for exploration and drainage, and most effi-
cient for after-care. This is the so-called S-incision, a main vertical
arm with an extension at the upper end in-
ward and at the lower end outward if nec-
essary. Preliminary to the after-treatment
of gall-bladder operations, it should be noted
that undoubtedly surgeons remove gall-blad-
ders which had better be drained, and it is
here appropriate, therefore, to insert remarks
on the place of cholecystectomy.

" (i) Certain lesions in themselves demand
removal of the gall-bladder whenever possible.
Such are new growths and gangrenes. (2) Cer-
tain other lesions of the gall-bladder are better
treated by cholecystectomy.^ These are the con-
tracted and inflamed gall-bladders with thickened

walls. All gall-bladders which do not permit easy and efficient drainage should
be extirpated, for in such gall-bladders the risks of drainage are quite as great
as the risks of extirpation, and the one great advantage of retention is im-

^ M. H. Richardson, Ann. Surg., iSqq, xxx, 17.
* Med. News, New York, 1903, Ixxxii, 17.

Fig. 152. — Bevan's Incision
FOR Operations on Gall-blad-
der AND Bile-ducts (Keen's
Surgery).

478 OPERATIONS ON THE ABDOMEN

possible — retention of the biliary reservoir to fulfil the functions of that
reservoir, and to permit, if necessary, renewed drainage in future years.
(3) Drainage is preferable in the dilated and infected gall-bladder, which,
however, is neither gangrenous nor to any great extent changed — the slightly
thickened gall-bladder containing gall-stones and infected bile. This gall-
bladder will, after drainage, become normal, and, therefore, capable of ful-
filling the functions of a gall-bladder. Through it the biliary passages will
become effectually drained, after subsidence of the temporary swelhng about
the cystic duct. (4) As a rule, drainage rather than extirpation is demanded
in acute cholecystitis with severe constitutional symptoms, when the gall-
bladder is dilated, or at least not contracted, and when it is not gangrenous.
(5) In chronic cholecystitis, with dilatation and thickening of the gall-bladder^
especially when a stone is impacted in the cystic duct, extirpation is the pref-
erable operation, unless the stone can be dislodged backward into the gall-
bladder, in which case drainage is, if not preferable, quite as advantageous as
extirpation. (6) In simple gall-stones, without visible evidence of infection
or chronic changes incompatible with restoration of function, simple drainage
of the gall-bladder is indicated. (7) In chronic pancreatitis, whether associated
with gall-stones or not, drainage through the gall-bladder is indicated. Cho-
lecystectomy is unjustifiable, for immediate drainage is essential. Further-
more, reopening of the biliary passages may, in the future, be required.''

The after-care of cholecystectomy is similar to that for cholecystot-
omy, which follows.

CHOLECYSTOTOMY

A piece of rubber tubing, in diameter ^ to 4 in., with fairly stiff walls,
rounded at the end, with one or two windows cut near the proximal
end, is inserted into the wound of the gall-bladder. It is long enough
to reach to the deepest part of the gall-bladder. It is held in by a purse-
string suture of catgut, placed far enough from the edge of the gall-
bladder wound to allow invagination of the gall-bladder wall round
the tube. This invagination is done in order that after removal of
the tube in due time the invaginated serous surfaces will approximate
and heal. This procedure is supposed to shorten to a notable degree
the duration of the biliary fistula. A Paul tube (p. 468) of small
diameter may be used in the gall-bladder instead of rubber. It is
held in with a catgut purse-string suture. Deep in the flank, or in any
other region where bile or other possibly infective matter has reached
during the operation, a wick or some other form of drain is placed.
The skin wound is entirely closed except for these wicks and for the
gall-bladder drainage-tube. The tube is now insured against pulling
out by motions of the patient by fastening it to the skin, as it emerges,
with a single stitch.

CHOLECYSTOTOMY 479

A voluminous dressing is applied, and the swathe is so pinned that
the tube emerges between two safety-pins where the ends of the swathe
proximate. A hemostatic forceps is snapped on the end of the drain-
age-tube until the patient reaches the bed. The drainage-tube is
then connected by a glass tube to a long rubber tube hanging over the
edge of the bed into a bottle fastened to the bed-frame. Siphon
drainage is then established.

McArthur recommends (as does also MatasO connecting periodic-
ally a saline drip to the tube in the gall-bladder to allow water to find
its way into the duodenum by way of the cystic duct, thus at one time
to allay inflammation of the common duct, to restore its patency, and
to get a larger quantity of fluid high into the intestines. This may be
valuable in any very septic case of cholecystitis or choledochitis.

The dressing is changed as often as it is stained. The tube is left in
the gall-bladder for a period varying from three days to two weeks,
depending on the amount of cholecystitis originally present and per-
sisting. Whenever, after the third day, the temperature becomes normal,
the drainage-tube is removed. The dressings then have to be changed
with great frequency at first. The skin is preserved against maceration
and irritation by the application of compound tincture of benzoin, sterile
zinc ointment, or some such emollient. The fistula will remain open
for a period varying from ten days to many weeks and even months.
They always eventually close if the common duct is patent and if no
malignant disease is present. The patency of the common duct is to
be proved by investigation at the time of operation, and by the presence
of bile in the stools.

The patient has five pillows on the second and third day and may get
up in seven to ten days. These patients are so often fat and very thick-
walled that one should be relatively conservative in getting them up.
Too much emphasis has been put upon the statement that ventral
hernia is relatively rare in the upper quadrants. Some of the worst
herniae seen are through gall-bladder incisions. The stitches should
come out on the tenth to twelfth day. The bowel should be moved
from the first with calomel and the alkaline salts. If after such mild
purging for a week or ten days no bile appears in the stools, it may be
assumed that the common duct remains or has become blocked, and
ultimately further operation may be necessary.

If the patient walks, a fitted belt may be desirable to hold on the bile-
stained dressing. Toward the end of the drainage the discharge will
appear in spurts, much one day and then none perhaps for two or three
days, then drainage again, etc.

* Surg., Gyn., and Obst., ion, xii, 185.

480 OPERATIONS ON THE ABDOMEN

Anemia should be treated ; fats and milk should be diminished or
absent in the early diet. Regular daily exercise, under a gymnasium
instructor, is to be begun at the end of three months, if the scar is firm.
The daily use of artificial Carlsbad or some similar salt, and the peri-
odic use of calomel are advised to maintain duodenal cleanliness and
to prevent possible recurrence of cholecystitis.^

Complications and Sequelae.— (i) Hemorrhage, delayed or
secondary, is not infrequent m jaundiced cases and in cancer of the
gall-bladder,

(2) Peritonitis may result from escape of infected bile during opera-
tion.

(3) A sUme not found during operation may get loose from deep in
the gall-bladder and block the drainage-tube or the common duct, and
symptoms of obstruction may reappear.

(4) Persistence of jaundice and clay-colored stools mean common-
duct obstruction due to duodenitis, choledochitis, impacted stone, or
cancer.

(5) Persistent Fisttda. — Ordinarily, the discharge of bile ceases
in from two to four weeks. It may persist many months. In such a
case the skin only should be kept open with a short piece of stiff
rubber tubing with a safety-pin as a cross-piece. Exploration as to
the cause, assuming that there be no signs of common-duct obstruc-
tion, should be postponed at least a year.

(6) Hernia Through the Scar, — Though this wound is so high
in the abdominal wall, we have seen some of the worst hernias through
it, one containing practically all the intestines and omentum. The
importance, then, of preventive measures is obvious.

(7) Typhoid fever has been observed shortly after this operation,
the patient being probably, at the time of operation, a bacillus carrier. ^

CHOLECYSTENTEROSTOMY

With the improved technique by which the common duct can be
reached to remove obstructions in any part of it the operation of con-
necting the gall-bladder and the intestine is now rarely necessary.
Performed with either a Murphy button or by direct suture, it calls
for no special after-treatment. A temp)orary drain goes down to the
site of operation, to be removed, if there is no leak, within two or
three days.

* E. M. Stanton. Jour. Am. Med. Assoc., 191 1, Ivii, 441 : End Results in Gall-bladder
Surgery.

*L. Amsperger, Med. Klin., Berlin, 1910, vi, No. 36.

CHOLECYSTGASTROSTOMY 481

Complications and Sequelae. — (i) The possibility exists of
injection oj tlie ducts and the h'ver from the intestine. The chance of
this may last a long time. This has been proved in one case/ where
death occurred fifty-three days after the operation, and was found to be
due to infection of the biliary passages in the liver, exhibiting numerous
abscesses. The escape of intestinal contents into the gall-bladder can
with certainty be prevented only by short-circuiting the intestinal con-
tents by an entero-anastomosis.

(2) Contraction of the opening may take place w hatever method is
used, unless the opening is made very large.

(3) Hemorrhage from the wall of the gall-bladder is distinctly pos-
sible, especially if malignant disease is present. If packing fails to
stop such a hemorrhage, the actual cautery should be tried.^

(4) The Button May Not Be Passed. — In such a case it probably
falls back into the gall-bladder and may there cause no inconvenience.

CHOLECYSTGASTROSTOMY

No special directions are necessary for this rare operation. The
bile is in no way injurious to the stomach, nor does it interfere with
digestion.^

^ Rickard, Bull. Soc. Chir., 1894, xx, 592, quoted by Jacobson.

^ Shephard (Ann. Surg., 1893, 581) reports a patient aged thirty-six, who had a bil-
iary fistula resulting from a previous cholecj'Stotomy for jaundice, pain, etc., performed
four months previously, when no stone was found. Owing to the annoyance of the con-
tinual discharge of bile, the abdomen was opened again by an incision internal to the old
fistula and a mass of malignant disease was now found involving the pancreas and duo-
denum. It was decided to unite the gall-bladder \\ith the colon instead of the duodenum
'*as being easier and more rapid, and quite as beneficial.** The button was introduced
without very much difficulty, a purse-string suture being first inserted. Owing to the
thickness of the gall-bladder there was some puckering, and the parts did not come to-
gether without considerable pressure on the button. On dropping back the bowel and
gall-bladder with the button there was no contraction, and the parts seemed to be in accurate
apposition and to lie comfortably. It was decided not to close the fistulous opening, as it
was felt that this would close of itself. On the morning of the fourth day (the patient
having gone on well in the interval) blood was found to be oozing from the gall-bladder and
the abdominal wound. In spite of gauze packing this continued and the patient passed into
a state of collapse. On op)ening the abdominal wound it was found that the hemorrhage
came entirely from the gall-bladder. The button had cut through the thick and friable
walls and could be easilv seen. To remove the button it was necessarx* to incise both
gall-bladder and bowel and unscrew the button. It being useless to reinsert the button,
it was decided to sew up the openings in the gall-bladder and colon. A fresh oozing
took place about twenty-four hours later, and the patient sank. A partial necropsy
showed that the obstruction of the common duct was due to malignant disease of ribs
and pancreas.

' Moynihan, Brit. Med. Jour., 1901, i, 1136.

482 OPERATIONS ON THE ABDOMEN

CHOLEDOCHOTOMY

After this operation the surgeon may either close the duct by suture
or may drain the duct by rubber tube. On the whole, at the present
date, drainage is the usual course. This drainage may be direct or
indirect: direct, if a small soft-rubber tube is put through the wound
in the common duct, entering the duct and bending upward toward the
liver, held in place by a single fine catgut suture. The tube passes up-
ward tow^ard the hepatic duct about an inch. If the opening in the
common duct is large, it may be made smaller by a stitch or two to fit
fairly well the drainage-tube.

**The tube is stitched in by a single catgut suture which picks up the
wall of the common duct a little outside the edge and passes through the tube.
So long as this stitch holds, — seven to ten days, — the tube will remain in place.
In addition to this tube another drain is necessary on the outer side of the
duct. For this I prefer a rubber tube split longitudinally, with a fine gauze
wick. • The tube lies to the outer side of the duct in the kidney pouch; it may
be brought out of the abdomen incision or made to present in a stab wound
of the loin — preferably the former. A third tube, to lie to the inner side of the
duct, is occasionally necessary. The gauze wick projects about 2 inches
from the inner end of these tubes. These tubes are left in from three to ten
days, as seems necessary. There is no advantage in removing them early. ' ^
(Moynihan, Gall-stones, 1904, p. 342.)

Drainage is indirect when the wound in the common duct is closed,
and the drain is left either in the gall-bladder or in the stump of the
cystic duct if the gall-bladder has been removed. I think it is conceded
that the best surgeons agree that suture of the common duct is "always
unnecessary and sometimes harmful.''

'Tf it is deemed prudent, the common duct may be closed by suture.
This is done by a continuous stitch from end to end of the incision in two
layers. It is important to avoid wounding or penetrating the mucosa, as
any suture which gains access to the lumen of the duct may form the
nucleus of a calculus. When the wound is securely closed, a split rubber
tube, with a gauze wick, may be passed down to the duct as a matter of
precaution in the unlikely event of any leakage ensuing.'* (Moynihan^
loc, cit., 343.)

CHOLEDOCHOSTOMY

This operation is done intentionally for enormous cyst-like dilata-
tions of the common duct, the opening in the cyst being sewed to the
peritoneum.* The after-treatment is that of cholecystotomy.

^ Russell, Ann. Surg., 1897, xxvi, 692.

HEPATICODOCHOTOMY 483

CHOLEDOCHENTEROSTOMY; CHOLEDOCHECTOMY

These operations also call only for a carefully placed wick in relation
to the line of sutures as a temporary safeguard.

CHOLEDOCHODUODENOSTOMY

This operation^ calls for no special directions in after-care. The
temporary preventive drainage is placed down to the site of operation
as a matter of safety.

**One point cannot be too frequently nor too strenuously emphasized;
that is, that drainage is the secret of success in gall-bladder surgery; it is always
an advantage, often imperative. In cases of cholangitis, as made manifest
by fever or jaundice, or both, and of pancreatitis, drainage must be practised
and should be maintained for a considerable time.'' (Moynihan, p. 354.)

DUODENOCHOLEDOCHOTOMY

In this operation, first done by McBurney in 1891, the duodenum

is opened and the termination of the common duct in the second portion

of the duodenum exposed. After the stone is removed the split ampulla

is not sewed. It is rather an advantage to leave it open. If the stone,

however, lay in the second portion of the duct, the opened duct will have

to be fastened again to the duodenum. The duodenum is then closed,

and a spiral drain is put down to the line of suture for temporary

drainage.

HEPATICODOCHOTOMY

This operation needs only to be mentioned and reference made to
a single characteristic case."

** Incision in upper right linea semilunaris. The gall-bladder was found
empty and flaccid, the ducts were palpated, and a stone was felt deep under
the liver in the hepatic duct. The stone could not be pushed along the duct
nor crushed with the fingers. No stone was felt in the common or cystic
duct. After separating numerous adhesions, the stone was shoved between
the thumb and forefinger of the left hand and pulled out from its deep position.
Adhesions and duodenum were pushed aside until the stone appeared between
the fingers, with only the peritoneum and the wall of the duct covering it. The
field of operation was packed with gauze to prevent contamination with bile,
the duct was incised, and a stone the size of a robin's egg extracted. The
duct was closed at once with catgut sutures, a second row of silk sutures, in-
cluding the peritoneum, being placed outside; the duct was held with the
fingers and very little bile escaped. A drainage-tube and gauze were packed

' Thienhaus, Ann. Surg., 1902, xxxvi, 928.
2 Elliot, Ann. Surg., 1895, xxii, 86.

484 OPERATIONS ON THE ABDOMEN

down to the sutured duct; the duct did not leak, and the second day the gauze
drain was removed. On the fourth day the abdominal wound was completely
closed by provisional sutures. The patient was well in three weeks.'*

HEPATICODOCHOSTOMY

In this operation the hepatic duct is opened and sewed into the
abdominal wound.^ Drainage in these cases is intended only until the
flow of bile can be reestablished into the intestine at some later opera-
tion. No particularly new features in after-treatment are noteworthy.

HEPATICODOCHOLITHOTRIPSY

In this operation 2 the stone is crushed in the hepatic duct by the
fingers, and this procedure is usually incidental only to operation on
some other px)rtion of the biliary system. No special after-treatment,
therefore, is to be noted.

GUNSHOT AND OTHER INJURIES OF THE ABDOMEN

It is to be assumed that all gunshot wounds of the abdomen shall
have exploratory operation. This is true in civil life, at least. Treves
found in the Boer w^ar,» it is true, that many cases of abdominal gun-
shot W'Ound which had undoubtedly suffered intestinal injury, endured
prolonged exposure, and tedious transportation, yet recovered with-
out operation. Treves went so far as to conclude that it is impossible
to operate in cases in which the abdomen is traversed above the
umbilicus, owing to the multiple character of the injuries, w^hile cases
in which the abdomen is traversed below the umbilicus get well without
operation. He advises operation only w^hen the bullet has escaped,
so that its course is known, and when the general condition is good and
there are signs of abdominal hemorrhage continuing. These conclu-
sions, however, refer only to wounds produced by bullets, such as the
Mauser, w^hich does not spread on impact, is of small diameter, and
travels with great velocity. One surgeon* found that Mauser abdominal
injuries, when not immediately fatal, have been followed by a recovery
in more than 60 per cent, of cases under expectant treatment.

In civil practice, however, every penetrating wound of the ab-
dominal wall is to be explored. An attempt is made first to stop

^ Leonard Rogers, Brit. Med. Jour., 1903, ii, 706, quoted by Moynihan.

* Baillet, Bull, et Mem. Soc. de Chir.. xxix, 1194, quoted by Moynihan.
^ Brit. Med. Jour., igoo, i, 1156.

* Spencer, Med. Annals, 1901, quoted by Jacobson.

GUNSHOT AND OTHER INJURIES OF THE ABDOMEN 485

hemorrhage. Then a systematic search for injuries of the viscera is
made, but with as Uttle evisceration as possible; that is, the intestine
examined is returned to the cavity as the next loop is pulled out.
Wounds in the alimentary tract are closed by linen thread or silk suture
in every instance, unless by so closing a kink is produced; in other
words, resection is avoided when possible. Drainage should be insti-
tuted in all cases into both kidney pouches, into the pelvis, and down to
the exact region of any sutured gut about which the surgeon has the
least doubt of viability. If the lesser omentum has been opened by
bullet or operation, and especially if there is the slightest possibility
of wounds of the pancreas, efficient drainage, which, indeed, amounts
at first to packing, should be established.

In most instances the patient should be able to get on without
nourishment for twenty-four to thirty-six hours. During this period,
if possible, such peristalsis even as would be excited by mild enemas
should be avoided, though distention is present and indication for
enemas exists. At the end of this time rectal feeding should be
begun, except in those instances where the large intestine was wounded.
Rectal feeding need not continue beyond sixty hours after operation,
except for injuries of stomach and duodenum. (See Gastro-enter-
ostomy, p. 457.)

If there are no signs of peritonitis or leakage from the various
repaired intestinal unions or from the pancreas, the wicks may be
withdrawn in forty-eight hours. If for wicks the spiral drains (see
p. 252) have been used, they can be extracted without much pain and
without tearing adhesions. Except in injuries of the large intestine, as
above noted, the bowels should be evacuated solely by means of enemas
during the first ten days. Morphin should be used as little as neces-
sary, and, preferably, always together with atropin.

CHAPTER XLV

OPERATIONS ON THE ABDOMEN (Ojntinued)

THE RADICAL CURE OF HERNIA

The dressing after operations for inguinal and femoral hernia

should be bulky enough to give some compression to the wound, in

order to prevent oozing of serum or blood, such as might collect be-

tween layers of muscle. This dressing may be held on with collodion,
but I have seen the skin, which in this region is especially thin and sen-
sitive in some people, show irritation, even to the extent of blistering,

THE RADICAL CURE OF HERNIA 487

after collodion applications. The dressing is better held on, therefore,
with strips of zinc-oxid plaster and a swathe applied, as in Fig. 153, or
with two T-bandages, the crotch pieces of the two being pinned or
tied up over the groin on each side respectively; best of all, the dress-
ing may be held on by a Cunningham hernia spica. (See Figs. 155-
157.) There seems to me to be not enough advantage from the appli-
cation of a broad gauze spica bandage (Fig. 158), over the dressing, to
offset the possible dangers to newly sewed muscle layers during the
manipulations necessary in the application of such a bandage. The

same holds true of the plastcr-of-Paris spica which some surgeons apply
to maintain flexion of the thigh. Whatever form of outside dressing is
applied, care should be taken that the testicles and scrotum arc well sup-
ported and their blood-supply not interfered with, otherwise hematoma
or gangrene may result. The patient should be put to bed. with the
thigh slightly flexed by means of a pillow under the knee to avoid un-
necessary strain on the lines of sutures. The patient should be kept
practically horizontal; every means should be taken to avoid cough,
efforts toward sitting up. or straining at stool; the bowels should be
moved by enemas only for the first ten days for this reason.

OPERATIONS ON THE ABDOMEN

The single intracuticular stitch should be removed about the tenth
day. The patient should not get up before the fourteenth daj-, and

laiM nidlh ;inil >! En. lonK; si the Mhcr end of Ihe flinnd a picie 14 in. lonK. Jlie apiJiiration 19 slunrd liy
n iilacing Ibc niicherlinn n( fLinnd iiiiiltr Iht riiRhlly flcwci thinh jimL in Ihe iTiitih lh.1l the short pliisiiT rnci

many surgeons make three weeks in bed the rule after inguinal herni-
otomy in men; he should avoid heavy Hfting for three months if pos-
sible. In children under live or six j'cars of age who are hard to con-

THE RADICAL CURE Of HERNIA 489

trol it is probably best to apply the plaster-of-Paris spica bandage
outside the dressing to assist in immobilizing. These directions apply
to all varieties of operation: the Johns Hopkins operation,' the Bassini

operation,' the autoplastic suture method of McArthur/ and femoral
hernia.*

' Halsted, Johns Hopkins Hosp. Bull., 1903, xiv, 208.

' E. Bassini. Atch. t. klin. Chir., 1890, xl, 429.

' L. L. Mr.\rthur, Jour. Am. Med. Assoc., 1Q04, xliii, lo.w.

' Hayward W. CushinR. Boston Med. and Surg. Jitur., 1888, tsis, 546.

490 OPERATIONS ON THE ABDOMEN

Retroperitoneal hernia, whatever the operation/ calls for no special
after-treatment except the general considerations of celiotomy and
intestinal surgery.

After the operation for obturator hernia ^^ no special details of after-
treatment are to be noted. The stay in bed should be the full three
weeks.

Epigastric hernia ^ presents only the problems of simple celiotomy.

Interstitial hernia,^ whether ventral or inguinal, calls for no detail
of after-treatment different from those already given.

Umbilical hernia ^ is undoubtedly best treated by the operation of
the type of Mayo. The dressing after this operation and that for
ventral hernia should be held on, and all tension on the wound removed
by the application of a large number of plaster straps in many direc-
tions, and also by a snugly pinned abdominal swathe. There is prob-
ably no increase of pressure if the patient sits partly reclining on a
bed-rest, if such a position is more comfortable. The bowels should
be kept freely open by enemas to avoid all straining at stool. The
skin stitches are removed on- the tenth day; the wound is kept rein-
forced by plaster straps for at least three weeks, and an abdominal
belt is usually advised. The patient should be in bed at least eighteen
days.

Complications and Sequelse.—d) Pulmonary or cardiac embo-
lism are always fearful possibilities, more probably if a large hernia of
long standing has been reduced or if a considerable mass of omentum
has been tied off and removed. (See Large Incarcerated Hernia, p.
492.)

(2) Sepsis should be uncommon. It usually starts in or just under
the skin, and should be checked at once by removing the skin-stitch
and applying a series of wet dressings. Deep sepsis may require
a thorough opening of the whole wound, sacrificing the cure of the
hernia to preserve the life of the patient.

(3) Persistent sinus may follow sepsis. The sinus will be found to
lead to a non-absorbable suture. If this does not come out in a few
days, the sinus should be explored with a fine crochet-hook till the
offending knot is found and extracted.

(4) Recurrence of the hernia may be seen as early as six weeks.

^ B. G. A. Moynihan, Retroperitoneal Hernia, London, iSgg, reviewed in Ann. Surg.,
1903, xxxvii, 120.

- Schopf, Wien. klin. W'och., 1903, xvi, 8.

* H. A. Lothrop, Boston Med. and Surg. Jour., 1901, cxlv, 589-611.

* P. Berger, Revue de Chir., Paris, Jan., 1Q02.
^ W. J. Mayo, Ann. Surg., Aug., 1901, xxxiv.

THE RADICAL CURE OF HERNIA 49 1

When so early, if not due to sepsis, the recurrence may be laid to
poorly nourished, worn-out tissues, as in the aged, or to giving way of
sutures. We believe catgut, except for superficial fascia, to be un-
suitable for this operation. Pagenstecker linen thread. No. 14 twisted
silk, kangaroo tendon, or silver wire ^ we believe to be more reliable.

(5) Slough or gangrene of testis will follow unnoticed or unrepaired
accidental wounding of the vas or the formation of one or both new
rings so tight as to shut off circulation in the cord. Unless the fault
IS discovered at the time of operation or within a few hours, the testis
will have to be removed, either in pieces from the sloughing wound or
as a whole, by formal operation.

Truss After Radical Cure for Hernia.— Drs. Bull and Coley
say: ^'Personally, we never advise a truss in children after operation,
and we consider the recumbent position for three montns entirely un-
necessary. Our experience, based on a series of upward of 600 cases of
hernia in children under fourteen years of age, has shown that two to
two and a half weeks is ample time for the child to remain in bed. The
subsequent history of these cases has been traced with scrupulous care,
and some of them have been well upward of seven years. Even in
adults we very seldom advise a truss after operation. There are, how-
ever, some cases in which a permanent cure will be more likely to be
obtained if a support be worn after operation. Such cases are those
beyond middle age, with poorly developed and Habby abdominal muscles
and a superabundance of fat. We would also include cases in which
hernia is of unusual size in adults past middle life."

It would seem reasonable, therefore, where an operation fairly satis-
factory to the operator has been done, to await signs of recurrence before
ordering a truss. Certainly the abdominal belt, with a plate in it
pressing over the scar, is not to be advised. It causes* local pressure
ischemia, and, therefore, slow healing of the wound, and renders the
abdominal muscles more flabby and more liable to stretch. A hernia
patient should be advised to avoid strenuous exercise in a position such
as would tend to open possible hernial orifices. For instance, he may
be advised not to lift heavy things unless his knees are kept together:
not to lift himself up by his hands, as in horizontal bar exercises or
climbing a mast.

In children under two years inguinal hernia can frequently be cured
by the use of a truss. For this purpose a worsted trtiss is to be advised
because of the cheapness and cleanliness. When soiled, it can be changed
and washed; it can be worn in the bath, and is less likely to irritate the

^ J. Wiener advocates silver filigree. Ann. Surg., 1910, lii, 678.

492 OPERATIONS ON THE ABDOMEN

skin than a spring truss. To apply such a truss the child is laid on his
back and the hernia reduced, a half skein of white Germantown worsted
is passed under the body at the level of the hernia, and is pulled through
until the end on the side of the hernia just reaches the internal ring;
the other end is passed through the loop of the first end, the bunch of
worsted, made by looping one end through the other, is then adjusted
firmly over the hernial opening, and the free end is passed under the
crotch and fastened by a safety-pin or a bit of bandage to the middle of
the part passed around the back. This truss should fit snugly, and
should be worn at night as well as during the day. The success of this
method depends upon the care with w^hich the mother carries out in-
structions in regard to adjusting the truss frequently.

LARGE INCARCERATED HERNIA

The fatal issue in many of these cases is due to the sudden and marked
increase of intra-abdominal pressure, especially limiting the function
of the diaphragm, which follows the reintroduction into an abdomen,
which has long since become too small to hold it, of a large mass of in-
testine and fatty omentum. If it seems best to operate these cases, they
should be submitted for a considerable period, whenever possible, to a
regimen that shall definitely reduce weight. By these means the mesen-
teric fat diminishes and the abdominal wall becomes thin.

The following history, which illustrates this point, is by the French surgeon, George
iVmaud, who published in 1748 *'A Dissertation on Hernias or Ruptures," quoted by
Marcy (Ann. Surg., 1900, xxxi, 71):

"Mr. Boudon recommended to my deceased father a man of forty years of age and
of a very strong constitution. He was extremely fat and 6 ft. i in. in height, French
measure. His name was Mr. Tregneux, was an inhabitant of Clamsey, in the diocese of
Auxerre. He had an hernia from his infancy, which had never reentered. It was 32 in.
in circumference at its lowest part, 19 at the ring, and 16 in length. For more than ten
years his penis had been lost in the bulk of the tumor, so that the preputium formed a kind
of depression like that of the navel, and in making water his urine was diffused over all
the tumor, which was very troublesome to him. As he was a timber merchant, his business
obliged him almost every day to ride forty or fifty miles on horseback, which induced him
to invent a large cavity in the fore part of his saddle, in which he placed his tumor. Being
at last reduced to such a condition that he could no longer follow his business, and being
afraid that this disorder, no less terrible than insupportable, would soon put an end to his
life, he determined to apply for relief. It was in 1726 that he was introduced to us. He
found a great deal of comfort from the recent example, which my father and I gave him,
of the cure of a similar disorder. He submitted to everything we prescribed, either for
his relief or radical cure, but on condition, said he, that he should have a little to eat, for
he was a prodigious glutton. Persons of this kind may observe a very strict regimen,
even by eating a litUe. We may, therefore, recede from the general rule in their favor
without any fear of doing harm, for their great appetite requires this kind of Uberty. He
was bleeded several times, then purged, and afterward used 12 or 15 baths. Twice
a day I made strong embrocations of his abdomen with oil of melilot, and covered the
whole tumor with a plaster composed of the emplastrum de vigo, prepared with a good

LARGE INCARCERATED HERNIA 493

deal of mercury, of the diabotanum, and the mucilages, and this I renewed every four
days. We made him every morning take lo, 12, 15, or 20 gr. of mercur. dulc. He drank
plentifully, and had four emollient and purgative clysters injected every day. Every four
days we purged him with cassia, with an intention to evacuate the humors and prevent
a salivation. This method succeeded very happily, for the evacuations lasted sixteen
days, and were so copious that they every day redoubled the patient's astonishment.

"The tumor during this time had lost about three-quarters of its bulk, and more than
a half of the remaining quarter we made to reenter by taxis, so that the hernia, being thus
reduced to one-eighth part of its bulk, was in a condition to be contained in the hollow
cushion of a truss. It afterward diminished insensibly for eight or ten days, during which
time we took care to fill the cavity of the cushion, in proportion as the bulk of the tumor
diminished. On the thirty-sixth day from the first venesection the parts reentered all
together and the testicle also. We then used a convex instead of the concave cushion.
The patient in a very short time resumed his strength and flesh, and followed his business
with a great deal more vigor than ever he had done. The first thing he did at his return
home was to make his wife pregnant, with whom he had had no amorous converse for ten
years before. He quitted the use of the truss eighteen months after; that is to say, in
1728.

"Twelve years after, he had occasion to come to Paris, where he called for me immedi-
ately on his arrival, rather to testify his gratitude than for any other reason; but as I did
not know him, he put me in mind of everything that had happened in 1726. I examined
the parts, which I found so firm and solid that one could have hardly imagined that he had
formerly labored under an hernia. The skin of the scrotum was returned to its natural
state, only it was very thick; and the bottom of the scrotum, which had approached to
the ring on account of the herniary sac of the testicle, was fixed or glued over the ring.
This portion of skin seemed to make a kind of stopper, which filled the cavity of it. But,
though the disorder had no appearance of a relapse, I ordered the patient to wear a truss
by way of prevention. The reason of which I shall afterward give in a particular instance.
From this observation it is sufficiently evident that what at first appeared a paradox is a
truth easily perceived by persons of penetration; but, as it may perplex the more ignorant
and illiterate part of mankind, I shall, for their sake, render it still more intelligible by a
method of reasoning as clear and perspicuous as I possibly can.

"The parts had insensibly accustomed themselves to this new abdomen which nature
had formed for them. They had there fixed a permanent residence for themselves, whence
it was impossible for them to remove on account of the adherences they had contracted.
Without the methodical assistance afforded it was impossible that they should ever of them-
selves have reentered the abdomen, but by the disposition into which they were put they
were forced to resume their natural place, though they were lean and emaciated, yet when
they were reduced, they resumed their former bulk, in the same proportion as all the other
parts of the body resumed their flesh. Now they could not slip out again, after they were
once in the abdomen, because they were become larger than the diameter of the ring, so
that the patient must necessarily have been cured long before he left off the use of the truss.
The following fable applied to this subject will more sensibly enable us to comprehend
what hinders these sorts of hernias from reentering and what obliges them to remain in the
abdomen after they are reduced.

*Into a wicker cask, where corn was kept.
Perchance of meagre crops, a field mouse crept;
But when she fill'd her paunch, and sleek'd her hide.
How to get out again, in vain she try'd.
A weasel who beheld her thus disturb'd,
In friendly strain the luckless mouse addressM,
'Would you escape, you must be poor and thin,
To pass the hole thro' which you entered in.'"

(Horace, Lib. I, Epist.)

494 OPERATIONS ON THE ABDOMEN

After operation the patient should be sat up at once in bed with
proper support to the wound, to diminish diaphragmatic pressure and
to forestall the occurrence of thrombosis and pneumonia. An abdominal
swathe should be worn for six months at least, and, in especially gross
patients, permanently.

Cardiac embolism and thrombosis or pulmonary embolism are much
to be feared, especially if the hernia was largely omentum and much
was resected. For an illustrative case see Chapter IX, p. 114.

STRANGULATED HERNIA (INGUINAL OR FEMORAL)

The patient should be kept in such a position in the bed that there
is little or no strain on the wound. It is theoretically good, at least, to
have the buttocks slightly raised above the level of the trunk, in order
that the reduced bowel may not lie in contact with the freshly sewed
ring and so become adherent to it. The patient should be given water
freely as soon as it can be borne by the stomach, but no voluminous
food-masses should be taken in for at least a week, in order that the in-
jured gut may have a chance to heal. The bowels should be moved by
enemas only, in order that no violent peristalsis shall take place above
the level of the injured gut. Even though such a wound as that of
strangulated hernia is supposed to be aseptic, it should not be allowed
to go a week or ten days without inspection; first, because the effort to
reduce the strangulated gut or the spilling of the serous content, so
often seen in the sac, may have infected the wound to some extent;
and, second, especially if the patient be an elderly person, there may
be no sign in temperature or pain to suggest sepsis, and yet examination
of the wound shows a considerable and wide-spread infection.

After the first few days, if it has been possible at the time of operation
to make a radical cure^ the case should receive the usual after-treatment
of a hernia operation. (See p. 486.)

If the condition of the gut was such that it seemed best to drairr
the wound, or if, as may be the case in strangulated femoral hernia, so
much of Gimbemat's ligament had to be cut that there is little chance
that an efficient closing of the defect has been made, it is well, while the
patient is still in bed, to have him measured and fitted to a truss, with
the idea of allowing him to get out and about for a time, and later, if
necessary, have him come back for a secondary operation.

Complications and Sequelce.— (i) Peritonitis, — This may be
due to the operation having been done too late, infection taking place by
actual rupture of the bowel or from transudation from the strangulated
part, or from the reduction of hernial contents, bowel, or omentum,,
^hich seem to the operator to be viable, but are not so.

STRANGULATED HERNIA (iNGUINAL OR FEMORAL)

495

(2) Sepsis. — Local sepsis is fairly common in cases not operated
within a very few hours. This complication calls for no special com-
ment here.

(3) The descent and restrangulation of the bowel where radical cure
was not attempted.

(4) Obstruction due to paralysis of the damaged intestine.

(5) Unobseri'ed reduction en bloc of the hernia during operation, or
multilocular hernial sac with a false reduction during operation from
one part of the sac to another.

c« 1

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. 1

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Fig. 159. — Large Ventral Hernia. Marked Aseptic Reaction.

Reduction en bloc ^^ is chiefly met in inguinal hernia owing to the
slight surrounding adhesions of the sac and sometimes to the force used
in attempts to reduce large hemiae. The sac, still strangulating its
contents at its neck, is displaced bodily between the peritoneum and the
muscles; or the sac is rent close to its neck and at its posterior aspect,
and some of its contents are thrust through into the extraperitoneal
connective tissues. The chief evidence of this occurrence is: though
the sw^elling has disappeared perhaps completely, this has taken place

496 OPERATIONS ON THE ABDOMEN

without the characteristic jerk or gurgle. On close examination, though
the bulk of the hernia has gone, some swelling is to be made out deep
near the internal ring, and the symptoms persist in an intensified form.
A second operation should be done immediately.

(6) Ohstriiction of the intestine by adhesions to the abdominal wall.

(7) Cicatricial stricture of the gut at the site of former strangulation.
These possible pathologic features must be in the mind of one who

watches symptoms after operations for strangulated hernia.

OPERATIONS ON THE PANCREAS

Acute Pancreatitis. — The wound in this fairly uncommon and
frequently fatal disease is packed with gauze, which acts, first, to stop
bleeding, and, second, to establish a drainage tract. Drainage in cases
of subacute pancreatitis, and often also in pancreatic cyst, is estab-
lished by the so-called lumbar route; namely, through a loin incision in
front of the left renal vessels.^ Such a wound follows the route usually
taken by nature when pancreatic suppuration points spontaneously.
The wound drains freely assisted by gravity, and presents no technical
peculiarities, if the first wicks are left in long enough to favor a large
direct drainage opening. Alcohol bathing, zinc oxid ointment, and
other means must be constantly employed to protect the skin round
the woimd from irritation and digestion.

Shock, sepsis, and hemorrhage are all here present, and are hardly
to be differentiated in importance. The usual indications thus suggested
must be followed. Most of the dangers should be over by the end of the
fourth day, after which convalescence should be rapid.

The wicks should gradually be withdrawn and made smaller. If
there is no contraindication, the sooner the patient is out of bed the
better.

Complications and Sequelse. — (i) Delayed and secondary
hemorrhage are very common, owing to the extreme vascularity of the
pancreas. This danger is so great that it may indeed be wise to exhibit
large doses of calcium lactate (see Chapter VI, p. 71) in operative
cases where the diagnosis is made and time permits.

(2) " In leakage of pancreatic juice into the parenchyma of the gland
and the surrounding peritoneal structures consists a greater danger
even than bleeding. The juice, even when sterile, does much positive
damage, which also diminishes the resisting power of the tissues so that
the mildest form of infection, ordinarily harmless, becomes of the gravest
significance. Infection is liable to reach the injured area through the

* J. Ransohoff, Ann. Surg., igio, li, 670.

OPERATIONS ON THE PANCREAS 497

pancreatic duct from the duodenum, in the same manner that it
passes up the common bile-duct; fat necrosis and pancreatitis, both
chronic and hemorrhagic, may be occasioned by trauma and hence
may result from operation. Peritonitis is very liable to result from
pancreatic leakage. This peritonitis may be aseptic, and is followed
frequently by intestinal paralysis, leading to rapidly developing ob-
struction, which often so modifies the symptoms as to lead to a serious
mistake in diagnosis." ^

Chronic Pancreatitis and Pancreatic I/ithiasis.— Operation
for this condition is very rare. G. Link^ reports a case wherein he
carried the tail of the pancreas through the abdominal wall, removed
the stones, and then drained the duct of Wirsung with a tube. The
drainage was collected at the wound in a rubber condom.

Wounds of the Pancreas. — Any wound of the posterior stomach
wall suggests that the same agent has made a wound of the pancreas.
Such a wound, therefore, is always sought, and if found, is packed with
a view to establishing drainage, because of the great danger of pancre-
atic leakage even through a small wound.

Drainage of Pancreatic Cysts.— These cysts are alwa>^
drained, and such evidence as we have seems to show that some
must be permanently drained, since, at least in those cases where
many of the principal ducts of the pancreas communicate with the
cyst, recurrence is almost certain and complete obliteration by
drainage almost impossible. In Mr. Jacobson's case ^ the swelling
reappeared about a year later, and is even said to have appeared a
third time after the second operation.

Dr. M. H. Richardson^ some years ago called attention to this lia-
bility to recurrence in drained pancreatic cysts:

" The patient was twenty-one. He had received a kick in the abdomen
three years before, which had confined him to bed for three weeks. Ever
since he had been liable to suffer attacks of epigastric pain. He had been
markedly jaundiced, was emaciated, and suffered a good deal from nausea
and depression. The swelling in the epigastric region was convex and uni-
form, and reached from below the tip of the ensiform cartilage to just above
the umbilicus, and laterally to near the ends of the eleventh rib. The tumor
gave the impression of being attached to some deep-seated structure. There
was trasmitted impulse synchronous with the pulse, but not expansible.

* Von Mikulicz, Trans. Cong. Am. Surg, and Phys., 1903.

* Ann. Surg., 1911, liii, 768.

* Trans. Med. Chir. Soc, Ixxiv, 455.

* Boston Med. and Surg. Jour., 1892, cxxvi, 441.

498 OPERATIONS ON THE ABDOMEN

As the swelling had refilled after two previous tappings, and as the swelling
and the patient^s distress were steadily increasing, laparotomy was performed.
An incision 3 in. long was made over the most prominent part of the cyst,
I J in. to the left of the middle line, extending to within i in. of the umbilicus.
The parietal peritoneum having been retracted to the margins of the wound,
the lower edge of the liver could be seen moving with respiration in the upper
angle, while the rest of the incision was occupied by a smooth reddish surface
which bulged strongly forward. Taking this to be the front of the cyst, and
having ascertained before the operation that the cyst was dull on percussion,
I was about to leave this for twenty-four hours, to become adherent before
it was mcised. The result proved that, if I had done so, the scalpel would
have passed through both walls of the stomach. Before dressing the wound
I again scrutinized the surface of the supposed cyst, and thought I found
evidence of involuntary muscular fiber, which threw doubts upon the swelling
being a pancreatic cyst. When the supposed cyst was examined between the
fingers, it proved to be the empty stomach, stretched very tightly over the
subjacent cyst. To get at this the stomach was drawn upward, that it might
be packed away above under the liver; but here an embarrassing difficulty
arose. As I pulled up the stomach, it was tightly jammed between the bulg-
ing cyst behind and the parietes in front; the omentum came up into the
wound in front of the cyst. The tension on the parts was so great, owing to
the rapid increase in the cyst, that there was no room above in which to pack
away the omentum. Pushing this to either side, already fully occupied, I
pulled down the stomach again. I accordingly drew the greater part of the
omentum out of the wound,* some of which was tied with catgut, and cut away:
most of it was left heaped up on the abdominal walls on either side of the in-
cision. One or two fine catgut sutures retained the omentum in position.
I next scraped through the two layers of the omentum, and exposed the sur-
face of the cyst for a space the size of a quarter. There was thus a some-
what conical passage leading from the abdominal incision, through a mass of
omentum, down to the anterior surface of the cyst. This last was very vas-
cular, and so tense that it was not thought advisable to put in a guide suture.
The patient passed through the next twenty-four hours fairly well. At mid-
night, August 23d, symptoms of collapse set in (hemorrhage probably took
place at this time into the cyst, a complication which must always be probable,
owing to the very vascular surroundings) ; the patient^s pulse at 2 a. m. had
run up to 163, and his condition pointed to a fatal ending at no distant date.
At 3 A. M. I passed a fine trocar into the cyst, and drew off 12 oz. of deeply
blood-stained fluid under very high tension. The sac was then incised and a
large drainage-tube inserted. A marked improvement at once set in. A
slight discharge of dark, treacley fluid necessitated changing the dressing twice
a day at first. The wound was all healed in two months.'^

* ** On another occasion I should divide the omentum by the transverse colon."

SPLENECTOMY

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SPLENECTOMY

This operation has been done^ — (i) for large wounds of the spleen
from gunshot or other injury; (2) for cyst, though this rare condition
if drained will always heal; (3) for
movable spleen; (4) for malignant
disease-; (5) for persistent malarial
tumor; (6) for splenic anemia or leuke-
mia. Of all these indications, the most
favorable is that of injury. Other-
wise healthy persons with spleen re-
moved seem to live on for years in per-
fect health , with no physiologic changes
to be observed, even in the blood.

The Mayos^ have had 10 splenec-
tomies with 9 recoveries. One was
lymphosarcoma, alive and well three
and one-half years after operation ; i
tuberculosis of spleen ; 4 were cases of
splenic anemia, 2 were Banti's dis-
ease, of whom I died; and 2 were en-
larged spleens of unknown origin.
The 4 splenic anemia cases had pain
in the long bones at intervals for sev-
eral months after the operation.

Complications and Sequelae.
— (i) Secondary hemorrhage has been
repeatedly observed, and apparently
in every case it has been due to re-
traction of one or more vessels from
the pedicle. In such cases the pedicle
has been tied when tense or each liga-
ture has taken in too great a portion
of the pedicle. Hemorrhage may take
place, due to general ooze from the
cavity in which the spleen was ad-
herent or from adherent omentum.
Should the stasis at the end of opera-
tion be in any way unsatisfactory,
the cavity must be packed for twenty-four to forty-eight hours.

•3

to
00

10
00

' J. Collins Warren, Ann. Surg., 1901, xxxiv, 521.

2 C. Bush, Primary Sarcoma of the Spleen, Jour. Am. Med. Assoc, 1910, liv, 453.

^ Coll. Papers, 19 10, 491.

SOO OPERATIONS ON THE ABDOMEN

(2) Sepsis. — There is no particular liability to sepsis after splenec-
tomy. There have been some observations which seem to show that
the spleen is at least one of the organs which is important in the work of
resistance against bacteria, but it is "proper to conclude that the re-
moval of the spleen does not alter particularly the individual suscep-
tibility to infection, and that its functions in this respect, if they do
actually exist on its removal, are readily taken up by other organs."^

May 22, 1907, one of us (L. R. G. C.) operated upon F. A. R., thirty-six,
male, spleen ruptured in an automobile accident. Splenectomy was done;
drainage left in forty-eight hours. Convalescence was complicated by ab-
scess of left lung, which to some extent must have modified the blood-count.
The man recovered in due time and is active and well at the present day
(Nov., 191 1), with no apparent physiologic abnormality. The blood-counts
are shown in table (p. 499).

APPENDICOSTOMY

This operation was first proposed by Keetley,^ who suggested that
by bringing the appendix through the abdominal wall and amputating
the apex it might be used as a spout to relieve the distention of a case
of obstruction occurring at a point below the cecum. The first
operation was done, however, by Weir,^ who used it for treatment in a
case of ulcerative colitis. In brief, the appendix is brought out
through a small incision, which must not be of the McBurney type,
lest muscle contracture cause slough of the appendix. Care being
taken to avoid 4:wists or constrictions of the appendix, it is pulled
out until the cecum is in contact with the parietal peritoneum.

Two or three days later, without anesthesia, the tip of the appendix
is sev^ered within \ in. of the skin and any bleeding point secured. The
exposed mucous membrane is caught, pulled out a little, and fastened
by one or two stitches to the edge of the skin. A rubber catheter is
introduced into the cecum, and, if desirable, irrigation or other treatment
can be given at once. If the lumen is small, it will readily dilate with a
catheter. Immediate opening of the appendix at the first operation
may be done, if necessary, with little danger. An illustrative case will
probably best show the post-operative details of appendicostomy.

"A fish-hawker, aged twenty-six, who had been a soldier, and had had
two attacks of dysentery, in Africa in 1900 and in India in 1906, complained
of six to eight motions of blood and slime daily, without pain and with no

* J. C. Hubbard, Boston Med. and Surg. Jour., 1909, clx, 746.

2 Brit. Med. Jour., 1894, ii, 1155.

^ New York Med. Record, Aug. 9, 1902.

APPENDICOSTOMY 5OI

marked emaciation. His general condition was excellent; the sigmoidoscope
showed considerable edema of the tissue, with marked inflammation of the
mucous membrane and superficial ulceration, especially marked at places
exposed to friction, such as the edges of the rectal folds.

'^Appendicostomy was performed on July 23, 1907, by Mr. Swinford
Edwards. Four days later irrigation was started, 6 pints of weak boric lotion
being slowly allowed to flow through the catheter into the cecum. A moderate-
sized vulcanite tube was passed through the sphincter for about 3 in. The
inflow was regulated so as not to allow of too great distention, and abdominal
massage along the course of the great gut employed. After about six minutes
the lotion began to flow from the rectum, bringing with it fragments of feces.
Before the outflow began, and when the patient's abdomen was distended and
tense, the catheter was removed from the appendix, and though no protection
against back-flow was taken, there was no trace of leakage, the muscular gut
and the valve of Gerlach proving competent to prevent any escape of the lotion.
After four days the lotion was changed to one of sodium bicarbonate (10 gr. to
the ounce) , and this was changed after two days more to one of protargol (4 gr.
to I pint). The patient remained in the hospital one month, and was taught
to conduct the irrigation himself. It was found that after a few days the rectal
tube was unnecessary, the patient evacuating the lotion as soon as the colon
became moderately distended. He was sent home with an abdominal plate,
fitted with a flat, thin pad — a contrivance found to be unnecessary in subse-
quent cases.

" After two months of self-irrigation daily with 6 pints of protargol lotion
he was again examined with the sigmoidoscope on October 29, 1907. The
mucous membrane was found to be slightly inflamed, and there was still some
edema of the submucous tissue, but no sign of ulceration. The patient him-
self stated that he was perfectly comfortable and at work; he occupied himself
for half an hour every morning with the irrigation, and after that had no further
trouble during the day. Throughout his diet was his usual one, and the only
other treatment was the administration of J gr. of calomel three times daily
v^hile in the hospital.**^

The time necessary to leave open this fistula varies from one to six
months in the treatment of ulcerative colitis.

Appendicostomy may be used instead of cecostomy for the relief
of abdominal distention, as in peritonitis' or malignant disease. Thus,
Dawson {loc. cit.) reports a case of Mr. Keetley's:

** The case was one of carcinoma of the greater curvature of the stomach,
involving the transverse colon and causing obstruction therein. Appendicos-
tomy was performed, and a few days later the lumen was gradually and suc-
cessfully dilated until it admitted a No. 4 rectal tube. Through this the in-

^ J. B. Dawson, Brit. Med. Jour., igoq, i, 78.
* E. W. H. Groves, Ann. Surg., 1909, 1, 1334.

502 OPERATIONS ON THE ABDOMEN

testinal contents drained well, the colon below the obstruction being emptied
by enemata. Later the gastric carcinoma produced obstruction of the pylorus,
with the usual signs of stenosis and dilatation of the stomach. Jejunostomy
was then performed, through which the patient was fed. The patient lived
for three and a half months, being fed directly into the jejunum and having
the bowels evacuated through the appendix. Death ensued, but was unac-
companied by the distress of either gastric dilatation or intestinal obstruc-
tion."

Jacobs and Rowlands mention a case of volvulus of the cecum,
operated on by Mr. Maunsell, in which, after unfolding the volvulus, he
performed appendicostomy, the result being that he effectually anchored
the cecum and so prevented a recurrence, and also was able to clear the
large intestine of feces for the introduction of hot saline to combat
shock.

This operation has been used also for amebic dysentery.^ Mr.
Keetley^ operated upon a child aged a year and ten months for in-
tussusception of the ileocecal variety. After the reduction, he per-
formed appendicostomy, the advantages he claimed for the procedure
being — (i) evacuation of bowels; (2) prevention of recurrence; (3)
rest given to cecum; (4) facility of giving saline fluid.

Mr. Dawson's further suggestion is quite worthy of consideration:
"This operation might be performed and the opening utilized for feed-
ing. The unsatisfactory results of prolonged rectal feeding are so well
known that the suggestion seems worthy of consideration. The opera-
tion per se is practically free from danger and allows nourishing fluids to
be passed into the colon, whence there is considerable absorption. It can
at least be safely assumed that the nutriment taken into the circulation
would be greater than in the case of rectal enemata. The cases for
which such treatment would be suitable are mainly those of ulceration
or new-growth of the stomach, in which rest of that viscus is indi-
cated."

APPENDICITIS AND ITS COMPLICATIONS

It is to be hoped that, as time goes on, more men will train them-
selves to do appendectomy ^ through the McBurney * incision, w^herein
the abdominal muscles are split rather than cut, making the so-called
gridiron opening between the fibers. The advantages of this incision

^ J. M. Anders and W. L. Rodman, Jour. Am. Med. Assoc, 1910, liv, 503.
2 Brit. Med. Jour., 1905, ii, 863.

'It is appreciated that, etymologically, appendicectomy is the better word.
*Ann. Surg., 1894, xx, 38.

APPENDICITIS AND ITS COMPLICATIONS 503

for all types of appendicitis, with few exceptions, have been set forth
in several places ^ since McBurney's original paper.

^ Among others, Crandon and Scannell, Boston Med. and Surg. Jour., 1905, cliii, 711.

"The muscle-splitting incision for cases of acute appendicitis, with abscess or without,
we wish to advocate and to defend, and, to that end, we adduce the following experience
and research:

" Technique. — The skin incision is so made that its middle is about three-quarters of
the distance from the navel to the anterosuperior spine. The incision is nearly transverse —
that is, it bisects the angle made by the external and internal oblique muscles as they cross
each other.

" Fibers of the external oblique aponeurosis are recognized, a nick is made with the
knife between two fibers and is enlarged by tearing, either with the knife-handle or with
the fingers. This wound is then held open with retractors.

** Thick muscle-fibers of the internal oblique are now seen running nearly t right
angles to the external oblique. A nick between fibers, as before, is followed by tearing
open of this muscle, as well as the transversalis beneath it, and the properitoneal fat with
the two fingers.

'^ .\fter good retraction to the full depths of the wound, the peritoneum is lifted
between two forceps, nicked and slit open transversely with blunt scissors.

^^Closing the Wound. — Two or three continuous catgut stitches close the peritoneum.

** One catgut stitch holds together the separated muscle bundles of the internal oblique.

** One or, at the most, two catgut mattress sutures close the external oblique.

** One or two buried catgut stitches hold together the subcutaneous fat.

*' An intracutaneous silkworm-gut or horsehair stitch closes the skin.

" Temporary Drainage. — As a precautionary measure, certain early cases of acutely
inflamed appendix require drainage for twenty-four hours with gauze or rubber dam.
For this purpose the wound is closed as l>efore, except for a passage large enough to admit
the drain and in addition one or two stitches of silkworm gut are put through the skin and
external oblique. These stitches are left with their ends tied together, and when the drain
is removed, are tied tightly to close the wound.

^^ Prolonged Drainage. — Cases which need drainage for several days or longer need no
sutures unless the wound is larger than need be for the purpose of drainage.

*^ Enlarging the Wound. — By enlarging the cut or split in each plane in cither direc-
tion, as seems necessary, the wound can be made large enough for all exploration de-
sired."

Should it even be desired for any reason to open as far down as the pelvis it will be
found that the limit to which the split in the oblique muscles and the transversalis ap-
proaches is the right linea semilunaris. WTien, therefore, in the sj^litting process this line
is reached, one may then cut freely down the semilunar line, making the whole incision
into a sort of trap-door. Through this a right tube or an ovary can be easily removed,
and such a wound is easily closed.

The Right Rectus Incision. — ** The rectus incision, 5»o called, goes through the skin
and anterior sheath of the right rectus, the muscle-belly is retracted toward the median
line (by some operators the muscle-belly is split), the posterior sheath is cut through, and
the peritoneum thus opened.

*' The advantages which lie in this incision are that it can he made quickly; that it
allows indefinite enlargement up or down; that it is more anatomic, less destructive, than
the early method of oblique incision through everything.

"The disadvantages of the rectus incision are, in our opinion, (i) That the rectus
muscle varies so much in width in dilTerent indinduals, that incisions intended to l^e over
the muscle-belly frequently come down directly on the linea semilunaris, making the whole
incision direct through the abdominal wall, with no safeguard against hernia in cases drained.

504 OPERATIONS ON THE ABDOMEN

I. McBurney Incision. No Drainage. — The intracuticular stitch
of silkworm-gut or horsehair is tied over a pad of gauze which rests
on the wound (Fig. 161). Outside of this are a few pieces of crumpled
gauze, held on by zinc-oxid plaster. An excellent device to hold on
the dressing is the zinc-oxid plaster straps and lacing (Fig. 162).
The single stitch is removed on the tenth day, and all tension is taken
off the incision by two or three narrow straps of plaster at right angles
to the incision, dimpling it in. This constitutes the only dressing of
such cases, and the plaster straps are left on or renewed until at least
three weeks from the day of the operation.

It is assumed that no wound is closed at the end of operation where
the appendix has showed on its surface any well-established acute
peritonitis. Some surgeons have set the patient upright in bed within
a few hours after operation. Except for purposes of drainage into the
pelvis, as in the Fowler position (Fig. 171), I see no advantages from this
procedure. Every patient is more or less prostrated by the ether and
its after-effects, by the psychic effect of having faced an operation,

(2) That there is a considerable chance of wounding the deep epigastric vessels, with trouble-
some hemorrhage. (3) That, as McBumey says, the incision makes *an overhanging
shelf under which one is obliged to work.* (4) That this incision frequently opens into
clean abdominal cavity, quite internal to the walled-off abscess; that this incision is internal
to the plane of the mesenteric origin. It will be remembered that Monks (Ann. Surg.,
1905, xlii, 554) has shown that the mesenteric origin serves to shut oil the right iliac fossa
to some degree from the rest of the abdominal cavity, allowing the fossa to drain first into
the pelvis. Repeated cases show that the infection is confined to the region beneath and
external to the cecum, and we believe it unwarrantable, therefore, to take the chanc e of
being (obliged to drain an abscess across a healthy gut, if such a procedure can be avoided.
(5) In cases drained, the skin tends to retract, leaving a broad area of rectus belly to
granulate in. (6) In cases drained the chance of hernia in the rectus incision is much greater
than in the muscle-splitting incision.

*• The Muscle-splUting Incision. — The disadvantages of this incision are that it cannot
be made so quickly, that it takes a certain amount of delica-^' of dissection and care, par-
ticularly if it is to be enlarged. (2) In cases of prolonged drainage much more care and
dexterity is required in replacing the wicks and in maintaining the drainage. This, we
believe, has been the main ground for objection to this incision. (3) A recent writer
has said, 'The gridiron incision should never be used in operating for an attack of acute
appendicitis. As one never can tell what the condition of the appendix is, there is danger
in an incision which cannot be enlarged without serious damage to the parts.*

" With this we entirely disagree.

" The advantages of the muscle-splitting incision are: (i) That in most cases it opens
directly over the seat of the disease; (2) that it is worth the care necessary to enlarge it
properly, since even after prolonged drainage we can practically assure the patient that he
will have no hernia. From the moment the patient leaves the operating table ever)- move-
ment involving contraction of the abdominal muscles tends to bring together the splits in
these muscles and thus close the gridiron; (3) because of this tendency of the wounds to
come together, stitches are of almost no advantage, and the surgeon is, therefore, never
tempted to omit the safeguard of temporary drainage in doubtful cases."

APPENDICITIS A-\D ITS COMl'LICATIQNS

505

and is niori.' or less uncomfortablL' on iitcount of pain or morphin.
It does not seem that anythinj; could be bettor for the patient during
the first day than horizontal rest.

The morniiis after operation, if there is no fever, no notable disten-

tion, and no great amount of pain, the patient should be set up in bed,
and if he stands this well, he may get into a chair in the afternoon.
On the second day the forenoon may be spent in bed and the time

5o6 OPERATICNS ON THE ABDOMEN

given up largely to the first high enema, the movement, and the ex-
haustion following it. In the afternoon of the second day and there-
after he may be up. and is to be encouraged to move about and be-
come normal in all necessary functions as soon as p

II. McBurney Incision. Temporary Drainage. — In this division
may be placed the cases where the appendix was deeply congested and
showed fibrin on its surface, or presented any contlition showJTip that

inflammation had penetrated through the walls of the appendix, and the
possibility exists that some infection may have taken place in the sur-
rounding region. Such cases the conservative surgeon drains tem-
porarily by means of a piece of rubber dam or a small sjiiral drain

APPENDICITIS AND ITS COMPLICATIONS

507

(p. 252), closing the wound by sutures, leaving only room enough for
the drain to emerge. Through the protruding drain there should be
put transversely a sterile safety-pin, lest the drain sli]) into the wound
during the tossing and turning of the first day after operation.

Such a temporary drain had best be left in thirty-six to forty-eight
hours. If at the end of that time there is no notable discharge, and
if the temperature is normal, or nearly normal, and has come down
continuously since operation, the temjwrary drain may be pulled out
and a provisional suture, which was jiut in and left in with its ends
knotted at the time of the operation, may now be tied. If when this

drain is pulled out there is a little secretion, or if there is the slightest
doubt as to the depth of the wound being clean and without pus-
formation, the short dressing forceps may be put into the wound im-
mediately after the drain is withdrawn and then allowed to open while
in the wound. Their spring will separate the lips of the wound a bit,
and into this space may now be poured a dram or less of sterile glycerin
or balsam of Peru. .\ small jiad is jjut over this and the swathe or strajjs
applied. The use of either of these agents serves a four-fold purpose —
they prevent the wound sealing together prematurely, they are slightly
antiseptic, they are stimulative, and they serve to shrink excessive
granulations.

5o8 OPERATIONS ON THE ABDOMEN

If one feels that there is some noteworthy infection in the depths
of the wound, another small wick must be inserted where the first was
withdrawn, and it may be even considered wise to remove a stitch or
two in order to establish better drainage.

III. McBurney Incision. Gangrenous Appendix or Abscess. — In
these conditions the best possible drainage is by means of a spiral drain
with enough gauze preferably, in my opinion, saturated with iodoform
lo per cent., protruding, say, i to 2 in. below the end of the rubber, to
form a certain amount of packing at the bottom of the cavity, whether
there is a definitely localized abscess or whether the case is one where
the abscess is^rming; that is, where the "chicken-broth" fluid or pus
is localized in the lower right quadrant. Such a drain, carefully placed,
reaching to the limits of the region infected and in contact with the ap-
pendix stump, may be well left undisturbed for from t^vo to six days. It
is a common procedure to *' start" the wick on the third or fourth day —
that is, to pull it just clear of the granulations in which it has embedded
itself — to pull it half-way out on the next day, and to remove it entirely
on the day following. If there are no local signs, such as tenderness,
spreading redness, bulging of the wound, exudation of pus round the
wick, or if there are no general symptoms indicating lack of free drainage,
such as rising temperature or pulse, or abdominal paresis, the wick
should be left undisturbed until the time limit set. As long as it remains
in place it is exciting conservative adhesions — it is establishing in the
whole region one clean-cut cavity without partitions and subca^'ities, it
is exciting granulation.

When the first wick is finally withdrawn from such an abscess cavity
it usually must be replaced by another, as the amount of excretion of pus
cannot be foretold in any given case. Where wicks have to be renewed, and
closing in of the abscess cavity is to be encouraged, the size of the wicks
should be successively reduced. In abscess cases, where granulation
had already begun before operation, pus is small in amount during
convalescence, and such a cavity may in a few days be filled with glycerin
and allowed to collapse.

In cases where there were a lot of adhesions, much fibrin, or foul-
smelling pus the first wick will have to be removed in a short time,
perhaps as early as the third day, and perhaps renewed daily thereafter.

Where there is a defim'te, easily accessible cavity to dress, wiping out
with a dry sponge often suflfices. Where the cavity leads deep into the
pelvis, and the daily pus is considerable in amount, there are instances
where irrigation of the cavity with salt solution or chlorinated soda
solution (1:80), using a slightly curved female catheter for irrigating

APPENDICITIS AND ITS COMPLICATIONS 509

nozzle, will best serve to clean the cavity. The danger cannot be over-
emphasized, however, if irrigation is used, that .the flxiid may not flow
out of the wound freely enough, may back up and drain through adhe-
sions into the general cavity, with serious results. Irrigation, then,
is only for selected cases, and the onset of the least pain during its
performance is a signal to stop.

In case much packing or several strips of gauze have been necessarily
left in, their early removal is extremely painful and may give definite
nervous shock to the patient who is at all sensitive. Other things being
equal, the longer such wicks are left in, within reason, the easier they
come out, because of the softening action of the pus around them. When
such considerable amount of packing has to be removed early, therefore,
particularly if the patient is one who does not stand pain well, — a child,
for example, — it is probably best, with the help of a safe anesthetist, to
give a few whiffs of nitrous oxid, ethyl chlorid, or chloroform, and pull
them out all at once. If there is good reason why such an anesthetic
should not be given, the packing may be got out by starting the wicks,
pulling an inch or t\vo out each day, and cutting it off, or, if the packing
is composed of several narrow strips, by pulling one out at a time.

In the region of a drained abscess there should be for twenty-four
hours practically no pain. If pain appears, it indicates lack of free
drainage, and the wicks should be started or withdrawn and new smaller
ones inserted. After this is done, the application of a hot salt and citrate
(4 and I : loo) poultice, or even of the old-fashioned flaxseed poultice,
may give great comfort and aid free drainage.

Some cases secrete an excessive amount of pus daily, and this amount
must determine the frequency of the dressing. As a rule, once a day
is enough. Some cases, however, may well be dressed every three or
four hours. The "let alone" policy with regard to a well-placed wick
is the best. There should be a reason for every dressing.

When the temperature is practically down to normal, even though
a considerable amount of suppuration is still present, the patient may
get up if the wound is well supported by straps or swathe. Getting the
patient partially or wholly up is frequently the best stimulant to rapid
convalescence.

IV. Right Rectus Incisioti, Wound Closed, — These cases, after they
have been sutured by layers and the abdomen is supported well by zinc-
oxid plaster straps or the laced straps (Fig. 162), call for no treatment
different from a median celiotomy. The patient may sit up the day
after operation.

Right Rectus IncisioUy Drained. — ^When, unfortunately, the surgeon

5IO OPERATIONS ON THE ABDOMEN

has to drain through this incision, care should be taken at the first re-
moval of wick or packing not to pull out a coil of small intestine, or even
to bring such a coil above the level of the parietal abdomen, for such an
occurrence makes ventral hernia much more likely. The wound should
be constantly supported by straps, and, as the wick get smaller, the
edges are pulled closer together at each dressing, until ultimately the
complete approximation of the two granulating surfaces is attained.
Undoubtedly the liability to hernia^ in these cases is due primarily to
lack of attention to just such details in the immediate after-care of the
wound.

Complicatioiis and Sequelae.— It is trite enough to say that
no two cases of appendicitis are alike, the possible postoperative com-
plications are so numerous.

(i) General Peritonitis, — See pages 174, 465, 468, 508, 509, and 517.

(2) Intestinal Obstruction. — If the abdomen does not distend, no
effort should be made to move the bowels for the first twenty-four to
thirty-six hours, perfect rest being the ideal abdominal condition. If
at any time, however, distention becomes notable, an effort should be
made to get rid of the gas. This distention may be due to a paresis of
the bowel from toxemia or from a peritonitis of any grade. Until a
good effort by means of a well-given and searching enema has been
made, the distention need cause no worry. Obstruction may be due,
however, to pressure of the packing or to newly formed bands or adhe-
sions in the region of the appendix. I have seen several cases where
the patient was not thoroughly cleaned out before operation, in which
fecal impaction in the rectum was enough to cause obstruction after
operation because the patient did not have strength to force the ob-
structing mass out.

(3) Fecal Fistula. — This condition may range from escape of pus with
merely a fecal odor, up to the free discharge of evidently fecal material.
It may be due to incomplete closure of the appendix stump by ligatures r
to a slipping of the appendix ligature; to the presence of a lost or un-
discovered fecolith in the bottom of the wound; or to a new break ii>

^ From the Boston City Hospital records since 1880 we find 22 hernias. This does
not represent all the hernias which have occurred, but only those which have come bacJ»
for operation.

Total hernias through appendectomy scars 22

Through old-fashioned direct oblique incision 17

Through right rectus incision 5

Through muscle-splitting incision o

These figures need no comment.

APPENDICITIS AND ITS COMPLICATIONS

the wall of the cecum or ileum, due either to a continuation of the
gangrenous process of the original disease, or to the careless removal
of an adherent drainage wick. For treatment, see pp. 280 and 468.

(4) Stitch Abscess .S^t Chap. XXIII, p. 253.

(5) Abscess in the abdominal wall near the region of the wound may
appear in places where the muscle layers have been excessively sepa-
rated during operation, or where the drainage gauze has become dried

» n • 1

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Fig. 166. — Acute Appendicitis.
Typical chart; rise of pulse on getting up and about.

and blocks the wound. The pus then burrows between the layers of
the abdominal wall, sometimes extensively. Careful burrowing with
the finger in the direction of the tenderness or swelling which indicates
the abscess should establish drainage and so relieve the condition.

(6) Lymphatic and Hepatic Infections. Subphrenic Abscess,^ — This
complication occurs approximately in i case in 1000. The abscess
may be within the peritoneal cavity or in the retroperitoneal tissue. If

* See also Chapter IX, p. 106 et seq.

512

OPERATIONS ON THE ABDOMEN

intraperitoneal, the abscess may occupy only a small portion of the
subphrenic space, either laterally, or in front, or behind. It may be
located high up under the dome of the diaphragm. The intraperitoneal
is far more common after appendicitis than the extraperitoneal. The
infection travels along the inner or outer side of the colon, or toward
its anterior aspect and the abdominal wall. Subphrenic abscess may
follow an attack in which there has been no suppuration in or about the

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Typical chart, irregularities of temperature depending Temperature on the fifth day due to minute stitch
on efficiency of drainage and on catharsis. abscess.

appendix. Following appendicitis it is usually situated on the right
side. It may occur as a result of a general suppurative peritonitis. It
is sometimes possible to trace a suppurative tract at autopsy from the
appendix to the subphrenic region. The complication follows not in-
frequentiy in case the appendix is retrocecal. Subphrenic abscess may
rupture into the lung. It is often complicated by pleural effusion, the
presence of which is explained by the proximity of the subphrenic space.
Symptoms. — Persistence of high fever, rapid pulse, and other signs

APPENDICITIS AND ITS COMPLICATIONS 513

of deep-seated infection, in spite of thorough drainage of the primary
appendix abscess. Duhiess corresponding to the left lobe. The ex-
ploring needle presents pus which may be mistaken for an empyema.
The acute form may come on in a few days. It may, hgwever, be
subacute or chronic.^ The development and symptomatology of this
complication may be shown by illustrative cases:

J. C. Munro^: " A girl of eighteen was operated upon within twenty-four
hours from the beginning of an attack of acute appendicitis. The gangrenous
appendix was removed and the wound was drained. There was no infection
of the peritoneum beyond the immediate region of the appendix which lay
posterior to the cecum. The mesenteriolum contained thrombi and was
removed. For a few days the condition was satisfactory, when the pulse
and temperature began to rise, and there was slight icterus, with definite he-
patic tenderness. Exploration of the sinus showed a small abscess posterior
to the peritoneum at the original site of the appendix. Improvement followed
drainage for a week, when the symptoms of sepsis again appeared, and three
weeks from the first operation a f)elvic abscess not connected with the first
wound was op>ened and drained. In spite of free drainage the patient did
not improve, but began to show evidence of trouble in the upper abdomen.
With more distinct signs as a guide, the abdomen was opened through an epi-
gastric incision five weeks from the time of onset, and a foul subphrenic ab-
scess to the left of the median line was drained. The patient did not improve,
however, but steadily became more and more septic until death three weeks
later."

Munro: " H. C. B., male, aged thirty-five years,^ had had several
attacks of severe abdominal pain and vomiting in the past six or seven
years. Each time he had been a little yellow, but without chills, and the
attacks lasted only a few days. Three days before entrance to the hos-
pital he had a sudden, severe attack of appendicitis, followed by slight
jaundice and a leukocytosis of 13,000. He was treated in the medical
wards for a month, during which time he had occasional chills and high
temf)erature, epigastric pain, progressive emaciation, variable jaundice,
and leukoc)rtosis increasing steadily up to 43,000. Examination showed
a much emaciated, jaundiced, septic-looking man, with an enlarged liver,
especially on the left, and doubtful tenderness over the appendix. Under
ether, the abdomen was opened in the median line, above the umbilicus.
One small, pinhead abscess was found on the anterior surface of therightlobe.
The left lobe was uniformly enlarged, but on the under side there was a deep,
slightly indurated swelling. This was opened and a cavity containing pus
was found. Careful exploration of the right lobe failed to show pus. The

^Katz and Kendirjy, Rev. de Gyn. et de Chir. Abdom., Paris, 190S, xii, 469.

* Ann. Surg., 1905, xlii, 692.

* Boston City Hospital Rejwrts, 1902, 146.

514 OPERATIONS ON THE ABDOMEN

gall-bladder and neighboring region were normal. The appendix, subacutely
inflamed, was removed through a small opening. The patient was in poor
condition before the operation, but on the following day the temperature had
fallen to normal and the pulse had fallen to 120. There was considerable
discharge fFom the liver. Three days later the temperature remained down,
but the pulse was rapid and weak, and he looked badly. Two days later he
died.

'^Autopsy showed between the spleen, stomach, left side of diaphragm,
the liver, and posterior wall of the peritoneal cavity an abscess containing
offensive, yellowish, semifluid material. All the mesenteric lymph-nodes
were somewhat enlarged. One node was softened, and contiguous to it was a
canal, that is, a mesenteric vein, with roughened yellowish wall admitting the
little finger and communicating directly with the portal vein. On section
through the left lobe, the portal veins were dilated and contained pus. In
the right lobe, particularly toward the superior surface and the right, were
numerous small abscesses, arranged in clusters, 3 to 5 cm. in diameter."

The next to the last case illustrates the subphrenic abscess alone;
the last, both subphrenic and hepatic infections. Dr. Munro continues:

" There must be a considerable variation dependent on the individual,
the type, and the amount of infection in the time required for the forma-
tion of pus in appreciable quantities. The clinical data on this point
are very vague, but frequently there may be a wide variation in certain
instances.

" The age at which these infections take place is limited mostly ta
young adults. According to statistics of Musser and others, children
below fifteen are quite exempt from portal infections.

" Diagnosis of either the lymphangitis or the pylephlebitis that is
secondary to appendicitis is at times impossible. In typical cases it ought
not to be difficult. We ought to consider its probability in cases exhibiting
sepsis, jaundice, hepatic tenderness.

" When the infection has attained the subphrenic space, the symp-
toms are more varied, and are frequently impossible of interpretation
without exploration or operation. To quote freely from Griineisen, we
must regard the subphrenic abscess as a circumscribed peritonitis, and hence
we often find acute, gradually increasing signs of peritonitis. At times
there is only dull pain. At other times the disease comes on suddenly
with collapse, chill, vomiting, severe pain, etc. Sometimes the course
is very obscure and the picture of the disease is not clear. Pain is incessant.
In most cases there is an elevation of temperature. On examination, we
often find irregular, marked arching in the lower portion of the thorax of the
diseased side. This does not behave in respiration in a normal way. The
intercostal spaces are obliterated, widened, or bulged, and frequently
painful on pressure.

APPENDICITIS AND ITS COMPLICATIONS 515

*' Lejars often found a characteristic point of very intense pain. The
upper boundary of dulness often stands in a convex line, and above the
dulness there is found normal lung resonance in case there is no pleural
effusion. In some cases one can determine a marked change in the upper
boundary of the dulness on inspiration. The change is small, chiefly because
the diaphragm pressed upward is weak and lagging. If there is gas in the
abscess, there is a clearly marked tympanitic zone to be recognized, which
changes with the position of the patient. One finds characteristically,
from above downward, first, normal lung resonance, below this a sharply
bounded tympanitic zone, and then a dull area due to the presence of the
pus. This three-layer arrangement in zones can almost be taken as path-
ognomonic. In left-sided abscesses the heart may be pressed somewhat
upward, but not to the right, while in right-sided abscesses the heart is
pressed very little toward the left. The liver and the stomach may be forced
down to a considerable degree.

'* The determination of pus by means of the exploratory needle is an
important aid in the diagnosis of deep-lying pus-cavities. Puncture is
best made in the region of the most marked dulness through the ribs, and
in the region where, in case of finding pus, one would eventually operate.
One must often make more than one puncture. In one case Griineisen re-
ports 36 trials at several sittings." The :c-ray may be a valuable method
of locating these abscesses.

To diagnosticate a typical case of portal phlebitis should not be
very difficult. One of Munro's cases illustrates significantly the char-
acteristics of the early stages.

^^ T. S., female, seventeen years old. .Ten days before entrance had an
attack of sudden, sharp pain in the region of the umbilicus, with vomiting,
which continued for two days. Four days before entrance she began to have
dull, continuous pain below the costal margin, followed by chills and sweating.
The white count was 8800. She was in the hospital two days before of)eration,
and grew distinctly worse during that time. There was very slight jaundice,
noticeable only on careful examination ; fulness through the right hypochon-
drium into the flank, with spasm and tenderness over the liver. There was
nothing to call attention to the appendix except a distinctly local tenderness
on deep pressure without spasm.

"Diagnosis of portal phlebitis following appendicitis was made, and under
ether the abdomen was opened over the right lobe of the liver, spasm persisting
even under anesthesia. On the upper surface of the right lobe there were three
or four groups of small abscesses. These were incised and the liver itself
opened up freely with the director and finger, but no more abscesses could be
found. The left lobe was normal in size. Various punctures were made else-
where in the liver without obtaining any more pus. Through a second ab-

5l6 OPERATIONS ON THE ABDOMEN

dominal opening a foul abscess cavity surrounding the appendix was op>ened
and drained. Two days later the appendix wound was clean and sweet.
Foul pus was escaping from the liver and the packing was removed without
hemorrhage. On the fourth day after operation patient was more or less
delirious, with considerable discharge from the liver, which seemed to be
mostly bile, and the next day she died."

To sum up the symptoms: Jaundice is usually present in some
degree. Chills are apt to come on early. Pain in the hypochondrium
is characteristic and of diagnostic importance, usually preceding the
jaundice or accompanying it. There may be vomiting or diarrhea.
The liver may be found somewhat enlarged and tender, and sometimes
enlargement of the spleen is to be noted. The temperature is irregular
and frequently makes wide excursions. The pulse is rapid and may
be dicrotic. In the acute forms there may be somnolence and coma,
or delirium.

Drainage must be established. For subphrenic abscess the ninth
rib is resected in the mid-axillary line. If the pleura is opened by this
procedure the parietal and diaphragmatic layers are sewn together.
After suture of the costal and parietal pleurae allow thirty-six hours to
elapse before incising the diaphragm, unless at the time of operation
the two layers of pleura were infiltrated and adherent to each other,
in which instance an immediate incision is made. If the diaphragm
bulges up against the pleura, no air will enter up)on incising the costal
layer. If, on the other hand, the border of a lung can be seen moving
freely up and down, it will be safer to suture the two layers and make
incision through the diaphragm from thirty- four to thirty-six hours later.
Drainage is maintained by rubber tubes or rubber bobbins, and if it is
efficient the symptoms should abate directly. Multiple abscess of liver
and portal phlebitis are, at present, practically hopeless conditions.

(7) Suppuration in Other Distant Places. — Such complications may
arise as a result of a pyemia or suppurative endocarditis, either of which
may complicate appendix abscess, particularly if not efficiently
drained. Separate abscesses may appear, through the insufficient
exploration at time of operation or due to inefficient after-care in
respect to drainage. Collections of pus, for example, may appear
in the loin, about the kidney, under the liver or diaphragm, or in the
pelvis. The possibility of such an occurrence should always be in
mind. They are suggested by persistent or rising fever, by pain here
or there, by the septic fades. Undrained pus in the pelvis will be
suggested by frequency of micturition or by ** bearing down " in bladder
or rectum. Rectal or vaginal examination should establish the diag-
nosis. Appropriate operative intervention should be made.

GENERAL PERITONITIS 517

(8) Empyema on the right side has been observed/ due probably to
extension of a subphrenic abscess.

(9) Iliac or Femoral Thrombosis and Phlebitis^ Thrombophlebitis. —
This complication is not common, but seems frequently to appear in
the simple cases, where least expected.^ It comes most often between
the tenth and fourteenth days in debilitated subjects^ commonly in
the left leg, and subsides harmlessly in a few days. For details of
onset, course, and treatment, see Part I, Chapter IX, p. 114.

GENERAL PERITONITIS

Many cases called general peritonitis are not actually general^ in
extent. So true is this that we strongly believe that the surgeon should
not, with certain exceptions, put his hand through the infected peri-
toneum or intestines which present in the wound, bathed in seropuru-
lent fluid or pus, and then force the hand in all directions through the
intestines for the mere purpose of finding out whether the inflamma-
tion is general or not. For the same reason it seems to be poor path-
ology and bad surgery to wash out an inflamed peritoneum unless there
is every sign that the disease is truly general. In other words, in many
cases an unwalled peritonitis is kept local by anatomic structures, as in
the right lower quadrant.^ The fact that there is no wall of adhesions
limiting a peritoneal exudate does not mean that the process is gener-
ally distributed throughout the cavity.

It is assumed, therefore, from the point of view of after-treatment,
that all exudation has been sponged and wiped out with great care and
thoroughness, and that the necessary number of drainage-tubes or
wicks have been placed in one or more incisions thoroughly to drain®
the pelvis and any other fossae which were evidently affected. In
certain cases, wicks or tubes will be put in through an incision in the
vaginal vault.

The patient is returned to bed and placed in the exaggerated
Fowler's position (Figs. 169-172), which directs the gravitation of all
fluids toward the pelvis. This nearly erect position has the greatest
possible value. It has been lately noted in general peritonitis after
typhoid perforation.^

* G. R. Fowler, Treatise on Appendicitis, Phila., 1894, 62.
^ W. Meyer, Ann. Surg., 1901, xxxiii, 605.

^ A. Sertoli, Gazz. degli Osped. e. della Clin., Milan, 1909, xxx, 121.
^ A. G. Gerster, Ann. Surg., 1910, li, 490.
^G. H. Monks, Ann. Surg., 1903, xxxviii, 574.

* Though Deaver now says, " When in doubt, don't drain," Ann. Surg., 1910, li, 480.
P. Wroth, Ann. Surg., 1909, 1, 842.

OPERATIONS ON THE ABDOMEN

Large quantities of saline solution are to be passed into the rectum
by the drop method. (Seep.45.) A tube with three or four openings

is introduced about 4 in. into the rectum. This tube comes from a
syringe-bag full of salt solution, which feels somewhat warm to the
hand (io5''-iio'' F.). The bag is placed just barely above the plane

GENERAL PERITONITIS

of the rectum, and the snap so placed on the exit tube thai the water
emerges from the end about 3 drops a second. The saline can be ab-

sorbed by the bowel at about this rate (ih pints per hour). By this
means, during the tirst twentj'-four hours, 6 quarts may be introduced.

In especially desperate cases intravenous saline infusion may be given
before and during operation — up to 4 pints in the course of two hours.'

520 OPERATIONS ON THE ABDOMEN

Food and drink are withheld by mouth to limit peristalsis. If hot
water is well borne, however, it may be given. Enough morphin is
given only to make life bearable.

Stimulation is to be given as necessary. For extensive vomiting,
gavage is to be practised. Distention and intestinal paresis are to be
met with the details already given. (Chap. XV, p. 165.) Cecostomy,
at this writing, seems to be an essentially life-saving procedure in
general peritonitis. It is our practice to introduce a Paul tube (p. 421)
into a cecostomy wound at the time of operation. Drainage is estab-
lished into a bottle at the side of the bed. Through this tube gas and
fecal matter pour; distention, which is mainly in the large gut, as a
rule, is relieved, and through the tube once or twice daily the large
intestine is washed out with salt solution. A milk and molasses,
or a compound turpentine enema, given as usual per rectum, is followed
by copious discharge through the cecal tube. If general peritonitis
supervene after other operations, the cecostomy may be done under
cocain anesthesia^ without difficultv.

If the wicks have been well placed, they should not be disturbed for
many days. It should be constantly remembered that after twenty-
four hours siphon drainage stops, but that the wicks are still valuable in
aiding the localization of diffuse processes.

TUBERCULOUS PERITONITIS

These wounds should not be drained. Because of the nature
of the disease and the general condition of the patient, the wound
may be slow to heal, and, for this reason the stay sutures should not
be removed until the fourteenth day, and the wound should then be
supported with extra care by plaster straps. Local tuberculosis
may develop in the scar.

From early in convalescence the patient should have the general
treatment of tuberculosis. He should sleep out-of-doors or as near to
that condition as possible. He should be slow to get up, and his ex-
ercise, gradually increasing, should be used, as it were, medicinally.
Theoretically, each period of activity will cause a certain amount of
lymphatic absorption either of toxins or of live bacilli. Hence,
exercise reasonably used should serve gradually to increase the in-
dividual's resistance through his specific antibodies.

The prognosis, if the peritoneum is the only part involved and
the environment can be controlled, should be good, and in from two
to six months the case may usually be considered as '' arrested. ''

* G. Volterrani, Riforma Med., Najxjli, 1910, xxvi, 246.

TUBERCULOUS PERITONITIS 521

Complications and Sequelae. — Bursting of the wound may
occur, as has been already suggested, because of the diminished heahng
power of the tissues (see p. 189).

A tuberculous sinus may be established if any part of the wound
gives way. Tincture of iodin swabbed in thoroughly every day or
two, together with direct sunlight, if it be feasible, should help such a
sinus to heal promptly except in very bad cases.

Acute miliary tuberculosis may rarely follow of)eration in ad-
vanced cases.

CHAPTER XLVI
OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

INCOMPLETE PERINEORRHAPHY AND THE REPAIR OF RECTOCELE '

The external genitals are douched with warm sterile water or salt
solution from a pitcher or douche-bag after each movement of the
bowels and after each urination. The labia majora are gently spread
by the sterile fingers of one hand in order to allow the entire perineal
body to be thoroughly cleansed. The vagina is not entered and the nose
of the pitcher or the douche-tube is not allowed to come in contact with
the parts. The drops of fluid remaining on the genitals after the douche
are lightly absorbed by touching the tissues with dry gauze, doing this
lightly several times until all moisture has been removed. No rubbing
movements are employed. The perineum is dusted with a powder
consisting of equal parts of compound stearate of zinc and boric acid.
Dry sterile gauze is then placed on either side of the stitches, and the
stitches are flattened and pressed into one of the groins surrounded by
the gauze. A tight T-bandage is employed.

The patient is not catheterized unless she is unable to pass her
urine; if necessary, the catheter is passed every eight hours. Unless
extremely uncomfortable, the patient is allowed to go for the first
eighteen to twenty-four hours after operation before resorting to the
use of the catheter.

The bowels are kept free by the administration of lo to 15 grains
of extract of cascara, night and morning, beginning on the morning
following the day of operation. In case the bowels do not move daily
by means of the cascara, an enema should be given in order to secure
a daily evacuation, taking care to pass the rectal nozzle along the
posterior wall of the rectum. Soft-solid nourishment is given until
the bowels move, and then full diet is allowed.

The patient is allowed to lie in any position, but should not be per-
mitted to turn herself. Tying the legs together and placing a pillow

^ An operation for the repair of a rectocele always includes perineorrhaphy.
522

INCOMPLETE PERINEORRHAPHY AND THE REPAIR OF RECTOCELE 523

beneath the knees are unnecessary, unless they add to the comfort of the
patient. When upon her side, the back should ahvays be supporicd by

a pillow crowded in behind it, in ordcT 10 <liminish any tension on the
stitches from the weight of the body.

The stitches are removed in ten to fourteen days. The iialient is
allowed to sit up in bed with a head-rest on the fourteenth liay and to

*■ V

-J

■get up out of bed on the seventeenth day. She can walk about on the
eighteenth day.

5^4

OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

Complete Perineorrhaphy.'- The after-troalmcnt. as already
described for Incomplete lacerations of the perineum, is carried out
with certain additions and modifications.

The bowels should be moved the next day after the operation in
the following way: On the morning after the day of operation an ounce
of castor oil should be given by mouth; twelve hours later an oil enema,
consisting of 8 oz. of warm sweet oil, should be given by means of a
rectal syringe. If the surgeon has any doubt about the ability and
experience of the nurse, he should give the enema himself. The syringe-
tip must be passed with extreme care into the posterior part of the anal
opening, and then very K<^nlly aJon;.; the jiosterior wall of the bowel
to avoid the rectal sutures. The oi! should lie introduced slowly, and
then the syringe must be withdrawn with the same caulion which was

used in its intrcwkicfion. The patient is instructed to allow the move-
ment to occur gradually and to make no straining efforts. It may be
necessary for her to remain upon the bed-pan for an hour or even longer
before an evacuation occurs. In case the desire to move the bowels is
felt after receiving the castor oil, before the enema has been given,
then the enema should be given at once, .\fter this the bowels must
be kept freely open by licorice powder, gi\'en in doses of i or 2 teaspoon-
fuls morning and nighl. No straining at stool is ever permissible, and
if at any time the patient experiences difficulty in defecation during the
first two weeks following operation, an oil enema must be given with the
precautions above described.

A liquid diet without milk is given until the bowels move. .Xfter

larly the sim[)lc ;

It operation of C, M. Wal

THE REPAIR OF CYSTOCELE 525

the bowels move, a soft-solid diet is allowed, but milk is restricted to
a minimum because of the character of the residue which it leaves in
the feces.

The stitches are removed on the fourteenth day. The patient is
allowed to sit up in bed with a head-rest on the twenty-first day and to
get up out of bed on the twenty-fourth day. She can walk about on
the twenty-fifth day.

The Repair of Cystocele. — No irrigations are necessary after
a cystocele operation, in the absence of a vaginal discharge, beyond a
careful cleansing of the external genitals with a sterile fluid after each
movement of the bowels and urination. In the presence of a vaginal
discharge, however, a vaginal douche should be carried out every twelve
hours in the following manner: A glass vaginal douche-tube is passed
carefully for its entire length over the perineal body, hugging it tightly,
the irrigating fluid being allowed to flow during the introduction. In
the removal the precaution is likewise observed to keep the nozzle
in close approximation with the perineal body. In the event of a
vaginal discharge, after the combined operation for cystocele and lacera-
tion of the perineum, the douche-tube must be passed with great caution
along the middle of the introitus vaginae, at a point equidistant from
its anterior and posterior angles. Such a vaginal douche should precede
the irrigation of the perineum.

The patient should be placed upon the bed-pan three hours after
the operation, and then be given the bed-pan every three hours in the
hope that she may pass her urine. But this she is rarely able to do.
The bladder should not be allowed to become distended. It is seldom
possible for the patient to go more than nine to twelve hours without
the occurrence of painful distention, and after this operation the catheter
shoijld not be w^ithheld more than six hours. Catheterization, if neces-
sary, should be carried out once in four hours for three days, then once
in SIX hours for three days, and then once in eight hours until the patient
can be induced to urinate spontaneously. Before resorting to the use
of the catheter, after any gynecologic procedure, persistent efforts should
be carried out to encourage the patient to pass her urine herself — /. ^.,
by hot compresses to the abdomen, thighs, and vulva, pressure over
the bladder, trickling of sterile water over the introitus, the production
of the sound of running water in the room, and lying on the face. Oc-
casionally a hot enema may have the desired effect.

The bowels are kept free by compound licorice powder and enemas
as above described.

Soft-solid diet is advisable until the bowels move, and then a full
diet may be allowed. During the entire convalescence it is well for

526 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

the patient to drink water copiously. In the event of the comph'cation
of vesical irritation supervening in the convalescence the patient should
be given cystogen, 5 gr. three times daily, and large quantities of
cream of tartar water should be administered.

As the stitches are entirely of catgut, it is unnecessary to remove them.
The patient is allowed to sit up in bed with a head-rest on the fourteenth
day and to get out of bed on the seventeenth day. She may walk about
on the eighteenth day.

Referen'ces

T, A. Emmet, A Study of the Etiology of Perineal Laceration with a New Method
for Its Proper Repair, Trans. Amer. Gyn. Soc, 188.3, ^'i"' iQ^-

E. C. Dudley, Jour. Am. Med. Assoc, 1906, xlvii, 1605.

C. P. Noble, Kelly-Noble, Gynecology and Abdominal Surgery, 1907, i, 350.

E. McDonald, Lacerations of the Perineum, Surg., Gyn. and Obst., 1908, vi, 47.

T. J. Watkins, The Operative Treatment of Cases of Extensive Cystocele and Uterine
Prolapse, Surg., Gyn. and Obst., 1909, viii, 47.

VESICOVAGINAL FISTULA

The after-treatment of a vesicovaginal fistula is of the greatest im-
portance in determining the success of the operation. Constant drainage
is maintained by a self-retaining catheter, which is removed, cleaned,
boiled, and replaced twice daily. Each time that the catheter is replaced
the bladder is irrigated with warm 4 per cent, boric-acid solution, allow-
ing not more than 4 ounces to enter the bladder at once, so avoiding
undue pressure upon the stitches. Once each day the patient is placed
in the Sims posture, the posterior vaginal wall being retracted by a
Sims speculum, and the stitches are gently irrigated with sterile water.
The anterior wall is then gently wiped, or, better, patted dry, using,
sterile absorbent cotton in preference to gauze because of its softer
texture, and then carefully powdered with equal parts of compound
stearate of zinc and boric acid. The vulva is covered with a sterile pad.
Constant drainage is continued until the tenth day. The stitches are
removed on the fourteenth day, most conveniently with the patient in
the Sims posture.

The patient may sit up in bed after the stitches are removed and get
out of bed on the fifteenth day.

The bowels are moved by a suds enema the morning after operation,
and are then kept open by extract cascara sagrada, lo gr., or some
other laxative, at night, an enema being given whenever the bowels do
not move freely with cathartics. After each movement the perineum
should be irrigated with sterile water, care being taken that none of the
fluid enters the vagina, and the vulva is covered with a fresh sterile
pad.

EXaSION OF THE VULVA 527

Water is given as soon as the patient is out of ether. By afternoon
of the same day the patient is able to take light nourishment — some form
of broth with crackers or toast, and the following morning may resume
her usual diet.

Hexamethylamin, lo gr. three times a day, as a prophylactic against
cystitis, may be given during the first ten days. Twenty grains of
potassium acetate may be given with each dose, and the patient should
drink 2 quarts of cream of tartar lemonade (see p. 567) daily between
meals, in this way promoting a continuous irrigation of the bladder
with a dilute, non-irritating fluid.

References

J. Marion Sims, On the Treatment of Vesicovaginal Fistula, Amer. Jour. Med.
Sci., 1852, xxiii, 59.

T. A. Emmet, Vesicovaginal Fistula, N. Y., 1868.
H. A. Kelly, Operative Gynecology, 1906, i, 425.

RECTOVAGINAL FISTULA

The operation for this condition should not be undertaken until the
bowel has been thoroughly cleaned out and the vagina rendered as clean
as possible, otherwise the most careful after-treatment may not be able
to avert failure.

The vagina is irrigated twice daily with sterile water, keeping the
douche-nozzle as close to the anterior wall as possible. The vulva is
covered with a sterile pad. The stitches are removed on the tenth day.

The bowels must be kept loose and the intestinal contents soft
from the beginning. All enemas are to be avoided. The morning of
operation the patient is given i ounce of Epsom salt. This is repeated
the following morning, and thereafter h ounce is given every morning for
ten days. After the tenth day, the bowels must be kept loose, but some
other cathartic, such as cascara or the compound cathartic pill, may be
employed.

The diet must be liquid, without milk, from four days before opera-
tion to the tenth day. From the tenth to the fourteenth day a soft-
solid diet may be taken, and, beginning with the fifteenth day, full diet
may be resumed.

The patient may sit up after the stitches are removed and get out of
bed on the twelfth day.

EXaSION OF THE VULVA

Excision of parts of the vulva may be indicated for malignant disease
— elephantiasis, pruritus, kraurosis, or tuberculosis. It is, as a rule,

528 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

possible to close the incision with silkworm-gut sutures. Owing to the
impossibility of preventing the urine and feces from soiling the dressing
the parts should simply be kept clean and dry, and covered with a sterile
pad. After each defecation or micturition the wound should be irrigated
with sterile water, and dusted with compound stearate of zinc and boric
acid, equal parts. The patient should be kept in bed until the stitches
are removed on the seventh day. Diet need not vary from that
ordinarily taken by the patient.

EXaSION OF URETHRAL CARUNCLE

Outside of rendering the urine dilute and non-irritating, this opera-
tion requires no special after-treatment. The patient should take
20 gr. of potassium acetate three times daily, and should be instructed
to drink 10 glasses of water daily.

Hemorrhage occasionally occurs, and will be controlled by a No. 00
catgut stitch in the mucous membrane. This may be taken with the
variety of needle designed for the repair of a vesicovaginal fistula, under
cocain anesthesia, obtained by placing a crystal of cocain hydrochlorid
in the urethra and allowing it to dissolve.

VULVOVAGINAL ABSCESS

The abscess should always be opened upon the inner surface of the
labium. The abscess cavity is tightly packed with sterile gauze and
the vulva is covered with a sterile pad. The packing is removed the
following day. This may be done either in the Sims or dorsal posture.
After the packing is out, the vulva should be washed off four or five
times daily with an antiseptic solution. The patient is to wear a pad
as long as there is any discharge. She may get up as soon as she is
completely out of ether. When the tenderness about the labium has
subsided, treatment of the gonorrhea should be continued or instituted.

In the rare cases in which a vulvovaginal abscess is successfully dis-
sected out without rupture, the incision should be closed with silkworm
gut. The stitches are washed off after each micturition or dejection,
and the vulva kept covered with a sterile pad. The patient may get up
the next morning, but should remain in her room until the stitches are
taken out on the seventh day.

Hemorrhage is the one complication to be looked for. If it occurs
after an abscess has been incised, it is treated by a larger and firmer
packing. When it occurs after an abscess has been dissected out, it
may give rise to a large hematoma in the labium. A moderate amount
of ecchymosis always occurs after this operation, and may usually be

VAGINAL SECTION FOR DRAINAGE OF PELVIC ABSCESS 529

disregarded, but if the whole labium becomes swollen and tender, the
stitches must be removed, the clot evacuated, and the cavity packed
for twenty-four hours.

CYST OF BARTHOLIN'S GLAND

All that has been said concerning the dissection of a vulvovaginal
abscess applies to the removal of a cyst.

VAGINAL SECTION (COLPOTOMY) FOR DRAINAGE OF PELVIC

ABSCESS

The pus-cavity is firmly packed with a large strip of sterile gauze,
or, if there are two distinct cavities, a separate packing is passed into
each. The vagina is also packed, and the vulva covered with a sterile
pad. The patient is put to bed in Fowler's position. At the end of
forty-eight hours, or sooner if there is a marked rise of temperature,
the packing is removed under primary anesthesia and replaced by a sterile
gauze wick or a wick to each pus-cavity if there are two. No packing
is now needed in the vagina. The dressing is changed every other day.
After the seventh day the sinus may be irrigated with i : 800 chlorinated
soda solution at each dressing. The sinus is drained by wn'cks until it
has closed in 2 in. in depth, and the temperature is normal. The
Fowler position is maintained forty-eight hours.

The patient is given water as soon as out of ether. Liquid diet is
started the next morning, soft solids the second day, and full diet the
fifth.

The bowels are opened by calomel the night after operation, fol-
lowed by an enema the next morning.

The patient may sit up in bed at the end of a week if the temperature
is normal, and may get up after the wicks are left out.

Complications and Sequelae. — Backing Up or Faulty Drainage,
— This is the most common complication. It is manifested by a sudden
or steady rise in the temperature, often accompanied by a chill and
vomiting, usually by abdominal pain. There is some tenderness, occa-
sionally some spasm, and sometimes a palpable mass in the lower ab-
domen. The patient is given primary ether, and two fingers introduced
into the sinus, which is dilated until the pocket of pus is felt as a round,
fluctuant mass, which is then broken into and evacuated. Then other
pockets are searched for, and the whole sinus thoroughly dilated and
packed. After this the patient should be treated as though she had
undergone a second vaginal section.

Peritonitis. — If, after a vaginal section, the temperature and pulse
34

530 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

rise rapidly, the abdomen becomes distended, more tender and more
rigid, and vomiting increases, the development of peritonitis may be
suspected. In such an instance the patient is given primary ether,
the packing withdrawn, and the cavity explored. If communication is
found with the peritoneum, it should be carefully enlarged and a rubber
drainage-tube passed into the peritoneal cavity. If a large enough tube
or a double tube is used, little difficulty will be experienced in keeping
it in place. This tube may be left in situ for four or five days unless
it becomes clogged or slips out, in which case it should be cleaned and
replaced. The patient should now be treated exactly as after a celi-
otomy for general peritonitis — high Fowler position, continuous rectal
saline, etc.

The greatest difficulty lies here in the diagnosis of beginning peri-
tonitis, for after all vaginal sections there is some reaction, characterized
by a higher temperature for twelve to twenty-four hours, with consider-
able tenderness and spasm. The rise in pulse-rate, combined with
abdominal distention and persistent vomiting, are the most important
aids in the diagnosis. Under no circumstances should the abdomen be
opened^ for we have in the vaginal opening the best possible mechanical
provision for drainage. Furthermore, in the large majority of cases
we shall be dealing with a somewhat localized pelvic peritonitis, and to
open the abdomen may result in breaking down some of the walling off
and scatter the process throughout the abdomen. If the patient will
not recover on vaginal, she will not on abdominal, drainage.

Hemorrhage, — Hemorrhage is seldom sufficient to give trouble.
The only treatment is to remove all the gauze from the abscess cavity
and repack firmly, with a firm vaginal pack in addition.

Injury to the Rectum. — This is more likely to occur in opening small
than large abscesses. The diagnosis will not be made until the first
dressing, when the fecal odor w^ill be detected on the packing. All
packing must be omitted and the vagina kept clean by sponging twice
a day with chlorinated soda solution (i : 800) until the fifth day, after
which douches of the same solution are given twice daily. An enema
of salt solution is given every day, and the bowels are kept moving from
above by catharsis. Spontaneous closure is the invariable result.

After this operation there remains for a considerable time a great
deal of induration throughout the pelvis and a more or less profuse
vaginal discharge. For the double purpose of depletion and cleanliness
the patient should take hot i : 800 chlorinated soda douches in the
recumbent position, with the hips elevated, twice a day. Depletion
with a glycerin tampon three times a week should also be practised.

VAGINAL SECTION FOR REMOVAL OF THE APPENDAGES 53 1

In many cases a symptomatic cure will be effected even though traces
of the inflammation remain on pelvic examination. In others, sooner
or later, symptoms return and celiotomy will then have to be done. It
must always be remembered that vaginal section has its chief usefulness
as a life-saving operation in cases of pelvic abscess where celiotomy
and removal of the appendages would be extremely dangerous, and
makes possible the removal of the source of trouble later, when it can
be done with little risk.

References

A. T. Cabot, Treatment of Pelvic Abscess, Amer. Gyn. and Ped., 1892, v, 540.
E. B. Young, An Analysis of Twenty-one Cases of Pelvic Abscess Treated by Vaginal
Section, Boston Med. and Surg. Jour., 1907, clvi, 76.

VAGINAL SECTION FOR REMOVAL OF THE APPENDAGES

This is done in preference to celiotomy by some surgeons. The
after-treatment does not vary from that after vaginal section for pelvic
abscess, except in the dressings and in the greater rapidity of conval-
escence. If the appendages have contained pus, the dressing is identical.
After the removal of an extra-uterine pregnancy, of ovarian cysts, or
chronically inflamed tubes, the vaginal vault is sewed up except for a
short space through which is inserted a small gauze drain. The vagina
is lighdy packed with sterile gauze. This wick and the vaginal gauze
are changed on the second day and removed for good on the fourth day,

except in case of an extra-uterine with rupture, or tubal abortion into
a walled-off cavity, in which event the drainage is maintained until the
cavity closes down, the wick being changed every other day. Fowler's
position is maintained until after the second dressing.

The patient may sit up on the seventh and get out of bed on the
tenth day.

Complications and Sequelae. — Injury to the rectum and peri-
tonitis are rare. The treatment is the same as described under vaginal
section for pelvic abscess.

Hemorrhage is more common than after pelvic abscess, and is to be
treated by drawing the stump of the amputated appendages down
through the vaginal opening by means of volsella or double hooks, and
picking up the bleeding point, which is then ligated if possible, or if
not, the clamp is left on for forty-eight hours.

References

W. H. Baker, Vaginal Ovariotomy, N. Y. Med. Jour., 1882, xxv, 250.
W. R. Pryor, The Treatment of Adherent Retroposed Uteri, Trans. Amer. Gyn. See,
1898, xxiii, 50.

533 OPERATION'S ON THE VAGINA, L'TERUS, AND ADNEXA

VAGINAL HYSTERECTOMY

Diessing.— if'i'a/Krc Metlwd.^M the coniplelion of the opera-
tion, a gauze wick is passed up into the pelvis through an opening
which is left in the vaginal vault, and the vagina packed firmly with
sterile gauze. The \-ulva is co\-ered with a sterile pad held by a T
bandage. The patient is put to bed in Fowler's (wsition. Unless there
is a sudden or marked rise in temperature, this dressing is left undis-
turbed until the fourth day, when it is removed and replaced. The
dressing is now changed every other day, the size of the wick being
decreased as the sinus closes down, and as soon as the sinus ceases to
discharge, the wick Is omilted entirely. The Fowler position is main-
tained until after the second dressing, or longer if there is profuse dis-
charge from the sinus. No irrigation is permissible before the eighth
dav.

Clamp Method. — .\\ the end of the operation a firm gauze packing
is carried up into the pelvis through the opening in the vaginal vault,
and the vagina packed in such manner that each ciamp is separated
from the others by gauze. The handles of the clamps are all tied to-
gether outside the \"uha, and gauze wound between and roimd them
(Fig. 176). They are then covered over with a large pad, wrung out
in some antiseptic solution, and outside of the whole a piece of oiled
silk is tied on. The oiled silk and the antiseptic pad arc changed after
each evacuation of the bowels or bladder. The clamps are removed
under primary anesthesia at the end of forty-eight hours, the sinus
rewickcd, and the vagina packed. The treatment from this point does
not differ from that after the ligature method, except that convalescence
is slower and less satisfactorv.

VAGINAL HYSTERECTOMY 533

Stay in Bed. — The patient may sit up in bed on the twelfth and
get out on the fourteenth day.

Bowels. — The bowels should be moved by 3 gr. of calomel in
divided doses the night following operation and an enema the next
morning. They should then be kept open by daily catharsis, compound
cathartic pills being a satisfactory agent.

Diet. — As soon as the patient is out of ether hot water, and shortly
cold water, may be given her. Early the next morning she is started
on hot broths. As soon as she is absolutely free from nausea, generally
by the morning of the second day, or, where the clamp method has
been employed, the third day, soft-solid diet may be begun. Chicken
is added on the fourth day and full diet is begun on the fifth.

Bladder. — The patient should be catheterized before the dressing
is introduced at the end of the operation, and if bloody urine is found,
an injury to the bladder should be searched for and repaired. In
this event a self-retaining catheter is kept in the bladder during the first
ten days, being removed, cleaned, boiled, and the bladder irrigated
twice a day. Where there has been no injury to the bladder, the patient
may be allowed to go until the bladder begins to be distended if unable
to void urine herself, and then urination is encouraged by hot fomenta-
tions to the pubes and running water. If these fail, the catheter may be
employed. In every case | gr. of morphin should be given subcutane-
ously before the patient leaves the table, and, where the clamp method
has been employed, this will probably be necessary every four hours,
as the pain is usually intense.

Complications and Sequels^.— Hemorrhage.— Tht ends of
the broad ligaments are brought down into the vagina after being
seized with a volsellum forceps, and the bleeding point found, clamped,
and ligated. If ligation is impossible, or the patient is in a very poor
condition, the clamp is left in place for forty-eight hours. In some
instances it will be necessary to include the whole end of the broad
ligament in the clamp.

Sepsis. — The employment of vaginal drainage and the Fowler's
position are directed to the prevention and control of infection, so that
no material change in the after-treatment will be made if infection does
occur. If there is a sudden. or steady rise of temperature to 103° or 104^
F. before the fourth day, the wicks are changed immediately, as this
indicates faulty drainage. Where there is a great deal of purulent dis-
charge from the sinus, irrigation with a solution of chlorinated soda
may be employed after the first week.

534 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

References

R. Olshausen, Weitere Erfolge der vaginalen Totalexstirpation des Uterus und Modi-
fication des Technik, Arch. f. Gyn., 1882, xx, 373.

J. P^an, De I'ablation des gros fibromes interstitiels du corps de I'uterus par la vou
perineo-vagino rectale, Ann. de gyn., 1894, xli, 522.

E. Doyen, Technique Chirurgicale, Paris, 1897.

W. R. Pryor, The Technique of Vaginal Hysterectomy in Cases of Pelvic Inflamma-
tion, Amer. Gynecol., 1903, ii, 102.

OPERATIONS ON THE CERVIX UTERI

Under this heading will be considered trachelorrhaphy and the
various plastic operations for dysmenorrhea, such as Dudley's, Rey-
nolds', Pozzi's, and others.

It may be appropriate to say a word about the method of suturing
the cervix in trachelorrhaphy. The sutures may be of silver wire or
catgut. The former will give the better cosmetic result, but catgut is
much easier to use and gives satisfactory results in everyday practice.
If wire is used, it is drawn through the cervix in a silk carrier. A regu-
lation cervix needle of the Sims or Emmet type is used. Each stitch
enters the vaginal surface of the upper lip and passes underneath the
denudation, emerging in the edge of the strip left undenuded to form the
wall of the cervical canal. It then reenters the edge of this strip on the
posterior lip, and emerges again on the vaginal surface at a point op-
posite to the original point of entrance. The first stitch is placed near
the inner and outer angles of the denudation, and each successive stitch
enters and emerges nearer the external os. On the vaginal surface the
stitches should enter and emerge \ in. from the edge of the denudation.
They should be tied without too much tension.

The after-treatment of these several operations is identical. Before
lea\nng the table the vagina is douched with sterile water and then
swabbed out with gauze, all blood-clot being carefully removed. The
vagina is douched daily with sterile water. Silver-wire stitches should
be removed at the end of two weeks. This is most conveniendy done
with the patient in the Sims posture, the wire being picked up with a
long clamp and cut with long-handled scissors. When catgut has
been used, unless the patient is a virgin, operated for dysmenorrhea, she
should report at the surgeon's office at the end of three weeks, and the
ends of the stitches picked off the cervix with a long-handled clamp.
The object of this is to stop the vaginal discharge which is kept up by
their presence.

The patient can take a light meal, consisting chiefly of soup or milk,
the evening after operation, and the following morning may be put at
once on full diet.

CURETTAGE FOR ABORTION AND MISCARRIAGE 535

The bowels are regulated by mild laxati\'es and enemas when neces-
sary.

The patient may sit li]> on the ninth and get up on the tenth day.

Complications and Sequelae. — Hemorrhage occurs with great
rarity, hut may develop where deep denudation has been necessary to
remove all scar tissue. A firm gauze pack is placed against the cervix,
and if this fails to stop the bleeding, the stitches must be removed and
new ones so taken as to control the bleeding \-essels.

Injury lo a ureter is a more or less theoretic complication, and could
only occur either due to an atypical anatomy of the ureter or a consider-
able lack of technique in operating.

T. A. Emmt't, Prmd|.k>s am]

PrarlicL- .>£ Gyi

iccnhgv.

1SS4. 466,

E. C. Duilli-y. A I'laslit i)],i.-

ralion iK^signo.

lighten iW-

Amer. Jour. OI«l., 1.S9T, :iNiv, 14:

S. Pozzi, On ihc Surgiial Trva

imcmof aM<.s

t Frc,|U..

MCau^-ui

Slcrilily in \\\>m<.-n, Surg., Gyn. ai

n,i OtraU'l.. 100

CURETTAGE FOR ABORTION AND MISCARRIAGE

When the patient is in a hospital, the uterus should not be jiacked
unless there is considerable bleeding. If the patient is in a private

B9l^ r

^^^^m^Jk

rti^ \

house or at a distance, it is the part of safety to pack firmly the uterus
and vagina. The pack is removed the next rfay and the uterus and

536 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

vagina left empty. \o vaginal douches are to he given before the tenth
clav.

■%,

The bowels are to be 0|)ene'l l»y an enema the morning after ojiera-
tion, and are kept open by the daily administration of cathartics.

Fic. i7g--P*(

Six hours after ojieration the patient is able to talie nourishment in
the form of broth or milk. The following morning she is started on
soft solids and the third day on full diet.

CURETTAGE FOR

TKIN AND MISCARRIAGE

537

She may sit up on tht ninth and jjct up on the tenth day.
Complications and Seqnelx.— Hemorrhage.— When the uterus
is left cm])(y, it sometimes becomes necessary to pack some hours

later to control hemorrhage. When the uterus has been lirmly packed,
serious hemorrhage is impossible. Sometimes after removal of the

packing a slight hemorrhage starts u]). If this docs not cease within
a few minutes, the uterus should be repacked with sterile gauze. This
may be removed twenty-four hours later with perfect safety.

538 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

Infection.— ^la.ny cases of miscarriaf^e are slightly infecled before
operation, as is shown by a moderate dej^ree of temperature. This, as
a rule, drops to normal within twenty-four hours after curettage. Occa-
sionally, within from twenty-four to forty-eight hours after operation,
there will be, with or without a chill, a sudden rise of temperature to 103"
or 104° F. This is usually due to a clot blocking up the cervix, and if
left to nature, the clot will usually be expelled and the temperature will
drop to normal again within twenty-four hours. If, however, the tem-
perature does not begin to drop within twelve hours, the cervix should
be gently dilated and the uterus washed out with four quarts of sterile
water. If the temperature stili persists, a culture should be taken
from the interior of the uterus with a Doederlein tube, and if a <;rowth

is obtained, a vaccine should be prej>ared from it. The vaccine treat-
ment of puerperal infection is as yet ex[>eri mental, but the operator is
not justified in leaving untried any treatment which may aid the re-
covery of the patient. (See Chapter LII.j The uterus should then
be washed out as before, and this time the uterine cavity should be
packed with a gauze sponge soaked in 70 per cent, alcohol. This is
repeated daily until the temperature begins to fall, or the uterus shuts
down so that the douche-tube cannot be inserted. When the tempera-
ture does not drop after the curettage, the uterus should be washed
out immediately after the packing is removed, after which the case
should be conducted as described above.

When the miscarriage has been voluntarily induced, a culture should

CURETTAGE FOR ABORTION AND MISCARRIAGE $$g

be taken before curettage, because infection is likely to be virulent, and
a vaccine should be ready for early use if emptying the uterus does not
bring about a drop in tem|jerature.

In addition to the local treatment, general measures are of great
value. The patient should be kept out-of-doors during the day, no
matter whether winter or summer. Strychnin sulphate, gr. ^^, and
whisky may be given every four hours. Xourishment should be
forced— «ggs, milk, cereals, broths, and meat being allowed, no matter
how high the temperature.

The pelvis should be examined every third day at least during the
course of the fever, so that any abscess in the broad ligaments will be
detected and may be opened. Localized foci which may develop in

any organ from pyemia should be watched for and treated. The
commonest of these are pneumonia, endocarditis, and joint infections.

General Ffritonilis. — This usually follows [lerforation of the uterus
in the attempt at criminal abortion, but may result from accidental
perforation by a curet in the hands of a skilful o]>erator.

The best treatment is vaginal drainage by ]x>s(erior col])otomy, as
described in the section on Pelvic Abscess (p. 529), followed by the
Murphy treatment, Fowler's position, continuous rectal saline, etc.

Pelvic Abscess.^Sec p. jsq.)

Salpingitis. ^Salpingitis due to puerperal infection is commonly
unilateral. It usually develops in the second week of convalescence,
and is characterized by an elevation of tem[)erature, with pain, tender-
ness, and spasm over one or both lower tiuadrants of the abdomen.

540 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

The treatment is rest in bed, liquid diet, free catharsis, hot flaxseed
poultices to the abdomen every two hours, and hot douches bvice daily.
The acute process will subside in seven to ten days, and salpingo-oophor-
ectomy may be done later if the tube remains enlarged.

Perforation of the Uterus, — Any surgeon who has curetted many
uteri has probably perforated at least one. Frequently there is ab-
solutely no ill effect. The occurrence is recognized by the curet sud-
denly passing into the uterus up to the handle. When this happens, the
curet should be withdrawn and all further maneuvers stopped. The pa-
tient is put to bed in the Fowler position. The pulse is recorded every half-
hour for twelve hours and a four-hourly chart is kept for three days. For-
tunately, this accident seldom happens until the uterus is nearly or quite
empty; in fact, it usually results from an overdesire to get the uterus
clean, so that there will be no need to pack the uterus. If there is much
bleeding, however, the uterus should be packed lightly and carefully.
If there is a steadily rising pulse, the abdomen should be opened and
the perforation in the uterus closed, and injury to the intestine sought
for. The abdomen should be closed with a wick to the point of injury.
A provisional stitch may be inserted at the site of the drain. After
forty-eight hours the wick is removed and the stitch tied.

If, after the uterus has been accidentally perforated, there appears
upon the four-hourly chart a steady rise of temperature and pulse,
together with increasing pain and tenderness in the lower abdomen,
celiotomy should be performed at once. The uterine wound should
be sewed up and the pelvic cavity drained. If peritonitis is found, the
regulation Murphy treatment is instituted.

References

A. Pinard, Traitement des Infections Pucrperals, Ann. dc gyn., 190Q, \\, 577.
L. v. Friedman, Puerperal Salpingitis, Surg., Ciyn. and Obst., 190S, vii, 476.
A. P. Heincck, Perforating Wounds of the Uterus Inflicted During the Course of
Intra-uterine Instrumentation, Surg., Gyn. and Obst., 1908, vii, 424.

H. M. Stowc, The Treatment of Abortion, Surg., Gyn. and Obst., 19 10, x, 80.

HYDATIFORM MOLE

After removal of an hydatiform mole the uterus is tightly packed
to control hemorrhage. This packing is removed at the end of
twenty-four hours. The same general rules apply to the immediate
convalescence as to that after miscarriage. The chief complications
are hemorrhage, perforation of the uterus, infection, and the develop-
ment of a chorio-epithelioma. The first three require no discussion
in this section (see p. 535)-

SYMPHYSIOTOMY 54 1

Chorio-epithelioma. — J. W. Williams' states that 50 per cent, of all
cases of chorio-epithelioma develop after hydatiform mole. Therefore,
every patient from whom a mole has been removed must be kept under
observation for from six months to one year. Repeated hemorrhage
from the uterus demands exploration with the curette and microscopic
examination of the scrapings. If these present evidence of chorio-
epithelioma, immediate radical operation offers the only hope of cure.

CURETTAGE FOR ENDOMETRITIS OR ANTEFLEXION

These will be considered together because their after-care is, for
the most part, identical. When the operation has been performed for
endometritis, the uterus is simply wiped out with dry sterile gauze,
then with gauze saturated with Churchill's tincture of iodin, and left
empty.

Where an anteflexed uterus has been dilated and curetted, the inter-
nal OS is kept open by means of a stem pessary. The uterus is carefully
wiped out with dry sterile gauze, the pessary inserted and stitched in
place by three silkworm-gut stitches through the holes in the flange
and the cervix. The vagina is left empty. This pessary is removed
at the end of ten days. The patient is placed in the Sims posture and
the cervix exposed. The sutures are cut with long-handled scissors,
and after this the pessary can be made to slip out by very slight traction
upon the flange.

The bowel should be opened by enema the morning after operation,
and kept open by daily catharsis. Six hours after operation the patient
may take some hot broth or hot milk. The next morning she returns
to full diet. The patient may sit up on the sixth, and get up on the
seventh, da v.

Complications. — Perforation of the uterus may occur. An old
salpingitis which has lain dormant for some time may be lighted up by
a curettage. What has just been said about these conditions under
curettage for miscarriage apply here also.

SYMPHYSIOTOMY

After the delivery of the child the bladder is catheterized, and if
bloody urine is withdrawn, an injury to the bladder is looked for and
repaired. When the open method has been employed, the pubic liga-
ments are united and the skin wound closed with a small gauze drain in
the lower angle. With the subcutaneous method no sutures are possible
except one or two in the skin at the upper opening. In the latter case

^ Obstetrics, p. 492.

542 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

a gauze wick is passed into the lower opening. After either method a
sterile gauze dressing is applied and held in place by adhesive straps.
A strong canvas belt extending from just above the crests of the ilia
to 6 in. below the trochanters, and well padded with cotton over the
prominences, is buckled about the pelvis. The patient is put to bed
with a sand-bag beneath each trochanter. The wound is inspected
at the end of forty-eight hours, and the wick left out unless suppura-
tion occurs. Stitches are removed on the tenth day. The v^lva is
kept covered with a sterile pad, and is irrigated with sterile water after
each urination or defecation.

Catheterization should be employed at the end of twelve hours if
the patient does not urinate spontaneously, and every eight hours there-
after if necessary.

The bowels are moved by castor oil on the evening of the second
day and kept open by daily catharsis if necessary.

The diet is liquid for forty-eight hours; soft solid on the third day;
chicken added on the fourth, and full diet begun on the fifth day.

The care of the breasts and other details of management of the
puerperium do not differ materially from those after any obstetric case.^
The patient is kept in bed four weeks, and wears a firm belt about the
pelvis for three months. At the end of this time she is able, as a rule, to
resume her ordinary habits of life.

Complications and Seqtielst.— Infection.— Vttnne infection,,
which is extremely common in the cases requiring symphysiotomy, is
manifested and treated no differently from sepsis after any other method
of delivery, as described in the section on Miscarriage. Infection of the
w^ound is also common and is treated the same as any other infected
wound. An absolutely afebrile convalescence from symphysiotomy is
almost unknown.

Hemorrhage from the venous plexus behind the symphysis is always
present at operation, and sometimes is not controlled by the sutures and
dressing, but requires packing.

Injury to the bladder is a frequent complication. It should be dis-
covered at operation and repaired. If this is not done, a urinary fistula
develops. Whenever the bladder is injured, whether repaired or not,
constant drainage by means of a self-retaining catheter should be in-
stituted, and the catheter removed, cleaned, boiled, replaced, and the
bladder washed out wnth 6 ounces of 4 per cent, boric-acid solution
twice daily. This is kept up for ten days. If the injury has not been
repaired or repair is unsuccessful, the fistula must be closed by opera-
tion at a later day.

PUBIOTOMY

543

Mf . V. P.. SO. «.

tHmonoais Vcntro«.auci)en&lon.

lif^s 5 Bi n El ffi [ffl n in m ri fw m "H PI w

Perineal and vaginal tears are common and should be repaired.
Their after-treatment does not vary from that described in the section
devoted to them.

Injury to the sacra-iliac joints from too great separation of the sym-
physis results in severe backache and interference with locomotion.
This is treated by a tight canvas or leather belt, which must be worn
for from six months to a year. A
plaster-of-Paris jacket may be nec-
essary for a time.

Hematoma of the labium from hem-
orrhage from the prevesical plexus is
common. Even very extensive ec-
chymosis and moderate-sized hema-
tomas are cared for by nature. When
a hematoma develops excessive size
or persists after ten days or two
weeks, it should be incised, its con-
tents evacuated, and the cavity
packed.

Failure of union at the joint, with
considerable mobility of the pubic
bones, resulting in a permanent im-
pairment of gait, occasionally follows
this operation.

Cystitis is common, especially
where the bladder has been injured.
For treatment, see Chap. XIV, p.

157.

PUBIOTOMY

What has already been said about
symphysiotomy applies in the main also to pubiotomy. The conva-
lescence, however, is more rapid and freer from complications. The
patient is able to get out of bed on the twenty-first day instead of at
the end of four weeks, and normal locomotion is possible much sooner
than after symphysiotomy.

The same compHcations occur, but less frequently. Failure of
union seems to make no appreciable difference in locomotion, as a
firm fibrous union takes place in these cases.

The belt may be omitted at the end of four weeks, instead of being
worn for three months, as in symphysiotomy.

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544 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

References

J. R. Sigault, Discours sur les avantages de la section de la s)Tnphyse dans les ac-
couchemenls, Paris, 1779.

R. P. Harris, The Remarkable Results of Antiseptic Symphysiotomy, Trans. Amer.
Gyn. See, 1892, x\'ii, 98.

P. Zweifel, Die subcutane Symphyseotomie, Centr. f. Gyn., 1906, xxx, 737.

L. Gigli, Taglio lateralizzato del pube, sua vantaggi, sua tecnica, Ann. di os. e. gin.,
1894, xvi, 649.

A. Doderlein, Ueber alte u. neue beckenervveiternde Operationen, Arch. f. Gyn.,
190^, Ixxii, 275.

E. Bumm, In Stoeckel, Symphyseotomie oder Pubiotomy, Centr. f. Gyn., 1906, xxx, 78.
C. G. Leopold, In Kannegeisser, Beitrage zur Hebotomie auf Grund von 21 Falle,

Arch. f. Gyn., 1906, Ixxviii, 52.

C. B. Reed, Pubiotomy, Amer. Jour. Otetet., 1909, Ix, 100.

OPERATIONS FOR RETROVERSION AND LESSER OPERATIONS ON

THE APPENDAGES

For the sake of convenience I have grouped together the numerous
abdominal operations for retroversion and the minor operations on
the appendages, such as resections of the tubes and ovaries and removal
of small ovarian cysts> since the general principles of after-treatment
are practically identical, and the several operations are frequently
combined.

Dressing. — Such cases are practically, without exception, closed
tightly in layers, and a thin dressing of sterile gauze held by adhesive
straps or laced plaster (Fig. 162, p. 506) is placed over the wound. The
stitches are removed on the tenth day.

If an operation for displacement of the uterus has been done, the
patient is not allowed to sit up in bed until the twelfth day, or to get
out of bed before the fourteenth. On the other hand, if only the ap-
pendages have been operated upon, she may sit up before removal of
the stitches and get up on the seventh day.

The general after-treatment and complication do not vary from
those of any of the simpler celiotomies.

References

H. A. Kelly, Hysterorrhaphy, .\mcr. Jour. Obst., 1887, xx, ^^.

R. Olshausen, Ueber ventralc Operationen bei Prolapsus und Retroversio uteri,
Centr. f. Gyn., 1886, x, 698.

J. C. Webster, A Satisfactory Operation for Certain Cases of Retroversion of the
Uterus, Jour. Amer. Med. Assoc, 190 1, xxxvii, 913.

J. M. Baldy, Retrodisplacements of the Uterus and Their Treatment, New York
Med. Jour., 1903, lxx\nii, 167.

D. T. Gilliam, Round Ligament Ventrosuspension of the Uterus, Amer. Jour. Obst.,
1900, xli, 299.

F. F. Simpson, Intra-abdominal but Retroperitoneal Shortening and Anterior Fixation
of the Round Ligaments for Posterior Uterine Displacements, Trans. Southern Surg, and
Gyn. See, 1902, xv, 223.

OVARIOTOMY 545

OVARIOTOMY

The after-treatment of removal of uncomplicated simple cysts,
even of large size, is identical with that described for the lesser opera-
tions upon the appendages. These constitute the majority of ovariot-
omies.

Drainage is required only when there have been many adhesions of
the cyst to the walls and floor of the pelvis, as a result of the separation
of which a large oozing surface is left behind which cannot be controlled
by sutures; whenever there has been infection, either in the cyst contents
or the peritoneal cavity; after the removal of malignant tumors where
there is ascites, and when a dermoid cyst has been accidentally ruptured
in removal and its contents have escaped into the peritoneal cavity.
An oozing surface requires a single gauze pack making firm pressure
against it. Where there has been ascites or infection, it is best to pass
a drain behind each broad ligament, although the tumor may have
been unilateral. Where a dermoid cyst has been ruptured, a single drain
which passes down behind the stump of the broad ligament on the
affected side and into the posterior culdesac is sufficient.

The simple exploration of the abdomen where a papillary adeno-
cystoma is found, and, after evacuating the free fluid, the wound is
immediately closed, does not require drainage, but if attempts at re-
moval of the growth have been made, a wick should be placed behind
each ligament. In some cases an ovarian cyst is so adherent as a
result of peritonitis that it is impossible to do more than evacuate the
cyst contents and remove part of the cyst-wall. In this instance a wick
should be passed into the cavity of the cyst, and a second one into the
abdomen just above the cyst, to wall off the pelvis from the general
peritoneal cavity.

When the drainage has been simply to control oozing, a provisional
through-and-through suture of silkworm gut is inserted at the time of
operation at the site of exit of the drain. At the end of forty-eight
hours the drain is removed and the provisional stitch tied. Healing
by first intention is the rule. In any other case drains are removed
on the fourth day, and, as a rule, can be replaced by a single small wick,
which is left out altogether the following day. The edges of the wound
are then brought together by adhesive strapping, and the dressing
changed every other day, as by this time the edges of the drained area
will be practically united.

Cases closed tight and those in which a provisional stitch is em-
ployed with success get up on the fifth day. Drained cases usually
may sit up on the twelfth, and get up on the fourteenth, day.

Complications and Sequelse. — ^The complications of celi-

546 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

otomy for this condition are the same as those for celiotomies in
general.

Slipping of a Ligature on the Pedicle, — This occasionally occurs.
The symptoms are those of secondary hemorrhage. The treatment is
to reopen the abdomen and retie the pedicle.

Injury to the Bowel. — This complication may result from the separa-
tion of an adherent cyst from any part of the bowel. The injury should
be repaired at the time of operation, and a gauze drain inserted to the
injured area, to be removed on the fourth day. If a fecal fistula develops,
the wicks are left out. The edges of the wound and the surrounding
skin are smeared with stearate of zinc ointment. After the seventh
day the fistula is irrigated twice daily with chlorinated soda in i : 800
solution. Spontaneous closure usually takes place in from two to three
weeks. If the fistula shows no signs of closing down after six weeks,
operative measures should be resorted to for its closure. (See also
Chap. XXV, p. 280.)

Injury to Bladder or Ureter. — These complications occur only with
extreme rarity. Their treatment will be the same as is described under
Hysterectomy (p. 552.)

Reference
A. J. C. Skene in Kelly-Noble, Gynecology and Abdominal Surgery, 1907, i, 587.

SALPINGO-OOPHORECTOMY FOR SALPINGITIS AND OVARIAN

ABSCESS

Dressing's. — Wicks may be necessary for either of t^^^o indications:
first, after separating adhesions an oozing surface which cannot be con-
trolled by sutures; second, whenever pus has escaped into the pelvis
in the process of separating and removing the diseased organs. In the
first instance a single wick is passed to the oozing surface, or one to
each, if there is an uncovered area on both sides of the pelvis, and a
provisional through-and-through silkworm-gut stitch is taken at the
site of exit of the wick. At the end of forty-eight hours the wick is
removed and the stitch tied. The wound is inspected again two days
later, and if the stitch is found to be holding, the wound is not disturbed
again until the tenth day, w^hen all the stitches are removed.

When drainage is required because of pus, a w^ick is passed behind
each broad ligament, if the operation has been bilateral, in such a w ay
that the two meet in the posterior culdesac and emerge side by side
in the lower angle of the wound. In this way the pelvis is walled off
completely across. Where operation is performed only on one side,
the drain should be passed behind the broad ligament and over into

SALPINGO-OOPHORECTOMY 547

the posterior culdesac, and then brought out in the lower angle of the
wound. The wicks are removed on the fourth day and replaced by
smaller wicks, one running to each sinus. At the third dressing a single
wick to the bottom of the pelvis is usually sufl&cient. After the tem-
perature becomes normal, usually about the fifth day, this wick is
shortened an inch daily, and when the sinus has closed to two inches in
depth, it is omitted entirely. The wound is then filled with glycerin or
balsam of Peru. The stitches are removed on the tenth day, but the
dressing over the wound is changed daily until the sinus is closed.
When discharge from the sinus has practically ceased, healing may be
hastened by strapping together the edges of the wound.

When the uterus is removed with the appendages, the method of
dressing is the same as when both sides have been removed without
the uterus. The wicks are passed behind the stumps of the broad
ligaments in the same manner, and brought together in the posterior
culdesac, so as to cover over the stump of the cervix and make their exit
from the wound in the same manner.

Sometimes after the temperature has once dropped to normal a
sudden or gradual rise again occurs, accompanied by pain in the depths
of the wound. This signifies backing up in the sinus, with formation
of a pus-pocket. The treatment is to explore the wound with the finger
under primary ether, dilating the sinus until the characteristic fluctuant
feel of a pus-pocket is detected. Dilatation of the sinus is continued
until the pus-pocket is entered and emptied. A drain is carefully
passed to the bottom of the pocket and left undisturbed for forty-eight
hours, after which it is changed daily, gradually being shortened as the
temperature falls and the pocket closes in.

Stay in Bed. — ^When the abdomen has been closed without
drainage, or where a provisional stitch has been employed, the patient
may sit up in bed on the ninth, and get out of bed on the tenth, day.
The stay in bed of the drained cases will naturally vary considerably.
A safe rule to follow is not to let the patient out of bed until the sinus is
closed above the level of the fascia, and then only with a firm adhesive
strap upon the woimd. Otherwise, the general rules for after-treatment
of celiotomies apply to this operation.

Complications and Sequelae.— /wywry to Bowel— ExXhtr the
rectum, sigmoid, or small intestine may be injured in separating a
densely adherent tube. If this is discovered at the time of operation,
the injury should be repaired, after which an extra drain is passed
especially to wall off the injured bowel. This drain is removed at the
same time as the others. Enemas should be avoided if the injury has
been to the rectum or sigmoid, and the bowels kept open if possible by

548 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

catharsis alone. If a fecal fistula results, the drains must be omitted
•entirely and the skin about the wound smeared thickly with stearate or
oxid of zinc ointment. After the seventh day the fistula is irrigated
twice daily with i : 800 chlorinated soda solution, and a copious rectal
irrigation with salt solution is given once daily. Spontaneous healing
in two or three weeks is the rule in small fistulie. It is not harmful, and,
in fact, better for the health of the patient to get her out of bed at the
end of three weeks, even if the fistula has not closed. If the fistula
shows no signs of filling in after six weeks, it should be closed by opera-
tion.

Injury to the Bladder and Ureters, — These are very uncommon
complications of the operations for salpingitis and ovarian abscess.
They are usually caused by needle-pricks. If the injury is discovered
at the time it is done, the bladder or ureteral wound should be closed
in with several fine Pagenstecher sutures. The drain is then disposed
so as to wall this area off from the peritoneal cavity. If the suture
has been unsuccessful or the injury has not been discovered at the time
of operation, the odor of urine will be found upon the wicks at the
first dressing. In this case it will be difficult to avoid infection, but, so
far as possible, the wound should be kept clean and the skin about it
protected f'-om maceration. Irrigation of the wound is contraindicated.
The repair of the fistula must be deferred until the wound has become
practically clean.

Phlebitis. — ^Thrombosis of the uterine, internal iliac, and common
iliac veins in succession, while less common than after operations on the
uterus, occurs with considerable frequency. (See Chap. IX., p. 114.)
Its onset is usually in the second or third week. The symptoms are
pain in the thigh, edema of the entire thigh and leg, and slight elevation
of temperature. The treatment is rest and elevation by the use of a
pillow and side splints. The patient is kept in bed for at least one week
after all swelling has subsided — i, e., a total period of six to eight weeks.
Citric acid in 20-gr. doses three times a day may be given, though the
citric acid treatment of phlebitis is still perhaps experimental. When
the patient gets out of bed, she should wear a flannel bandage. There
will be some swelling of the ankle, whenever the patient is on her feet
a great deal, for six months or a year, and the bandage should be worn
during this period.

References

H. A. Kelly, Operative Gynecol., 1906, ii, 270.

S. E. Tracy, Preparatory and After-treatment of Celiotomy Cases, Surg., Gyn. and
Obst., 1909, viii, 645.

TUBERCULOUS SALPINGITIS 549

TUBERCULOUS SALPINGITIS

This deserves especial attention because the management of the
after-care differs decidedly from that of other forms of salpingitis. At
the operation all the tuberculous pelvic organs should be removed,
including, in many cases, the uterus. The abdomen is then closed with-
out drainage, because if drainage is instituted, the walls of the sinus be-
come infected with tubercle and the sinus is likely to persist indefinitely.
The patient should be got out-of-doors by the fifth day, and the regula-
tion dietetic and hygienic measures for the treatment of tuberculosis
instituted. After this time the case is to be regarded solely as one of
tuberculosis and treated accordingly. The wound is inspected on the
tenth day and the stitches removed. The time of getting up is to be
governed by the temperature, as in any case of tuberculosis.

Complications and Seqnelae. — Tuberculosis in Other Organs, —
Some involvement of the peritoneum is invariable except in the very
earliest stage. Opening the abdominal cavity and removing the major
focus of infection frequently is followed by cure.

Tuberculosis of the intestines, pulmonary tuberculosis, and general
miliary tuberculosis are also frequent complications. In all cases it
must be remembered that once the tuberculous focus has been removed
as far as possible and the peritoneal cavity has been exposed to air,
light, or whatever the agency is which is so effective in many of these
cases, the case becomes one of tuberculosis instead of salpingitis and is
to be treated accordingly.

Injury to the Bowel. — Large tuberculous tubes and tuberculous pelvic
abscesses frequently become densely adherent to the rectum, and the
pus burrows into the rectal wall. Under such circumstances injury
to the rectum is unavoidable. This is the gravest possible complica-
tion. The friable condition of the rectal w^all makes repair difficult.
The omentum and sigmoid are usually adherent or involved with tubercle
to such an extent that they cannot be brought down to cover over the
weak place. Finally, with the tuberculous condition of the rectal wall
itself, these factors all tend to the establishment of a fecal fistula, which
becomes a tuberculous sinus, and is, therefore, likely to persist indefinitely
until the patient, weakened by the disease and the fistula, succumbs.

If the rectum is injured, it should be stitched over as well as pos-
sible. A drain has then to be inserted; it should be placed not directly
against the stitches, but a little higher up, so as to wall off the wounded
part of the rectum, but to avoid direct contact with it, otherwise, remov-
ing the drain would increase the danger of fistula by breaking up adhe-
sions. The local treatment of such a fistula is the same as for any other

550 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

fecal fistula, but hygienic measures are of the utmost importance. At-
tempts at repair are practically hopeless.

Either the sigmoid or the small intestine may be adherent to a tuber-
culous tube or abscess and occasionally may be injured. The prognosis
is more hopeful than when the rectum is injured. The treatment is
identical, except that after the fistula has persisted for t\vo months, an
attempt at dissection of the fistula and even resection of the gut should
be made.

Tuberculous Sinus Persisting After Operation. — The healing of a
sinus which persists after a drained case is promoted chiefly by hygienic
measures. The use of bismuth paste may be tried, but is seldom suc-
cessful. Repeated applications of tincture of iodin give the best result
locally. After six months, if it still persists, an attempt at dissection may
be made. It must be remembered that bowel is frequently adherent
at the bottom of the sinus, and that such a maneuver may result in a fecal
fistula. It is in some cases better to leave the sinus altogether alone
since, beyond the inconvenience of having to keep it clean and covered,
the patient does not suffer. The treatm.ent by the means of vaccine
therapy is often beneficial. (See Chapter LII.)

References

J. B. Murphy, Tuberculosis of the Female Genitalia and Peritoneum, Amer. Jour.
Obst., 1904, xlix.

F. B. Lund, Tuberculosis of the Peritoneum, Boston Med. and Surg. Jour., 1908,
clix, 885.

E. B. Young, A Case of Tuberculous Salpingitis with Rupture into the Rectum, etc.,
Boston Med. and Surg. Jour., 1905, clii, 551.

W. H. Allport, Tuberculous Infections of the Peritoneum, Surg., Gyn. and Obstet.,
1909, ix, 529.

ABDOraNAL HYSTERECTOMY

Dressing^. — After the supravaginal amputation of a myomatous
uterus the abdomen is closed in layers without drainage, unless there
is an amount of diffuse oozing which makes temporary packing neces-
sary. The first dressing is done on the ninth day, and the stitches re-
moved. The patient gets up on the tenth day.

After total extirpation of the uterus for malignant disease, drainage
should always be employed. This may be effected either by a small
wick passed into the vagina through a small opening in the vault, or by
a small abdominal wick, according to the preference of the individual
operator. In either case the wick is removed at the end of forty-eight
hours and replaced by a smaller one, which is entirely omitted after
twenty-four hours more. If abdominal drainage has been employed,
the edges of the wound are strapped with adhesive plaster. The dress-

ABDOMINAL HYSTERECTOMY

551

ing is changed every other day. The stitches are taken out on the ninth
day, and the patient may get up on the tenth day. After omission of
the vaginal wick, nothing further is necessary, but a profuse vaginal dis-
charge may be relieved by chlorinated soda douches (i : 800) after the
seventh day.

The management of bowels, diet, etc., does not differ from that
after any celiotomy.

m:«. c. t. s.

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Unexplained continued temperature. On the thirteenth day decomfx>sed clot discharged from the amputated

cervical canal with immediate drop.

Hysterectomy, as an adjunct to the removal of pus-tubes, will be
considered under that head, since the essential principles of after-treat-
ment will be those of operations for salpingitis.

Complications and Seqnelae. — The complications common to
celiotomies in general may occur after this operation. In addition to
these, certain special complications deserve mention.

Pelvic Hematoma, — Blood from a slipped ligature or from an oozing
surface may collect under the stitched pehic floor, and give within a
few hours great pain or signs of hemorrhage. Vaginal examination

552 OPERATIONS ON THE VAGINA, UTERUS, AND ADXEXA

shows a bulging, boggy vault. Unless within a few hours the symp-
toms abate, the wound must be opened, the clot turned out, and the
bleeding stopped. Slight oozing may give no immediate symptoms,
but after some days slight continued temperature (Fig. 185) and con-
stant pain will indicate a pehnc collection of serum or clot. Douches
may lead to drainage, or it may be necessary to dilate the cervical
stump to insure evacuation.

Ligation of the Ureter, — This accident may occur in either form of
hysterectomy, but most frequently occurs during total extirpation. If
only one ureter is tied off, there are, as a rule, no symptoms. Rarely
there may be some pain in the region of the kidney. When both ureters
are ligated, there is, of course, complete suppression of urine, and death
rapidly ensues from uremia. If discovered in time, an attempt to undo
the damage by operation should be made.

Injury to the Ureter. — This occurs not infrequently in the course
of the radical operation for cancer of the uterus. If discovered at the
time it is done, the injury should be repaired and a small gauze wick
placed to the seat of suture, which is removed at the end of forty-eight
hours, and left out. If the repair is unsuccessful or the accident is not
discovered at the time of operation, urine is discharged from the wound
when the wick is removed. In this event the wound is simply kept clean
and the parts protected from irritation, the repair of the fistula being left
until a later date. In the case of an abdominal fistula, these indications
are met by wiping the skin about the wound with 70 per cent, alcohol
twice daily, after which it is smeared with zinc ointment, and the whole
covered with sterile gauze. Where vaginal drainage has been employed,
the vagina is swabbed out with 4 per cent, boric acid solution twice daily.
The skin about the vulva is smeared with zinc ointment and a large
sterile pad worn over the vulva.

Injury to the Bladder, — This may be discovered at operation and
repaired. In such a case it is safer to insert a self-retaining catheter
and put the patient on constant drainage. This catheter is removed,
cleaned, boiled, and replaced twice a day, and the bladder is irrigated
each time with 4 per cent, boric-acid solution, using not over 4 ounces,
so as not to throw much tension on the stitches. Constant drainage is
maintained for ten days. A small gauze wick is inserted to the point of
injury after the suture is completed. The wick is removed at the end
of forty-eight hours and left out. Hexamethylamin, in yj-gr. doses
three times daily, should be given to render the urine antiseptic.

When the injury is repaired and does not heal, the urine is discov-
ered by its odor on removing the drain. In this event the same direc-

INOPERABLE MALIGNANT DISEASE OF PELVIS 553

tions as for the care of a ureteral fistula are to be followed. In any case
hexamethylamin (yj gr.) three times a day should be employed as a
urinary antiseptic.

Thrombosis of the Pelvic and Iliac Veins. — This complication fol-
lows hysterectomy more frequently than any other operation. It occurs
usually during the second week of convalescence. It is manifested
by swelling of the thigh and leg, accompanied by more or less pain and
elevation of temperature. The treatment is elevation and immobiliza-
tion by means of a pillow and side splints, such treatment to be continued
until all swelling has disappeared. Pain is to be controlled by ice-bags
and morphin. Citric acid in 20-gr. doses three times a day is considered
theoretically as an aid in preventing coagulation, and should be tried.
The patient must remain in bed for one week after all swelling has dis-
appeared. When the pillow and side splints have been discontinued,
the limb should be bandaged from the toes to the groin with a flannel or,
better, an " Ideal " bandage. Some swelling of the ankle while the pa-
tient is on her feet will persist for from six months to a year.

Pulmonary Embolism, — This occurs as the result of dislodgment
of a clot in the iliac vein, and generally results in death. It may happen
at any stage of the convalescence, but is most common between the fifth
and fourteenth days.

Myocarditis. — Arterial changes and myocardial degeneration are
observed in a large percentage of fibroid cases, and after operation may
cause considerable worry; 15 minims of tincture of digitalis three times
a day should be given whenever there is cardiac irregularity after opera-
tion. All cases of sudden death after operation which are not due to
pulmonary embolism can probably be ascribed to this condition.

•

References

H. A. Kelly and T. S. Cullen, Myomata of the L'terus, 1909, 654.

J. G. Clark, Kelly-Noble, Gynecol, and Abd. Surg., 1907, i, 744.

E. Wertheim, Zur Frage der Radikaloperation beim Uteruskrebs, Arch. f. Gynak.,
1900, Ixi, 627.

M. Hofmeier, Ueber die Haufigkeit der Thrombose nach gjnakologischen Opera-
tionen und im Wochenbett, Cent. f. Gyn., 1909, xxxiii, 21.

H. Crouse, Thrombi and Emboli, Surg., Gyn. and Obst., 1909, ix, 663.

S. E. Tracy, Fibromyomata Uteri, Surg., Gyn. and Obst., 1908, vi, 246.

J. A. Sampson, Ureteral Fistula; as Sequelae of Pelvic Operations, Surg., Gyn. and
Obst., 1909, viii, 479.

INOPERABLE MALIGNANT DISEASE OF PELVIS

In inoperable carcinoma of the uterus relief is demanded of four
symptoms: pain, cachexia, hemorrhage, and discharge.

For pain^ morphin furnishes practically the only relief. According

554 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

to Maier,^ however, aspirin is of great value, and this is worth trying
first.

For cachexia, iron, arsenic, and strychnin, the hypophosphites, and
the various bitters may be tried. Much of the loss* of strength and
flesh is due to absorption from the sloughing cancerous mass, and
marked improvement often follows morcellation.

Hemorrhage and discharge may be considered together, for both are
due to the same cause — sloughing of the growth. Morcellation with
a sharp curette, followed by the application of the Paquelin cautery
or 95 per cent, carbolic acid and alcohol, should be i>erformed under
ether. The resulting crater is packed tightly with iodoform gauze for
forty-eight hours to control hemorrhage. This packing is then omitted
and bidaily douches of chlorinated soda (i : 800) instituted.

A sudden severe hemorrhage can practically always be controlled
by a tight vaginal pack. Morcellation can be done, of course, only
in cancer of the cervix. In carcinoma of the corpus, discharge and
hemorrhage are somewhat less annoying, but frequently require cu-
rettage.

Of the methods which have been advocated as of possible value in
checking the extension of carcinomata, the x-ray and radium may be
mentioned as foremost. Owing to the anatomic location and the deep-
seated nature of the growth, radium is to be preferred to the x-ray.
Wickham and Degrais^ have reported 2 cases where marked im-
provement followed its use; in i even to the extent of apparent cure.
Radium is worth trying, but only in inoperable cases.

Trypsin was first suggested as a possible cure for cancer by Beard.^
Graves'* has used it in 6 cases of cancer (i of the uterus and 5 of the
breast). Although extension of the growth continued, injection of
the ferment into a single nodule always caused that nodule to cease to
grow and sometimes to disappear. Sloughing and pain were less
noticeable under its use. Pusey,^ on the other hand, reported unfa-
vorable results: the development of abscesses at the site of injection
and increase in cachexia.

Trypsin treatment is carried out daily. Injections are made by
means of a hypodermic syringe directly into the growth, beginning
with 5 mm. and increasing the dose gradually up to 60 mm. A few

* Therapeutic Gazette, 1908, N. S. xxiv, 460.

* Radium Therapy, English Translation by Dore, p. 283.

* Lancet, 1902, i, 1758.

* Boston Med. and Surg. Jour., 1908, clviii, 121.
^ Jour. Am. Med. Assoc., 1906, xlvi, 1763.

CELIOTOMY FOR EXTRA-UTERINE PREGNANCY 555

drams of the same preparation are injected into the uterine canal,
and I to 2 ounces diluted with 3 parts of water are left in the vagina,
the outlet being plugged with cotton and the hips kept elevated for
two hours.

Gellhom^ has obtained good results from the use of acetone.
This hardens the growth, just as it hardens tissue in the laboratory,
and gets rid of the hemorrhage and discharge. The cervix is first
thoroughly morcellated. Treatment is begun on the fourth or fifth
day after operation and repeated three times a week. The vulva and
lower part of the vagina are first smeared with vaselin for protection
against the acetone. The patient's hips are elevated on cushions and
I to 2 ounces of pure acetone poured directly into the crater through
a tubular speculum. The patient is kept in this position for half an
hour. The acetone is allowed to run out through the speculum and a
cotton tampon smeared with vaselin is introduced.

Inoperable or recurrent sarcoma may be treated with Coley's
toxins of erysipelas and Bacillus prodigiosus. It will seldom be pos-
sible to make injections directly into the tumor, and subcutaneous
injections must be employed alone. In a recent paper Coley^ reports
3 cases of inoperable sarcoma arising in the pelvic organs apparently
cured by this treatment. The technique is described elsewhere (p.

797).

CELIOTOMY FOR EXTRA-UTERINE PREGNANCY

A patient operated upon for unruptured tubal pregnancy is to be
treated exactly as described for the after-care of the lesser operations
upon the appendages. The complications to be met are the general
ones to which any celiotomy may be subject.

When rupture or tubal abortion has taken place into a walled-off
cavity before operation, a wick should be passed into this cavity and a
provisional stitch inserted. The wick is removed in forty-eight hours
and the stitch tied. The case is now treated as if sewed tight in the
beginning.

When rupture has taken place into the general peritoneal cavity,
the ruptured tube and the broad ligament should be tied off, the tube
removed, and the peritoneal cavity thoroughly cleansed of clot. If
the peritoneum can be got clean of practically all clot, the abdomen may
be sewed up tight, but if much clot remains, and especially in cases where
rupture has taken place several days before operation, a gauze wick
should be passed into the pelvis behind the affected broad Ugament.

* Amer. Jour. Obst., 1909, lix, 799.

2 Surg., Gyn., and Obst., 191 1, xii, 174.

556 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

A provisional stitch is also inserted. At the end of forty-eight hours
the wick is removed and the stitch tied if there are no symptoms of peri-
tonitis.

In the after-treatment of these cases we are deahng with patients in
a state of profound anemia and shock, and immediate treatment should
be carried out along the lines already laid down. (See Chaps. VI
and VII.) If the patient passes safely through the first five days, she
is then in condition to be treated according to the general rules for celiot-
omy patients. Some form of iron, preferably Blaud's mass, should be
administered during the convalescence. The time of getting up will
vary largely with the degree of anemia. Many patients may get up by
the tenth day, and all by the end of t^vo weeks, in the absence of com-
plications.

Complications and Sequelae. — Those mostly to be feared are
ileus and peritonitis. As these are treated of in their respective chapters,
nothing further will be said here concerning them. Other complications
of anesthesia and celiotomy may occur, and should be dealt with by ap-
propriate measures.

References

J. W. Williams, Obstetrics, 1908, 623.

F. S. Newell, Sixty Cases of Extra-uterine Pregnancy, Boston City H(J6p. Repf:)rts,

1905, XV, 26.

CESAREAN SECTION

Dressing^. — The abdomen is closed without drainage. A dressing
of sterile gauze is placed over the wound. A folded towel is placed just
outside of this above the fundus, and a tight swathe applied. A sterile
pad is placed on the vulva and the patient is put to bed. The pulse
is taken, and bleeding from the vulva looked for every fifteen minutes
for two hours. The proper way to look for hemorrhage is not to pull
the bed-clothes down and look at the pad, but to turn the patient
slightly on one side and look at the sheet underneath. The blood gravi-
tates into the bed, soils only the lower part of the pad, and cannot be
seen by simply separating the thighs and looking down from above.

The vulvar pad is changed as often as soiled, and after each dejection
or micturition the vulva is irrigated with sterile water, care being taken
that none of the water enters the vagina, and a fresh sterile pad applied.
This care is continued to the tenth day, after which an ordinary, non-
sterile sanitary pad is worn and the irrigations stopped. After the
tenth day a daily mild antiseptic douche may be given to clear out the
lochia.

CESAREAN SECTION 557

The wound is inspected on the tenth day and the stitches removed
if healins: has been normal.

Bowels. — The bowels are moved in forty-eight to sixty hours unless
distention appears before then.

Diet. — Water is given as soon as out of ether. Liquid diet is started
the following morning and soft solids the second day. Chicken is al-
lowed on the fourth, and full diet on the fifth, day. The diet must
differ from that given other celiotomies, in that it must consist largely
of liquids throughout the convalescence in order to keep up a sufficient
secretion of milk.

Bladder. — Every possible aid to natural micturition, such as hot
applications to the thighs and vulva, trickling of hot antiseptic solution
over the vulva, and, finally, a hot enema, must be tried before catheteri-
zation is allowed, because the pelvic congestion and increased vascularity
due to pregnancy render the bladder more susceptible to infection.
If the patient has to be catheterized, hexamethylamin, 7 J gr. three times
a day, is to be given during the convalescence.

Breasts. — The baby is put to the breast the following day, nursing
on alternate breasts at four-hour intervals for five minutes until the
milk appears in abundance, when nursing is permitted every tw^o hours
for not more than twenty minutes. The nipples are washed off with 4
per cent, boric-acid solution before and after nursing, and covered with
clean cold-cream between nursings. If the nipples become tender, 50
per cent, alcohol is substituted for the boric-acid solution after nursing
and nursing is conducted through a nipple-shield. If the nipples become
cracked, the cracks are painted daily with compound tincture of benzoin
and the nipple-shield is used. If the breasts become caked, a tight
breast bandage is applied.

Stay in Bed. — The patient may sit up on the t\velfth, and get out of
bed on the fourteenth, day.

Complications and Sequelae. — (i) Hemorrhage. — A moderate
postpartum hemorrhage occasionally occurs, and is rarely severe
enough to affect the pulse. An extra dose of ergot is given hypoderm-
ically and the hemorrhage soon stops. A serious postpartum hemor-
rhage after Cesarean section is practically unknown. Hemorrhage
into the peritoneal cavity is also a rarity, since no arteries are cut in
the operation.

(2) Acute Abdominal Distention. — Greater or less degree of dis-
tention occurs after every Cesarean operation due to reactionary
dilatation of stomach or intestines suddenly released from pressure.
It may be a serious complication very resistant to treatment. If it

558 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

be due to stomach, for Diagnosis and Treatment see p. 183. If it be,
as is more common, a dilatation of intestines, strychnin ^V to ^V gr.
every four hours subcutaneously and a succession of enemas are to be
given. Milk and molasses, the compound turpentine or ox-gall, i
ounce to the pint, may be tried. If all fail and the condition becomes
serious, as indicated by rising pulse, cecostomy may be necessary.

(3) Infection. — The uterine stitches occasionally become infected.
This will result in sUght foulness of the pads and a little elevation of
temperature. Usually after a few days the stitch is discharged through
the vagina and the temperature falls.

Septic endometritis is very rare in good practice, for the operation is
always done before the patient has been long in labor, and the patient
is not examined by unclean hands. The occurrence of either of these
factors ought to contraindicate Cesarean section in the beginning, or
should constitute an indication for a Porro operation rather than a
conservative Cesarean section. If septic endometritis does occur, local
measures are contraindicated on account of the wound in the uterine
wall, and the treatment should be directed to increase the patient's resist-
ance by forced nourishment and stimulation and by vaccine therapy*
Whisky in half-ounce doses and strychnin in -g^-gr. doses every four
hours may be given. A culture may be taken from the uterus and an
autogenous vaccine prepared and used for treatment under direction
of one expert in this matter. The patient should be out-of-doors if
possible.

The development of peritonitis or pelvic abscess should be met by
vaginal drainage if possible. If not, the lower angle of the wound may
be opened and drainage secured through the abdomen. Further treat-
ment of these conditions is as directed in other chapters.

(4) Phlebitis. — This is probably the most common complication of
Cesarean section. It usually makes its appearance in the second week,
and is characterized by a slight elevation of temperature and pain and
swelling of one or, rarely, both lower extremities. The treatment is rest
in bed with elevation and immobilization by a pillow and side splints.
This is maintained for one week after all swelling has disappeared — i. e.^
usually a period of six to eight weeks. Pain is relieved by ice-bags to
the thigh and morphm. Citric acid in 20-gr. doses three times a day is
given with the purpose of diminishing the coagulability of the blood.
The value of this measure has not yet been finally determined.

Threatened Breast Abscess. — This also appears about the second
week or later. It is characterized by a sudden rise of temperature,
usually with a chill and a slightly reddened tender lump in one breast..

EXTRAPERITONEAL CESAREAN SECTION 559

The treatment is: first, take the baby off the affected breast; second,
open the bowels freely with Epsom salt; third, apply an ice-bag to the
breast; fourth, support the breast and the ice-bag by a bandage.
Usually the temperature begins to fall within twenty-four hours and
tenderness gradually subsides. The baby is allowed to nurse on the
well breast, and twenty-four hours after tenderness has disappeared
and the temperature has been normal may be put back on the affected
breast. A small lump may persist for a time, but in the absence of
tenderness or elevation of temperature does not contraindicate nursing.
The lump will gradually disappear. If, instead of quieting down, the
temperature remains elevated and the lump becomes more tender,
red, and indurated, it should be incised and the contents evacuated.
The Bier treatment and vaccine therapy here have value.

(5) Subinvolution. — In an ordinary obstetric case the fundus uteri
sinks below the symphysis about the tenth day. After Cesarean sec-
tion, however, adhesions to the uterine scar frequently maintain the
uterus in a position well up out of the pelvis, so that its presence on
palpation of the abdomen does not in itself indicate that the uterus is
subinvoluted. The diagnosis is made, therefore, on the character of
the lochia. Normally, about the tenth day the lochia becomes pale
and white. The persistence of bloody or brown lochia after this period
indicates subinvolution, and should be treated by rest in bed and hot
douches until the lochia becomes pale.

(6) Other Complications. — Besides these special complications, any
of those common to all celiotomies may occur.

References

C. M. Green, F. S. Newell, L. V. Friedman, N. R. Torbert, N. R. Mason, R. L. De
Normandie, A Study of the First Series of One Hundred Cesarean Sections Performed at
the Boston Lying-in Hospital, Boston Med. and Surg. Jour., 1909, clxi, 803.

A. Couvelaire, Considerations sur la technique de I'operation c^sarienne conservatrice,
Ann. de Gyn., 1909, Ixvi, 657.

E. Reynolds, The Cesarean Section from the Standpoint of Personal Experience,
Surg., Gyn., and Obst., 1908, vi, 502.

E. P. Davis, The Treatment of Infected and Complicated Cases of Labor by Ab-
dominal Section, Surg., Gyn., and Obst., 1909, viii, 365.

N. R. Mason and J. T. Williams, The Strength of the Uterine Scar after Cesarean
Section, Boston Med. and Surg. Jour., 1910, clxii, 65.

EXTRAPERITONEAL CESAREAN SECTION

This operation, as introduced by F. Frank,^ A. Doederlein,^ and
others, has attained great popularity in the German clinics.

* Archiv. f. Gyn., 1909, xxxii, 133.

* Centr. f. Gyn., 1909, xxxii, 121.

560 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

In Frank^s method the uterus is approached by a transverse in-
cision through fascia, muscles, and peritoneum just above the pubes,
opening the abdominal cavity. The peritoneum on the anterior face
of the uterus is incised transversely just above the bladder reflex,
and dissected upward, exposing the lower uterine segment, and then
stitched to the upper side of the incision in the parietal peritoneum.
The uterus is then opened by a transverse incision and the child ex-
tracted by forceps. The uterine wound is then sewn up with catgut
in clean cases, and the abdominal wound in layers with chromicized
catgut, leaving a small gauze drain down to the uterine wound. In
infected cases an iodoform wick is passed down into the vagina through
the cervix, and another, through the uterine incision, is brought out
through the abdominal wound. Sellheim's technique differs only in
the use of the Pfannenstiel incision, and the dissection of the perito-
neum from the bladder, entering the uterus without opening the peri-
toneal cavity. Doederlein makes a vertical median incision, and
dissects through the paravesical tissue, retracting the bladder to the
right and opening the uterus by a vertical incision without injuring the
peritoneum.

Where drains are used they may be removed at the end of forty-
eight hours, and replaced or not as the amount of discharge and the
patient's temperature may determine. Where the muscles are cut
transversely, as in Frank's operation, convalescence is delayed, the
patient being kept in bed four weeks.

Complications and Seqnelae. — (i) Injection. — Since this opera-
tion is indicated chiefly in infected cases, this is frequent. Thorough
drainage of the uterus and the wound must be maintained until the
temperature falls to normal. Irrigation of the uterus through the
incision may be carefully carried out. The chief reliance must, how-
ever, be placed on general measures — food, fresh air, iron, arsenic,
strychnin, and alcohol (see p. 317)-

(2) Hemorrhage. — Hemorrhage in the abdominal incision is to be
treated by ligature of the bleeding point when possible. When, as
more frequently happens, it is the result of a general ooze, it can be
controlled by packing the wound tightly for forty-eight hours.

(3) Injury to the Bladder. — When discovered at the time of opera-
tion it should be repaired at once, and a small wick passed to the point
of suture for forty-eight hours. Constant drainage by means of a
self-retaining catheter should be maintained for ten days. This cath-
eter must be removed, cleaned, boiled, replaced, and the bladder
irrigated with 4 per cent, boric solution twice a day. Hexamethylen-
amin in 7^-gr. doses may be administered three times a day.

VAGINAL CESAREAN SECTION 561

When repair is unsuccessful or the injury is not discovered at the
time of operation, urine is discharged from the wound when the wick
is removed. In this event the woimd is kept clean and covered with a
sterile absorbent dressing. The skin may be smeared with a stearate
of zinc ointment above the wound. If the fistula does not heal after
a period of several weeks, operation should be undertaken for its repair.

Besides these special complications, any of those common to the
classical Cesarean section or any other major operation may occur.

VAGINAL CESAREAN SECTION

Vaginal Cesarean section, introduced by A. Duhrssen^ as a rapid
method of emptying the uterus in eclampsia, placenta praevia, etc.,
has met with widespread popularity. The incisions in the uterus are
closed with a continuous suture of catgut; the vaginal mucosa, with
interrupted catgut, leaving a small drain to the vesico-uterine space
for twenty-four hours. When the operation is done for placenta
praevia it is wise to pack the uterus before suture. This pack may be
removed at the end of twenty-four hours.

The after-treatment in general does not vary from that of any
operative intrapelvic delivery, and the same general complications
may occur. Certain special complications demand further mention.

Complications and Sequelae.— (i) Infection of the Wound.—
Any elevation of temperature during the early days of the puerperium
demands inspection of the cervix, especially if pus is discharged from
the vagina. Fever may be due simply to retention of the lochia from
sewing up the cervix too tightly; and if the lochia are scanty the cervix
may be dilated slightly and the uterine cavity washed out with salt solu-
tion. If pus is seen coming from the stitch-holes or the incisions, the
sutures should be removed at once. If the incisions appear clean the
case is presumably one of intra-uterine sepsis and should be treated
accordingly.

(2) Hemorrhage. — Moderate hemorrhage always occurs during the
operation, but it usually stops when the incisions are sewed up.
Rarely it may be necessary to pack the vesico-uterine space. When
the hemorrhage comes from inside the uterus the usual measures for
postpartum hemorrhage — massage of the uterus, ice to the fundus, er-
got, a hot intra-uterine douche, packing, and compression of the
aorta^^should be employed.

(3) Injury to the Bladder. — This accident is uncommon and is

^ Centr. f. Gyn., 1904, xxviii, 409.

- Momberg, Cent. f. Chir., 1908, xxxv, 679.

562 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

usually the result of faulty technique. If discovered at the time of
operation and the patient's condition will warrant it, the injury should
be repaired. In any case constant drainage of the bladder by means of
a self-retaining catheter should be maintained for ten days, and hexa-
methylenamin given in yi-grain doses three times a day. When a
fistula persists for some weeks after delivery it should be repaired by
surgical means.

OTHER OPERATIONS

Alexander's Operation, — See Inguinal Hernia, page 486.

Atresia of Uterus, Operation for, — See Trachelorrhaphy,^ page 534.

Atresia of Vagina, Operation for, — See Colporrhaphy, page 522.

Fistula, VesicO'Uterine, Operation for. — See Vesicovaginal Fistula,
p. 526.

Gartner's Canal, Abscess of. — See Vaginal Section, p. 529.

Imperforate Hymen, Incision of. — No after-treatment except pos-
sible dilatation.

Inversion of Uterus, Celiotomy for. — See Celiotomy, p. 550.

Inversion of Uterus, Vaginal Operation for. — See Operations upon
Cervix Uteri, p. 534.

Myomectomy. — See Hysterectomy, p. 550.

Vaginal Cysts, Excision of. — See Colporrhaphy, p. 522.

ECLAMPSIA

Eclampsia is a condition with which the surgeon may meet at
any time when dealing with pregnant women. Its onset is usually
characterized by edema of the face and hands and headache. If the
urine is examined, as it should be, it will be found at this stage to
be scanty in amount, to contain from \ to \ per cent, of albvunin, and
numerous hyaline, fine granular, epithelial, and sometimes fatty casts.
Blood is present in greater or less amount, together with renal epithelium.
Dimness of vision from albuminuric retinitis is the next symptom to
develop. Epigastric pain is the forerunner of convulsions.

The typical eclamptic convulsion is of short duration, seldom lasting
over one minute. It begins in the external eye muscles, extends to the
face, and then becomes general. It is clonic in character. As the
convulsion subsides, respiration, which has become suspended during
its acme, is reestablished, breathing becomes stertorous, and the cyanosis
gradually subsides. The patient may regain perfect consciousness,
but, as a rule, passes into a noisy, restless delirium, which is interrupted
frequently by further convulsive seizures.

^ W. p. Graves, Boston Med. and Surg. Jour., 1910, clxiii, 753.

ECLAMPSIA 563

Before the onset of con^'ulsions or the development of eye symptoms,
medical treatment is imperative. The indications are, first, to decrease
metabolism, especially nitrogenous metabolism, to its lowest possible
state, and, second, to favor the elimination of toxins and waste products.

The patient is put to bed in a darkened room, on a liquid diet,*
and given at once morphin (]- gr.) and hyoscin hydrobromid (y-J-Q-gr.)
hypodermically. This may be repeated as often as every four hours if
necessary to keep the patient quiet.

The channels of elimination to be favored are the skin, kidneys, and
bowels. The first is to be stimulated only by heaters and blankets.
Hot packs and hot-air baths have cost many lives by their depressing
effect. Pilocarpin is contraindicated because of the danger of edema
of the lungs.

The renal secretion is to be stimulated by diuretics and the ingestion
of large quantities of fluid, provided there exists no edema. A 2-quart
pitcher of cream of tartar lemonade should be placed by the bedside
and forced upon the patient until she has taken it all. Water may be
introduced by rectum or subcutaneously. Diuretin (20 gr.) in combina-
tion with 10 minims of digitalis every four hours is by far the most
effective drug for this purpose.

S. D. Jacobson^ has advocated the continuous rectal instillation of sugar
solution, on the theory that eclampsia is caused by the retention in the
blood of sodium chlorid and other salts which the damaged kidneys are
unable to throw off. On the same theory he contends that the saline in-
fusions are harmful.

The bowels should be moved by the administration of i ounce of
Epsom salt.

If, under this treatment, the patient shows no improvement at the
end of forty-eight hours, she must be delivered. If severe eye symptoms
develop, if epigastric pain appears, or if the headache and edema increase,
she must be delivered at once. A single convulsion is an immediate
indication for delivery.

When a convulsion occurs, a gag should be placed between the teeth
to prevent the tongue from being bitten. Ether or chloroform should
never be given. The convulsion is too short to allow the patient to inhale

* Jaeger (Deut. med. Woch., 1909, xxxv, No. 41) commends highly the withdrawal
of salt and restriction of fluids in banishing edema and preventing convulsions. Milk
contains too much fluid. Unsalted egg dishes and butter, rice cooked in milk, sago,
baked potato, puddings, gruels with cream and sugar, vegetables, fruit, and weak tea
but no coffee, should constitute the diet-list.

2 Am. Jour. Obst., 1910, Ixi, 871.

564 OPERATIONS ON THE VAGINA, UTERUS, AND ADNEXA

enough to do any good. Furthermore, respiration is practically sus-
pended at the acme of the convulsion. Finally, when the convulsion
is drawing to a close, the cyanosis is intense and the ether will, of
course, displace a certain percentage of the oxygen which the patient
needs badly. After the patient is fully out of the convulsion, she
should at once be placed under ether and kept there to prevent more
convulsions while preparations are made for delivery.

We believe strongly that any time after the sixth month eclampsia
which does not yield to preventive treatment should have Cesarean
section. This procedure has the advantages, first, of speed, and, sec-
ond, that the abdominal cavity can be left full of salt solution, which is
an ideal immediate treatment.

After delivery the stomach is washed out and 2 ounces of Epsom
salt, 2 minims of croton oil, 30 grains of diuretin, and 10 minims of
digitalis are introduced through the tube. A quart of salt solution is
injected into the lower back or under the skin of the abdomen. Mor-
phin (I gr.) and hyoscin (jJcr gr.) are injected hypodermically and
repeated every four hours unless the respiration drops below 10.
Much of the toxin may be eliminated by bleeding. For this reason
ergot is never to be given. Venesection should be practised when
there is a full, high-tension pulse, i pint of blood being withdrawn and
replaced by an equal quantity of salt solution.

Transfusion has been reported by G. W. Crile,^ F. S. Newell,^ and
others. The value of this procedure has yet to be determined.

As soon as the patient is able to swallow, water should be continu-
ally forced upon her. Diuretin (20 gr.) and tincture of digitalis (10
min.) are given every four hours. If she remains unconscious, they
are introduced through the stomach-tube, together with a pint of
milk, every four hours, and i quart of salt solution is given under the
skin at the same intervals. If the bowels have not been well moved
before operation, they must be started by a compound turpentine
enema immediately, without waiting for the purges to act.

Renal decapsulation in eclampsia was advised by G. M. Edebohls,^ follow-
ing his experience with this operation for nephritis, and a considerable number
of cases have been reported by him and others. It is hard to justify this

* Hemorrhage and Transfusion, 1909, p. 519.

* Boston Med. and Surg. Jour.. 1910, clxii, 213.
' Am. Jour. Obst., 1903, xlvii, 783.

EARLY RISING AFTER LABOR 565

procedure because eclampsia is not primarily a renal condition; and recent
experimental work by H. Ehrenfest^ has shown that after decapsulation
there is a marked decrease in the urinary secretion for twenty-four hours.
This fact alone contraindicates the operation in eclampsia.

If the patient has been delivered early, recovery usually takes
place, manifested by returning consciousness, cessation of convul-
sions, increase in the secretion, and diminution of the pathologic
elements of the urine. The patient is to be kept on milk diet until
the albimiin drops to yV of i per cent., when she may be allowed
cereals, bread, and toast, but nothing else until the urine has cleared
up entirely. The patient is usually able to get out of bed by the four-
teenth day. In mild cases nursing is allowed, if there is any milk,
after the third day. In the majority of these patients, however,
the milk-supply is deficient or absent.

When, after delivery, the convulsions do not cease and the patient
sinks more deeply into coma, death may be predicted with certainty.

Postpartum eclampsia is to be treated by the same medical meas-
ures as described for the antepartum. These cases commonly recover.

EARLY RISING AFTER LABOR

It may not be out of place here to say a few words on the subject of
getting patients out of bed in the early days of the puerperium.
PfannenstieP and E. Martin^ were the first to carry out this custom
in a considerable series of cases. Only absolutely normal cases were
selected, and these were allowed to get up first at the end of fifteen to
twenty-four hours after delivery, but were allowed only very light
exercise. Their results were excellent. No case in either series de-
veloped thrombosis. Involution of the uterus proceeded normally,
and strength returned quickly. Nevertheless, in spite of their good
results, it must be remembered that the class of patients that make up
the German clinics is very different from that which is met with in
private practice in this country, and one must select with the greatest
care the cases to get out of bed early.

* Surg., Gyn., and Obst., 191 1, xiii, 296.

2 Alvensleben, Centr. f. Gyn., 1908, xxxii, 1184.

^ Monatschr. f. Geb. u. Gyn., 1908, xxvii, 248.

CHAPTER XLVII

OPERATIONS ON THE PENIS, SCROTUM, URETHRA,

AND PROSTATE

General Considerations. — In all postoperative treatment it
behooves the surgeon to conser^•e to the best of his ability the function
of the eliminative organs, for faulty or disturbed elimination is likely
to lead to disaster unless promptly alleviated. In genito-urinary work
the attention paid to elimination must be doubled, because the chief
eliminative system, the urinary apparatus, is involved by the operation
and its function is already more or less impaired. The operation is
performed with the intention of removing the cause of the functional
impairment; the after-treatment must strive to restore natural function
or, at least, preserve what is left. To this end the kidneys must be made
to act freely and easily; their product, the urine, must be kept or made
qualitatively normal, and given an unobstructed outlet; existing infec-
tion must be eradicated or subsequent infection prevented; and, last
and always, the patient must be kept comfortable.

Renal Activity.^— Postoperative urinary suppression occurs more
frequently after genito-urinary operations than after operations of any
other sort. Its cause cannot always be determined, for infection does
not explain every case. Suppression due to infection will be discussed
later; the so-called idiopathic or reflex cases of suppression will here
be considered. Many causes are assigned to explain this condition:
poor general health, prolonged anesthesia and operation, shock, chronic
nephritis, reflex irritation from the urethra, and so on. The thoughtful
surgeon operates so far as possible only under the most favorable condi-
tions, often delaying operation until he can improve the patient's general
condition, and always operating as rapidly as safety permits; and never-
theless, in spite of every care, he often finds suppression threatening.
It is a good plan, therefore, to anticipate trouble and to institute pro-
phylactic treatment from the start. As soon as the patient's stomach

^ See also p. 386.
566

RENAL ACTIVITY 567

permits, he should be encouraged to drink as much water as he feels
that he can take. A kidney will excrete a large amount of dilute solution
when it will balk at concentrated fluids. An excellent device to increase
the intake of water is to give palatable drinks; none excels the simple
cream of tartar water:

Lemons 2

Cream of tartar 2 drams

Hct water i pint

Sugar q. s.

Keep a pitcherful at the patient's elbow and see that he drinks long
and often. He will take much more of this than of plain water. More-
over, it has a slightly diuretic action and is stimulating to the kidneys.

The diet should be liquid for at least the first few days, bland and
non-irritating, with a low salt and proteid content, to spare the kidneys.
Once renal function is well established, the diet may be gradually in-
creased. Meat and meat soups and extracts contain too much protein
compounds to be safe and had better be avoided until later.

In spite of every care, sui)pression of urine may supervene. As a
rule, the warning is ample. The only sure way to detect its onset is
to measure the twenty-four-hour amount of urine in every case. This
procedure is as simple as it is important, and should be faithfully car-
ried out until satisfied that all danger is past. A steady decrease in
the twenty-four-hour amount is a danger-signal worth observing. If
this occurs, the patient should be kept in bed on a milk diet and given
alkaline diuretics, such as the acetates, citrates, and tartrates, and
cathartics until the bowels are freely open. These simple measures
suffice to arrest a certain proportion of cases. A continued decrease in
the twenty-four-hour amount calls for free watery movements and
active diaphoresis. A poultice, which may be made of digitalis leaves,
over the kidneys acts surprisingly well in promoting excretion of urine.
All the usual treatment for acute renal disease must be promptly given —
the case is desperate and calls for desperate measures.

Urine. — Most genito-urinary cases coming to operation are passing
urine which possesses pathologic constituents. In the majority of cases
the urine as it leaves the kidneys is nearly normal; it is the pathologic
process lower down in the urinary tract that changes its character.
Infection any\vhere along the urinary tract adds to the urine pus, bac-
teria, blood, and local tissue-cells. Mechanical obstruction causes
stasis and retention of urine, which gives rise to anatomic changes in

568 OPERATIONS ON PENIS, SCROTUM, URETHRA, AND PROSTATE

the urinary tract, with concomitant alterations of function. The retained
urine decomposes and ferments; a catarrhal condition of the mucosa
results, with its profuse discharge of mucus. Such a condition readily
favors infection, which sooner or later is bound to supervene. The
operation supposedly removes the cause for the pathologic state of the
urine, but the process may have gone on for a sufficient length of time
to cause tissue changes which, in turn, serve to perpetuate the abnormal
constituents of the urine.

As an infected or decomposed urine flowing over an operative
wound is a real danger, the sooner the abnormal urine can be cor-
rected, the better. To this end the free diuresis already advocated
serves, by thoroughly washing out the urinary tract and by causing
increased frequency of urination, to prevent retention. In addition,
as a urinary disinfectant, hexamethylamin (urotropin), 7^ gr. three
times a day after meals, should be given as soon as the stomach
will tolerate it. Owing to the slight renal irritation which this drug
causes, it is well to omit it every fourth day. Continue the drug until
the urine becomes normal. If the urine remains foul in spite of the
antiseptic drugs and cystitis is present, wash out the bladder with some
mild antiseptic, such as boric acid. Strong antiseptics may give rise
to pain and make the cystitis worse. If, however, there is no improve-
ment, a dilute solution of silver nitrate may be used (i : 4000), increasing
gradually up to i : 800. In washing out the bladder only 2 or 3 ounces
of fluid must be injected at a time and allowed to run out again, this being
repeated until the solution comes back clear. The fluid should have a
temperature of about 100° F. The best apparatus is a soft-rubber
catheter attached to a funnel, or a glass irrigating nozzle connected with
a fountain syringe. (See also Chap. XIV, p. 154.) If the urine is
strongly alkaline, benzoate of ammonium can be given in lo-gr. doses;
if strongly acid, bicarbonate of soda in 10- to 20-gr. doses should be used.

Locally, much can be done to improve the urine. The field of
operation is, as has already been stated, commonly the seat of a low-
grade, but nevertheless persistent, infection, which it is the object of
the operation to relieve, and that, too, in the presence of infected urine.
As Francis S. Watson has epigrammatically expressed it, ^* Asepsis in
geni to-urinary work is drainage." All operative wounds, except in
the rare clean cases where there is a fair chance for first intention,
must heal from the bottom by granulation. There must be no
chance for pocketing of infective material; no blind recesses to harbor
small collections of urine; and, so far as possible, no uphill drainage.

INFECTION 56Q

Thorough frequent irrigations of all wounds with mild antiseptics serve
to keep them clean and free of debris; gauze packs and wicks rarely
stay placed in wounds discharging urine, and when they do, become
plugs rather than drains. In many cases for the first few days the urine
escapes by preference through the operative wound, which must, there-
fore, be kept unobstructed.

Unobstructed Natural Outlet for Urine. — Many gcnito-urinary cases
come to operation for the relief of urinary obstruction. The ojicration
relicvesthedifficulty, often, of necessity, by making a tcmjwrary artificial
outlet for the urine as well as removing the obstruction in the natural
outlet. During the process of healing, therefore, the natural passages
must be kept wide open. Failure in this regard may mean that the

operation is a failure; and in those cases where an artificial outlet has
been made, this outlet will persist indefinitely as a urinary sinus so long
as obstruction to the natural oudet exists. The means of keeping the
urinary passages open will be taken up in detail later.

Infection, — Existing infection is best combated by the free diuresis,
competent drainage, frequent irrigation, and administration of urinary
antiseptics already described. The same measures scrie also to prevent
the occurrence of infection. In addition, the operative wound should
be kept covered with a sterile dressing, frequently changed. Infection
once started calls for more frequent irrigations and the relentless use
of the knife. Ail the tissues must be laid wide open. Hot soaks in a
sitz-bath are in\-aluable and comforting. Uncontrolled infections have
a direful tendency to spread upward along the urinary tract, where the
difficulty of combating them is doubled.

570 OPERATIONS ON PENIS, SCROTUM, URETHRA, AND PROSTATE

Comfort of the Patient.— Hardiy anything more uncomfortable
can be imagined than the postoperative genito-urinary case, with his
urine constantly dribbling away, beyond his control, keeping his dressing
wet and diffusing a rank odor of stale urine. Nothing can be too trivial
to perform which will add an atom of comfort. Use large absorbent
dressings and change them every hour if necessary. A little menthol
or charcoal sprinkled in the dressing will disguise or absorb the odor
markedly. Keep the edges of the wound and the surrounding skin
smeared with zinc-oxid ointment to protect the skin, which easily becomes

Flc. i8;.— CONVEM

red, burning, and itching from the constant bath of urine. Bed-sores
form quickly if the patient lies for hours in a wet dressing or a wet bed,
and are difficult to heal.

CIRCURiasiON

The method of dressing whereby a roll of gauze is tied along the
wound by the long ends of the interrupted catgut sutures is ingenious,
but is not to be commended. This ring of gauze gets hea\7 and stiff
with blood, gets foul in o<lor, and gets loose here or there irregularly,
according as one or another stitch gi\-es way. Interrupted catgut stitches
should be used, cut short.

At the end of operation on an adult the glans should be cohered
with a plentiful mass of eucalyptus vaselin (5 [>er cent.), the region of
the wound bandaged with a few turns of some kind of chemical gauze,
held in place by a narrow adhesi\e strij), barely tight enough to hold
it. .^n infant needs no fixed dressing. .\ mass of absorbent cotton

HYPOSPADIAS 571

should now envelop the organ, and the whole be held up by a T-
bandage or some other modification of the jockey-strap. After each
micturition more vaselin should be put on. The dressing should be
entirely changed at least once in twenty-four hours.

For the first twenty-four hours the less the patient is on his feet the
better. Sodium bromid (40 gr.) in a glass of water should be given
to adults at bedtime the first three nights to avoid painful erections.

Complications and Sequelae.— (i) Hemorrhage from a re-
tracted vessel may take place, even to an alarming amount, in children.
The bleeding point must be found and tied. Sometimes blood collects
between the layers in the form of a hematoma. This should be opened
and evacuated under aseptic precautions, otherwise the clot is likely to
become septic and cause sloughing of the flap.

(2) Sepsis always appears to a mild degree. A considerable
amount of swelling may be expected, and calls for no treatment unless
accompanied by much pain. In this case the organ may be soaked in
salt and citrate or warm myrrh wash. Spots of foul-smelling gangrene
near the stitches are touched with carbolic acid followed by alcohol.

If the skin-flap has been cut too short, erections will be painful until
the scar has stretched.

MEATOTOMY

This operation is usually done as a preliminary step to further opera-
tion on the urethra. Nevertheless, it requires some attention. The
operation leaves a wound which is washed with urine at every micturi-
tion. There is scarcely any danger from absorption in so small an
open wound, but a concentrated urine on the raw surface will smart and
burn. It will add greatly to the patient's comfort, therefore, if vaselin
be kept thickly spread in and around the meatus and if the patient be
given alkaline diuretics by mouth for the first few days. Any dressing
after the first bleeding has ceased is superfluous. Forty-eight hours
after operation pass a sound (No. 30 French) through the meatus and
repeat every other day until no bleeding follows.

Meatotomy exactly in the middle line we have known in two in-
stances to destroy sexual appetite. If the incision is made slightly to
one side of the frenum, there need be no apprehension on this score.

HYPOSPADIAS

The after-care of this operation calls for the greatest patience and
attention to details. The soft-rubber draining catheter should be kept
in position a week if possible. As a rule, however, the bladder of the

572 OPERATIONS ON PENIS, SCROTUM, URETHRA, AND PROSTATE

child is intolerant of a catheter more than three days. At the end
of that time, therefore, it is frequently necessary to remove the catheter
and keep it in the new urethra only. The catheter must be taken out,
cleaned, and passed into the bladder to draw the urine every three or
four hours. Complete union of the full length of the wound is hardly
to be expected at the first operation, but at each operation some gain
should be made. The wound must be dressed tvvo or three times a day,
iodoform being invaluable.

EPISPADIAS

This rare operation presents no questions in after-treatment not cov-
ered in Hypospadias (supra). In each of these operations two objects are
to be constantly in mind: first, that the external wound, the site of the
old urethral opening, heals; second, that the new urethra be kept patent.
The external wound is to be treated aseptically, like any clean wound.
This wound will heal without the formation of a sinus provided the new
urethra be kept patent. The slightest narrowing at any point endangers
the breaking down of the operative wound, with the persistence of a
troublesome urinary sinus. Sounds every other day, therefore, are the
only remedy. After two weeks the interval between the passage of
sounds may be lengthened to twice a week, then once a week, then once
in t\vo weeks, and so on, omitting them entirely at the end of a year.

HYDROCELE

Treated by Injection, — The use of iodin or plain phenol has
fallen into disuse. Occasionally, injection of a mixture of equal parts
of phenol, alcohol, and glycerin is used. The fluid is drained off with
a medium-sized trocar, and from i to 3 drams of this mixture are
injected in through the trocar still in place. The end of the trocar is
now covered with the finger, and the scrotum gently manipulated to
bring the fluid into contact with all the folds of the sac. At the end of
about four minutes whatever fluid will run out is withdrawn, and the
cannula wound is sealed with collodion.

Within two or three hours there are heat, pain, and swelling — a con-
dition of acute hydrocele. The patient should be kept reclining twenty-
four hours. Ice should not be used until it is estimated that enough
inflammation has ensued to destroy the membrane lining the sac. The
swelling usually lasts three to four weeks.

After l^xcision of the Sac. — The operation here assumed is
that in which the major part of the sac is removed, leaving only enough

VARICOCELE 573

margin on each side of the epididymis to fold back and be sewed over

that region and the cord. The patient should be in bed at least

three days, the scrotum well supported upon the pubes. Silk, linen,

or catgut sutures in the skin are preferable to the stiff silkworm gut, for

ob\ious reasons. Hematoma and sepsis are to be watched for. The

wound should be healed in ten days. A suspensory should be worn for

two months.

VARICOCELE

It is assumed that the operation which has been done is that m which
a section of the varicose cord, excluding the vas and its vessels, has been
excised, and the cut ends tied together to bring the testis into normal
position. A dressing should be applied similar to that for inguinal
hernia, taking particular care that the scrotum is efficiently supported.
Uncomplicated, the scrotal wound should heal as any clean wound.
The patient may get up at the end of a week, the scrotum being supported
for two months in a properly adjusted suspensory.

Complications and Seqnele^.— Hemorrhage.— Bleeding may
occur in the scrotum from the slipping of ligatures or, a still more serious
matter, the proximal end of the cut cord has been known to retract
through the canal and bleed into the abdominal cavity. This possibility
should be in mind, and signs of hemorrhage in the scrotum or of internal
hemorrhage should be met by an immediate secondary operation, opening
up the region thoroughly until the bleeding end is found and secured.

Atrophy of the Testis. — This may occur even though the vas has not
been injured, and a statement of its possible occurrence must be made
to the patient before operation. It calls for no treatment.

Gangrene of the Testis. — This will occur if the vas is cut or if every
artery is cut, though it is very difficult to cut all the vessels without
injuring the vas, or it may be the result of a tight or improperly applied
bandage. When this process begins, the wound opens and the sloughing
testicle presents itself. It may be cut away as fast as it extrudes, without
anesthesia, or, to save time, if it is evident that complete death of the
testis is unavoidable, castration may be done at once. Radical opera-
tion should not be hurried into, however, for, after slough of all save
the skin and the testis, the testis may remain viable and the skin-edges
be brought gradually together over it by means of adhesive strips, and
give finally — so great is the adaptability of the scrotal tissues — a good
cosmetic result.

574 OPERATIONS ON PENIS, SCROTUM, URETHRA, AND PROSTATE

UNDESCENDED TESTIS

Unless the cord, when freed by dissection or elongated by dissecting

away its veins and unfolding the kinks, is long enough to allow the testis

to remain in the scrotum without being held under considerable tension,

the operation will ultimately fail, the testis being actually drawn back

into the canal or drawn up so tightly against the external ring as to

cause constant and unbearable discomfort. Wherever the testis rests

without undue tension within the scrotum, there are no special directions

in the care of the wound, which resembles that after inguinal hernia.

Special pads or other apparatus for holding the testis down are of no

value. A testis which has long been retained is likely to have lost its

power of functioning on account of pressure atrophy, so that this operation

performed in an adult is not likely to have any effect on a preexisting

sterility.

CASTRATION

The wound after this operation calls for no special treatment. Wounds
of the scrotum, on account of the folds in the skin, are liable to sepsis.
The stump of the cord, unless the precaution is taken of sewing it into
the abdominal ring, may retract and bleed. Hernia is likely to make its
appearance after castration.

INTERNAL URETHROTOMY

As soon as the operation is completed, irrigate the bladder and
urethra thoroughly with hot boric-acid solution (2 per cent.). Do not
tie a catheter into the anterior urethra unless there is considerable
hemorrhage. Put the patient to bed, and start on cream-of-tartar
water and urotropin as soon as the stomach permits. He is not
let up until the kidneys are actively secreting. Immediately after the
first urination following operation irrigate the urethra through a Valen-
tine nozzle or one of its modifications with warm silver nitrate solution
(i: 2000). Forty-eight hours after operation irrigate the urethra again
with the same solution; pass sounds or the KoUmann dilator into the
bladder to maintain the caliber to which the urethra has been cut, then
irrigate again. Repeat the irrigation and sounds every other day until
no bleeding follows. This indicates that the wound has healed, and its
surface is covered with mucous membrane. Thereafter pass sounds
twice a week, then once a week, gradually lengthening the interval, and
omitting them entirely at the end of a year.

Frequently repeated irrigation as described above keeps the urethra
clean, combats any tendency to infection, and does more to prevent
reflex urethral chill than all other measures. When least expected, the

EXTERNAL URETHROTOMY

575

passage of a sound will cause a chill, followed by a rise of temperature
and considerable exhaustion, due to reflex causes. Why this should
occur is not to be satisfactorily explained, but that it does occur is an
established fact, most disfjuieting to the
patient. (See Chap. XIV, p. i6i.} A
Harm drink and heaters \\\ll encourage
him to regard the chiil as a small matter.
Morphin usually acts w ell. A single chili
is no cause for alarm, but rej>eated chills
after the passage of sounds arc likely to
mean threatened infection. Keep such a
patient in bed under regular constitutional
treatment. Fortify the kidneys with
diuretics and irrigate the urethra after
each urination. Watch carefully for col-
lections of pus round the penile urethra
and in the perineum and open them
promptly.

Complications and Sequelae. —
This operation is rardy ])raclised by
American surgeons because of the dangers
of hemorrhage, perineal abscess, extrav-
asation of urine, and e\-en septicemia, ''''^i,'|^i~^™iTH''KuBflE"covE'"r"'^
Hemorrhage after internal urethrotomy

may be met by tying in a maximum sized soft catheter, with compres-
sion against the catheter from without. Since the other complications
are to be met only by a perineal section, we then ha\e the after-con-
ditions of externa] urethrotomy. .As a matter of practice also there is
no time saved by an interna! operation over the external one.

EXTERNAL URETHROTOMY

This is the operation of choice for deep strictures, and the only one
for impassable strictures. Immediately after the operation irrigate the
bladder and whole urethra with hot boric-acid solution (2 per cent.).
All surgeons agree that after this operation a catheter must be tied into
the bladder, but are about evenly divided as to whether it should be
tied in through the perineum or through the urethra. In cither case use
a soft-rubber catheter (\o. 30 French), Only as much of the catheter
as contains the fenestnim should project into the bladder. As a pre-
caution against plugging, an extra window may be cut in the catheter
opposite and proximal to the other.

576 OPERATIONS ON PENIS, SCROTUM, TRETHRA, AND PROSTATE

To hold a catheter in the perineum use a Watson perineal button of
hard rubber (Fig. 189). With the catheter in place and the wound
covered w ith sterile gauze, pass the large central hole of the button
snugly over the catheter and against the perineum. Through each pair
of lateral holes in the button pass a strip of tape. Pass two ends of the
tapes backward and upward over the buttocks; the other two fonvard
and upward over the pubes; tie ail the ends together over the symphysis
just above the root of the penis. The catheter must fit the button
closely or it will not stay in place. Place a large dressing on the peri-
neum perforated for ihe catheter and held in position by a T-bandage.
.\ piece of rubber tubing, one half split into four tails, may be used in-
stead of the button.

.■\s soon as the patient is in bed, fasten to the open end of the catheter
with a piece of glass tubing a long rubber tube which leads lo a bottle
beneath the bed (Fig. 2or). A loop of the tube should be held by a safety-
pin to the under sheet to allow slack for the patient to roll round in bed.
If the bottle be tied to the side of the bed, there will be less danger of dis-
arranging the apparatus should the bed be carelessly moved. .-\s soon
as the bladder fiils the urine flows out into the tube, spontaneously estab-
lishing siphon drainage. At the end of forty-eight hours dress the perineal
wound and remo\'e the catheter. Ajjply a large absorbent dressing and
change it as often as it becomes saturaled with urine. For the first
few days all the urine will escape through the perineum, perhaps in-
voluntarily. Twenty-four hours after the catheter has been removed
irrigate the bladder and urethra with hot silver nitrate solution (i : 2000),

EXTERNAL URETHROTOMY 577

pass sounds up to the size of the normal urethra, then irrigate again.
Repeat the irrigations and sounds every other day until bleeding ceases;
then twice a week, as described under Internal Urethrotomy.

If, as is preferable, the catheter is to be tied in through the urethra,
it is held in place by any one of several ways. The best, from the point
of view of cleanliness and efficiency, is as follows: Two pieces of i-in.
tape 8 in. long are fastened by their middle with a safety-pin through
the tape and catheter exactly at the meatus. The ends of the tape are
then passed down each side of the penis, and are held there by two

Fig. 190. — Catheter Held in Penis.

Two pieces of cotton tape arepinned at their middle by a safety-pin to the appropriate point on the catheter.
The four ends are carried back to the root of the penis, and a narrow strip of adhesive plaster is bound loosely
(to allow for future congestion) about penis and tapes. Over this strip the ends are turned back, and, to prevent
slipping, bound down by a second circular turn of adhesive. A third collar of adhesive is applied just behind
the corona. During the applicaticm the skin of the penis should be kept on a stretch, to prevent any play of the
catheter in and out.

circular turns of zinc-oxid plaster about A in. wide. By this method
the glans is free from any permanent application and remains, there-
fore, unirritated. This retaining apparatus can be readily changed,
if need be, without disturbing the catheter (Fig. 190).

As soon as the patient is in bed establish siphon drainage, as described
above. This method, if carefully applied and cared for, drains the
bladder as well as the perineal catheter does, and, in addition, di\'erts
the stream of urine from the wound. On the other hand, it is not as
comfortable for the patient and is often troublesome to care for. Oc-
casionally the catheter excites such spasmodic contractions of the

•>4

578 OPERATIONS ON PENIS, SCROTUM, URETHRA, AND PROSTATE

urethra that the catheter is buckled completely out in spite of the fact
that the retainer tapes hold firmly, and the attempt to keep it in place
must be abandoned. Leave the catheter in situ if possible four to seven
days. By that time, often before, a seropurulent discharge will be found

oozing from the urethra round the catheter. This secretion is the re-
aclion of the urethra against the foreign body which it contains. If
the <iischarge becomes profuse, remove the catheter promptly, but wait
until the fifth day if possible. Twenty-four hours after removing the

catheter irrigate and sound the urethra as abo\-e. Rarely by the fifth
day is the perineal wound found so far healed as to prevent the escape of
some urine through it during the act of micturition.

After the removal of the catheter, irrespective of the way in which it

EXTERNAL URETHROTOMY

579

had been worn, every attention must be gi\en to healing the perineal
wound and keeping the urethra open. At first it is not unusual to find
that there is some loss of control of the sphincter, allowing the urine to
dribble away involuntarily. This loss, as a rule, is regained a day or

two after the catheter is remo\ed. .About a week after the operation
the patient begins to pass some urine through his penis. As the perineal
wound heals, more antl more urine comes through the penis, until, finally,
it all comes that way. Occasionally after a day or so without perineal

i small amounts of urine again escape from the perineum. This
need offer no cause for alarm, provided the urethra is well dilated, for
it soon ceases. The patient can materially help to send his urine through
his penis if, during the act of micturition, hi' will stand perfectly upright

580 OPERATION'S ON PENIS, SCROTUM, URETHRA, AND PROSTATE

and press his thighs closely together or stand cross-legged. As long as
any urine escapes through the perineum the dressing should be changed
after every urination. The patient can be taught to attend to this
matter himself.

The secret of success lies in thorough and persistent use of sounds.
The scarred urethra must be kepi stretched up to normal caliber.'
The slightest narrowing Is enough to prevent the healing of the perineal
wound and to perpetuate a urinary sinus. Any tendency toward con-
traction must be combated by more frequent sounding than that ad-
vised above. Leaving a sound in the urethra for five to ten minutes
is often efficacious in overcoming a tendency to contraction. It is
hard to convince patients of the necessity for the prolonged use of

sounds; failure to do so often means an unsuccessful operation and
sometimes a urinary sinus in the perineum.

Ho\ve\'er dirty the bladder before operation, the short period of
drainage and unobstructed outflow suffice to clean it up surprisingly
well. If it is thought necessary, the bladder may be irrigated daily or
oflener through the retained catheter; free diuresis and urinary anti-
septics complete the cure.

Some cases of long-standing stricture are complicated by such con-
ditions as extravasation of urine, peri-urethral abscess, or a watering-
pot perineum full of scar tissue. In any case, no amount of gcKxl after-
treatment will correct or make u[) for an inefficient operation. In
short, the stricture must have been fully divided, the draining catheter
must be extended well into the bladder, and the perineal wound, how-
ever small, must be a triangle, its base at the skin. That is to say,

' O. Horwilz. -Ann. Sufr,. ioio. U. 557.

EXTERNAL UEETHROTOMY 5S1

whatever drainage there is must be efficient. In uncompJicatcd and
simple strictures the perineal wound may be made \cry small, may be
drained with small strands of iodoform gauze, and, if the urethra has
been sewed over the catheter, as is sometimes advisable, the wound may
never leak urine. In cases with abscess or exlravasalion, however, the
wound should be large, and packed lightly with enough iodoform gauze
to maintain the wound as a single cavity for a time; the dressing should
be changed once or twice in twenty-four hours, so as to keep it sweet.

For the frightfully septic cases, where multiple incisions of buttocks
and scrotum have been necessary, dressings every three hours may help:
remove all ihe packing, sponge out the depths of the wound with chlorin-
ated soda (i ; 800), pack lightly witli iodoform gauze, apply a large salt
and citrate poultice, with a many-tailed bandage, and place outside

all this dressing a constantly refilled hot-water botlle, taking great care
that no burn shall occur. When the wound (or wounds) is a single
clean cavity wherein there seems to be no danger of side ])ockets forming,
ail packing or drainage should be left out; the woimd, however, should
be repeatedly cleaned mechanically and dressed with some stimulant,
such as balsam of Peru.

Complications and Sequelae.— Phif^giii^ of lalhc/cr whh blood
or pus may take place at any time. The danger of this is largely averted
if, before insertion, as already described, an exira window is cut in the
end of the catheter ojjposite the usual opening and about \ in. higher.
If the catheter becomes effectually plugged, either it may be forced out
by the efforts of the bladder to empty itself or the bladder may fill up
and the patient present all the signs and symptoms of distention.

582 OPERATIONS ON PENIS, SCROTUM, URETHRA, AND PROSTATE

When, in spite of the retaining apparatus, the catheter is forced out,
it must, of course, be replaced at once. A soft catheter cannot usually
be readily passed through a urethra which has recently been operated.
The surest and easiest way to get a soft catheter back, with the least
number of attempts and the least discomfort to the patient, is to make
the catheter rigid in the usual curve by insertion into it of a small sound
or probe to serve as a stilet. A catheter thus stififened is to be thoroughly
lubricated and inserted like a sound, remembering always that the
roof of the urethra is supposed to be uninjured and is the part, therefore,
to follow as a guide.

If the catheter be plugged, but remain in position, warm boric-acid
solution should be forced through it from a fountain syringe or, better,
in short sharp spurts from a hard-rubber hand syringe until the clot is
dislodged and the drainage is well reestablished. Sometimes suction
will work where pressure will not. Blowing, on the other hand, is not
to be encouraged. One of us once saw a case in consultation, after
external urethrotomy, which presented the curious symptom-complex
of marked distention, no passage of urine, bulging and resonant bladder.
The case was cleared up by the explanation of the attending physician
that he was accustomed to blow into the catheter to dislodge clots.
Removal, cleaning, and reintroduction of the catheter saved the day.
Where there is much bleeding it is always wise in prostate as well as
stricture cases to have the catheter irrigated every half-hour for the
first three hours after operation to forestall any such difiiculty.

Hemorrhage at any time during the first three days after operation
may take place from a considerable vessel in the bulb, or may persist
from the very time of operation where the urethra and its surrounding
tissues are congested from prolonged inflammation. If the hemorrhage
is from the urethra itself, as in the case of internal urethrotomy (see
p. 574), it is best controlled by the insertion of a catheter of maximum
size. Such a catheter gives uniform pressure to the whole urethra and
should stop the bleeding. If this is insufficient, the perineal wound may be
tightly packed with iodoform gauze, which may, in addition, if one
chooses, be soaked with adrenalin solution (i: 1000). If the bleeding
is arterial and not controlled by packing, it may be necessary to get the
patient into the lithotomy position and explore the region of the wound,
with or without anesthesia, to find and tie the bleeding vessel.

Sepsis, — Infection in the region of the woimd should be met as sepsis
everywhere — by the maintenance of perfectly free drainage and frequent
dressing. Occasionally in parts of the urethra distal to the wound
peri-urethral abscess may arise, particularly if the draining catheter

EXTERNAL URETHROTOMY 583

is left in too long. This is characterized by pain and fever, the appear-
ance of induration along part or all of the penile urethra, and, in due
time, by the escape of pus from the meatus, on squeezing the indurated
part or, possibly, even by the abscess pointing through the skin. This
complication should be preventable or, at the worst, should be recognized
at once, before it assumes any considerable importance. The draining
catheter should be withdrawn, the abscess kept empty by repeated
milking, done at least, for example, every two hours. The urethra,
from the meatus to perineal wound, should be irrigated with a small-
caliber soft-rubber catheter, first put in deeply and gradually withdrawn
while irrigating, in order that the whole urethra shall be cleaned. This
should be done every three or four hours.

Epididymitis may follow this operation by infection through the
ducts in the prostatic urethra. This is more likely to appear also if
the draim'ng catheter is left in too long, and, like peri-urethral abscess,
seems to depend upon the seropurulent discharge which we described
above. The catheter should be removed, the bladder should be washed
out twice a day, the testicle should be efficiently supported by a tin shelf
across the thighs or by adhesive plaster, and either an ice-bag or flax-
seed poultice applied, whichever is the more agreeable, though the
former is more likely to abort a beginning process.

Persistent Perineal Fistula, — Urethral fistula after external ure-
throtomy may be said normally to persist for any period from a few
days to a few weeks, and its time of closure must vary, as in all wounds,
with the ability of the patient to heal, dependent on his resistance
and general state of health and on the local conditions in the perineum.
If, after several weeks (it cannot be stated more exactly), the amount
of urine passed by the meatus does not continuously increase over that
passed through the fistula, there is probably a mechanical reason. A
valve-like flap may exist in the urethra just distal to the wound, or there
may be a urethral stricture distal to the wound, either recurrent or
not originally cut. In any case the cause, apart from any maUgnant
disease, is probably mechanical, and the persistence of the fistula means
that the urine chooses to take the easier channel of exit. The treatment
is by the use of sounds through the whole length of the urethra. If,
as is usual, a meatotomy has been done at operation, the ordinary steel
soimd is used, beginning with the largest size that can be passed, and
increasing as rapidly as possible, with daily passings, imtil No. 30 or
31 French is reached. If meatotomy has not been done, the curved
Kollmann dilator must be used.

584 OPERATIONS ON PENIS, SCROTUM, URETHRA, AND PROSTATE

RUPTURED URETHRA

Here perineal section will have been performed and a catheter
passed the full length of the urethra and left in place for drainage.
The urethra, when possible, will have been partly or even entirely
sewed up at the torn place over the catheter. Some cases may heal
by first intention, but more often they behave as after external urethrot-
omy. (See p. 575). The catheter is left in place five to seven days,
unless there appears an excessive urethritis with toxic symptoms. Two
days after the removal of the catheter a steel sound or Kollmann
dilator must be passed, and thereafter as in the case of external
urethrotomy.

On rupture of the fixed portion of the urethra where the liga-
mentous attachments of the prostate are torn, affording communica-
tion between the prevesical space and the perineum, the drainage-tubes
should go well up into this space or even down through a small supra-
pubic wound.*

Complications and Sequelse. — Hemorrhage and shock may be
considerable; both are amply met by saline proctoclysis and by abun-
dance of pure drinking-water.

Extravasation of urine may occur unless the perineal wound is large
enough thoroughly to drain the region of the trauma. Not infre-
quently there has been a certain amount of extravasation of urine or
blood before the case arrives in the surgeon's hand. When this occurs,
every effort must be made to forestall or combat cellulitis.

PERINEAL PROSTATECTOMY

Since most patients on whom prostatectomy is done are somewhat
advanced in years, it is as well in most of them to begin salt solution
under the breasts at the moment of operation. After the completion
of the operation the patient should not leave the table until all consider-
able hemorrhage has been obviously checked and free passage of fluid
in and out of the bladder through the perineal catheter (with two fenes-
tra) has been clearly demonstrated. Two small tubes or catheters
fastened side by side may be used instead of one catheter. These serve
for inlet and outlet respectively. One is fairly sure to remain un-
plugged. The drainage catheter is held in by the Watson button
(Fig. 189) or by the split collar-tube, or in some other eflScient man-
ner, and the patient is put to bed, the drainage-tube being imme-
diately connected with a bottle hanging at the side of the bed. The
tubing should be led out under the thigh and the knees supported by

*0. C. Gaub, Jour. Am. Med. Assoc., 1910, Iv, 2048.

PERINEAL PROSTATECTOMY

585

a pillow. In this way the patient is free to turn in bed without dan-
ger of pulling out the catheter.

Instead of a perineal catheter, Watson's hard-rubber perineal
drainage-tube may be used (Figs. 197 and 198).

The catheter should be removed at the end of twenty-four to forty-
eight hours, but may need to be replaced. A stilet is used to stiffen
it for the purpose of getting it back if necessary. Unless retention of urine
appears, the patient should be set up in bed the day after operation
and should be out of bed the second day if possible. Cases in which
retention with fever persists cannot get up so soon. A sound must be
passed on the third day and twice a week thereafter for two to six months,
according to the individual tendency to form stricture of the urethra.
(See also Cystotomy, p. 600.)

Out-of-door and general tonic treatment should be instituted.

Complications and Sequelse. — Hemorrhage, — External hemor-
rhage is unlikely if the wound has been packed. The bladder may
fill, however, and the patient show signs of internal concealed hemor-

FiG. 197.— Watson's Hard-rlbbek Plrineai. Drain-
age-tube.

Showing sliding collar to hold perineal straps.

Fig. 198.— Watson's Perineal Drainage-
tube.

Front \new of sliding collar.

rhage, or the bleeding may not be enough to give general symptoms,
but enough, nevertheless, to plug the drainage catheter with blood-clot.
The drainage, then, whether there be signs of hemorrhage or not, must
be tested every hour or two for the first twelve hours at least. If it
stops as if plugged, fluid may be forced from a relatively great height
in the fountain syringe and so drive out the clot, or a hand syringe may
force the clot out and the bladder should then be washed with a solu-
tion as hot as can be borne imtil the return is blood free. If the hemor-
rhage then continues to any considerable degree, the patient must be
put in the lithotomy position, the packing removed, the bleeding point
found, snapped, and tied, and the wound freshly packed.

Suppression of urine is combated by forcing fluids into the body by

586 OPERATIONS ON PENIS; SCROTUM, URETHRA, AND PROSTATE

all means — namely, mouth, skin, and rectum; by exhibition of digitalis;
by application of poultices or hot- water bags over the kidney regions;
by hot pack or hot-air bath if the matter becomes serious. For drugs,
a pill of f-grain of digitalis tol. every 4 hours, and caffein soda-ben-
zoate, I grain subcutaneously every hour for several hours, will stimu-
late the kidneys.

Retention of Urine. — In the median perineal incision type of opera-
tion, such as that of Watson and others, the sphincter is either stretched
to temporary paralysis or so torn that what urine appears in the bladder
later usually drains without trouble. In the dissection operations of
the Young type, the sphincter, as a rule, is not affected, and on re-
moval of the catheter the cases with long dilated, fibrous, degenerated
bladder walls will continue to fill up in an atonic manner, just as they
did before operation. In these cases, therefore, constant drainage must
be maintained, sometimes many weeks, with irrigations one, two, or
three times daily with hot boric acid, salt solution, or potassium per-
manganate, until a certain amount of tone is recovered. Any type of
operation should be followed by bladder washings until there is no
evidence of atonicity or cystitis.

Infectiofi, — The case may die almost immedi-
ately from surgical kidney; extensive infection of
the wound may appear in cases of chronic foul
bladder poorly prepared for operation; in patients
much debilitated; after operations involving much
mutilation. Free drainage and careful and fre-
quent dressings constitute the treatment.

Persistent Perineal Fistula, — It is to be decided
that this condition exists, not necessarily upon per-
sistence for a number of weeks or months, but only
if there is exhibited no tendency for the amount of
perineal discharge to diminish, and at the same
time if it be certain that the urethra is patent.
Some effort to stimulate healing, in the way of bal-
sam of Peru, nitrate of silver. Friar's balsam, etc.,
Sounds should maintain the urethra at No. 30
French. After six months a secondary operation to close the fistula
should be done.

Persistence of incontinence, either through a perineal fistula or through
the meatus, signifies a probable incurable injury to the sphincter. For
this, however, the application of static electricity, with one electrode on
the perineiun and one over the lumbar spine, may be tried. An ambu-

FiG. 199. — Male Urinal.

Soft-rubber, suspended by
belt, wOTn in trouser-leg.

should be made.

SUPRAPUBIC PROSTATECTOMY 587

latory urinal (Fig. 199) should be used when necessary. Excoriations
should be prevented by applications to the skin.

SUPRAPUBIC PEOSTATECTOMV

This operation, though relatively in disfavor in American practice
at the present writing, seems to have the advantage that it affords in-
spection of the prostatic tumor and perhaps, therefore, more delib-
erate treatment with regard to the special formation that the enlarge-
ment presents; and that a suprapubic cystostomy may be done some
time previous to the removal of the prostate, thus giving time for
draining and cleaning up a distended foul bladder. It has the dis-
advantage that adequate drainage is difficult and that ascending in-
fection of the kidneys seems liable to occur.

The patient is put to bed and drainage through the urethra and the
suprapubic wound is immediately established. An ingenious and ade-

r small-calibfr soft-rabber lub.-, ru=ed logelhfr (Dr. Horace Pj

quate method has been devised by Dr. Horace Packard,' of Boston
(Fig. 200). Some operators prefer a single tube with a diameter of as
much as 1 inch." Without special apparatus, however, drainage can be
efficient if the patient receives intelligent and conscientious attention
day and night for the first three or four days. He should sit up in bed
the day after operation and in a chair as soon as possible, returning to
nearly normal conditions with as great rapidity as is allowed. Water
is forced into the body by all methods from the very moment of opera-
tion. Urinary antiseptics are given constantly. For other details oi

' N. E. Med. Gaz., 1007. xvii. i,v

' p. W. Basham. Med. Assot, of Southwest, Oct., igio.

588 OPERATIONS ON PENIS. SCROTtfM, URETHRA. AND PROSTATE

after-treatment see Suprapubic Cystotomy {p. 600) and Genera! Con-
siderations on Genito-urinary Cases (p. 566),

Complications and Sequelae. — Shock complicated with hemor-
rhage is probably the commonest cause of death. SaHne solution,

>«-*■

adronahn, heaters, all the means already described (Cha|). VII, p. gi),
are to be at hand.

Hemorrhage. — The patient should not leave the table until all
notable hemorrhage has been checked. If a considerable bleeding
starts up in bed, the prostatic cavity must be jiackcd ihrouj^h the supra-
pubic wound. The packing should be of i<Hioform gauze or plain j^auze
saturated with adrenalin if necessary. The packing should be removed
in most cases at the end of twelve hours.

Sepsis. — .\scending infection may cause a double pyelitis, which may
be rapidly fatal. Mere absorption of septic products from the prostatic
wound cavity in cases inefficiently drained is enough to cause fatal issue.
In the latter case treatment is obvious. In pyelitis large quantities of
water, urinary antiseptics, poultices or heaters over the kidney regions,
am! general supportive treatment should give results. Suppression of
urine is always to be feared. Prophylaxis )iy means of previous water

PROSTATOTOMY FOR PROSTATIC ABSCESS 589

saturation should be efficient against it, but if diminished secretion
just after operation is apparent, besides salt solution under the skin,
the patient should be given poultices over the kidney regions and diu-
retics by mouth. Sweating, using a hot-air bath when indicated, should
be induced.

PROSTATOTOMY FOR PROSTATIC ABSCESS

Inasmuch as prostatic abscess can almost always be opened without
entering the urethra, it is to be treated as any abscess: iodoform gauze
tampon for first dressing, rubber tube subsequently if the skin-wound
tends to close too rapidly.

Constant urethral drainage may be necessary in some cases because
of spasmodic or inflammatory retention. Frequent hot sitz-baths aid
drainage and give great relief. The coincident gonorrhea must be
treated.

CHAPTER XLVIII
OPERATIONS ON THE KIDNEY, URETER, AND BLADDER

NEPHROTOMY

The kidney may be subjected to a small incision, as for abscess, or
it may be split open its entire length in order to get out a large stone or
a number of stones in the pelvis or the calices. The loss of blood
after either procedure is usually considerable. If necessary, the ap-
propriate constitutional treatment for hemorrhage should be instituted.
(See Chap. VL) The shock following this operation is, most likely, due
in great measure to the hemorrhage. If the kidney was found to con-
tain stones and no appreciable amount of pus, the wound in the kidney
is to be closed by interrupted mattress sutures of No. i or 2 chromic
catgut. This should immediately control hemorrhage and should give
a fair chance of primary healing of the kidney wound. A cigarette
or spiral drainage leads down to the kidney.

If the pus in the kidney is enough in amount to make it merely a
pus-cavity, or if the hydronephrosis is such that only a shell remains,
and if also it has been determined before the operation that the patient
has another kidney (by cutting down on it or by catheterizing the ureters),
a nephrectomy will be done either primarily or after splitting the kidney.

(See p. 597-)

If, however, for any reason the kidney itself is to be drained, a spiral
drain with 2 in. of gauze protruding from one end may be packed into
the purulent or bleeding cavity. A voluminous dressing is applied and
the patient lies on his back with an additional small hard pad under
the lumbar region to help prevent backache. Saline adrenalin solu-
tion— 0.6 and 1 : 50,000, made by adding common salt (i dram) and
adrenalin solution, i : 1000 (2^ drams) to i pint of sterile water — should
be started under the breasts as soon as the patient is on his back, and
should be given to the limit of capacity of both breasts. Salt solution
should also be started by the slow method per rectum and kept going
twenty-four hours. Tincture of digitalis or strophanthus may be added
to the enema if it seems best, and strychnin given subcutaneously
(^ gr.) every one to six hours if indicated. The pads must be
changed as often as they are wet. The patient must be kept warm to

590

NEPHROTOMY 59 1

the extent of mild perspiration, and must be encouraged in every way
to drink.

Occasionally bleedmg occurs on removing the packing which has
been placed in the kidney, because the blood-vessels in this organ have
especially thin walls. On this account it is well to postpone withdrawing
the tampon imtil it has been loosened by the suppurative process, and
even then it should be removed a little at each dressing until it has all
been loosened. In the mean time the urine drains round the gauze,
through the wound, and the mucous membrane lim'ng the ureter has
an opportunity to become normal, because the flow of purulent urine
through it has ceased. The urine usually becomes clear in a few days
because the drainage is so free that there is no accumulation. The pelvis
of the kidney contracts for the same reason.

For nourishment during the first week milk should be the main re-
source. Begin by adding an equal quantity of boiling water, together
with a litde lime-water. After that start soft solids and begin a rapid
resumption of house diet. The amount of meat and eggs in the diet will
depend somewhat upon the chemical composition of the stones removed
and upon the reaction of the urine during convalescence. In a urine
which tends to be strongly acid meat once a day is probably best. If
the urine is alkaline, more may be given. If the urine continues to be
alkaline, sodium benzoate (5 gr.), dissolved in a glassful of water, should
be given three or four times a day. Whether the urine contains pus
or not during the first tw^o or three weeks, hexamethylamin should be
given, 5 to 7J gr., dissolved in much water, three or four times a day,
with a view to rendering the urine sterile and bland.

The amount of urine, day and night, separately, should be carefully
noted from the first, together with any gross appearance of blood therein.
The blood should diminish and not be apparent to the naked eye after
the third dav in most cases.

Double nephrotomy offers some curious problems in after-treat-
ment, as a personal communication from Dr. F. S. Watson will show.

" The features of the after-treatment of that case of double nephrotomy
were:

'*(i) The manner of arranging the drainage (Figs. 202, 203, 204).

'^(2) The fact of the infection, and acute abscess of the second kidney,
some nine years after the first one had been operated upon also for acute
abscess.

''(3) The fact that the patient has been, except for some few weeks of
which I will speak in a moment, comfortable, free from disagreeable odor,

592 OPERATIONS ON THE KIDNEY, URETER, AND BLADDER

dry, and without disability, he having pursued an active, hard-working life
during the whole time since the first operation, which was in 1894, with the
above-noted exception.

^'(4) The fact that the first kidney operated upon, which was so greatly
injured as to have made it seem wise to have removed it at the outset, had
the patient^s condition at the time allowed it to be done, has ever since the
original operation continued to supply urine having a specific gravity of
from loii to 1017, and urea from 1.30 to 1.50, taking 2 as the normal quan-
tity (the second kidney was much less seriously and less extensively damaged,
although it had a large abscess in it), has secreted a urine of nearly normal
quantities of the solid constituents, since it was operated upon. The drain-
age through the loins has been uninterrupted from the time of its being in-
stituted in both kidneys — fifteen years in all.

"(5) The fact that the patient went on in perfectly good health for twelve
years without any evidence of calculus-formation in either kidney.

"(6) That he then began to have calculi from both kidneys, which con-
tinued for several months, when I operated on the right and later on the left
kidney, removing a lot of gravel and putty-like phosphatic concretions and
calculous material in small masses from one kidney and a large single phos-
phatic calculus from the other.

"(7) The fact that he has had no symptoms of renal calculus since these
operations, two years ago, and continues to be in excellent condition and
hard at work.

^'(8) That the urine has since then become much clearer than at any
previous time and is free from blood.

** These are the most interesting features of the case subsequent to
operation.

" The kidneys have been washed out night and morning ever since the
OF)eration with i : 4CX>d or 6000 solution of potassium permanganate, or
sterile saline solution, or boric acid, 4 per cent, solution, through the Watson
drainage-tubes. The tubes have been changed for clean ones each time
this has been done. The fistulae have never been allowed to contract, and
the drainage-tubes have always been kept of large size, their calibers about
i in. The best p>ossible drainage has thus been maintained.

*' Finally, hemorrhage took place from the kidney operated on first,
twelve years after the op)eration. Nevertheless, daily irrigations went on
as usual. Two weeks later he came to my office, and uix)n having the tube
from the kidney replaced after it had been withdrawn to cleanse it, and
without any trouble having occurred in getting it back again, a sharp
hemorrhage suddenly occurred from that kidney, I succeeded in partially
controlling it and got him to the hospital, where I laid open the whole of the
tract of that fistula, found the hemorrhage to be proceeding from one point
especially of the renal substance close to the inner orifice of the fistula, and
after extracting a calculus from the kidney by forceps through the now much-

NEPHROTOMY 593

enlarged canal of the fistula, I succeeded in wholly arresting the bleeding
by tamponing the wound and bleeding surface af the kidney, after which
we had no further trouble of any kind."

Complications and Sequelae. — Secondary hemorrhage may take
place at any time for from a few hours to weeks, months, or even years
after operation if fistula persists. This may be due to inefficient hemo-
stasis at the time of operation; it may be due to ulceration of a remaining
stone into a renal vessel; it may be due to the presence of an unsuspected
new-growth underlying the stones, or may be apparently a general venous
ooze from the whole cut surface. Such bleeding must be met for the
time being by packing the wound with gauze soaked with adrenalin, or
at any time by secondary operation, even by nephrectomy, if packing
does not control it.

Sepsis. — ^This may be superficial or deep, and may or may not cause
general symptoms. If the kidney has been torn and the urine was foul,
or if repeated packing has been necessary to stop bleeding, deep infec-
tion will probably appear. For this condition drainage must be free
and eflScient.

Suppression or uremia may take place at once, or at any time up to
tw^o weeks. It is seen more often in those beyond middle life and in
those with stiff arteries and high-tension pulse, or in those in whom the
other kidney is suffering with stone or other disease. Preventive treat-
ment (p. 566) is, of course, the most important. Every means must be
taken to produce sweating and diuresis.

Persistent uriftary fistula after nephrotomy presents a difficult prob-
lem. Until the ureter has become normal, and especially in cases in
which the disease has existed a long time, the wound in the kidney will
not heal, and a fistula may persist, which is not only disagreeable, because
of the odor and sensations of dressings constantly wet, but also because
it results in distressing excoriations of the skin on account of the irrita-
tion of the urine. The problem of collecting the urine from such a fistula
so as to allow the patient to lead an ambulatory life is well met by Dr.
F. S. Watson ^s ingenious apparatus. The apparatus consists of the
following parts:

(i) A cup-shaped hard-rubber shield perforated by two holes, one in the
center of the shield and having the size of No. 28 of the French scale of measure-
ment for urethral instruments; the other, which is somewhat smaller than the
first, is placed just within and at the lowest point of the cup of the shield. A
short hard-rubber tube is fitted into the last-named hole, and onto the farther
end of this tube is attached another of soft rubber which passes to the smaller

594

OPERATIONS ON THE KIDNEY, URETER, AND BLADDER

o£ the two upright tubes of metal that are upon the upper surface of
the receptacle (Fig. 203).

The leakage, which is so distressing a feature to the patient, and, be-
cause of the uriniferous odor, makes the condition so unpleasant to others,
takes place around the outer sides of the tube which drains the kidney.
It is this leakage which must be provided for by the apparatus, and it is
done in a very simple manner by this contrivance, thus: As fast as the
urine escapes upon the surface of the body it is necessarily caught within
the cup of the shield and is withdrawn from it by the small tube which

drains the latter as fast as the urine collects in it, and conveys it to the
receptacle. The shield is provided with a soft-rubber rim, which fits
into the raised edge of the rubber cup, and the shield is kept firmly
pressed against the surface of the body by an elastic belt which is at-
tached to each of its wings and which buckles in front {Fig. 202).

(j) A receptacle made of German silver which has a capacity of 9
ounces,

(3) A second belt, which is attached to the receptacle in the manner
shown in Fig. 202, and which also passes around the body and buckles in
front.

NEPHROTOMY S95

(4} Upon the lower part of the can is a metal cap, which can be detached
from it. From the middle of this cap projects a short metal tube, over the
end of which a soft -rubber tube is slipped; the further end of this tube is

furnished with a hard-rubber cap. by unscrewing which a hole is opened in
its stem and allows the contents of the can to escajie through it. Except
at the time at which the can is l>eins thus emptied, the end of the tube is

596 OPERATIONS ON THE KIDNEY, URETER, AND BLADDER

worn beneath one of the elastic belts, which retains it at whatever point is
most convenient to the wearer (Fig. 204).

(5) The only other feature of the apparatus which requires description is
the arrangement by which the tubes connecting the shield with the recep-
tacle are attached to the latter. This is done by passing the lower ends of
the soft-rubber tubes into the two metal nozzles — or, if preferred, slipping
them over them — which are placed upon the upper part of the receptacle.
The manner in which the connection is made, as well as the relative posi-
tions of the shield and receptacle and other details of the apparatus, are
shown in Figs. 202 and 203.

Fig. 204 shows the apparatus as it appears when properly placed on the
patient's back.

The further points to be noted in connection with it are as follows:

The hole in the shield through which the tube which drains the kidney
passes must be a little smaller than the tube, in order that the latter shall
bind it in and thus be prevented from slipping to and fro. If in any case
the tube should be too small to do this, its size can be increased by slipping
over it a short bit of another and larger tube at the point at which it passes
through the shield.

The receptacle can be worn inside the trousers, and is so small and flat
that it attracts no attention and causes no discomfort.

Instead of a receptacle of this form the ordinary portable rubber urinal,
which is attached to the leg, may be worn if preferred, the connecting tubes
being united into one, near the shield, and lengthened, as may be required.
The objection to this arrangement is the difficulty of keeping the rubber bag
clean and odorless.

At night the metal receptacle is detached, the tubes of the shield are
lengthened by attaching others to them, and these are carried to a bottle or
other receiving vessel placed beside the bed. The patient should assume a
semirecumbent position at night in order to secure the best drainage of the cup
of the shield.

The connections of the belts with the shield and can respectively should be
so arranged as to be detachable, in order that the other parts of the apparatus
can be boiled, which should be done once daily. The tube draining the
kidney should be changed for a fresh one each day, the one not in use being
kept in an antiseptic fluid.

When the tube which drains the kidney has been properly adjusted in the
organ, a mark should be made up<m it at the point at which it emerges from the
outer side of the shield, in order to avoid the necessity of having to readjust
the tube each time that it is changed. The tube's inner end should rest
within the renal pelvis in most cases, and should be so placed as to cause
no pain to the patient.

NEPHRECTOMY

597

NEPHRECTOMY

The dressing should not be so voluminous that it makes a mass
uncomfortable to lie on. Temporary drainage is in the renal space*
In bed the patient is surrounded by heaters, and symptoms of shock and
hemorrhage attended to as they appear. Uncomplicated, the sutures
should be out on the tenth day, the patient up when the remaining
kidney seems to have assumed its doubled function.

If the nephrectomy has been for tuberculosis of the kidney, it is to
be supposed that the ureter was followed down and removed. In the

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wound, therefore, if there is any question of tuberculosis remaining,
it should be treated later by repeated applications of tincture of iodin,
as in tuberculous wounds elsewhere.

Abdominal nephrectomy y a very rare operation, calls for no special
consideration apart from nephrectomy in general.

Complications and Sequelae. — Suppression of Urine.^Aher-
care of nephrectomy, as in nephrotomy, should be at first directed to-
ward encouraging the other kidney tt> rise to its increased labor. It has

SqS operations on the kidney, ureter, and bladder

been contended by some that too high an arterial pressure might be in-
duced by forcing the ingestion of fluids, but it seems to us doubtful if
suppressive congestion of the other kidney is ever due alone to pressure
froih too great a volume of blood in the systemic circulation. It seems
more probable that uremic suppression is due, on the contrary, to the
concentration of blood containing too much matter to be excreted.
The same consideration may be applied to meet the objection that
one should seek to avoid the raising of blood-pressure until thrombosis
is well established in the renal pedicle after nephrectomy.

In the matter of postoperative suppression there is one prophylactic
possibility of which too little is ordinarily said. To quote F. Tilden
Brown*: "A word about the prevailing method of posturing patients
for nephrectomy. Of course, an extension of the iliocostal space greatly
facilitates operation. This is ordinarily secured by bags of sand or air
underlying the opposite anterolateral region of the abdomen. When,
by such an arrangement, the spine is sufficiendy flexed to extend the
operative field, the pelvis is nearly lifted from the table, and the pyramidal
support thus bears a considerable part of the total weight of the body.
This pressure impinges upon a yielding surface immediately about the
sound kidney, and that the organ may be heavily compressed against
the spine, with deleterious consequences, appears to us quite possible.
Experiments showed that 30 per cent, of the body weight was in this
w^ay superimposed on this region alone."

This evil is avoided by the use of an operating-table with the double-
inclined plane arrangement (such as the Cunningham table), but it would
seem as if there should be an actual gap between the planes to underlie
that part of the trunk which ordinarily sustains all the lifting strain in
the varieties of "nephrectomy" tables.^ As Dr. Brown says: **We feel
that every consideration should be accorded to the single healthy gland
(kidney) during the removal of its mate."

Nitroglycerin and adrenalin, which cause a rapid rise in arterial ten-
sion, should be avoided if possible. The surgeon should rather trust to
strychnin with digitalis or strophanthus to overcome the shock of oper-
ation. The observer may be easily led to mistake a condition of delayed
surgical shock for auto-intoxication due to renal suppression. The
former is probably the more likely, and should be ruled out before
anuria is diagnosticated.

1 Non-obstructive, Postoperative Anuria, Ann. Surg., 1981, xxxiii, 225, et seq.

* There has been much recently written on the matter of orthostatic albuminuria and
the general relation of posture to kidney disease. See G. Pechowitsch, Deut. Med. Woch.,
1910, xxxvi, 2020.

NEPHRORRHAPHY

599

Hemorrhage, — ^At the time of operation the ligatures must be placed
with all the care possible, using the so-called surgeon's knot, as small
a mass being included in each tie as is feasible. The wound should be
well retracted and well lighted, and every oozing point which appears
after fairly vigorous sponging should be deliberately tied. If bleeding
still persists, or cannot be reached by ligature, the hemostatic forceps
or clamp should be left in situ for two days. If this is done, the
greatest care must be taken to so build the dressing round the handle
of the forceps and to so place the patient that the weight of the body in
the recumbent posture shall not bear on the forceps. In some
cases the dressing pad stains

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through with bright blood re-
peatedly to an extent which is
disturbing. If this occurs, par-
ticularly with rising pulse, and
it is known that every reason-
able effort was made to control
bleeding by direct ligation at the
time of operation, the patient
should be turned over on the
well side, the wound opened and
tightly packed with iodoform or
some other chemically treated
gauze. In packing a capacious
cavity of this sort one should
leave the end of each strip which
has been introduced protruding
from the wound, in order that
later, when the packing is re-
moved, nothing may be left.

NEPHRORRHAPHY

This operation is rarely nec-
essary. Whatever the type of
operation used, the patient should be on the back about twenty-one
days to allow thorough organization of the adhesions about the kid-
ney in its new place. After this the patient may acquire strength as
rapidly as possible, avoiding, however, great muscular strain, such as
requires the fixing of the diaphragm and reaching upward or back-
ward. Other than this there are practically no special directions for
convalescence.

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Uneventful recovery.

6CX> OPERATIONS ON THE KIDNEY, URETER, AND BLADDER

Complications and Sequelae.— A'm)fe in the Ureter. —li is pos-
sible that by the operation the kidney has been fastened in such a
position as to kink the ureter or to interfere with the blood-supply.
This is called strangulation or acute dislocation of the kidney, and an
immediate secondary operation may be necessary.

The newly fixed kidney may tear away. Even so, if the patient be
kept on his back, there should be enough raw surface in the region of
the wound to enable the kidney to adhere. Certainly no second
operation should be attempted for many months at least.

OPERATIONS UPON THE URETER

After operations upon the ureter, whether the operation has been
for ureteral obstruction or for accidental or operative injury to the
ureter, the wound must be drained down to the site of ureteral opera-
tion, but in such a way that there shall be no obstruction due to the
drain. The drainage, if there is no leakage of urine, needs to be in place
only twenty-four to thirty-six hours. Occasionally the abdominal
wound has been closed primarily.^ If urine escapes to a notable de-
gree from the wound, means should be taken to protect the skin (p.
570) or to collect the urine, as in a persistent nephrotomy fistula

(p. 593)-

SUPRAPUBIC CYSTOTOMY

In these cases it is assumed that the bladder is closed by interrupted

catgut sutures, but the wound down to the bladder is left open. This

procedure may be followed unless one of the following conditions is

present: (i) Cystitis, especially with foul-smelling urine; (2) when the

stone was partially embedded in the bladder-wall or for any other reason

the bladder was torn or bruised, as in the separation of a tumor; (3)

hemorrhage, either present or reasonably to be expected. If the bladder

is closed in this condition, it will fill with clot, cause violent tenesmus,

and finally tear itself open through the line of sutures.

"The drainage of the bladder (after suprapubic cystotomy) by catheter
in the urethra and siphonage is so difficult, the patients being so unsatisfact-
ory for the first week or so, owing to the constant soakage in spite of volumin-
ous dressings, that wherever it is possible the bladder opening should be closed
by sutures. This is especially the case in elderly flabby patients with dam-
aged kidneys and unsatisfactory vital power and will. Such tend to become
apathetic, to lie helplessly on their backs, down in the bed, thus easily get
stasis in their lung bases and bronchopneumonia, together with a low septic
condition of the wound. The nursing in such cases is greatly helped by sutur-
ing of the wound, thus keeping the patients dry. One of the first to adopt this

^ H. Cabot, Boston Med. and Surg. Jour., 1910, clxiii, 789.

SUPRAPUBIC CYSTOTOMY 6oi

plan successfully was Dr. L. S. Pilcher, of New York: a catheter was used until
the nmth day; the patient, an adult, went out on the fourth, and on the four-
teenth day was shown to the New York Medical Society, primary union having
taken place throughout the whole extent of the wound, without unpleasant
symptoms of any kind. Mr. Anderson (Lancet, 1890, i, 898) sutured the
bladder in a boy aged ten. Acute pneumonia complicated the after-treatment,
and on the night of the fourth day prolonged coughing tore open the wound.
The case did well. During the first few days, if the urethral catheter becomes
plugged, some urine, possibly septic,, may be forced out between the sutures
before the bladder wound is finally closed. If this extravasation takes place
deep down in a wound like this, where the superficial parts have been closed,
there is the gravest peril of a fatal issue from septic purulent infiltration of
the connective tissue of the cavum Retzii, pelvis, and abdominal wall.'' *

Complications and Sequelae. — Shock may appear immedi-
ately after operation. This is partly because patients, as a rule, are
old; because persistent hemorrhage has been usually going on for a
long time before, and because during operation there may have been
considerable hemorrhage.

Hemorrhage. — Bleeding may continue unchecked from the time of
operation or may start up secondarily two or three days after operation.
Where the growth was in the lower segment of the bladder, near the
exit, if bleeding is not stopped by simple packing, a small bougie may
be passed by urethra into bladder, and a tampon may be made as
follows:^ A small shirt-button is placed in the center of 15 or 20
layers of gauze, 8 or 10 in. square. A long loop of silk is passed
through the gauze, through the button, and back through the gauze, and
the silk loop is then pulled by means of the bougie through the supra-
pubic wound and out through the urethra or the perineal wound, as one
exists, dragging after it the conical tampon of gauze.

Sepsis, — This may follow partly from lowered resistance on account
of the age of the patient or from a previous dirty condition of the bladder.
In the latter case sepsis should have been anticipated by preliminary
suprapubic drainage and irrigation. If sepsis occurs after operation,
ample drainage must be established and repeated irrigations practised.
Boric-acid solution (3 per cent.) or normal salt solution may be passed
through the urethra or the perineal tube until it comes out suprapubically
perfectly clear. This should be repeated as often as every two hours
until acute signs or symptoms subside.

Peritonitis has followed where the operation has caused a perforation
of the bladder-wall. This accident may easily happen when a polypoid
tumor is pulled up from the fundus and snipped off.

^ Jacobson, 1902, ii, 404.

2 A. T. Cabot, Med. Rev., New York, Sept. 17, 1892.

602 OPERATIONS ON THE KIDNEY, URETER, AND BLADDER

Fislula. — In some cases it is found advisable to allow a suprapubic
opening to persist, as, for instance, in the presence of malignant dis-
ease. The patient may be up and about, so far as his general condi-
tion will allow, with a drainage catheter passing through the fistula
into the bladder. This may discharge into a large pad of gauze or its
outer end may be carried into a rubber urinal strapped about the
waist or thigh. Dr. Watson has designed a belt plate of hard rubber,
curved to fit the body, through which a hole is bored obliquely, of the
proper size to fit the catheter snugly. This is held in place against
the fistula by a belt of broad strapping, and serves to prevent the
drainage catheter from slipping in or out.

Walker ' has devised another method to take care of this drainage,
at the same time to prevent maceration of the skin and the general dis-
*- 36 inches 1

comfort of a wet dressing. " The device consists of a pure gum rubber
sheet, I yard square, with a round hole in the center 6 to 8 inches in
diameter. The material is similar to that used by dentists.

" The sheet is laid on the patient immediately next to the skin so
that the opening falls over the suprapubic wound. The usual amount
of absorbent gauze is then laid on the wound, and the borders of the
sheet are folded in, covering the gauze completely. The sheet with
the enclosed gauze is held in place by an ordinary abdominal binder
'Johns Hopkins Hosp. Bull.. 1911, Ksii, 160.

MEDIAN PERINEAL LITHOTOMY 603

or Scultetus bandage. By this arrangement whenever the gauze be-
comes saturated the fluid drains mto the dependent portion of the
sheet, where it collects and allows almost no leakage for several hours,
during which time the patient's bed and clothing are kept dry. When
properly adjusted the sheet is also of very material aid in protecting
the clothing when the patient is in a wheel chair or walking about. A
large opening in the rubber is necessary in order to supply a sufficient
absorptive surface for the gauze. This arrangement has been found
to work admirably with some patients, keeping them almost dry; for
others, owing to the configuration of the abdomen, it will prove less
satisfactory, but in all cases it undoubtedly adds to the general com-
fort."

LATERAL CYSTOTOMY

This operation for stone is practically never done in the United
States now, the perineal or suprapubic routes or lithotrity having taken
its place. The lateral wound gapes and is slow to heal.

MEDIAN PERINEAL LITHOTOMY

The advantages of median perineal lithotomy have been summed
up thus by Dr. W. T. Briggs : *

" (i) It opens up the shortest and most direct route to the bladder;
(2) it divides parts of the least importance; (3) it is an almost bloodless
operation; (4) it affords a passage for any calculus which can be safely
extracted through the perineum; (5) it affords the best passage for the
fragmentation of unusual calculi; (6) it reduces the death-rate to a
minimum." In his first 74 cases, none died. Nevertheless, this opera-
tion, except when stone is removed incidental to perineal prostatectomy,
is rarely practised in America. For after-treatment see Perineal Prosta-
tectomy, p. 584.

Complicatioiis and Sequelae. — Shock, — As a rule, unless there
has been much tearing in the operation, shock is not severe. Children
stand it very well.

Hemorrhage, if it does not come from a vessel that can be reached
by a forceps which is left for a time in situ, may be controlled by tem-
porary packing of the bladder through the wound with gauze, which
may be soaked in adrenalin.

Local sepsis is the most common cause of death, due to extravasa-
tion of foul urine into lacerated tissues of the pelvis. Free, almost
ruthless, incisions must be made to relieve this condition. Extension of
this process may show itself first or last as peritonitis.

^ Trans. Amer. Surg. Assoc., v, 127.

6o4 OPERATIONS ON THE KIDNEY, URETER, AND BLADDER

Surgical Kidney, — This condition (p. 163) may be expected after
any operation on bladder or urethra. The same is true of urethritis , per-
sistent fistula, caUing for later operation; incofitiitence of urine, where
the prostatic urethra has been extensively injured during the removal
of the stone through it; sterility, due to destruction of ejaculatory ducts
in the prostatic urethra.

VAGINAL CYSTOSTOMY

This operation is of the greatest value in the treatment of obstinate
chronic cystitis in women. It consists in the formation of an artificial
vesicovaginal fistula for the purpose of establishing constant drainage
of the bladder. It may be performed under cocain. Following this
operation the tub-bath method of constant irrigation, as devised by G.
L. Hunner/ is employed. An ordinary bath-tub is used. The patient
is supported upon strips of canvas which are fastened to the edges of
the tub by brass clips. A space is left beneath the vulva for the out-
flow from the bladder to escape. The patient may either lie down or
sit up. In the latter case the strip at the head of the tub is drawn tightly
across, and pillows placed on top to act as a support for the patient's

back. A few slats are placed across the top of
the tub and covered with bed-clothing.

Constant irrigation is maintained from a
large irrigation jar at a height of 3 to 4 feet
above the vulva, connecting with a self-retain-
ing catheter which is inserted through the
urethra. The overflow escapes through the
cystostomy opening. Warm 4 per cent, boric-
acid solution is used for the irrigation. The
Fig. 208.— Female Urinal for patient is kept in the tub during the day, but

Ambulatory Use. . , . . , . .

goes to bed at night, weanng a rubber urmal
(Fig. 208). Hexamethylamin, 10 gr. three times a day, and the inges-
tion of large quantities of water, should be prescribed.

In case there is excoriation about the vulva or the bladder is very
irritable, the tub should be filled with \a arm water to above the patient's
hips, more being added when necessary.

The tub treatment is carried out until the exudate disappears from
the bladder-wall, all vesical irritability has subsided, and the bladder
is of approximately normal capacity. After this the patient may get
up and be allowed to go about, wearing a rubber urinal. The cystos-
tomy wound is left open for six months, the bladder being irrigated

* Jour. Amer. Med. Assoc, 1907, xlix, 2066.

EXSTROPHY OF BLADDER 605

daily. The operation for its closure does not differ from that for any
vesicovaginal fistula (Chap. XL VI, p. 526). Neither does the after-
treatment.

The diet should be largely liquid. Tea, coffee, alcohol, and con-
diments are forbidden.

The bowels are best attended to at night if the actual bath is used.
They should move at least once in every twenty- four hours.

EXSTROPHY OF BLADDER

Plastic Operations, — These operations, all more or less variations of
the type of Mr. Wood/ for the time being require the anterior surface
of the body to be somewhat flexed to prevent pulling on the flaps. After
the operation the patient should, therefore, be kept propped up in bed,
the shoulders rounded over forward, and the knees flexed. A broad
flannel strap or bandage, passed under the knees and over the shoulders,
will surely prevent sudden extension of the body. Unless there is a
definite contraindication, the patient should be kept quiet, even to
stupidity, with morphin. The wounds should be dressed frequently
and drainage of the newly formed bladder, with frequent washings,
maintained for at least ten days.

Cystocolostomy {MaydVs Operation), — By this operation the
trigone of the ectopic bladder, with its ureteral orifices, is transplanted
into the wall of the sigmoid.

^^\ boy five years old was operated on in May, 1897. In March, 1898, his
condition was reported by the operator as admirable. Quantity of urine,
1000-1200 cc. in twenty-four hours; specific gravity, 1.013; slight amount of
albumin; no pus. The boy was able to hold urine five hours at a time, and
then to eject it in a good stream from the rectum. In August, 1899 (a year
and a half after the operation), the condition continued as satisfactory. The
patient, now a rapidly growing and strengthening boy, enjoyed living, retaining
his urine for six or seven hours during the daytime, but relieving himself often
at night or running the risk of wetting the bed while in deep sleep. "^

Complications and Sequelae. — In 17 operations there were 2
deaths — one from shock and the other from infection. " The secondary
accidents noted were —

" (i) Fistula of the urinary passages, with the accompanying local-
ized peritonitis, all of which cases recovered.

** (2) Pyelonephritis, as the result of ascending invasion, resulted in
the death of one case after a period of four months.

^ Med. Chir. Transactions, London, Hi, 85.
*Herczel, Centralbl. d. Ham- u. Sexorg., 1899, 563.

6o6 OPERATIONS ON THE KIDNEY, URETER, AND BLADDER

** (3) Urinary incontinence was present in only 2 cases. The other
patients were able to hold their urine for at least three hours, sometimes
six or seven hours, and in i case throughout the night. The urine was
voided sometimes mixed with fecal matter, sometimes alone. The
tolerance of the rectal membrane was perfect.

*^In spite of the fact that this operation is undoubtedly far more
severe than the plastic operation, the immediate results are extremely
good and far better than those of the older methods.^ Time alone can
settle the question as to whether destruction of the kidneys from ascend-
ing inflammation will be a more common late result than after a plastic
operation/'^

* See Bransford Lewis, Ann. Surg., June, 1900, xxxi.
*Jacobson and Steward, ii, 448.

CHAPTER XLIX
OPERATIONS ON ANUS AND RECTUM

FISSURE IN ANO

Thorough dilatation of the sphincter under a general anesthetic
cures this condition. The sphincter must not be stretched, however,
till entirely relaxed under the anesthetic. By not taking this pre-
caution an incontinence has been noted far more disagreeable than
the condition for which the operation was done.* There may be
enough infection in the fissure to spread into the deeper tissues after
dilatation and cause a perineal or an ischiorectal abscess. The first
movements after this operation should be assisted by oil enemas.

FISTULA IN ANO

In this disease, whether tuberculous or not, all attempts to sew up
the wound, even after the most thorough treatment with antiseptics,
so often fail that it will be assumed that the common operation of cutting
through the fistulous tract and through the external sphincter muscle
into the anal canal, with or without excision of the lining of the fistulous
tract, has been performed. The wound should be painted with full -strength
tincture of iodin, packed with iodoform gauze, and a fairly stiff soft-rubber
tube, surrounded by gauze and rubber tissue (Fig. 87, p. 252), passed
through the thoroughly dilated sphincter up into the rectum, as in the
case of operation for hemorrhoids. Postoperative pain and spasm
may be forestalled by inserting one or t\vo morphin and belladonna sup-
positories into the anal canal before the patient leaves the table.

On the second day this rectal plug should be extracted, some aperient
water given, and, after the movement, the wound thoroughly cleaned,
again painted with tincture of iodin, and lightly packed with iodoform
gauze. This procedure of bowel movement, followed by cleaning and
dressing, is to be done daily, care being taken not to get the iodin on the
surrounding skin.

After the second day the patient should be out-of-doors, but still
recHning, all day if possible. These wounds, tuberculous or not, heal

^ E. Melchoir, Miinch. med. Woch., 1910, Iviii, No. SS-

607

6o8 OPERATIONS ON ANUS AND RECTUM

much better out-of-doors. The ideal conditions are to have the
patient on the roof or in some other isolated place, where the region
of the wound can be exposed to direct sunlight, just short of excessive
sunburn, daily.

The patient should be up and about by the fifth day unless the
wound is unusually large. If the fistula is not extensive, and if condi-
tions are such that the patient must be gotten back to his work as soon
as possible, the daily dressing with tincture of iodin may be omitted as
soon as it is evident that the fistulous tract is granulating in well, and
the patient given suppositories of iodoform and tannic acid, of each,
I gr., to be inserted twice daily after cleansing the part. The bowels
should be kept semifluid for some days. Control of the rectal contents
should be satisfactory by the fifth day unless — (i) the external sphincter
were cut in two places (a bad procedure, if at all avoidable); (2) the
internal sphincter has been cut; (3) the cut has extended through the
vaginal sphincter. Control does reappear in many cases even when the
operation has made one of these procedures necessary, but complete
control can never be promised, and operative repair of the sphincter
is sometimes necessary.

Healing of these wounds seems, more than in many other kinds and
situations, to depend to a great degree on the general condition of the
patient. In tincture of iodin we have undoubtedly the best antiseptic
and stimulant for the region.

PILONIDAL SINUSj CYST OF COCCYX

The treatment of these embryonic remains should be mentioned
here only because of their regional relation to the subjects of this
chapter.

They are usually not operated upon until septic, and the abscess-
condition not infrequently leads the surgeon to forget that an epithe-
lial-lined canal leads deep to the region of the coccyx and must be
removed by dissection and curette. (See Branchial sinus, p. 443-)
The wound is tightly packed at first, and is dressed about the third
day, painted deep with tincture of iodin every second or third day,
and is thus induced to heal from the bottom.

IMPERFORATE ANUS; IMPERFORATE RECTUM

Unless the operation attempting, first, to connect the rectum with
the anal depression or, second, to connect the rectum with an artificial
anus in the normal situation, succeeds at once and remains perforate,
an inguinal colotomy must be made. In either case the problems in-
volved in the treatment are the same as in colotomy, at first at least.

HEMORRHOIDS 609

ISCHIORECTAL ABSCESS

The abscess-cavity is wiped out dry. Tincture of iodin is painted
over the whole lining wall, including the incision through the sphincter,
if one has been made. The wound is packed with 10 per cent, iodoform
gauze to distend it and render it into one cavity without pockets. A
suppository of morphin and belladonna, of each, \ gr., is placed in the
rectum; a voluminous dry dressing is held on by a T-bandage.

The original packing need not be changed in most cases until the
third or fourth day. It is then entirely removed, tincture of iodin
again applied inside, and a smaller drainage wick of iodoform gauze
inserted. The dressing is now done daily, but the iodin need only be
used every third day. Direct sunlight on the wound, if practicable,
greatiy advances the healing. An emollient is kept round the anus and
edges of the wound.

The patient is out of bed as soon as he can sit on an inflated rubber
ring without too much discomfort. The bowels are moved daily from
the beginning.

Complications and Sequelae. — Spread of Infection. — Cases in
which the incisions are to any degree ineflScient in position or size may
form new pockets; the infection may spread completely over the but-
tock or forw^ard into scrotum or labium majus; from the rectum may
appear a secondary infection with tetanus or the gas bacillus (bacillus
aerogenes capsulatus), even resulting fatally.

Retention of urine may be bothersome for a few days, as after any
rectal operation.

Loss of sphincter control will not appear if the muscle has been cut
only once; if more than one incision through it has been made, a secon-
dary operation may be necessary weeks or months later to restore its
integrity.

Recurrences are not uncommon. In view of the theory that a certain
percentage of cases are associated with tuberculosis, it is well to take
measures to combat any tendency to this disease.

HEMORRHOIDS

Clamp and Cautery Operation.— It is understood that the
sphincter has been absolutely paralyzed by thorough, slow dilatation.
The hemorrhoid masses have been burned off along lines parallel to
the ^xis of the anal canal, all immediate hemorrhage has been stopped,
a gauze plug, containing a fairly stiff soft-rubber tube in its center for
the passage of gas, and wrapped in rubber dam, has been placed in the
rectum, protruding from it. A T-bandage holds the dressing firmly
:j9

6lO OPERATIONS ON ANUS AND RECTUM

against the parts. Before the rectal plug has been inserted at the end
of the operation a suppository containing i to J gr. morphin sulphate
and } gr. extract of belladonna has been inserted.

Uncomplicated, there is inevitably considerable pain, which should
be controlled by the administration of morphin. There should be no
bleeding. Surgeons are at variance on the question as to whether or not
one should use the rectal plug. Personally, we cannot see any notable
difference in the convalescence either way, particularly if the original
dilatation of the sphincter has been complete.

Similarly, if the piles have been burned from a dilated anus, there
can be no ground, on the plea of insufficient healing, to prevent a move-
ment of the bowels for from five to seven days. Best results, indeed,
seem to follow early movement of the bowels; the packing of the lower
bowel with fecal matter retained for several days tends to produce con-
gestion in the recently operated area. Two Seidlitz powders or a dose
of castor oil is given on the third day, and when the desire for a move-
ment comes, 6 or 8 ounces of warm sweet oil are injected through a
tube passed 4 or 5 inches up, in order to soften the presenting fecal
mass. The first movement should then be easy, though pain is some-
times so severe that the patient faints, and for this possibility the nurse
should watch. After each movement and morning and night for a
week a suppository containing —

Iodoform, i gr.

Tannic acid i gr.

Cocoa-butter q. s.

should be inserted within the rectum. After a week one such suppository
should be used after each movement.

The patient should stay in bed a full week, first, because recumbency
is the most comfortable position, and, second, because of possible com-
plications.

Unguentum gaUce cum opio (B. P.) is an excellent ointment, applied
at night and after each movement to the whole anal region, to help
shrink away redimdant tissue.

Complications and Sequelae. — Hemorrhage, — Bleeding may
occur because the clamp has bitten too deeply into the submucous tissue,
or too much has been included in the clamp and the wound separates
shortly afterward. Bleeding is likely also if the cautery has been too
hot, cutting the piles off too cleanly, leaving no eschar. If the hemor-
rhage is considerable, an attempt may be made to control it by packing.
If it is arterial, this will probably fail and the patient must be put in
the lithotomy position, the bleeding point found, clamped, and tied.

HEMORRHOIDS 6ll

Embolism, — Fatal embolism has been reported at any time up to
the eighth day after this operation, though it is more likely after ligature.
Treatment is, of course, of no avail, but the possibility of this occurrence
should be always in mind when giving a prognosis of this relatively
unimportant disease and in allowing the patient to get out of bed too
early.

Sepsis, — Dilatation of the sphincter may cause numerous fissures,
any one of which may become infected, and even lead to a large ischio-
rectal abscess. Sepsis may, in persons in reduced condition, take the
form of a prolonged ulceration of the several stumps. This should yield,
however, to good hygiene and the suppositories as above.

Stricture of the Rectum, — ^This after-efifect is practically unknown
after a careful operation, but may occur where the clamp has not protected
underlying tissues from the cautery. It can be met and controlled by
repeated use and slow passage of a rectal bougie.

Retention of Urine, — In operations about the anterior quadrants
of the rectum one should always bear in mind the possibility of injuries
to the urethra, and also the fact that much manipulation and trauma-
tism of these parts may result in an acute irritation of the peri-urethral
tissues, which will cause a temporary edema and constriction of the
urethral canal. In such cases it will sometimes be found impossible
to pass an ordinary soft-rubber or flexible catheter into the bladder,
and one should always be provided with a siher catheter in order to be
able to draw the urine. As soon as the distention subsides, these sug-
gestions of stricture rapidly disappear. It is advisable to induce the
patient to urinate before attempting to catheterize him if possible, even
if he has to stand on his feet to do so. It is well to wait for from four
to fourteen hours before resorting to the catheter, only varying this rule
in such cases as suffer from distention of the bladder. A certain amount
of cystitis and atony of the bladder may be developed by too long delay,
but it much more frequently occurs as a result of too frequent and
too early catheterization, even under the most particular aseptic precau-
tions.* The catheter may be perfecdy sterilized and the operator as
clean as antiseptics can make him, and yet, as the walls of the anterior
and deep urethra cannot be sterilized, slight traumatism, such as may
be produced by the softest instrument, will sometimes set up an attack
of urethritis and cystitis which will take months to clear up.

Firm packing of the rectum may cause retention of urine, and some-
times even render the passage of the catheter impossible. When this
occurs, the dressings should be removed, and frequently after this is done

* S. Hadda, Berlin. Klin. Woch., 1910, xlvii, No. 34.

6 12 OPERATIONS ON ANUS AND RECTUM

the patient can pass urine voluntarily. In all cases before the catheter is
passed the anterior urethra should be flushed with boric-acid solution.

Treatment by I^igature. — This operation is used relatively
little in America, and in the after-care arise, as a rule, only t\vo com-
plications: (i) Hemorrhage, If the ligature, insecurely placed or tied
around too wide a base, slip sufficiently, hemorrhage may take place and
require the application of a hemostatic forceps, to be left in position.
(2) Pain after this operation may call for considerable amounts of
morphin.

Whitehead's Operation.^— in this operation, after dilatation,
the whole pile-bearing area is cut away in a cuff or cylinder and the
edge of mucous membrane is sewed down to the skin with interrupted
chromic catgut sutures. If the continuous suture is used, one suture
should not go more than a third of the way round the circle, lest the
whole act as a purse-string. Catharsis should be regulated as after the
cautery operation, and the same directions hold with regard to anti-
septics, iodoform being the best dressing.

The possibility of stricture after this operation is always to be men-
tioned. If the operation is done properly, namely, excising only mucosa,
not removing too wide a cuff, and stitching with great care, stricture will
not occur.

HemorrJiage, which is sometimes supposed to be a common complica-
tion of this operation, should not occur if ordinary precautions are
taken to tie off bleeding points before completing the operation by
sewing down the amputated mucosa to the anal margin. Pain may be
severe in a certain number of cases; it seems to be dependent, in some
measure at least, on tightly drawn sutures. It will be less if the sphinc-
ter has been sufficiently stretched as to become paretic, and if a morphin
and belladonna suppository has been inserted. It yields rapidly to
hot boric fomentations applied locally. Bishop ' recommends the
early administration of gentle laxatives, such as cascara and licorice
powder, after operation, so as to forestall the formation of hard masses,
such as might in their passage cause damage by tearing and splitting
the partly healed tissues.

PROLAPSE OF RECTUM

The after-treatment of this condition differs in no way from that of
Whitehead's operation for hemorrhoids (see above).

* Brit. Med. Jour., Feb. 26, 1887.

* Ibid., Oct. 30, iQOQ.

kraske's operation for cancer of the rectum 613

KRASKE'S OPERATION FOR CANCER OF THE RECTUM

Access to the rectum by resection of the sacrum was first described
by Kraske in 1885 before the Deutsche Gesellschaft fiir Chirurgie.
Since the publication ^ of his original article his method has been modified
by a large niunber of operators. As these operations differ from Kraske's
only in minor ways, the after-treatment of all is essentially the same,
therefore it will be understood that what is said here concerning the
Kraske operation applies equally to all other methods of excision of the
rectum by the sacral route.

The operation should be preceded by a few days of careful pre-
liminary treatment, diminishing as far as possible the intestinal contents
by enemas, catharsis, and a diet consisting of liquids without milk.
As in all rectal operations, the sphincter ani must be thoroughly stretched
before the operation is begun. The method of choice in dealing with
the bowel after resection of the portion containing the growth is end-to-
end anastomosis of the proximal and distal portions. When this can
be satisfactorily accomplished, the rectum is packed through the anus
with gauze surrounding a rubber tube which is passed up beyond the
point of suture. The rubber tube allows the passage of gas and the
gauze pack protects the line of suture. If the peritoneal cavity has
been opened, the peritoneum is united to the serous coat of the bowel
except for a small opening through which is passed a gauze wick. A
second gauze drain is so passed into the wound as to surround the line
of anastomosis, and the remainder of the incision closed with silkworm-
gut sutures. A large sterile gauze dressing is placed over the wound
and held in position by adhesive straps, outside of which a swathe and
T-bandage are worn.

The patient is put to bed lying on his side and J gr. of morphin is
given hypodermically before he comes out of ether. The diet during
the first ten days should consist of liquids without milk. On the fourth
day the dressing is done, the wicks removed, and replaced by smaller
ones. The gauze and tube are removed from the rectum and the
bowels opened by an oil enema ^ retained one-half hour and followed
by a copious irrigation of plain water. The stools are now kept liquid
by the daily administration of salines, oil enemas being given whenever
there is the slightest tendency for the feces to become hard. The gauze
pads on the wound should be changed after each movement. The wicks

* Archiv f. klin. Chir., 1886, xxxiii, 563.

2 Care must be exercised in introducing the rectal tube. A case has come to our
notice where fatal peritonitis resulted from the nurse forcing the tube through the line of
sutures into the peritoneal cavity.

6l4 OPERATIONS ON ANUS AND RECTUM

may usually be omitted on the fifth day. If there is much discharge
from the sinus, it should be irrigated daily with chlorinated soda solution
(i : 80). The stitches are taken out on the tenth day.

If the patient is old or in poor physical condition, he should be got
out of bed into a chair at the end of forty-eight hours. Otherwise he
will be more comfortable in bed for ten days. After the tenth day soft
solids may be added to the diet. Full diet is begun at the end of two
weeks. After the first ten days the bowels are kept moderately free by
catharsis. Oil enemas are no longer necessary.

The rectum must be examined at frequent intervals after this opera-
tion to detect recurrence of stricture from contraction of the scar. This
inspection should be made at least twice every month for six months,
then once each month for the remainder of the first year, and at least
once in three months until five years have elapsed from the time of
operation.

Where, as often happens, it is impossible to unite the bowel ends
after resection, the proximal end is sutured to the skin of the sacral
incision, making a sacral anus. A wick is passed into the peritoneal
cavity, which is always opened under these circumstances, above this
anus, and a second into the postrectal tissues below it. The remainder
of the incision is closed with silkworm-gut. The wicks are removed
and omitted on the fourth day. The stitches are taken out on the tenth
day. The artificial anus is treated the same as one in the anterior
abdominal wall.

Complicatioiis and Sequelae. — Infection. — ^This is the most
common complication, and often leads to sloughing of the line of suture
in the bowel, resulting in a fecal fistula.

Fecal Fistula. — ^When a fistula develops in the sacral wound, the gauze
must be removed from the rectum and the wicks taken out of the wound.
The sinuses and fistula should be irrigated twice daily with a i : 80
solution of chlorinated soda. The skin about the fistula is smeared with
10 per cent, stearate of zinc ointment and a large absorbent pad, fre-
quently changed, is used to catch the discharge from the wound. The
fistula usually closes spontaneously, but if it does not after waiting for
three months, it must be closed by operative means.

Injury to Adjacent Organs. — ^The bladder, urethra, prostate, or semi-
nal vesicles may be injured, and if not repaired, may result in a fistula
between the rectum and the geni to-urinary tract, which is likely to carry
infection to the bladder and kidneys. Injury to the vagina may result
in a rectovaginal fistula which, however, as a rule, will close spontaneously
unless recurrence takes place in its walls.

weir's combined operation for cancer of the rectum 615

Disturbances of the Urinary Tract. — These may be slight and transi-
tory as a result of pressure of the dressings, or reflex irritation from
the trauma of the operation, or they may be so severe as to result in
uremia.

Hemorrhage. — This is rare. If not controlled by packing in the
wound and rectum, the incision must be reopened and the bleeding
point found and ligated.

Stricture of the Rectum, — ^This is to be anticipated by frequent in-
spection of the rectum and the passage of rubber bougies whenever any
tendency toward narrowing of the lumen appears.

Incontinence of Feces. — This is to be avoided whenever possible
by preserving the external sphincter at operation. When it is necessary
to sacrifice the sphincter, incontinence may be avoided, or at least
diminished, by Gersuny's method, which consists in twisting the bowel
180 to 275 degrees on its long axis before suturing it to the skin, or by
the method of Willem, in which the rectum is brought out through the
fibers of the gluteus maximus, which serves as a new sphincter.

Recurrence. — When there seems to be a chance of entirely removing
it, the attempt should be made to excise the recurrent growth. If this
fails or appears impossible, palliative treatment directed to the patient's
comfort should be instituted.

WEIR'S COMBINED OPERATION FOR CANCER OF THE RECTUM

This operation, described by Weir in 1900,^ consists in the abdominal
resection of the rectum completed by suture of the cut ends, which are
both drawn down through the anus, outside of the body. The bowel
is then returned inside the pehis, the peritoneum over the pelvis and
the abdominal wound in the mean while having been closed without
drainage. An incision is made through the skin between the tip of the
cocc3rx and the anus, and a rubber drainage-tube passed through this
into the postrectal space as high as the peritoneum. A rubber tube
surrounded by gauze is then passed up inside the rectum until its upper
end lies above the line of suture. The anus and postrectal wound are
covered with a large sterile pad, held in position by a T-bandage. Both
tubes are removed on the fourth day, the rectal tube omitted, and the
postrectal shortened. The postrectal tube is shortened daily and
usually may be omitted on the ninth day The abdominal wound is
simply dressed with sterile gauze and left undisturbed until the tenth
day, when the stitches are removed.

The patient is kept on a diet of liquids without milk throughout the

^ Jour. Amer. Med. Assoc, 1901, xxxvii, 801.

6l6 OPERATIONS ON ANUS AND RECTUM

convalescence. . In the absence of distention the bowels are not moved
until the ninth day. Calomel is given the evening before the eighth,
and on the morning of the ninth a high oil enema, retained one-half hour,
followed by a high suds enema. After this the bowels are kept open
by daily catharsis. The patient is allowed to sit up in bed on the eighth,
and get up on the tenth, day. The subsequent care of the patient is
the same as described for Kraske's operation.

Complications and Seqnelse. — Peritonitis, shock, secondary
hemorrhagey and other complications common to all celiotomies, may
occur and should be treated by appropriate measures.

Distention, — Every effort should be made to control distention by
hot applications and the careful passage of a small rectal tube or large
catheter up through the rubber tube in the rectum into the sigmoid.
If these fail, catharsis should be resorted to, and the use of enemas as a
last resort.

Infection in the perirectal tissues may result in a fecal fistula dis-
charging through the postanal wound, but this, if simply kept clean
by irrigations with chlorinated soda solution, will usually close spon-
taneously.

Injury to adjacent organs should be less common than after Kraske's
operation, since in this procedure the dissection is, for the most part,
carried out under the eye.

Of disturbances of the urinary tract, stricture of the rectum, recur-
rence and incontinence of feces, that which has already been said under
Kraske's operation applies here.

The after-treatment of the other methods of combined operations,
including the elaborate technique lately described by W. C. Lusk,* is
identical with that described for Weir's operation.

VAGINAL PROCTECTOMY

This is the method of choice for the removal of cancer of the rectum
in the female. The vaginal wound is closed with heavy catgut or with
silkworm gut except at its upper portion, where a small drain is inserted
if the {peritoneal cavity has been opened. A rubber tube surrounded
with gauze is passed into the rectum through the anus and carried above
the line of suture. This and the vaginal wick are removed on the fourth
day and entirely omitted. The stitches are removed on the tenth day.
Other details of treatment are exactly similar to those described for
Kraske's operation.

* Surg., Gyn. and Obstetrics, 1908, vii, 113, also ibid., 1909, ix, 491.

CHAPTER L
OPERATIONS ON THE EXTREMITIES

AMPUTATIONS

In general, where the wounds are sewed tight, they present no dis-
tinctions from other simple incised wounds. If, on account of oozing
from muscles, rubber dam, tube, or gauze temporary drainage has
been put in, this may be withdrawn at the end of twenty-four hours
and the provisional suture tied. The sutures should be left in a full
ten days, and after their removal the wound should be reinforced by
two, three, or more zinc-oxid plaster strips, so narrow that they will not
cover the whole wound, but long enough to distribute the strain of the
end of the stump along the length of the limb. A splint is applied to the
stump, protruding to protect the end. A cradle holds the bed-clothes up.

The stay in bed is from ten days to a number of weeks, according
to the nature and healing of the wound.

Complications and Sequelse. — Sepsis may be met by drainage
through the wound opening, as litde of it, however, as will insure efficient
outlet. A persisting sinus means either a deep-lying infected ligature
or necrotic bone. The latter may be only unremoved splinters of bone
or may be the cut end. Thirteen to sixteen weeks should be given,
however, before any secondary operation is undertaken, unless special
indications arise. During this period splinters and small chips of bone
will ordinarily separate and come out.

Thrombosis and Embolism, — In patients with arteriosclerosis or other
cardiovascular disease, including myocarditis, in patients suffering
profoundly from shock, in cases of infected wounds, and in other condi-
tions, thrombosis is always a possibility. When this occurs, with its
cyanosis, edema, or threatened gangrene, the treatment is largely ex-
pectant. The limb must be kept warm, slighdy elevated, and all sudden
movements must be especially pre\^ented, lest embolism occur.

Painful Stump, — This diagnosis must not be made too quickly.
Every newly healing bone or scar is somewhat sensitive, and the degree
of sensibility varies with the character of the individual. A scar badly
placed, in such a way that it bears against the clothes, bandage, or
apparatus, causes a kind of painful stump. The expression, however,

617

6l8 OPERATIONS ON THE EXTREMITIES

is properly applied to a stump in which a severed nerve or nerves are
caught in the scar, and to cases where the flaps are too short and are
adherent to the bone in such a manner that pressure or pull causes pain.
For all degrees of sensitiveness not due to the last hvo causes, massage
with cold cream, wintergreen oil, zinc-oxid ointment, or some other
such emollient preparation, together with hot and cold sprays and
exposure to the sun, will quickly harden the stump. Fairly tight applica-
tion of a Shaker flannel bandage, or a so-called "horse" bandage,
will help to cause atrophy of the stump, help it to assume the ultimate
form for the artificial limb socket, and prevent edema. Under such
bandaging, also, sensitiveness not due to an organic cause will rapidly
diminish. If these all fail to relieve the condition, further operation
must be done — either removal of an inch or more of bone or the dis-
section out of the nerve-ends and their removal.

Amputations of the Shoulder and Shoulder-girdle.— The

dressing after either of these operations is held in place by adhesive
straps and a bandage or swathe passing about the chest and over the
shoulder.

After amputation of the shoulder-girdle pneumonia appears to be
a relatively frequent complication. All possibility of hypostatic con-
gestion should, therefore, be guarded against by raising the patient
high in the bed, and frequent turning from side to side.

The Arm. — ^A relatively small dressing is held on by adhesive
straps and bandage. A large pad is placed between the stump and
the chest and a swathe band holds the arm against the chest for the first
five or six days. The stitches are removed on the tenth day, the wound
then being supported by adhesive strips.

Forearm. — The arm is immobilized for ten days by an internal
angular splint applied with the forearm intermediate betw een pronation
and supination. The splint should project beyond the stump for i or 2
inches, thus furnishing a certain amount of protection for it.

Fingers. — The hand is supported by an anterior splint extending
from the bend of the elbow to just beyond the finger-tips, and carried in
a sling. The splint is taken off at the end of ten days.

Hip. — This is the most severe of all amputations/ and measures
to combat shock form a very important part of the after-treatment.
Pressure on the stump is avoided by a small firm pillow beneath the
ischial tuberosity on the amputated side and a cradle over the pelvis.
The dressing must be large because there is usually free drainage of
serum from the wound. It is held in place by plaster straps, outside

* Chavasse, Lancet, 1900, ii, 154.

LIGATION OF THE INNOMINATE ARTERY 619

of which a figure-of-8 bandage is applied about the pelvis. The dress-
ing should not be disturbed for at least four days, if possible, because
of the additional shock. The bowels are not opened for this length
of time in order not to run the risk of soiling the dressing. The greatest
of care must be observed to prevent bed-sores.

Thigh* — A copious dressing is used because here, too, the discharge
of serum is considerable. A well-padded posterior splint is applied,
extending a little beyond the end of the stump, held on by strips of ad-
hesive plaster and a spica bandage. The distal extremity of the splint
should be elevated on a pillow^ in order to relax the quadriceps extensor.
The splint is worn for ten days.

I^g. — After the dressing is applied the knee is immobilized and the
stump supported by a long ham splint, which is held on by plaster
straps and a bandage. It is important that the splint extend beyond
the end of the stump, so as to furnish protection for it. This splint may
be removed at the end of ten days.

Toes. — After amputation of the toes rapid union of the wound is
promoted if a long plantar splint is worn for ten days, but this is not
absolutely necessary if the patient will faithfully use crutches and keep
the foot off the ground for this length of time.

References

Petersen and Gocht: Amputationen u. Exartik. kiinstlichen Glieder, Stuttgart, 1907,
\^^th complete bibliography.

Bier: Ueber Amputat. u. Exartik., Volkmann's klin. Vortrage, 1900, No. 264, 1707.
Bryant and Buck: Amer. Pract. Surg., New York, 1908, iv, 263.

LIGATION OF THE INNOMINATE ARTERY

Aneurysm of the innominate artery was first successfully treated
by ligation by Burrell.^ Access to the artery is gained by resection of
the right sternoclavicular articulation and a small portion of both the
sternum and clavicle. The method was described first by Cooper in
1859,^ but was not used again until Burrell, at the time unaware of
Cooper's work, performed the same operation.

The muscles overlying the artery and the skin are sutured without
drainage, and a dry sterile dressing, held in place by plaster strips, is
applied. This is left undisturbed until the tenth day, when the stitches
are removed. The right arm is wrapped in cotton or sheet-wadding
and bandaged to keep up its heat. In Burrell's case the pulsation in
the right radial artery returned on the sixth day. To insure rest for the

^ Boston Med. and Surg. Jour., 1895, cxxxiii, 125.
^ Amer. Jour. Med. Sci., 1859, xxxviii, 395.

620 OPERATIONS ON THE EXTREMITIES

vascular system the patient is kept in bed, on a light diet, and given
morphin, | gr., every four hours. The latter is a very important part
of the after-treatment. The bowels are moved on the fourth day and
kept free. The patient is allowed out of bed at the end of eight weeks.
There is some swelling and more or less loss of strength in the arm for a
time after the operation.

LIGATION OF THE CAROTID ARTERY

Complications and Sequelse. — Cerebral Symptoms. — These are
said to occur in as many as 25 per cent, of cases, and may appear at once
or not until some days after operation. All such symptoms are due
to the diminished cerebral blood-supply, and vary from faintness, giddi-
ness, impaired ^lsion, up to complete hemiplegia in those cases where
the circle of Willis is congenitally incomplete.^ The after-treatment
involves no special detail beyond perfect quiet until the new conditions
are well established.

Sepsis is always possible, and where this occurs and silk ligatures
have been used, the sinus will probably persist at least three weeks, until
the silk comes away. Wherever notable sepsis takes place, the danger
of secondary hemorrhage is considerable.

Recurrent pulsation frequently appears, but nevertheless the cerebral
pressure is undoubtedly diminished and the object of the operation thus
accomplished.

Lung complications are said to be not uncommon, due to the dimin-
ished freedom of respiratory movements secondary to the disturbed
circulation in the brain and medulla.

LIGATION OF THE SUBCLAVIAN ARTERY

Complications and Sequelae. — The mortality in this opera-
tion is high (out of 48 cases, 25 die).

Sepsis is the greatest danger. If it occurs outside the aneurysmal
sac, the dangers are, of course, principally from secondary hemorrhage.
If sepsis occurs within the sac, the liability to infection seems to be in-
creased from the fact that the ligature is so close to the sac that the clot
is poorly formed and loose, and embolism is liable to occur. In such
cases the swelling, which has first diminished, now, in the second or
third week, begins to increase in size, with pain and tenderness, but with-
out pulsation. This must be emptied by incision, and in this event
secondary hemorrhage is liable to take place and can be met only by

* Walter C. Howe (Boston City Hospital Reports, 1903, xiv, 162) reports such a rase
and gives complete bibliography of the subject.

ARTERIAL SUTURE 62 1

attempts at packing. Hemorrhage at any time after operation may be
looked for, even though asepsis is perfect, because of the diseased con-
dition of the artery walls which lay behind the original lesion.

Faulty circulatian in the arm causes the limb to become numb, cold,
stiff, and weak. After the wound is thoroughly healed, this is to be met
by the application of warmth, massage, and electricity.

A cord of the brachial plexus may be included in the ligature. Such
a mistake causes an agonizing pain at the site of operation and through-
out the length of the arm. It must be immediately relieved by further
operation, removing the ligature and placing a new one properly.

The pleura may be injured when the needle is passed during the
operation, but, except for infection, this accident is of litde importance.

The phrenic nerve or the subclavian vein may rarely be injured at
the time of operation, but these are rather operative details.

LIGATION OF THE EXTERNAL ILIAC OR FEMORAL ARTERY

Complications and Sequelae. — Sepsis and secondary hemorrhage
from sepsis or slipping ligature are always possibilities, and call for no
new directions for treatment.

Gangrene of the limb should be uncommon if the limb is well pro-
tected by horizontal position, wrapping in cotton, and careful use of
heaters.

Pain at site of operation may be persistent as the result of the tying-
in of some nerve-filament.

Swelling of the limb is to be met by wearing a flannel or elastic ban-
dage for the first few weeks.

ARTERIAL SUTURE

The first suture of an artery was performed by Hallowell,^ an English
surgeon, in 1759. The method which he employed was to pass a pin
through the lips of a wound in the brachial artery and then wind a thread
about it. The operation was successful. Eck^ was the first to suc-
cessfully perform lateral anastomosis. Von Horoch' attempted end-
to-end arterial suture, but this was first successfully performed by
Abbe^ by means of a glass bobbin. Since then arterial suture has
been developed by Murphy, Jaboulay, and Brian. Within the last
few years the brilliant experimental work of Jaboulay 's pupil, Carrel,^

* Lambert, Medical Observations and Inquiries, London, 1762.
2 Militar-Med. Jour., cxxxi, 1876.

' Allgem. Wiener med. Zeit., 1888, xxxiii, 263, 279.

* N. Y. Med. Jour., 1894, lix, 2>3'

^ Jour. Amer. Med. Assoc., 1905, xlv, 1645; Ann. Surg., 1906, xliii, 303; Surg., Gyn.,
and Obst., 1906, ii, 266; Bull. Johns Hopkins Hosp., 1907, xviii, 18.

622 OPERATIONS ON THE EXTREMITIES

Guthrie, and others has aroused renewed interest in this operation.
Lund,* Sherman,^ Ehrenfried and Boothby,^ and others have reported
successful cases of arterial suture. The number of cases is still lim-
ited, but from the study of the available literature the following rules
for after-treatment may be set forth as conservative and satisfactory,
to be later modified as experience with this operation increases.

The superficial structures are united with catgut, and the skin with
silkworm-gut or horsehair, leaving a small opening into the tissues about
the vessel through which is inserted a rubber-tissue drain. The wound
is dressed with sterile gauze and the limb immobilized by a splint.
The drain is removed after twenty-four hours. The stitches are
taken out on the tenth day. Immobilization is continued up to three
weeks. In the upper extremity the patient may go about carefully
after ten days, but in the lower, he should be kept in bed three weeks.

The resume of a case may be of interest:

T. G. was brought to the Relief Station of the Boston City Hospital at
4.30 p. M., April 23, 1911, by a police ambulance, with the story that he had
been stabbed in the left groin. He was conscious, restless, and pale, pulse
80, of small volume and low tension. Just below Poupart's ligament on
the left was a narrow, somewhat pouting, clean-cut slit in the skin about
f inch long, running nearly transversely. There was considerable blood
on the thigh and the clothes covering the thigh. About the wound was
some swelling. No pulsation in the femoral artery or its branches below
this point was made out.

The thigh was cleaned and shaved. On the passing of a director into
the wound, to ascertain where to introduce a wick, active arterial hemorrhage
ensued. The wound was packed and a sterile dressing was applied with
pressure. Heaters and blankets were ordered, and salt solution adminis-
tered by rectum. Patient was cold, restless, and weak for two or three
hours, but then became more quiet, stronger, and warmer. There was no
return of pulsation in the branches of the femoral artery. Operation was
advised and accepted.

Operation, Drs. Crandon and Ehrenfried: Under ether an incision was
made above and parallel to Poupart's ligament. The external iliac artery
was found and a Crile clamp applied. An incision 5 inches long was made
over and parallel to the femoral artery, the region of the punctured wound
was laid open, and the dissection carried down to the femoral artery. This
was found completely severed, though the ends were held together beneath
by some strands of uncut adventitia. The surrounding tissues were infil-
trated with blood-clot. The vein and nerve were intact.

' Ann. Surg., 1909, xlix, 394.

2 California State Medical Journal, 1908, vi, 56.

'Ann. Surg., 1911, Hv, 485.

MATAS' OPERATION FOR ANEURYSM 623

Crile clamps were applied to the artery, the adventitia trimmed away,
and the ends sewed together by the technique described by Ehrenfried and
Boothby {op, cit.). The clamps were taken off, and then the clamp on the
iliac artery was removed. There was some oozing of blood from the anasto-
mosis, which ceased in two minutes under light pressure. Pulsation was
readily felt beyond the suture.

The abdominal wound was sewed up in layers, the thigh wound, by mass
sutures. Sterile dressing was applied. Stimulation, heaters, and blankets.

The recovery was rapid and uneventful, despite the weakness of. the
patient from loss of blood. When seen the next day the left foot was warm,
and on the day following pulsation of the dorsalis pedis could be made out,
and heaters and blankets were discontinued. The temperature and pulse
were normal on the fourth day, and remained so. On May 3d the stitches
were removed and on May 7th the patient went home well, except for a small
granulating area at the site of the original wound.

Complications and Sequelae. — The chief complication to be
feared is thrombosis, which may result in obstruction of the circulation and
occasionally gangrene.

Arteriovenous Anastomosis. — This operation, employed with
some success by Hubbard,^ for gangrene of the leg, is as yet on the surgi-
cal frontier. The after-treatment is that for ligation of a large artery.

MATAS' OPERATION FOR ANEURYSM

In the Matas ^ operation, either with or without obliteration of the
lumen of the artery, the aneurysmal sac is occluded by a deep stitch of
silkworm gut or catgut on either side of the wound, passing through the
skin and both walls of the sac, and tied over a roll of gauze to maintain
sufficient tension without cutting into the skin. The skin is then sutured
to the middle of the bottom of the sac with silkworm gut or catgut, the
same stitches uniting the skin-edges. The furrow thus formed is filled
with sterile gauze. The entire limb is then wound with cotton, rein-
forced over the line of the artery. Outside of this several strips of card-
board are placed, covered, in turn, by more cotton or sheet-wadding,
and a firm gauze bandage applied from below upward.

When the seat of the aneurysm is the brachial artery, the arm is held
in a sling and a circular bandage or swathe applied. Where the femoral
or popliteal artery is involved, the limb is immobilized by a posterior

^ Ann. Surg., 1906, xliv, 559; 1908, xlviii, 897.

2 Trans. Amer. Surg. Assoc., 1902, xx,396. See alsoF. G. Balchand F. T. Murphy,
Boston Med. and Surg. Jour., 1909, clix, 860; G. P. Hamner, Jour. Amer. Med. Assoc.,
1910, liv, 1942.

624 OPERATIONS ON THE EXTREMITIES

splint. The fingers or toes, as the case may be, should be left exposed
in order that the state of the circulation may be determined. K the
extremity remains warm and the color good, the bandages are changed
only when they begin to loosen, usually in about forty-eight hours, but,
in the absence of the elevation of temperature, the gauze over the wound
is left undisturbed until the tenth day, when the stitches are removed
and all dressings and splints omitted. In the case of aneurysms of the
lower extremity the patient should not begin to use the limb for three
weeks, and in those of the upper extremity vigorous movements should
be avoided for some time, but gentle ones may be attempted after the
tenth day.

Complications and Sequelae. — Gangrene may result from the
imperfect establishment of collateral circulation, which is unavoidable;
or as the result of the formation of a clot at the site of distal compression,
which becomes an embolus and lodges in a vessel beyond the aneurysm.
This must be regarded as an accidental failure of technique. From
either cause gangrene is rare and requires amputation.

Secondary hemorrhage can occur only as a result of imperfect tech-
nique and demands ligation of the arterial trunk.

Suppuration is the most frequent complication and probably depends
in some measure on failure perfectly to obliterate the aneurysmal cavity.
It is manifested by elevation of temperature and severe pain at the site
of the incision. The treatment is the same as for any wound infection.

VARICOSE VEINS OF LOWER EXTREMITY

After the commonly employed type of operation, that of Mayo,^
using his vein enucleator and making three to five or more incisions,
there remain several small wounds which are sutured and covered
with a thin layer of sterile gauze held in position so as not to slip by
adhesive strapping. Collodion is not so good. If the older technique
of dissecting out the venous trunk is performed, there will be, instead,
one or more long wounds, which have to be carefully sutured and which
are hard to keep from becoming septic. After the dry sterile dressing
is applied, the extremity is bandaged from toes to groin with a 3-inch
"Ideal" bandage.

The patient is kept in bed with the leg elevated on a pillow for twelve
days, the bandage being reapplied daily, but the wounds left undisturbed
until the tNvelfth day, when the stitches are removed and the dressing
omitted. The patient is then allowed to get up, but continues to wear
the bandage for three months.

*C. H. Mayo, Surg., Gyn. and Obst., 1906, ii. 385.

SUTURE OF TENDON AND MUSCLE 625

When a varicose ulcer has been excised and grafted, a roll of gauze
is placed about the leg above and below the area. A sheet of wire gauze
is passed about this portion of the leg, and held with adhesive plaster
in such a manner that it is supported by the two rolls of gauze above
referred to and does not come in contact with the grafted area. The
bandage is then applied over this. Thus the progress of the graft may
be watched without disturbing it, and at the end of twelve days this
dressing is removed for the first time, and a simple protective dressing
only is worn over the grafted area from this time.

Where there is an extensive eczema of the extremity complicating
varicose veins which cannot be cleared up by a careful preliminary
treatment before operation, this area should be sealed over with com-
pound tincture of benzoin until the operative wound is sufficiently
well healed (two or three days) to prevent the entrance of infection.

Complications and Sequelae. — Infection and pulmonar>' em-
bolism occur in rare instances.

SUBACROMIAL BURSITIS

The operation devised by E. A. Codman^ for this condition in-
cludes the removal of that part of the subdeltoid sac which protrudes
beyond the tip of the acromion, and the possible scraping out of any
area of degeneration in the insertion of the infraspinatus beneath the
floor of the bursa.

The wound is sewed tight and the hand and forearm are put in a
sling. No great effort should be made at fixation or even rest. At
the end of four days passive movements should be begun, and at the
end of one week all motions within usual limits should be freely made.
Recovery with all functions should be complete within a month.

OLECRANON BURSITIS

Excision in the aseptic cases and crucial incision in the septic
cases should both be followed by fixation of the elbow with an internal
angular splint. The open infected wound is packed with gauze and
kept so, renewed daily, until granulations fill it.

SUTURE OF TENDON AND MUSCLE

Wounds of tendons are most common at the wrist. Instances of
ruptures of the long head of the biceps, the quadriceps extensor, and
other muscles and tendons have been reported. If an important tendon

* Boston Med. and Surg. Jour., 1908, clix, 533.
40

626 OPERATIONS ON THE EXTREMITIES

is divided, in part or completely, the wound is thoroughly cleaned, the
tendons sutured with fine silk or Pagenstecher, and the wound closed
with silk or silkworm gut. If the wound is much lacerated or there is
particular reason to fear infection, a very small rubber tissue or catgut
drain may be inserted just under the skin, to be taken out after forty-
eight hours.

The dressing should be voluminous enough to absorb all the oozing.
A splint must be so designed and applied that the part is so flexed or
hyperextended, as the case may require, that no tension is allowed to fall
on the um'ting tendons. A splint, anterior or posterior, is applied to the
opposite aspect of the limb from that of the wound, long enough to fixate
all the joints between the points of origin and insertion of the muscles
involved. If made of wire, it can readily be bent to the proper angle,
otherwise it is built up or padded at the distal end in order that the
flexion or hyperextension may be eflSciently maintained. The forearm
and splint are then bandaged and the arm carried in a sling.

The wound is inspected without removing the splint if possible,
at the end of forty-eight hours, and again on the fourth day. On the
seventh day the stitches are removed.

The time for removing the splint and beginning motion cannot
be arbitrarily stated. The purpose of after-treatment is to prevent too
firm adhesions of the united tendon in its sheath, and, at the same
time, to avoid undue strain on the new union. The arm is kept on the
splint for four weeks, but after the second week the splint should be
removed Uvice a week and careful passive motion of the fingers carried
out, great pains being taken not to flex or extend them to an extent to
strain the sutured place.

At the end of four weeks the splint is omitted and careful use of the
forearm begun. Massage and passive motion should be carried out
until the stiffness disappears. Wounds of the tendons at the wrist are
frequently complicated by injury to the median nerve, which should be
repaired at the same time, and treated by electricity after removal of
the splint.

After wounds of the larger tendons, such as the biceps or quadriceps
extensor, have been sutured, the limbs are best immobilized by plaster-
of- Paris. In wounds of the biceps tendon the arm should be maintained
in acute flexion for six weeks, after which careful use may be begun.
After suture of the quadriceps extensor the limb should be immobilized
in extension by a plaster spica extending from the crests of the ilia to
the ankle. This is worn for eight weeks, after which passive motion is
begun, but no active use of the leg is allowable for three months.

NERVE SUTURE 627

TENDON TRANSPLANTATION

The general after-care for tendon transplantation/ whether the
healthy tendon be sewed into the paralytic tendon or directly into the
periosteum, involves no principle different from that of tendon suture.
Bearing in mind the poor blood-supply of the tendons, the same con-
servatism is exhibited before subjecting the sutured region to great
strain. A split plaster cast should be worn for six or eight weeks, and
then, on a leg, a properly constructed brace should be applied. Massage
and passive motion should be carried out assiduously by an expert.

NERVE SUTURE

The nerves most commonly injured and treated by suture are the
musculospiral in fractures of the humerus, the median at the wrist, the
ulnar near the internal condyle, and the facial nerve. The skin incision
is closed without drainage unless the injury was accompanied by con-
siderable trauma to the soft parts, and covered with a small, dry,
sterile dressing, and the arm immobilized in such a position that the
nerve will be under no tension. In suture of the musculospiral and
of the ulnar this is secured by a straight internal splint extending from
the axilla to the finger-tips, maintaining the arm in the position of com-
plete extension. After suture of the median nerve, which is nearly
always accompanied by suture of one or more of the tendons at the
wrist, unless the tendon suture has been done previously and the nerve
injury overlooked, a posterior splint is applied reaching from the
elbow to beyond the finger-tips and bent up or padded at the distal
extremity to maintain flexion at the carpus.

In the absence of tendon injury immobilization is maintained for
two weeks, after which massage and electricity are commenced and the
patient gradually allowed to resume the use of his arm. Electricity
should be given daily for fifteen minutes, beginning with the galvam'c
current applied to the muscles supplied by the sutured nerve. As soon
as the muscles begin to react to stimulation of the nerve above the
point of suture the electrode should be applied to the nerve itself. As
soon as regeneration is sufficiently advanced to produce reaction to the
faradic current, this may be employed. Massage three times a week
will aid in maintaining the nutrition of the paralyzed muscles. The
maximum improvement after nerve suture may not be reached for one
year, hence treatment must be faithfully continued for this length of
time.

^E. H. Bradford and R. Soutter, Boston Med. and Surg. Jour.. 1907, clvi. 655.

628 OPERATIONS ON THE EXTREMITIES

SUTURE OF THE BRACHIAL PLEXUS

The wound is closed except for a small drain at its dependent portion,
if necessary, and a plaster bandage is applied in such a way as to
elevate the shoulder, rotate the chin, and incline the head toward the
affected side. The wound may be dressed through a window cut in
the plaster over it, the wick being removed on the second day and
omitted. A dry sterile dressing is applied until the wound is united.
The stitches are removed on the seventh day. Immobilization is main-
tained for three weeks, after which the plaster is removed and electricity,
massage, and passive motion of the arm carried out daily after the same
principles which apply to the after-treatment of suture of smaller nerve-
trunks. Improvement is slow and may progress during several years.

NERVE ANASTOMOSIS

The first successful nerve anastomosis in man was reported by Sick
and Sanger in 1897.^ The distal stump of a paralyzed musculospiral
nerve was grafted into the median, and the patient regained perfect
control of the muscles supplied by both nerves. Anastomosis of the
spinal accessory and facial was performed in 1895 by Ballance,^ and
by Faure -^ in 1898. Both operations were failures. The first success-
ful anastomosis of these two nerves was done by Kennedy in 1899.* In
Kennedy's case the operation was performed for facial tic, and anasto-
mosis followed immediately the interruption of function of the facial
nerve. Anastomosis of the hypoglossal with the facial was likewise
first performed by Ballance {loc, cil.) in 1903. Since the work of these
pioneers the operations of facial anastomosis have been performed
by a considerable number of surgeons, particularly for nerve injury
during mastoid exenteration. The results have been, on the whole,
promising. Mintz^ found in 22 published cases only 7 which were
absolute failures. In infantile paralysis nerve anastomosis was first
performed by Peckham,® who grafted certain branches of the internal
popliteal into the paralyzed external popliteal nerve.

Facial paralysis is only treated by operation when careful electric
nerve examination shows the degeneration to be complete and the
history is of such traumatism as to make a diagnosis of complete
destruction of the nerves practically positive. The most satisfactory

^ Arch. f. klin. Chir., 1897, liv, 271.

2 Brit. Med. Jour., 1903, i, 1009.

' Gaz. des Hop., 1898, 71'" annee, 259.

* Phil. Trans. Roy. Soc, 1900, cxciv, 127.
■'* Cent. f. Chir., 1904, xxxi, 684.

* Providence Med. Jour., 1900, i, i.

NERVE ANASTOMOSIS 629

operation in our experience is that of W. W. Grant, of Denver.^ He
divides the spinal accessory just before it enters the sternomastoid,
and carries the end up to the distal end of the paralyzed end of the
facial nerve, which is divided at the styloid foramen. He then divides
the descendens h>poglossi f inch down its course and sews it to the
peripheral stump of the spinal accessory.

The after-treatment of nerve anastomosis does not differ from that
of simple nerve suture as regards electricity, massage, immobilization,
etc. After operations upon the facial nerve the skin incision is closed
with an intracuticular suture of silkworm-gut and covered with a
sterile cocoon, which is removed at the end of ten days and the stitch
taken out. The head and neck should be so bandaged as to hold it
fixed for the first week in order to minimize scar formation. The
patient may get out of bed at the end of a week. Electricity is begun
at the end of ten days. Almost at once the patient may show better
control of food in the paralyzed cheek, and improvement in appear-
ance of the face in repose, but the first facial motion, always asso-
ciated with the shoulder motion when the spinal accessory is used,
will not appear until about four months, and the maximum improve-
ment may not be observed short of a year.

After anastomosis of the internal with the external popliteal the
incision is closed without drainage and the limb immobilized for two
weeks in plaster. At the end of this time the plaster is taken off, the
stitches removed, and massage and electricity commenced.

Complications and Sequelae. — The complications of facial
anastomosis are paralysis of the muscles supplied by the sound nerve,
resulting in paralysis and hemiatrophy of the tongue when the hypo-
glossal is used, or paralysis of the sternomastoid and trapezius if the
spinal accessory is selected, accompanied by a tendency to contraction
on the part of corresponding muscles on the opposite side; and associ-
ated movements of the groups of muscles supplied by both nerves. The
second of these results in more or less severe spasm of the muscles of
the face with attempts to move the shoulder or tongue, as the case
may be.

Atrophy and paralysis may be, to a considerable extent, obviated
by not completely dividing the sound nerve, but merely taking part of
it to form the anastomosis. Even under such circumstances more
or less atrophy and paralysis will result, but this will entirely clear up
within two or three months. Electricity should be applied to the mus-

* Traumatic Facial Paralysis, Jour. .\mer. Med. .\ssoc., 1910, Iv, 1438.

630 OPERATIONS ON THE EXTREMITIES

cles normally supplied by the sound as well as those by the paralyzed
nerve.

Associated movements of the facial muscles with the trapezius muscle
or the tongue, depending on whether the spinal accessory or the hypo-
glossal nerve is employed, are usually present, but may be greatly dimin-
ished by reeducation and exercises.

PSOAS ABSCESS

Whether a psoas abscess ruptures and, therefore, makes its own
vent, or is opened by primary operation, the after-treatment is the
same.

If the site of the original disease is in the spine proper, it is assumed
that the back has been fixed with relative lordosis in a plaster jacket.^
If the disease is in the sacro-iliac joint, for fixation of the pelvis a tight-
fitting girdle may be employed if it gives subjective relief. Proper
care of the sinus and its discharge consists only in cleanliness. The
skin about the mouth of the sinus is cleaned once, t\Nice, or oftener
daily, according to the amount of discharge; it is then gone over with
70 per cent, alcohol; some emollient skin protective, such as zinc oint-
ment, is spread about, and a probe wrapped in cotton saturated with
tincture of iodin is run deep into the sinus once daily. If practicable,
the region is exposed to direct sunlight.

Everything possible for general hygiene should be done, Uventy-
four hours a day out-of-doors being one of the most important
requisites.

Complications and Sequelae. — Obstruction to the Drainage. —
The reappearance of local pain and tenderness, with fever, particularly
if the amount of discharge is at the same time markedly diminished,
should suggest that the sinus no longer efficiently drains the cavity.
A flexible uterine sound may be inserted gently and manipulated until
a thorough opening is assured.

Distant or General Tuberculosis. — It should always be in mind that
the disease may be manifest at the same time in lungs or kidneys or
other parts, depending much upon one's particular resistance to this
infection. The wise use of tuberculin should be considered.

Neuralgia. — Rarely, in a healing sinus which points in the groin
the contraction of scar tissue may involve the anterior crural or other
nerves with paresis of the quadriceps extensor and much neuralgic
pain. Time and galvanism may give relief, otherwise it will become
necessary to free the nerve of pressure by operation.

* E. G. Brackett and L. R. G. Crandon, Boston Med. and Surg. Jour., 1905, cliii, 515.

PALMAR ganglion; TUBERCULOUS TENOSYNOVITIS 63 1

INGUINAL BUBO (ABSCESS OF THE GROIN)

The vertical incision is by far the best, in that it drains most effici-
ently and heals without the edges dimpling in, as they do in the parallel
to groin incision. Iodoform gauze or paste packing for the first twenty-
four hours is used for ambulatory cases. If the patient can remain
recumbent, the salt and citrate poultice most favors drainage. As
healing proceeds the oleoresin of copaiba or balsam of Peru may be
used. To stimulate indolent granulation tincture of iodin in the depths
of the wound is the best application. Superabundant granulations
should be cut down with scissors curved on the flat.

The origin of the enlarged lymph-node should be sought on genitals
or lower extremity and treated.

PARONYCHIA AND PERIONYCHIA

If the septic process involves the sulcus from which the nail arises,
it tends to become chronic, with deformity of the nail unless early in the
disease the nail is removed. Mere incision, as a rule, is not suflicient.
If the nail is removed, no incision is necessary. After removal a rubber
finger-cot with a few drops of glycerin in the distal end of it is slipped
over the finger, and under these conditions it is allowed to macerate,
with an occasional cleaning, for two or three days. At the eiid of this
time all dressing is removed except a bit of balsam of Peru or scarlet
red ointment until the epithelium is formed over the bed of the nail.
The new nail will grow in from four to six months.

INGROWING TOE-NAIL

Whatever the type of operation, one expects a mildly septic wound.
Salt and citrate soaks and poultices are to be used until the active in-
flammation has subsided. Emollient dressings are used during the
healing.

Proper shoeing should be prescribed. (See p. 352.)

PALMAR GANGLION; TUBERCULOUS TENOSYNOVITIS

If primary union takes place after the excision of the melon-seed
sac, the most important part of after-treatment consists in contin-
uous efforts to prevent the matting together of the denuded tendons.
This calls for active and passive motion of the fingers to their limits.
Should a wound not heal by primary union, it should be treated as any
open tuberculous wound; namely, by daily application of tincture of
iodin and exposure to sunlight.

632 OPERATIONS ON THE EXTREMITIES

DUPUYTREPTS CONTRACTION

Practically the only operative procedure now carried out in these
cases of contraction of the palmar fascia is the so-called open method,
by which the fascia is dissected out. This is to be preferred over the older
methods of subcutaneous fasciotomy and the V incision of Busch,
through skin and fascia, sewed up as a Y, because of^ — (i) the lessened
liability to recurrence; (2) the lessened danger of injuring nerves and
vessels; and (3) the short after-treatment, without the necessity of
wearing expensive and irksome mechanical appliances. The dissec-
tion can be carried out through a longitudinal incision over each con-
traction band (Kocher), or, better still, in case two or more fingers are
afifected, a U-shaped flap can be turned back on the wrist (Keen),
uncovering the entire palm.

The importance of complete asepsis is to be emphasized. The
hand should be thoroughly cleaned before the operation (Chap.
XXXIX, p. 383), and it should be protected with care until entirely
healed. Sepsis in the wound frequently means permanent loss of
function through interference with the tendons. Ligatures should
be avoided so far as possible.

Sometimes not only the palmar fascia and its prolongations into
the fingers must be excised, but the resulting contraction of the flexor
tendons in old cases must also be corrected by splitting and hemi-
section. The hand should be made to straighten freely. It should be
held straight and a few sutures of horsehair put in to approximate the
skin edges. A sterile dressing should be applied and the hand and
finger bandaged to a wooden palmar splint or to a malleable iron strap,
which should extend from the wrist to the tips of the afTected fingers.
This should be left on six days, by which time the skin will be fairly
well healed. Gentle passive movements should now be given the
fingers and the wound redressed. Stitches should be out on the eighth
or tenth day, and if at the time of operation the hand was put up
slightly flexed, it should be fully extended by this time. After the
stitches are out the collodion dressing should be applied, to be kept on
until the healing is absolute and massage and passive movements
regularly instituted. On returning to work the patient should wear a
leather protector in the palm.

If the contraction has been severe, the fingers had better not be
put up straight immediately after the operation on account of the pain
from stretching the digital nerves, which have been structurally short-
ened. In extensive dissections, also, a slight degree of flexion is
usually recommended until circulation is adjusted.*

* .\. H. Tubby, Trans. Amer. Orthop. Assoc., 1900, xiii, 149, and Lancet, 1901, i, 90.

SKIN-GRAFTS 633

Calot * is more radical, and holds the hand in complete extension
or even hyperextension, then inserts the sutures and puts on a plaster-
of- Paris mitt, the end of which is trimmed off so as to uncover the pulps
of the finger-tips and allow the circulation and innervation of the fingers
to be closely observed. The day after operation this is bivalved in
order to relieve internal tension. It is kept on three weeks, and then
removed and the fingers manipulated.

SKIN-GRAFTS 2

Thiersch Grafts. — A convenient and efficient form of dressing
is sterilized silver-foil, after the manner first advised in America by
Halsted at the Johns Hopkins Hospital. Virgin silver-foil comes in
books, each leaf separated from the next by a sheet of tissue. One
or more books are put between two blocks of wood and the w hole steril-
ized by baking. The silver book, having the folded edge cut off, now
becomes a pile of alternate foil and paper tissue. After the grafts are
placed they are fairly well dried by very gentle sponging. A layer of
tissue with foil on top is now reversed ov-er the grafted area and the paper
withdrawn, leaving a layer of silver which shortly breaks up into granu-
lated particles. One method is to cut the original sheet into strips
and apply, leaving the paper well wet, in clap-board layers, next the
silver. Better, in our experience, is it to remove the paper. When
the whole area is well covered with silver, loosely packed sterile gauze
of considerable thickness, so as to absorb the ooze, is placed o\'er it
and a dressing which will not confine the discharges applied. If the
part grafted is a limb, it should be fixed in a splint. As a rule, no further
dressing need be done for seven days. At that time the gauze next
the silver should be teased off, wetting at the same time with sterile
saline solution, taking time and care to remove it. Dry dressings for
a few more days should result in complete healing. Uncovered areas
will need regrafting later.

Thiersch grafts may be dressed from the first by clap-board layers
of sterile cotton cloth in J-inch strips containing holes here and there
for the escape of serum. A dry dressing is applied outside of these
strips.^

Judd, of the Mayo clinic,^ dresses the grafted surface with forty to

^ L^Orthop^die Indispensable, 1909, 705.

2 For a recent consideration of this subject see Ehrenfried and Cotton, **Reverdin and
Other Methods of Skin-graft," Boston Med. and Surg. Jour., 1909, clxi, 911.
' Brockway, Johns Hopkins Hosp. Bull., 1889, i, 36.
* Coll. Papers, 1910, 538.

634 OPERATIONS ON THE EXTREMITIES

fifty layers of dry gauze, all applied at once. The gauze pad is a little
larger than the grafted area, and is held in position during the placing
of many pieces of adhesive plaster so that it cannot move. This
dressing is covered with one of cotton and bandage, and is left in
place eight to ten days.

Reverdin Grafts. — These grafts are removed from a clean area
of skin with a needle and a knife. The process does not hurt enough
usually to make cocain necessary. Such points of skin are then laid
here and there all over the clean granulating area to be grafted. Silver
foil, or sterile fenestrated compress cloth, or gauze waterproofed in
celloidin may be placed next the grafts, and a dressing applied as for
the Thiersch method.

Wolfe Grafts* — These grafts include the whole thickness of the
skin into the subcutaneous tissue, and will take very well on face and
neck; less well elsewhere. Dry dressing should be used, the greatest
care being taken that there is enough pressure to hold the graft against
the area upon which it is planted, but not enough pressure to discour-
age circulation into it.

Flap Grafts. — A voluminous dressing of dry sterile gauze, with
absolute fixation of the parts by adhesive strapping or plaster-of-Paris
is advisable. Forty-eight hours after operation a window should
be lifted in the dressing and the wound secretions noted. If sepsis is
evident, the opening should be enlarged and a moist dressing of boric
acid or weak chlorinated soda solution applied, to be changed every
twenty-four hours or oftener. If there is no secretion, maintain
absolute asepsis. Frequently the tip of the flap will necrose, as well
as corners or angles. These slough away under dry dressings, and the
space left uncovered fills in by granulation.

The pedicle should be severed as soon as it is reasonably certain
that the flap has grown to the base on which it rests, and shows the
pink color of good circulation. This varies from the sixth to the
fourteenth day. In doubtful cases the pedicle can be severed or tied
off gradually, from day to day.

CHAPTER LI
OPERATIONS ON BONES AND JOINTS

EXaSION OF ELBOW

Passive motions of the fingers and wrist should begin on the second
or third day. The new flail-joint at the elbow should be moved pas-
sively as early as the eighth or tenth day. This may be done by putting
the joint up after the operation on an internal angular splint, provided
at its angle with a turn-buckle. Twisting this turn-buckle will give a
gradually regulated and safe movement. If the operation has been
for tuberculosis, persistent remains of the disease or sinuses may
modify the treatment, but if the excision has been for traumatic anky-
losis, constantly increasing passive motion should be practised after
the tenth day and active motion tried in three weeks.

Ability to use the new joint depends much on the character of the
patient, his courage, and previously acquired mechanical dexterity.
The patient should be given a weight to carry, such as a pail each day
containing more water. In the case of a child, the sound arm may
be bound up so that the excised joint must be used.

The operation is, indeed, but a small part of the treatment. Rota-
tion of the* forearm will be lost, and mere rotation of the whole limb
at the shoulder substituted unless early care is taken to preserve fore-
arm rotation. At first the upper end of the forearm should be firmly
held by one hand and the patient's hand rotated passively with the
nurse's other hand. At the end of four months motion in the new
joint should be free and fairly efficient, but the final perfection of the
joint may not be attained short of a year.

Excision of the joint for tuberculosis is now rarely practised, treat-
ment for this condition having reduced itself to hygienic regulation
and the use of fixation, with or without passive congestion or vaccines.
Occasionally operation will have to be done for drainage. When the
tuberculosis has subsided and has been quiet three or four years, then
excision may be practised, if advisable, as if the condition were merely
traumatic, and the after-treatment is, of course, the same.

EXCISION OF SHOULDER- JOINT

In general, the same comments should be made concerning the
after-care in this operation as in the case of the elbow. Passive move-

635

636 OPERATIONS ON BONES AND JOINTS

ment should not be begun until the deep parts of the wound are suf-
ficiently healed; that is to say, ten to fourteen days. Then passive
motion is followed by increasing, graded, active motion. A large enough
pad must be maintained in the axilla to prevent the new head of the
bone being pulled in against the coracoid process, and to hold it instead
in the glenoid cavity. The normal motions of the humerus, in rela-
tion to the scapula, should be recalled and resumed, in order that none
should be lost. The motions, such as sweeping, rotating the crank of
a clothes-wringer, bringing a gun into proper position at the shoulder,
may all be practised.

EXaSION OF WRIST

Passive motion of the fingers should be begun on the second day,
the wrist or seat of operation, however, being thoroughly supported
and fixed by splint and dressing. If motion of the fingers is not begun
early, the tendons become adherent and the hand is useless. As the
parts get stronger the splint is made shorter, though some support should
be worn until there is no tendency for the new joint to collapse in any
direction — in short, until it is strong. Some kind of leather support,
molded to fit the limb from the middle of the forearm to the knuckles,
should be devised.

EXCISION OF HIP

The wound is closed except for a space at the lower angle, where
a provisional stitch is inserted and a cigarette drain passed. At the
end of forty-eight hours the drain is removed and the stitch tied. Gold-
thwait, Painter, and Osgood ^ insist upon the importance of this early
closure of the wound. The patient is kept in bed six weeks, with ex-
tension to the limb. At the end of this time a plaster spica is applied
with the thigh in abduction and slight outward rotation, and the patient
is got up on a high sole and crutches. Weight bearing should not be
attempted for ten to twelv^e months, although the spica need not be
worn more than three or four months unless there is great instability
of the remaining joint.

EXCISION OF KNEE

The result of this operation is a stiff knee. No sutures are neces-
sary in the bones. The wound is closed with a small drain which is
removed at the end of forty-eight hours, and a pre\iously inserted pro-
\isional stitch tied. The limb is immobilized in a plaster reaching
from the perineum to the toes. The leg should be put up in about

^ Diseases of the Bones and Joints, Boston, 1909, 242.

OPEN (or '^compound") FRACTURES 637

5 degrees of flexion at the knee-joint rather than in complete extension,
as this will give a less awkward limb. At the end of three weeks the
patient is gotten out of bed, and in two weeks more locomotion with
the aid of crutches and a high sole on the shoe of the opposite foot is
begun. At the end of eight weeks the plaster is taken off and the
union tested. If firm, weight bearing may be begun at ten weeks.
The plaster should be reapplied and worn until the end of twelve
weeks.

OPEN (OR "COMPOUND'') FRACTURES

After the operation the limb should be put up in permanent appa-
ratus adapted to the site and nature of the fracture, except where the
trauma was attended by much mangling of the tissues, with the con-
sequent increased possibility of direct infection. In this case the ap-
paratus should be designed to facilitate the necessary change of dressing,
while yet maintaining the fragments with sufficient firmness to avoid
pain or excessive deformity. During the first week attention should be
focused on the wound rather than the fracture.

Ordinarily, under our present-day conservative treatment, unneces-
sary manipulation of the wound is severely avoided. The skin and such
torn tissue as presents through the wound is cleaned scrupulously, as
little trimming as possible is done, and then the parts are restored
as nearly as may be to their normal relations, without further devitaliz-
ing the bruised tissues by handling or strong antiseptic irrigation. If
the skin wound is not large, it is left open for drainage of exudate, which
is sure to follow. It may be enlarged. If the fracture is deep, a drainage
tract may be maintained by a coiled piece of rubber dam or a small
soft tube. Unnecessary sutures are a distinct evil and deep sutures
are rarely indicated. If catgut is used for the skin, the stitches may
be left to take care of themselves, if no infection follo^^ s and there is no
drainage to remove, until such time as the dressing or plaster-of-Paris
is removed for the purpose of inspecting position.

There is a large series of open fractures which, after operation,
should receive as good fixation as though there was no external wound;
for instance, an open fracture in the middle of the leg or forearm is
preferably put up in plaster-of-Paris. Care should be taken that a
smooth, voluminous dressing of gauze is first applied to absorb the abun-
dant serosanguinous exudate, and that the plaster bandage is loose
enough to allow for some postoperative swelling. This exudate in-
creases the pressure within the bandage, and great care should be taken
to watch the toes or the fingers, that if they become at all cold, blue,

638 OPERATIONS ON BONES AND JOINTS

or edematous, the plaster may be split down one side and the edges
wedged apart, or, if necessary, along both sides ("bivalved"); straps
of webbing should then be buckled around to keep the two halves in
place.

If there is no evidence of pressure, the general pain in the limb
may and should be controlled by morphin durin<; the first thirty-six
hours. If the pain continues more than thirty-six hours, something
is wrong. Use no more morphin, but split the plaster and, if necessary,
remove it to find the source of discomfort. Often a little adjusting
of the paflding is all that will be necessary. The circulation may be
interfered with so seriously, either from pressure of the apparatus or
injury of vessels from trauma or subsequent manipulation, that gangrene
ensues and amputation is necessary. We have seen this ha])])cn in

fracture of the lower end of the femur from injury to the popliteal
vessels.

If there are no signs of infection, the {iressing in an undraincd case
should not be removed until the wound has healed, that is, ten days or
two weeks. Then the apparatus should be removed, the wound in-
spected, stitches taken out, and, if advisable, an .v-ray taken to show
whether or not readjustment is necessary. New apparatus should
now be applied, after any indicated manipulation is performed, to
allow for the remo\al of the wound dressing, the reduction of the j>ost-
operative swelling, and the atrophy of disuse. After this the treatment
is that for closed fractures of the same tyjje.

In case drainage has been left, as is frequently the case, provision
should be made for dressing the wound after forty-eight hours. If
the fracture has been put up in plaster, a window should ha\'e been cut
or the piaster split before it has hardened, and the lid held in place by

OPEN (or ^* compound '') FRACTURES

639

means of webbing straps or adhesive plaster until the proper time
arrives, when the sheet-wadding is cut away with scissors and the
dressing exposed. Forty-eight hours is long enough to allow primary
infection to become apparent in drained cases. If the dressing shows
nothing but clean senmi, it is aseptically removed, a new dressing ap-
plied, the window-lid put in place and fixed by a plaster-of -Paris
roller, and the limb is not again disturbed imtil the ten days or two
weeks are up. Careless tech-
nique at this first dressing is,
without doubt, frequently re-
sponsible for secondary infection
of open fractures in hospital
cases.

A patient receiving an open
fracture, unless he is suffering
from some concurrent disease,
does not exhibit any elevation of
temperature if seen immediately.
The temperature after the oper-
ation may be expected in the first
twenty-four hours to rise to 99.6°
F. If on the second day it con-
tinues to rise over 100° F. (see
Chart, Fig. 21, p. 62) and is as-
sociated with pain, the presence
of an infection should be assumed
and the wound examined. If
sepsis is apparent in a reddening
about the wound, localized super-
ficial tenderness, or a seropuru-
lent ooze from the wound or the
suture tracts, or if, on the first

dressing in drained cases, seropus appears on the dressing, or follows
after the drain when it is removed, the case should at once be submitted
to an aggressive routine treatment. The apparatus should be adapted
to allow easy and generous access to the wound. Sutures should be
removed to promote unrestrained exit for tissue ooze, and the wound
may have to be enlarged for the same purpose. Counteropenings
should be made for more eflScient drainage, and fenestrated rubber
tubes inserted wherever they will be of service. If the infection is
especially virulent in its manifestations, through-and-through rubber-
tube drainage should be instituted at once. Hot antiseptic (and asep-

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. 1

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Qnfin f-

CAj

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jfS

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«q:

cc
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a

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Fig. 210. — Open Fracture Operations.

Aseptic reaction continued over several days, as is usual

in these cases.

640

OPERATIONS ON BONES AND JOINTS

tic) absorbent comprt'sses should be applied and renewed every two
or four hours, as the urgency of the case demands, day and night. Later
on, as the pus tracts have become more or iess walled otT, through-and-
through irrigation may be instituted, having a care that the pressure
shall not distribute infected matter to jilaces as yet uninfected. In
badly septic cases continuous \\arm irrigation or continuous hot soaks
should be practised when feasible.

In cases of frank sepsis the fracture should be judiciously ncpjlecled
for the time being, and nicety of ap]X)silion should be forgotten. To
fixate the part in something approximating normal posilion, and at
the same time to allow ample access to the wound, will require an ap-
paratus which may tax the ingenuity and the mechanical skill of the
surgeon. Plaster-of-Paris is adaptable to this sort of dressing. If
there is hut one sinus, a generously sized window may be cut out, and
if the plaster is weakened thereby, it can be reinforced bj' ridges of plaster
U[i and down the sides, or by bridges of strap iron, with their extremi-

mmmJ

ties incorjjorated in the plaster above and below the opening. In cases
of m.ultiple sinuses or through-and-th rough openings a separate plaster
can be put on above and below the wound and these uniled by iron
bridges.

The disadvantage of the fenestrated plaster lies in the uncleanliness
at the edges of the window. The moisture from the poultices soaks
up into the sheet-wadding, organisms enter and thrive on the debris
of exfoliated skin, and sometimes such air-bome bacteria as the bacillus
of green pus (Bacillus pyocyaneus) find their habitat here and form
a disagreeable complication. Various methods have been devised
to form a water-tight line of juncture bet^veen skin and dressing at the
edge of the plaster, such as lining the plaster with oiled silk or rubber
dam. The best scheme of which we know is that described by Crouse.'
He dissolves dental rubber (No. 2) in commercial chloroform, and

> Virginia McH, Scnii-Mnrthly, loo.i. viii, i^i.

OPEN (or "compound") FRACTURES

641

Stirs into this paste shredded absorbent wool. After drying the skin
carefully he caulks the opening between plaster and skin with this
mixture, which dries into an impervious water-tight coating. He
then applies a coat of shellac over the entire plaster.

If there is much discharge or if pus issues from two or more
sinuses, then it is frequently advisable to use some other form of ap-
paratus, such as a Cabot [joslerior wire splint (Fig. 211). This should
be well an<! comfortably padded and, on a leg, there should also lie
well-padded sideboards. The two side pieces and jiosterior "ire splint,
properly padded, form a three-sided box which, strapped together.

holds the leg firmly. The wire splint with its foot-piece keeps the foot
at right angles and prevents rotation of the lower fragment, and e\-cn
-when taken down to do the dressing, maintains the position of the
foot with assurance ("Fig. 212). If the condition necessitates the em-
ployment of the hot soak, and the location of the fracture adapts itself

642

OPERATIONS ON BONES AND JOINTS

to this procedure, the wire can be passed through rubber tubing before
it is bent. It is then fixed to the limb by adhesive ])liister ('A-hich will
have to be rcenforced frequently) and splint and the extremity can be
immersed in the bath.

The old-established pillow-and-side splint (Fig. 214) is an excellent
temporary apparatus -for a septic open leg fracture, but it has the dis-
advantage of needing the constant attention of the surgeon. The

dressing cannot here be done by the nurse, or even by the surgeon alone,
as each time it is performed the foot must be held carefully in the cor-
rect position by a second person, otherwise there are apt to be pain and

OPEN (or " COMPOUND ") FRACTURES

643

rotation of the lower fragment. If the wound is on the under side of
the leg or thigh, nothing is better than the Smith anterior splint
apparatus (Fig. 216), which keeps the leg constantly suspended hori-
zontally in such a way that the sinus can be dressed without disturb-

ing the patient or the relation of the fragments (Fig. 217). Unless
carefully applied it is, however, apt to be irksome.

Open fractures of the femur and of the humerus can best be treated
by extension. For open fracture of the femur the classic Buck's ex-
tension is applied, two long strips of adhesive i)laster extendinf^ on

each siiie of the leg from 2 inches above the malleolus up as far above
the knee as the nature of the wound allows. They arc heid firmly
to the leg by further strips of adhesive plaster applied spirally. The
leg should lie naturally on a posterior splint, extending from the begin-
ning of the tcndo Achillis to the buttock, padded to fit the ctyitour of
the leg. Round the thigh the dressing should be maintained by loosely

644 OPERATIONS ON BONES AND JOINTS

applied coaptation splints, held in place by straps with buckles, allow-
ing frequent easy removal, if necessary, to get at a wound or sinus.
About 20 to 35 pounds weight should be applied, connected by a pulley
over the end of the bed to the adhesive straps through the agency
of a *' spreader'' acting like a whiftle-tree, 2 inches below the foot. A
T-splint should be placed along the outer edge of the leg, extending from
4 inches below the foot to within 6 inches of the axilla, where it is held
in place by a pocket swathe; the purpose of this is to prevent undue
motion of the body, not of the leg. The straps and splints should not
exert pressure against any bony points, especially the malleoli, tip of
the heel, the outer border of the tibia, and the patella. The patient
should lie upon a Bradford frame.

The complicated modifications of Buck's apparatus, which -entirely
conceal the leg, especially the application of starch bandages, though
giving a more finished appearance, are undesirable. We haAc seen
a beautiful apparatus, in which the leg was encased from toes to groin
in neatly applied starch bandages, on removal reveal the leg alive with
maggots, such as are not infrequent in neglected septic wounds. They
cause no temperature and often remarkably little itching; they pos-
sess a characteristic odor which is not readily forgotten. Maggots
may be present for weeks under a bandage or in a plaster bandage
without being suspected.

When a Hoffa table (Fig. 53, p. 221) or other suitable apparatus
is at hand, and there is good reason to suppose the wound will remain
aseptic, a plaster spica bandage may be applied in open fractured
femurs. A plaster spica is distinctly contraindicated in those cases
in which temporary drainage has been instituted or sepsis is expected,
or where there are no provisions for proper application of the apparatus.

In the treatment of open fracture of the humerus the use of the ex-
tension principle with patient in bed is to be recommended. Treat-
ment by ambulatory apparatus should not be considered until all danger
of infection in the wound is passed. If at first an ambulatory apparatus
has been used and the wound becomes infected, the seriousness of the
condition should be explained to the patient; he should be put to bed
and an extension apparatus applied. Under this form of treatment
the wound can be readily and painlessly dressed, and at the same time
the fragments are maintained in the best possible apposition.

For extension of the arm apply a strip of adhesive plaster on each
side from just above the styloid process to as high up the arm as the
location of the wound will permit. Reinforce these with spirally applied
strips of adhesive. To the lower end of each of the extension strips a strap

OPEN (or "compound'*) FRACTURES 645

of webbing is stitched, which passes down beside the forearm and hand
to a spreader, from which a rope goes over a pulley at the foot of the
bed. About 10 to 20 pounds of weight are applied. The arm should
lie naturally on a well-padded splint extending from the tips of the
fingers to the axilla. A T-splint should be applied between the arm
and the body, on the same side as the injured arm, extending to the
axilla. It is held in place by a pocket swathe around the body, as in
the femur apparatus. The dressing is maintained by coaptation splints
lightly held in place by straps with buckles allowing easy removal.

Complications and Sequelae. — In open fractures there exists
an increased liability to complications, such as osteomyelitis, fat embol-
ism, thrombosis and pulmonary embolism, and non-union.^ These
must be borne in mind. The occurrence of virulent sepsis and septico-
pyemia, gas-bacillus infection, or gangrene will frequently indicate
immediate amputation of the limb.

On account of the seriousness of infection in open fractures, from
the moment the operation is completed until the wound is firmly united
all aseptic precautions should be scrupulously employed; dressings
should be done only when necessary and with the most minute care
to prevent possibility of infection.

As moist dressings are frequently used in open fractures that have become
more or less infected, a word of caution is necessary in regard to their prep-
aration. In many hospitals it is the custom to use a basin kept on the ward
car for holding the solution; this basin is rarely or never boiled; it may have
just been used to receive catheterized urine or infected dressings; it is often re-
turned to the ward car with simple rinsing in cold water. For the preparation
of a moist dressing, a boiled basin should be insisted upon; if no large boiling
tank is in the ward, it is a simple matter to put the basin on the gas stove par-
tially filled with water and allow it to boil for about five minutes. This effectu-
ally sterilizes it. Nurse and ward attendants should be made to realize that
mild antiseptic solutions, weak corrosive, boric acid, alcohol, etc., as ordinarily
employed, will not sterilize basins.

Occasionally it becomes advisable to give the infected wound a hot soak,
especially in open fractures of the small bones of the hand that are infected;
here again the soak-basin is often used from patient to patient without boiling,
a thing that ought never to occur. It should be sterilized beyond all possibility
of question before being used in these cases. Through the neglect of boiling
dressings and soak-basins we have seen an infection travel along the entire
surgical ward; one of these cases died.

* F. W. Murray, Treatment of Delayed Union by Thyroid Extract, Ann. Surg., 1900,
xxxi, 695; L. Morel, Parathyroid Treatment of Fractures, Arch. G6n. de Chir., 191 o, iv, 245.

646 OPERATIONS ON BONES AND JOINTS

Open fractures are very apt to show a low-grade infection, charac-
terized by the discharge of 3 or 4 drams of seropurulent matter daily
for several weeks. This discharge is usually maintained by small free-
lying bits of dead bone, or irritation from the ends of the fragments
which, denuded of periosteum, become ebonized and act as foreign
bodies. If it persists unduly, the fragments should be found and re-
moved, or even the tip of the bone may have to be removed with rongeurs.

In cases which have been discharging for a long time and the
discharge suddenly ceases, pocketing of pus should be suspected, and
this may even occur with little or no rise of temperature. The pocket
usually is in the fatty connective tissue between the skin and muscle
fascia. Often it is advisable to make the incision through the skin,
not in the center of the fluctuating area, but at a more dependent
point, to allow more efficient drainage.

In lower leg fractures, after the wound is practically healed and the
patient is allowed up and about on crutches, blisters are apt to de\'elop
from the exudation of serum as a result of the unaccustomed dependency
of the limb and the resumption of function. These sometimes become
infected and cause repeated breaking down of the wound. To fore-
stall this occurrence the plaster should be split and the leg frequently
inspected. Blisters, as soon as formed, should have the skin entirely
removed and a dressing of some aseptic emollient applied.

OPERATIVE FIXATION OF FRACTURES
(Wiring, Suturing, Parkhill Qampt Wire Nail, Bone Peg, Bone Plates)

Operative methods of fixation of the fragments after fracture have
been in use for nearly sixty years. The earliest method employed
was wiring. In later years wire has become largely replaced by ab-
sorbable sutures, because its presence, acting as a foreign body, has
frequently led to conditions necessitating its removal. Other devices
also for retention of the fragments in apposition have been devised,
such as the Parkhill clamp, the wire nail, and the bone peg.

In principle the mechanical measures are the same as for any cor-
responding fracture which has not been wired or sutured. The treat-
ment of the wound is that of any aseptic closed wound. Where wire
has been used and there is persistent suppuration, the wire must be
cut down upon and removed.

The Parkhill Clamp. — This was first presented by Parkhill in
1897.^ Briefly described, it consists of four screws, two of which are

* Trans. Amer. Surg. Assc^c, 1897, xvy 257.

OPERATIVE FIXATION OF FRACTURES 647

inserted into each fragment, and the four held together by a clamp
outside the wound. The incision is closed except for the passage of the
four screws, and covered with sterilized gauze, which is passed beneath
and round the clamp, and the limb inclosed in plaster. At the end of
ten days the wound is dressed through a window in the plaster and
the stitches removed. The plaster is omitted at the end of from four
to six weeks in the smaller bones, or eight weeks in the case of the femur,
and the clamp is then removed and the screws easily taken out of the
bone. The screw-holes are covered with sterile gauze for a few days
until they are closed in. In all bones except the femur the union by
this time is suflBcient to allow use. The femur should be again put
up in plaster for three weeks, and weight bearing is not allowed until
the end of the twelfth week.

The Wire Nail. — This finds its chief use in fractures of the neck
of the femur. Silver nails, screws, and ivory pegs have also been used
in the same manner. According to Sir William McCormack,^ the
first operation of this character was done by v. Langenbeck. The
first in America was done by Willy Meyer.^ The largest number of
cases reported by any one man was reported by Nicolaysen,^ who had
performed 21.

Nicolaysen's technique differs from that employed by most of the
other operators in that the nail is simply driven in through the skin
without making an incision. The nail is wound about with sterile
gauze and a plaster spica is applied reaching from the iliac crests to
the toes. At the end of four weeks a window is cut over the trochanter,
and the nail, which is always loose, is removed. At the end of eight
to ten weeks the plaster is removed and the patient gotten up on crutches.
At the end of three months weight-bearing is begun. The after-treat-
ment of cases in which an incision has been employed is substantially
the same. The incision is closed without drainage and a sterile dressing
applied. On the tenth day a window is cut in the plaster and the
stitches removed. Some surgeons cut down upon the nail under cocain
and remove it at the end of six weeks. Others leave it in situ indefi-
nitely.

This operation seems to be remarkably free from complications.
In 36 cases collected by H. Augustus Wilson^ the only complication
was suppuration in the wound, which occurred in one case.

^Antiseptic Surgery, London, 1880. 200.

2 Ann. Surg., 1803, xviii, 30.

' Nord. Med. Ark., Stockholm, 1897, viii, i; also ibid., iSqq, x, i.

*Amer. Jour. Orthopedic Surg., 1907-08, v, 339.

648

OPERATIONS ON BONES AND JOINTS

Bone pegs and ferrules were introduced by Senn.' They have
the advantage of being absorbable. The after-treatment is the same
as for the suturing of a fracture with any absorbable material.

I^ane'S Bone Plates. — These ingenious mechanical devices are
rapidly coming into more extensive use. They are made of metal
and celluloid in various shapes: the best known in this country are
the rigid steel plates described by LaneHFig- 218). The wound should
be closed with intracuticular catgut in order that no subsequent dress-
ings need be necessary. The bone plates are intended only to hold the
ends in apposition, and the whole limb, therefore, must be held in

fixation by plaster-of- Paris bandage with as much care and with as
thorough immobilization of the joints as in a simple fracture, and as if
no plate had been used. Thus, for the leg the plaster extends from
base of toes to groin; for fractured femur it extends from foot to ribs;
for forearm, from fingers to shoulder.'' The wounds should in all
simple fractures and most open fractures, if treated at once, heal by
first intention. In the tibia the plate must be necessarily so super-
ficial that it here acts most often as a foreign body. M. S. Hender-

' Ann. Surg,. iSg^, itviii, i;5.
'Lancet. 1907, i, 1283; Ann. Surg.,
' E, Martin, Jour. .\mer. Med. .-Vaso

OPERATIVE FIXATION OF FRACTURES 649

son, of the Mayo clinic, reports^ the use of the metal bone splint in
27 cases, in only 2 of which has it been necessary to remove the
splint. This report is better, however, than the average. F. B. Lund,^
in II recent cases of non-union and mal-union, has reported i case of
infection and 4 in which removal of the plate was necessary. Another
series of 19 cases included 7 in which the plates had to be removed.
The plate may be the nidus of actual infection or may be acting only
as a foreign body, and when removed may have already accomplished
its purpose of fixation. Unless the suppuration, therefore, is active
the plate is to be left in position from two to six weeks.

Operation for Fractured Patella. — Operative treatment of
this condition has shown a constant tendency to simplification. Elabo-
rate methods of application of silver wire have fallen into disuse.
It is now fairly well established that the lateral tears in the capsule
are of importance, and that careful approximation of torn edges of the
capsular ligaments is of more value than strong suture material ap-
proximating bone. The liability of the synovia to infection is generally
considered greater than that of the peritoneum. The knee should
be opened with as much respect as the cranial cavity.

After the dressing, either a plaster-of- Paris bandage should be
applied from above ankle to groin, or a long, well-fitting ham splint
may be used. In either case, enough padding should be put in the
popliteal space to avoid hyperextension, which is unnecessary and
uncomfortable.

The skin sutures should be removed at the end of ten days; the
wound is then reinforced with plaster straps and the splint continued.

Four weeks from operation, passive motion, slight and gentle at
first, is begun, and two weeks later use of the leg may be begun with
only a flannel bandage over the knee. From that time on further
motion of the joint should be encouraged, and at the end of the eighth
week may be forced to a degree short of painful. The flannel bandage,
if necessary, from ankle up, should be worn until the tendency to edema
of the leg disappears — possibly three months.

Complications and Sequelae.— ^e/^^w.— Infection of the skin
should be suspected if slight temperature persists or if there is super-
ficial tenderness through the dressing. Prompt detection and atten-
tion to such infection often precludes the disaster of deep infection.
Infection of the knee-joint is one of the most serious calamities of sur-
gery, and can be met only by prompt opening of the wound, washing

^ Coll. Papers, 19 lo, 531.

2 Boston Med. and Surg. Jour., 191 1, clxv, 827.

650 OPERATIONS ON BONES AND JOINTS

out with saline, and efficient drainage. The joint is, of course, neces-
sarily sacrificed, and more than that, the infection is so serious that
life is often held in the balance.*

Persistent Adhesions. — This condition is met as after operations
for dislocated cartilage, but force must be applied with good judgment,
lest separation of the newly healed patella take place.

Suture of the Olecranon. — The wound is closed without
drainage, and the arm, in extension, put up in a plaster reaching from
the axilla to the ends of the metacarpal bones. The wound is dressed
and the stitches removed through a window in the plaster at the end
of ten days. The plaster is taken off at the end of four weeks and
passive motion begun.

OPERATIONS ON THE KNEE : DISLOCATED CARTILAGE, SYNOVIAL

FRINGE

The after-care is made most simple if the joint has been opened by
a lateral curved incision, convex forward in the skin, and a transverse
incision of the capsule itself, the latter part going backward beyond the
middle of the tuberosity. If this method of entering the joint is used, the
skin heals freely movable over the deep scar, and there is not presented
a single healing plane from skin to knee-joint, with the dangers of
direct infection. With this method of incision, then, or a direct vertical
incision, the joint need only be splinted after the application of the
dressing by four rolls of cotton wadding, each 2 inches in diameter
and 2 feet long, placed equidistant about the joint, parallel with the leg.
Such a method of splinting will allow the knee to rest in a comfortable
position — that is to say, slightly flexed — and will allow slight movement
from the start. Troublesome adhesions are much less liable to form.
The skin stitches are removed in ten days. All splints are then re-
moved, a flannel bandage is applied, and passive motion is begun.
Four days later active motion should be tried and the patient should
be encouraged to get about, using crutches or two sticks at first. When
the leg is first hung down, edema of the foot and leg may appear. A
flannel bandage from foot to above knee-joint will control this within
a week in a vigorous person.

Complications and Sequelae. — 5^/?^/:?.— Infection of the skin
around the wound may be easily met and o\ercome. Any persistent
temperature, tenderness, or pain should lead to immediate investiga-

^ David D. Scannell (Boston Med. and Surg. Jour., 1906, civ, 568) reports an exceed-
ingly dirty open fracture of the patella, which, conscientiously cleaned, healed by first
intention.

OPERATION FOR RECURRENT DISLOCATION OF THE SHOULDER 651

tion of the wound, even as early as the second day. Skin infection
may thus be checked where it is, before it penetrates the capsule. In-
fection of the knee-joint is a disaster covered under Suture of Patella
(p. 649) .

Adhesions. — The knee after this operation is always limited in
motion at first. After the hventy-first day passive motion should force
flexion. The thigh should be put over the knee of the surgeon or over
the arm of a chair, and the leg gently but firmly flexed, gaining a little
each day. For active motion, the patient should stand and slowly stoop,
thus forcing flexion with his body weight. To these procedures may
be added intelligent massage and, at times, baking may be helpful.
For obstinate cases flexion may be brought about by special apparatus,
such as that of Zander.

OPERATION FOR RECURRENT DISLOCATION OF THE SHOULDER

Up to 1894 excision of the head of the humerus was the method of
treatment in vogue for recurrent dislocation of the shoulder, although
Gerster ^ makes casual reference to a case operated upon by him in
1883, in which he excised a portion of the capsule of the joint. In
1894 Ricard ^ reported 2 cases successfully treated by taking a reef in
the capsule.

To Burrell ^ is due the credit of originating and perfecting the technique
of shortening the capsule by partial excision and suture, which he de-
scribed in 1897, with the report of two successful cases. The advantage
of BurrelPs method over Ricard's is obvious, since the former allows
exploration of the interior of the shoulder-joint and the removal of
loose bodies which are occasionally found.

The after-treatment of both BurrelPs and Ricard's operations is
identical. The capsule is sutured with catgut, the muscles brought
together, and the skin wound closed with silkworm-gut. A dry sterile
dressing fixed with collodion or plaster straps is applied and the arm
put up in a Velpeau, with the elbow ele\'ated and carried inward to
ward the median line. The arm is not disturbed until the tenth day,
when the first dressing is done and the stitches removed. The Vel-
peau is replaced and continued until four weeks from the date of oper-
ation, when massage and passive motion are begun, and the patient is
allowed to return to work at the end of eight weeks.^

1 C. F. Painter and A. P. Cornwall, The Technique of Arthrotomy, Boston Med. and
Surg. Jour., ipio, clxiii, 601.

2 Rules of Aseptic and Antiseptic Surgery, New York, 1888, 8.
' Bull, de Tacad. de med., 1894, N. S., xxxi, 330.

* Amer. Jour. Med. Sci., 1897, N. S., cxiv, 166.

^T. T. Thomas, Jour. Amer. Med. Assoc, 1910, liv, 834.

652 OPERATIONS ON BONES AND JOINTS

OPERATION FOR PURULENT ARTHRITIS

It will be assumed that no joint is incised for drainage unless the
presence of infected fluid has been determined by needle puncture.
The knee will be drained by an incision each side of the patella. The
ankle will be drained by an incision just in front of each malleolus.
The wrist will be drained by an incision over each styloid process.
For these three joints through-and-through drainage will be established
by a single piece of rubber dam. The elbow, shoulder, and sterno-
clavicular joint are drained by a single incision, the rubber dam being
held in by a single stitch through it and the skin.

The best dressing for drainage undoubtedly is the salt and citrate
poultice. The rubber dam is withdrawn in from forty-eight to ninety-
six hours. The poultices are maintained one or two days longer if
the temperature has not reached normal. Passive motion should be
begun by the fifth day, unless the process is still very active and painful,
and continued in increasing duration daily. If permanent ankylosis
supervenes, operation and the use of Baer's membrane should be con-
sidered.^

OSTEOMYELITIS

For our earliest conception of the regeneration of bone from perios-
teum after subperiosteal resection of the diaphysis we are indebted
to Ollier.2 His technique was carried out with successful issue in
2 cases of suppurative periostitis by Cheever in 1868.' The opera-
tion was performed in France and England by Duplay, MacDougall,
and Holmes, but it was not accepted in Germany until Jottkowitz*
reported a successful regeneration of the femur after excision of the
shaft. The pathology of the method of treatment of osteomyelitis
by early resection of the necrotic bone, allowing regeneration from the
periosteum, was studied by E. H. Nichols in 1898,^ and his suggestions
were carried out by Hayward W. Gushing.® For an exhaustive
description of the pathology of osteomyelitis and the technique of
operation, the reader is referred to the masterly article read by Nichols^
at the meeting of the American Medical Association in 1903.

^ R. B. Osgood, Boston Med. and Surg. Jour., 191 1, clxv, 86.

2Trait6 Experimentale et Clinique de la R^g^n^ration des Os, et de la production
artificielle du Tissue Osseux, Paris, 1867.

' Reproduction of the Tibia, Med. and Surg. Reports of the Boston City Hospital^
1870, i, 362.

* Deut. Zeit. f. Chir., 1899, Hi, 213.

^ Communication Mass. Med. Soc., 1898, xvii, 875.

* Ann. Surg., 1899, xxx, 468.

' Jour. Amer. Med. Assoc., 1904, xlii, 439.

OSTEOMYELITIS 653

The consideration of the after-treatment may be divided into that —
(i) Of the acute stage; (2) of the subacute; and (3) of the chronic.

Acute Stage. — In the acute stage there is more or less extensive
suppuration in the marrow The pus is evacuated by incision of the
soft parts and removal of a portion of the cortex of the bone. The
wound is packed with iodoform gauze and a few stitches taken at the
extremities. A moist citrate salt dressing is applied and the limb im-
mobilized by a splint. The dressing is done at the end of forty-eight
hours and daily thereafter. At each dressing the cavity is irrigated
with chlorinated soda solution (i : 80) and repacked. In exceptional
cases the bone regenerates completely and the wound heals spontane-
ously. Usually, however, a sequestrum forms, which must be removed
by a secondary operation.

Subacute Stage. — This secondary operation in the case of bones
having an accessory bone to serve as a splint, as the tibia, should be
performed while the periosteum is still plastic, but has begun to ossify
in its deeper layers — ordinarily about eight weeks after drainage of the
acute suppuration. In the case of bones like the humerus, which have
no such accessory support, it is necessary to wait until the regenerating
periosteum has obtained sufficient stiffness to prevent distortion by
muscular pull, but not long enough to allow the periosteum to have
lost its power of central growth. The proper time for operation may
be estimated by the thickness of the involucrum, the rule given by
Nichols {loc, ciL) being to operate when the total diameter of the in-
volucrum is about equal to one-half the diameter of the normal shaft.
This is usually about twelve weeks after the drainage of the abscess-
cavity.

The after-treatment of operations on both types of bone is identical,
the later operation requiring as much time for regeneration as the
earlier. The wound is closed with or without drainage, according to
the amount of discharge from the cavity before operation, a moist anti-
septic dressing is applied, and the limb immobilized in plaster. The
patient is kept in bed about two weeks when a bone of the upper ex-
tremity is involved, but the plaster is continued for about six months,
after w^hich regeneration should be complete enough to begin use. In
bones of the lower extremity the patient is allowed up on crutches
and a high sole at the end of six to eight weeks, but the plaster is con-
tinued until from six to eight months, after which it is removed and
weight-bearing gradually begun. Small sinuses may form during the
convalescence from one of these operations and require curetting, but
usually they will eventually heal without further difficulty.

654 OPERATIONS ON BONES AND JOINTS

Chronic Stage. — In the chronic cases the sequestrum becomes
surrounded by a wall of dense bone which has no power of central
growth, and its removal, therefore, is not followed by closure of the
cavity. Various procedures have been devised for this purpose. Hamil-
ton * tried to graft in pieces of sponge in the hope that they would serve
as a framework for the formation of the new bone, but this method has
proved an utter failure.

Schede ^ disinfected the cavity as thoroughly as possible, allowed
it to fill up with blood, and then sutured the skin over the top, allowing
the blood-clot to organize and the cavity in this way to become filled in
with fibrous tissue. In spite of the obvious difficulties in the way of
rendering the cavity sterile, this method has sometimes proved success-
ful. The best method is that of Neuber,^ who cleans out the ca\nty,
draws in the adjacent skin and soft parts, and nails or sutures them to
the bottom of the cavity, thus lining it with skin.

The Mosetig-Moorhof method * consists in rendering the cavity
as nearly aseptic as possible, drying it, and filling it with a mixture of —

Iodoform 60 parts

Spermaceti 40 parts

Oil of sesame 40 parts

which is poured in warm and then hardens and hermetically seals the
cavity. The soft tissues are then sutured over it. The originators
reported 120 cases successfully treated by this method. Nichols,^ how-
ever, has not seen such satisfactory results.

OPERATIONS FOR BOW-LEGS. KNOCK-KNEES, AND COXA VARA

These will be considered together for the sake of convenience-
Two forms of operation are in use — osteoclasis and osteotomy. The
former is employed in the ordinary outward bowing of the femur.
The latter is the method of choice when the deformity is in close rela-
tionship with a joint, as in knock-knees or coxa vara, or where both
anteroposterior and lateral bowing are present. Osteotomy is done
at various levels, being called Gant's operation when done below the
trochanters; Macewen's, above the condyles; and Trendelenburg's,
when both the tibia and fibula are sawn through just above the mal-
leoli.

^ Edinburgh Med. Jour., 1881, xxvii, 385.
^ Deut. med. Woch., 1886, xii, 389.
^ Arch. f. klin. Chir., 1879, xxv, 316.
* Centralbl. f. Chir., 1903, xxx, 433.
^ Keen's Surgery, Phila., 1909, ii, 43.

CLUB-FOOT (CONGENITAL EQUINOVARUS) 655

The after-treatment is the same for both osteoclasis and osteotomy,
except after Gant's operation. Plaster bandages extending from the
groins to the toes are applied, maintaining the limb in the corrected
position, and are worn for four weeks, and then cut along each side
so that they may be taken off at night. At the end of six weeks they
may be removed entirely and weight-bearing begun if the union is firm.
After subtrochanteric osteotomy a double plaster spica extending to
the ankles, applied with the limbs in abduction, is worn for six weeks,
then omitted at night for two weeks more, and finally left off altogether
at the end of the eighth week, at which time weight-bearing may be
commenced.

Complications and Sequelae.— These operations are seldom
accompanied by special complications. Delay in union sometimes
occurs after osteotomy and requires a longer period of fixation in plaster,
together with efforts to influence nutrition. In children, the frequently
coexisting rachitis must be treated. Recurrence of the deformity
sometimes takes place and necessitates a repetition of the operation.

Convulsions occasionally occur after or during the progress of
orthopedic operations. A. Schanz^ believes these to be due to fat
embolism. On the other hand, Codivilla^ explains them as the result
of traction on nerve-filaments, especially of the sciatic. Working
under his direction, V. Neri^ produced experimentally a similar symp-
tom-complex by traction on the sciatic nerve in animals. Accordingly,
Codivilla advises as a prophylactic measure the use of extreme care
and gentleness in the stretching of soft parts at operation; and when
convulsions do occur, to place the limb in a position to relieve the
tension on the nerve, and to loosen the extension if any is being used.

CLUB-FOOT (CONGENITAL EQUINOVARUS)

The operation may consist in — (i) manual correction; (2) sub-
cutaneous tenotomies; (3) open division of the resistant structures
(Phelps) ; (4) forcible correction with instruments, and (5) bone opera-
tions. In any case, the foot should be held overcorrected in plaster-
of-Paris for four to twelve weeks, depending on the age of the patient
and the degree of deformity. The patient should then be fitted with
a Bradford or Taylor club-foot shoe; in an infant the plaster should be
continued, removing it at intervals to allow of manipulation, until he
is old enough to walk, when a brace should be applied. After the

^ Cent. f. Chir., 191 1, xxxvii, 43.

* Deut. med. Woch., 1910, xxxvi, 2134.

* Zeitschr. f. orthopad Chir., 1909, xxiv, 87.

656 OPERATIONS ON BONES AND JOINTS

brace is discontinued, it may be well to have the child wear a shoe
having a lift of f to f inch along the outer border of the sole.

The following technique of plaster application, recently described
by Ehrenfried,* is particularly adaptable to the postoperative treat-
ment of infants and young children:

"The plaster is applied from thigh to tips of toes, with the knee flexed,
so as to prevent the cast from twisting on the leg, and allowing a return of the
varus deformity. The skin should be clean and dry and well powdered, and
the foot and leg should be evenly and snugly padded with narrow sheet-wad-
ding. The bony prominences should be generously covered, but if too much
wadding is used it is likely to pack together, so that the foot and leg become
loose in the cast.

"If the plaster is applied to the best advantage, three 2-inch rolls are
ample in a young infant, and four 3-inch bandages will suffice for an older

Fig. 219. — Diagram Showing Advantaof. in- Applying a Collar and Allowing it to Sft Hkfoiu: At-
TKMPTiNG to Maintain Position o\ kr Old Mlthod of Attfmpting to Ovkrcorrect With Plaster
still Wet (Ehrenfried).

child. Of the first roll, half is used in making a collar about the forefoot.
This is so applied — the foot hanging relaxed — with circulars and reverses,
as to lie snugly against the foot. It should extend to the tips of the toes,
but should not cramp them or hide their extremities. It should fit closely
against the inner border of the great toe, to its very tip, so as to give efficient
leverage in abduction. The remainder of the roll is applied in circular turns
about the thigh, carried as high up as possible.

" No further plaster is applied until the collar has set. When this has
become solid, one can efficiently manipulate the forefoot as a unit and
apply a considerable amount of force without cramping or dislocating the
toes, or causing pressure sloughs, for the pressure is not concentrated, but
is distributed evenly through the collar (Fig. 219).

* Boston Med. and Surg. Jour., 1909, clxi, 741.

CLUB-FOOT (congenital EQUINOVARUS)

6S7

" The second roll is applied, after six or eight minutes, in the form of circu-
lar turns over the thigh and under the ball of the foot. These turns are drawn
as tightly as possible, with the object in view of flexing the knee and dorsiflexing
the foot at acute angles. If the bandage goes high up on the thigh and far out
on the foot, there will be a considerable leverage at the command of the operator
(Fig. 220). This roller should always be applied in such direction that the
turns, when drawn tight, will naturally assist in elevating the outer border of the
foot and maintaining eversion, thus: on the right leg the plaster should be
applied, as ordinarily, in the direction of the hands of a clock; on the left, in the

Fig. 220. — Diagram Showing the Advantage of Circular Turns Over the Thigh and Under the
Foot in Gaining and Maintaining the Greatest Possible Amount of Dorsiflexion (Ehren-

FRIED).

reverse. The last inches of this roller should be used in making a tight circular
or two about the calf to draw the plaster which has just been applied close in to
the leg.

" The third roller is put on immediately and is used to cover in the knee and
heel, which have not yet been touched. The plaster here need not be thick, as
it is not essential in maintaining the position; and for the sake of lightness it
had best be appHed in recurrent turns (Figs. 221 and 222).

'' A plaster applied in this way will hold all the correction which can be
gained by manipulation, with the exception of abduction. To obtain this,
the foot should be held abducted while the plaster is drying. In holding the

658 OPERATIONS ON BONES AND JOINTS

HALLUX VALGUS 659

position care should be taken not to indent the plaster with the fingers, or a
slough may result. After it has dried sufl&ciently to maintain its own position,
any trimming which may be necessary about the toes is performed, and it is
a good rule also to split the plaster part way down the outer side, so as to allow
of its being remoyed more readily in case of emergency or when the proper
time arrives.

" The child is not allowed to depart until it is certain, from the color of the
toes, that there is no interference with circulation; and the mother is instructed
to bring the baby immediately or remove the plaster herself if the toes become
white or blue. In a resistant foot, where considerable pressure may have to
be exerted, there is always some danger, but with this form of plaster it is at
a minimum because there is no pressure from plaster under the popliteal space
or in the bend of the ankle.*'

Complications and Sequelae. — Slough and interference with
circulation from pressure of the plaster.

Rigid foot, depending sometimes on maintaining the foot too long
in plaster without manipulation, and sometimes resulting necessarily
from the operation.

Recurrence of the Deformity, — This latter complication is practically
bound to occur unless the postoperative care is followed out with the
utmost patience and assiduity. The foot must be retained in over-
correction by plaster or apparatus, in marked cases, for two years in
children and one year in adults; if by plaster, the bandage must be
changed every two weeks to allow of mam'pulation. The patient should
be kept under observation for a year or Uvo longer. The tendency to
toe-in must be opposed.

HALLUX VALGUS

The operation of Weir, whereby the exostosis is removed and the
severed dorsal tendon is sewed into the side of the phalanx, and W.
J. Mayors operation, whereby the exostosis is removed and the bursa
is turned in to make a new joint surface, are the t\vo best operations.
For either, the curved incision, convex downward, has the best blood
supply, and, therefore, heals best. The objection that the shoe will
press against the scar so placed is theoretic only. A wad of cotton is
placed between the great and next toe. No splint need be applied;
the bed-clothes should be so held up that their weight shall not come
on the toes. The patient may get out of bed on the second day, but
the leg should be kept horizontal for a week. At the end of ten days
the stitches should be taken out and w^alking should be attempted. The
pledget of cotton should be kept between the toes for four wxeks at
least. Right and left stockings should be used, if obtainable, and
flexible anatomic shoes should be prescribed. (See Chap. XXXVI, p.
352.)

66o OPERATIONS ON BONES AND JOINTS

OPERATION FOR SPINA BIFIDA

After operations for spina bifida the one great essential to success
is the prevention of infective material entering the wound. When the
defect is at the lower end of the spine, in close proximity to the rectum,
and the skin over the sac is already macerated and septic, this is
far from easy, and requires the utmost care and watchfulness on the
part of the nurse. The wound is closed tightly with continuous cat-
gut, reinforced by a few silkworm-gut sutures. A dry dressing is
applied and held in place by a tight band. Outside of this a second
dressing is placed, which can be changed as often as soiled. The inner
dressing must be changed about every other day because of the con-
dition of the skin and the danger of the gauze becoming soiled. The
silkworm-gut stitches are taken out at the end of a week. The nursing
or feeding of the infant must, of course, go on as before the operation.
A temperature during the first day or two of the convalescence, even of
105° F., does not necessarily indicate any serious complication. The
same is true of rise in the pulse-rate. Of much more importance is the
way the child takes nourishment. A refusal to nurse or take the bottle
is often the forerunner of a serious complication.

Complications and Sequelae. — Lovett^ has reported 24 per-
sonal cases with a mortality of 37^ per cent., 11 of which were in private
practice, with only 2 deaths. He collected 88 cases from the literature,
with 30 deaths.

(i) Meningitis, — This is an extremely serious complication, and
results from infection, whether at the time of operation or entering
the wound afterward. Twitching of the face, eyelids, or hands should
be treated by the injection of chloral (i gr. for an infant of one month)
or potassium bromid (5 gr. at one month) by rectum, repeated, if neces-
sary, every hour for three doses. Tapping of the ventricles is useless.

(2) Leakage of Cerebrospinal Fluid, — If this cannot be controlled
by pressure, an additional suture must be inserted in the wound, for
unless this leakage can be stopped, death is almost inevitable. The
child is kept lying on its back with the pelvis elevated to prevent too
rapid drainage.^

(3) Superficial Infection of the Wound, — ^Lovett {loc. cit.) stated
that he had met with a few cases of superficial infection, in none of
which had the wound broken down or any other serious complication
occurred.

(4) Later Complications. — An operation for spina bifida cannot be

* Amer. Jour. Orth. Surg., 1907-08, v, 208.

* B. Heile, Berlin, klin. Woch., 1910, xlvii, 2301.

LAMINECTOMY 66l

considered as successful until after the elapse of at least three years,
since within this time many of the children die from hydrocephalus,
convulsions, or intestinal complications. Sachtleben* gives this secon-
dary mortality as 29 per cent.

LAMINECTOMY

The dura is closed without drainage, but a gauze or cigarette drain
is placed down to the dura, and the aponeurosis, muscle, and skin are
closed except at this point. The skin sutures are of silkworm-gut.
A sterile gauze dressing, held with adhesive plaster, is applied, and
outside of this a swathe, if in the dorsal, or a bandage, if in the cervical,
region.

The first dressing is done at the end of forty-eight hours and the
wick omitted. After this the wound is inspected and the dressing
changed at from twu- to four-day intervals, depending upon the amount
of discharge from the sinus. The stitches are removed on the fourteenth
day.

Where the operation is done for a tumor or some similar condition not
associated with injury, no especial support for the spine is necessary.
The patient is placed on an air-cushion and may be turned from side
to side without great difficulty. At the end of three weeks the patient
may get up and begin to move about.

On the other hand, when the operation has been performed after
a fracture of the spine, the convalescence is fraught with complications
and difficulties. When the fracture is in the dorsal or lumbar region,
the spine is immobilized by sand-bags placed under the back and the
patient is placed on a Bradford frame (a gas-pipe rectangle supporting
a canvas hammock). When the cervical region is involved, extension
is employed by means of an extension apparatus like that used for cer-
vical caries. If the patient survives this, immobilization and extension
must be employed for at least six to eight weeks and the patient is then
put in a plaster or leather jacket, which is worn for months or years.

These patients are always, at least at the outset, partly or completely
paralyzed below the level of the lesion. This necessitates the most
careful nursing to prevent bed-sores. The skin must be rubbed ^vice
a day with 50 per cent, alcohol and powdered with talcum or starch and
zinc dusting-powder, especially in the folds. The subcutaneous bony
processes must be protected from pressure by inflated rubber rings.
If there is incontinence of sphincters, a large oakum pad must be placed
beneath the buttocks, frequently changed, and the skin in the region

^ Inaug. Diss., Breslau, 1903; Cent. f. Chir., 1904, xxi, 341.

662 OPERATIONS ON BONES AND JOINTS

carefully dried and powdered. In spite of the necessity for immobiliza-
tion the patient must be turned from side to side, still supporting the
spine with sand-bags, however, to avoid continuous pressure on any
one spot and hypostatic congestion of the lungs. If the skin becomes
broken, the spot must be protected by an inflated ring and the alcohol
and powdering process repeated with increased frequency.

Retention of urine is the rule, but the patient should be catheter-
ized. Catheterization almost inevitably results in cystitis, but it is
delayed in proportion to the cleanliness exercised in the use of the
catheter.

Massage and electricity to the paralyzed extremities will aid in
restoration of function if there is to be any, and later a brace may be
devised, if necessary, to allow the patient to walk. The diet should
be chiefly liquid for the first few days, and if the patient survives and
gains in strength, a fairly extensive diet may be allowed later, even
small amounts of meat and vegetables being given after the first week.
The bowels are moved by enemas if necessary.

Complications and Sequelae. — (i) Leakage of cerebrospitial
fluid after operation is controlled by a tight pressure bandage on the
wound.

(2) Meningitis is one of the most common complications and is
almost necessarily fatal.

(3) Bed-sores should be treated by relief of pressure, using an in-
flated ring, and the daily application of a lo per cent, iodoform in lanolin
ointment. Bed-sores may be the result of trophic disturbances as well
as pressure, and under such circumstances result fatally with great
rapidity. (See Chap. XXXII.)

(4) General infection, pneumonia , bladder infection extending to
kidneys, and shock are common causes of death after fractures of the
spine.

(5) Cystitis, when it occurs, must be treated by constant drainage
and daily bladder irrigations with 4 per cent, boric acid or i : 5000 silver
nitrate solution. Urinary antiseptics are given by mouth.

CHAPTER LII
THERAPEUTIC IMMUNIZATION AND VACC3NE THERAPY

By George P. Sanborn, M.D., Boston

Sometime Assistant in the Laboratory of Professor Sir A. E. Wright, St. Mary's Hospital, London; Physi-
cian for Vaccine and Serum Therapy, Boston City Hospital

Principles of Immunization

Spontaneous recovery from bacterial disease and future lessened
susceptibiKty to a similar infection is evidence that a self-immunizing
power exists; that there is a cellular mechanism of considerable effi-
ciency capable of reacting against bacteria in a destructive manner.
Considering the wide distribution of bacteria in the body, and the
constant exposure to infection of various kinds, we must look upon a
condition of health as a result of the efficient working of this cellular
mechanism; upon actual infection, as indicating its failure; upon
localized infection, as success in protecting the body from the spread
of disease, but failure in being unable to extinguish the infection
locally.

The arrest of pulmonary tuberculosis due to careful hygiene, the
antitoxin treatment of diphtheria, of tetanus, cerebrospinal menin-
gitis, the success of surgery in the treatment of local infections, may be
taken as clinical e\ddence that the immunizing mechanism may be
favorably influenced by treatment. The success of small-pox vac-
cination and the antityphoid inoculation of Wright, of the antirabic
inoculation of Pasteur, are clinical evidence that the immunizing
mechanism is capable of reacting to artificial stimulus in the estab-
lishment of a condition of immunity.

Laboratory research throws considerable light on the means
through which this immunity is brought about. The basis for the
power of self-immunization is that inherent in the animal organism
to adapt itself to overcome changing conditions and noxious influences.
Botany furnishes an example of this adaptation by an experiment
of growing a plant in a poisonous atmosphere. By starting with a
small, gradually increasing percentage of noxious gas, the plant is
found to develop the ability to exist in a concentration such as would

663

664 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

have killed it had the eventual concentration been used at first.
Spontaneous recovery from infectious disease, protection by inocula-
tion or vaccination, are examples of this truth of adaptation.

The purpose of this chapter is to consider the means of increasing
the efficiency of the immunizing mechanism. The following meas-
ures will be considered: Extirpation, drainage, antiseptics, determina-
tion of blood fluids to the affected part by (i) active hyperemia, (2)
passive hyperemia, (3) massage, or (4) suction, antitoxins, vaccines,
exercise, rest, hygiene, bacteriotropic chemicals.

When spontaneous recovery from infectious diseases takes place
the blood is found to possess the ability to destroy the particular
infecting organism or to neutralize its specific toxin, which it did not
possess before. Ehrlich injected ricin into animals in gradually
increasing amount, and found that finally they were able to survive
a dose which if given at first would have caused them to succumb.
This adaptation of the am'mal to withstand toxic doses of ricin de-
pended upon the ability of the mechanism of adaptation to elaborate
a substance with selective neutralizing action upon the toxin; in other
words, specific antitoxin. Horses treated by injection of increasing
doses of diphtheria toxin became immune to excessive doses, quite as
Ehrlich's animals had become immune to ricin. The blood-serum of
the treated horse had the ability of neutralizing the toxin when mixed
in proper proportions, a quality which the normal serum did not
possess. When in human beings recovery from diphtheria takes place
without the injection of antitoxin we know that the mechanism of
immunity has produced sufficient antitoxin to neutralize the poison
entering the blood-stream. Immunity thus produced is active.
Active immunity, then, is that which results from actual infection.

When, in a case of diphtheria, symptoms of toxemia are marked
we conclude that the immunizing mechanism is producing antitoxin
in insufficient quantities to neutralize the toxin as it enters the body.
In such cases we must conceive that the cells concerned in the pro-
duction of antibodies are subject to toxic overstimulation and their
functioning temporarily paralyzed. Injection of antitoxin at once
relieves the cells of the stress of excessive toxemia. This neutraliza-
tion of toxin in the body by injection of antitoxin is entirely inde-
pendent of the patient's immunizing mechanism, and will take place
if the circulation is sufficiently good for the antitoxin to be taken into
the blood-stream. Immunity of this type is termed passive, in that
the immunizing mechanism of the patient has little to do with the
result produced.

OPSONIN AND PHAGOCYTOSIS 665

IMMUNIZATION AGAINST THE BACTERIAL CELL

The power of the animal body to produce substances which shall
protect it is not limited to poisons or toxins. It is found also that in
response to infection with living or to the inoculation of killed patho-
genic bacteria there is a response which may not only direct itself
to the neutralization of the poisons which they contain, excrete, or
secrete, but also which may direct itself to the actual destruction of
the invading bacteria. These antibacterial substances, to be found
in the blood subsequent to infection or to inoculation with certain
killed bacteria, are, for the most part, directed only against those bac-
teria and their poisons which constitute the actual stimulus to the
formation of these antibacterial substances.

ANTITROPINS: AGGLUTININS, BACTERICIDINS, AND BACTERIOLYSINS

So far it has been impossible to isolate these newly formed protec-
tive antitropinSj as they are termed, and they are only differentiated
by the different manner in which they severally exert their power
against the bacteria in response to infection with which they have
been produced, and by their behavior when subjected to certain la-
boratory tests. In response to actual infection with certain organ-
isms, such as typhoid, cholera, and some others, or to inoculation with
killed cultures of the same organisms, the blood-serum is found to have
acquired the power of agglutinating, killing, and dissolving these organ-
isms when brought into contact with them in vitro, and these substances
are named, respectively, agglutinins, bactericidins, and bacteriolysins.
They are not to be demonstrated in an effective amount with serum of
normal individuals. In the common infectious processes due to the
staphylococcus, streptococcus, pneumococcus, and some others, the
blood-serum itself has no such inherent destructive action so far as is
now known, and hence these substances do not seriously enter into con-
sideration as means of protection against these organisms. In the
bodily reaction against typhoid, colon, cholera, and some other infec-
tions the r6le of these antibacterial substances appears to be an
important one.

OPSONIN AND PHAGOCYTOSIS

There is, however, beyond these distinctly antibacterial substances
a fourth factor, the opsonin, which, working in conjunction with the
leukocytes and other phagocytic cells, accomplishes the destruction of
bacteria. The opsonin so affects the bacteria by combination with
their cell protoplasm that the phagocytic cells are enabled to ingest

666 THERAPEUTIC IMMUNIZATION AND VACaNE THERAP\

those microorganisms with which they come into contact. Whereas
the first three antitropins are produced by the body only in response
to a Umited number of infections, the opsonin and the phagocytes
in conjunction exert their destructive effect against all pathogenic
bacteria. As is well known, Metchnikoff, as far back as 1883, at-
tributed recovery from infectious diseases, decreased susceptibility
to any infectious disease from which an individual has recently re-
covered, and in certain cases natural immunity, to the ability of the
leukocytes to ingest and kill bacteria. He did not, however, recog-
nize that the serum had an effect upon bacteria to prepare them
for phagocytosis, but supposed that if the serum had any effect
it was exerted in the way of stimulating the leukocytes to greater
phagocytic activity. In 1895, when Denys and LeClef produced
immunity to the streptococcus by injecting rabbits with increasing
numbers of these organisms, they considered that the reason for this
immunity was the increased ability of the rabbits' leukocytes to ingest
bacteria, but they also attributed this increase in phagocytic power
to the effect of some newly acquired characteristic of the serum result-
ing from inoculation, which had the effect of stimulating the leuko-
cytes themselves more actively to attack and ingest the bacteria.

Actual Role of Opsonin. — The demonstration of the actual
role of opsonin is the result of the researches of Wright and Douglas.
They showed that the leukocytes owe their ability to ingest bacteria
to the presence in the serum of a substance whose function it is to
combine with the bacterial cell and render it palatable to the leuko-
cytes; that this opsonin does not exert a stimulating action upon the
leukocytes themselves in the process of ingesting bacteria; that, in the
absence of serum, bacteria are not ingested by leukocytes excepting in
a negligible degree; that opsonin is a constituent of normal serum, and
is much larger and more effective in amount in the serum of animals
that are made immune to some microorganism by protective inocula-
tion; that, in the human being, upon recovery from certain infectious
diseases, increased opsonic power is demonstrable; that opsonin in
normal blood is active in preparing nearly all varieties of bacteria for
phagocytosis; and that, where there is effective response to any par-
ticular infection leading toward recovery, the increase in the phago-
cytic power is directed only against the infecting organism, the effi-
ciency of phagocytosis against other organisms being approximately
as found in uninfected individuals.

Importance of Phagocytosis to Opsonin. — When path-
ogenic bacteria penetrate the skin or mucous membrane they find

OPSONIN AND PHAGOCYTOSIS 667

opposed to them in the blood-serum neither the agglutinin, bacterici-
din, or bacteriolysin of specific nature, or in amount sufficient to exert
destructive action. This is because, although normal blood may be
lytic, agglutinative, or bactericidal to a very slight degree against
some organisms, it is inconceivable that such normal action can have
any great degree of efficiency. These substances are only called into
being some time after infection has taken place, when their presence
may be demonstrated in the blood-serum. In other words, they
develop as a result of the stimulus afforded by the bacterial poison
in the tissue. They are specific, in that they are directed only against
the particular germ at the stimulus of which they have been developed.
They constitute the secondary specific defence which the cellular mecha-
nism automatically offers after infection has taken place. These specific
means of defence are developed in response to infection by only a few
types of organism, such as colon, typhoid, cholera, and some others.
In the blood-serum, after infection by the staphylococcus, streptococ-
cus, pneumococcus, none of these substances is in effective amount.
In favor of this is the finding of Nuttall, and later of Wright, that the
blood exerts no bactericidal action on the staphylococcus; of Denys,
that the serum of rabbits immunized to the streptococcus had no
bactericidal action.

We must, therefore, at present assume that we have in phago-
cytosis and the opsonin which renders it possible the predominating
factors as first defence against infection. The opsonic power, or the
power of rendering bacteria fit for phagocytosis, is, in general, equal
in uninfected individuals. It is directed with apparently equal ef-
ficiency against any and all pathogenic organisms. We must look
upon the phenomenon of inflammation in its initial stages as the
effort of immunizing mechanism to bring to the point of infection
through hyperemia a continually replenished supply of phagocytic
cells and of opsonin.

In the case of streptococcus, pneumococcus, and staphylococcus
actual infection signifies the failure of the initial phagocytic resistance.
As secondary defence, we find specific increase in opsonic power and
usually no other specific antibacterial element in efficient amount.

Theories as to the Origin of Opsonin and Other Anti-
tropins. — Opsonin and other bacteriotropins probably originate from
the connective-tissue cells as a result of their stimulation by the specific
poisons, inducing them to react in the formation of these protective
substances. It is reasonable to look upon these protective substances
as free receptors which are able to act in their destructive manner upon

668 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

the bacterial cells. In favor of local production of opsonins, that is, at
the point of inoculation of killed bacteria, there is considerable evi-
dence. Theoretic conception of the formation and the manner of
action of opsonins and other antibacterial substances, developed as a
result of inoculation of killed cultures of vaccine, is well shown in Fig.
223. It will be seen that the bacterial vaccine injected locally is sup-

TiMueceuA

Of»*NlZCD jt^

DACTCRtOTflOP(n»

Fic. 223. — Chart Illustrating the Probable Mode of Action of Vaccine When Injected.

posed to disintegrate in the subcutaneous tissue, setting free its specific
poisons, which act upon the body cells and stimulate them to pro-
duce corresponding antisubstances or antitropins, according to the
character of the microorganism injected. These new substances,
opsonins, bacteriddins, agglutinins, etc., as the case may be, are sent
forth into the blood-stream, and conveyed to all parts of the body to the

■"k^^ KZ) TISSUE CELLS

BACYrniOTROHNV

Fig. 224. — Chart Illustrating the Effect of Manipulating an Infected Focus, in Disseminating
Bacteria, and the Probable Mode of Action of this Living Vaccine.

foci of infection and combine with the bacteria in a destructive manner.
In the case of opsonin, a combination is effected with the bacterial
cell which renders it subject to phagocytosis.

Wright not only demonstrated the r61e of opsonin as a factor of
predominating importance in the protective mechanism of the body,
but also developed the method of Leishman, so that it could be

OPSONIN AND PHAGOCYTOSIS 669

used to measure, more or less accurately, the effective opsonic power
of the blood in many infectious processes. The effective opsonic
power of the blood is to be taken as meaning the relative efficiency
of phagocytosis at the instance of the patient's serum, compared to
that induced by the serum of normal individuals, against the same
microorganism. The result of this comparison, that is, the ratio of
the two, he termed the opsonic index.

Determination of the Opsonic Index.— Wright's method for

this determination is briefly as follows: Into a capillary pipet, as shown
(Fig. 225), with a rubber teat aflSxed, are drawn equal volumes of the
blood-serum of a normal individual, of blood-corpuscles which have been

OtAOT.tt

rttt Kt3t*c

A B C C

ftClOe V^tTM ftMCAU

^ TUftea^CBACitu ^ 5eRun — ' iN«c«Teo cbssactckia Too ^/r<ftixwcMf«i

fM. n»m»a.9

Tuaencue eACikLi ^ 9crun — iM«asTco uo AAcrcniA !•• fMouwocm

^ B E InuSiaiocji

^MA^m»ca

PMA4INOCK

Fig. 22s. — Essentials and Method for Determination of the Tuberculo-opsonic Index.

washed free from serum, and of an emulsion of bacteria against which
it is desired to determine the opsonic power of the patient's serum.
Each of these three volumes is drawn into the pipet separated by an
air-bubble, and then expressed upon a slide, mixed thoroughly, drawn
into the pipet again, the pipet sealed in a flame, and incubated for
fifteen minutes at 37.5° C. A similar procedure is carried out, using
the same corpuscle and the same emulsion of bacteria, but the patient's
serum instead of the normal, and incubation is carried out for the same
length of time. These pipets are removed at the end of the incuba-
tion period, the small end broken off, and the contents expressed upon
a clean slide, mixed thoroughly, and a small drop of this mixture placed
upon a clean slide, and a smear made. Each of the mixtures is treated
in this way. If the smears are then stained and the leukocytes scru-

670 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

tinized it will be found that they have ingested numbers of bacteria
in each of the specimens. All the bacteria contained in 100 leukocytes
in the case of each slide are counted, and the average number ingested
by each leukocyte is calculated. This number is termed the phagocjrtic
index. The opsonic index is determined by dividing the average number
of bacteria f)er leukocyte which have been ingested in the experiment
with the patient's serum by the average number ingested in the experi-
ment when the normal blood-serum is used. The resulting figure repre-
sents the ratio between the phagocytic power of the patient's and the
normal serum, the normal serum being considered as unity. An opsonic
index, therefore, of 1.5 indicates that the effective phagocytic power or
opsonic power of the patient's blood is one and a half times that of the
normal individual. If the result of the division is 0.5, it shows that the
effective phagocytic or opsonic power of the patient's serum is just half
that of the normal individual. In order to obtain an average normal
serum it is the custom to mix the blood-serum of several individuals who
are known not to be infected with the particular organism in question.

Sisrnificance of Measurements of the Opsonic Power of
the Blood. — Inasmuch as, in response to infections by all pathogenic
bacteria, opsonin is a factor in the immune reaction, we expect the
measurement of the opsonic power of the blood to give some indication
as to the character of the response. In infections due to staphylococci,
streptococci, and pneumococci, and others in which phagocytosis ap-
pears to be the predominating factor, we expect the opsonic index to
furnish a more definite clue to the success of the response to bacterial
stimulus than in infections such as colon and t>T)hoid, iii which, in
addition to opsonin, we find agglutinin, bactericidin, and bacteriolysin
as factors in the inmaune reaction. We can only say that the opsonic
power elevated above the normal is indicative of a favorable response
of the immunizing mechanism. It is possible also to measure roughly
the agglutinin and bactericidin. Attempts at measurement of these
factors are more important as a basis for certain fundamental truths
as to the functionating of the mechanism for adaptation than as rep-
resenting any definite valuation of the efficiency of the immunizing
mechanism in any given case.

To summarize briefly, the animal body has the ability to adapt
itself to noxious influences in a varied manner, depending on their
chemical character. The seat of this mechanism of adaptation lies in
some particular cells or groups of cells. These cells have the power,
in response to noxious stimuli, to form substances which are applied
by means of the blood to neutralize such stimuli or destroy them if
they be bacterial in type. A condition of health presupposes con-

OPSONIN AND PHAGOCYTOSIS 67 1

stant activity and eflSciency of this mechanism directed against bac-
teria endeavoring to invade the tissues. Actual infection indicates
its failure. Recovery from infection indicates its complete success.
Chronic local disease indicates a partial success in protecting the rest
of the body, but failure in being imable to extinguish the infection
locally.

The finer workings of this immimizing mechanism appear to be
manifested largely in the production of specific chemical substances
which circulate in the blood, as antitoxins, to neutralize the poison:
agglutinins, bactericidins, bacteriolysins, and opsonins, which have
specific chemical effect upon the bacteria leading to their destruction.
The prevention of infection seems largely due to eflScient phagocy-
tosis, this depending upon the normal antibacterial constituent of the
blood, opsonin. The other chemical means of defence are only called
into being after disease has foimd its foothold.

Acquired Immunity. — Recovery from an infectious disease, and
subsequent non-susceptibility to infection by the causal microorgan-
ism, presupposes that adaptation has taken place, and in some in-
fections, such as typhoid, we may find expression of this phenomenon
in the acquired ability of the blood fluid to agglutinate, kill, and dis-
solve the typhoid bacillus. We anticipate a definite degree of im-
munity from this disease as long as we find evidence of specific anti-
typhoid power in the blood. Even after they disappear the usual
freedom from subsequent attacks of the same disease suggest that the
immunizing mechanism still retains latent power for renewed attack,
if it becomes necessary.

We must attribute recovery from measles, scarlet fever, and small-
pox to a similarly fashioned process, though neither the microorgan-
isms nor specific antibacterial substances in the blood after recovery
have been demonstrated. Immunity thus acquired is usually per-
manent.

Recurrences of pneumonia, erysipelas, and furunculosis are com-
mon. The reason appears to be that the persistence of specific opsonin,
which apparently is the most important factor in immunity, is of brief
duration after recovery from the attack.

Artificially Produced Immunity. — If it be desired to produce
immunity to a specific infectious disease, it is obvious that means must
be used which will insure the presence of specific antitropins in the
blood. This result may be produced by inoculations with living atten-
uated microorganisms, producing a non-fatal disease, or by injection
of killed microorganisms known to produce the particular disease.

672 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

We have an example of immunity through production of non- fatal
disease in the protection against small-pox. The universal success of
vaccination in connection with other successful attempts at immuni-
zation of animals by using attenuated bacteria, as in the case of an-
thrax, furnishes a basis for the belief that the immunity is due to a
similar production of antitropins and has the same basis of cell stimula-
tion and adaptation.

Immunity Through Injection of Killed Bacteria. — The immunizing
mechanism shows a remarkable versatility in its varied methods of
adaptation against different bacteria. This must depend on differ-
ences in the chemical composition of the bacteria or of the toxin they
produce. In diphtheria the disease is chiefly produced through diffus-
ible toxin. Immunity appears to depend chiefly upon the defence
fashioned particularly to neutralize the toxin. In the case of typhoid
no diffusible toxin comparable to that of diphtheria has been demon-
strated. In this instance the antibacterial attack is distinctly against
the bacterial cell. It is quite the same in pneumococcus, streptococcus,
and staphylococcus infections.

The stimulus to the formation of these distinctly antibacterial
substances must derive itself from the chemical quaHties of the pro-
tein composing the bacterial cell. It is inconceivable that the intact
bacterial cell can serve as such a stimulus, and it is probable that the
antigenic activity reaches its fullest efficiency only upon disintegra-
tion of the bacteria in the tissues.

Definition of the Term Vaccine. — The immunizing response of
the body in the production of bacteriotropic or antitoxic substances de-
pends upon the stimulus afforded by pathogenic microorganisms or
their toxins. This response takes place, first, in the natural course of
the disease process; second, as the result of protective inoculation with
attenuated microorganisms; third, of killed microorganisms; fourth,
of bacterial poisons, secreted or excreted, or produced through disin-
tegration of bacteria in their growth upon culture-media.

To such inocula Wright has given the term vaccines. The bac-
terial cell exerts its most efficient stimulus only when disintegrated, so
that its chemical constituents are set free; consequently we should
define vaccine as any chemical substance which, when it is introduced
into the body, induces the elaboration of protective substances, bacte-
riotropic or antitoxic elements.

Bacterial Vaccine. — A bacterial vaccine is a suspension of
killed bacteria in suitable solution, with sufficient added preservative,
as carbolic acid, to insure constant sterility. Such a vaccine is stand-

OPSONIN AND PHAGOCYTOSIS 673

ardized as to the number of separate bacteria contained per cubic
centimeter, or weight of bacterial substance per cubic centimeter.

We have in the case of typhoid, plague, and cholera examples of
bacterial vaccines in protective inoculation. In protective inoculation
against small-pox the vaccinating stimulus is living, producing a mild
disease and resulting in development of specific protective elements.
Antirabic vaccine is composed likewise of living attenuated micro-
organisms given in successively increasing doses.

Production of immunUy after infection has taken place by means
of vaccine was first accomplished by Pasteur in antirabic inoculation.
The purpose was to produce by artificial means a more rapid develop-
ment of specific protective substances than would occur in the natural
course of the disease. It is assumed that antirabic vaccine, though
attenuated, has the chemical properties of the virulent virus, but is
incapable of producing disease. It is assumed that there is insufficient
formation of antibodies normally because the cells in and about the
focus of disease are subject to toxic overstimulation and do not func-
tionate efficiently. Injection of a harmless vaccine in unpoisoned
cellular tissue exploits the immunizing function of the normal cells in
the interests of cellular tissue already poisoned and unable to func-
tionate.

Demonstration of Production of Antitropins by the Use
of Killed Cultures and Their Application for Production of
Immunity in Human Beings. — Pfeiffer found that specific agglu-
tinatingpower developed in the blood of individuals inoculated by killed
typhoid culture. Based on this finding, Sir A. E. Wright pursued fur-
ther studies, and found that after a single inoculation the bactericidal
power of the blood could be increased sometimes a thousandfold.
Later he demonstrated that a high opsonic power could also be pro-
duced. These findings suggested the use of killed cultures to immu-
nize by artificially inducing elaboration of specific typhotrophic sub-
stances. Wright tested the efficiency of this method during the Boer
War in South Africa. The results more than fulfilled expectations.
Mortality and incidence of the disease among those inoculated were
each cut down one-half, compared with the same in an uninoculated
group.

As a result of his study of the production of bactericidins in the
blood of individuals subsequent to protective typhoid inoculation,
Wright was struck by the fact that there was a definite sequence of
events in the production of bactericidins in every case, and that the
same sequence of events is to be observed in the production of other
43

674 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

antibacterial substances, particularly the agglutinins and the opsonins.
The features of the bodily reaction Wright gives as follows:

In every case following inoculation of vaccine there is a negative
phase, characterized by an impoverishment of the blood in antitropic
substances. (Associated with this negative phase is a condition of in-
creased susceptibility to bacterial infection or to the toxic effect of the
toxin used. This negative phase coincides with the period which may
be associated clinically with greater or less constitutional distress.)

Succeeding the negative phase is a so-called positive phase , charac-
terized by flooding the circulating blood with newly formed antitropic
substances. (It is presumed that this phase is associated with a maxi-
mum resistance to bacterial invasion and minimum sensibility to the
poisonous action of the vaccine.) There next comes a fall in the bacte-
riotropic content, resulting in a slightly lower bacterial resistance, but,
compared to the period before inoculation, the blood shows an increase
in its antitropic elements. (The body at this period, however, and
subsequently seems to possess a greater power of response to the same
vaccinating stimulus.) Wright sees in the negative phase a period of
stimulation of the body-cells by the vaccine; in the positive phase, a
period in which active protective response is heralded by marked in-
crease in the antitropic substances, and after the remission of the
stimulus and a sHght fall in the antibacterial power, a more or less con-
tinued period of increased resistance.

The importance of this sequence of events, which he has shown to
be the case in the production of bactericidins, Wright believed to be
fundamental, as a delineation of the character of protective response
in general. If this is so, measurements of other protective substances,
such as antitoxins, agglutinins, and opsonins, should follow a like course
in their development. Ehrlich and Brieger, in 1893, showed that a
corresponding curve was obtained from measurement of the antitoxic
content of the blood subsequent to inoculation. Jorgensen and Madsen
found that the law of positive and negative phase applied likewise to
the elaboration of agglutinins after inoculation in typhoid and cholera.
Later, by measuring the variation in the phagocytic power subse-
quent to staphylococcic inoculation, Wright showed that the same
sequence of negative and positive phase was to be observed.

THERAPEUTIC INOCULATION

Therapeutic inoculation, as developed by Wright, is an offshoot
of protective inoculation. His study of the immunizing response
following protective inoculation led him to suspect that a similar

THERAPEUTIC INOCULATION 675

response might be produced in the case of actual chronic infectious
disease; that the antibacterial power of the blood could be increased
by inoculation of killed bacteria. In 1900 he made use of a staphy-
lococcic vaccine in a case of chronic skin infection. About a year
later he published his results of therapeutic inoculation in staphy-
lococcic infections. He found that, in connection with the clinical
success of the experiment, the phagocytic power of the blood was in-
creased following the inoculation; that there occurred the same
sequence of negative and positive phase in the variation of the phago-
cytic power of the blood that he had observed following protective
typhoid inoculation in the variation of the agglutinins andbacteri-
cidins. This definite sequence of variation in the antibacterial
power of the blood following inoculation by vaccine, the negative
phase followed by the positive phase, shown by Ehrlich and Brieger
to take place in antitoxin production; by Jorgensen and Madsen
in the case of agglutinins after typhoid and cholera inoculation;
by Wright in the case of agglutinins and bactericidins following
typhoid inoculation; and, lastly, in the phagocytic power of the blood
following staphylococcic and other vaccines, may be termed the law
of negative and positive phase, and is of absolutely fundamental im-
portance for several reasons, particularly as indicating the char-
acter of the response to be sought in the endeavor to increase the
antibacterial power of the blood.

Thus it remained for Wright to show that the antibacterial power
of the blood could be increased by appropriate inoculation after infec-
tion had taken place and had become chronic; that, correlated with
this evidence of heightened immunity, clinical improvement took
place.

The Relation of Protective Inoculation to Therapeutic Inoculation.
— The success of protective inoculation in general cannot be ques-
tioned. As against typhoid, it induces the formation of antibacterial
substances in the blood that could not be demonstrated before.
It cannot be said, however, that in the case of normal individuals a
total lack of immunity to any infection exists. Protective inocula-
tion materially raises the specific antibacterial power of the blood,
in which, in all probability, some degree of immunity already ex-
isted.

In protecting against streptococcus, pneumococcus, staphylo-
coccus, and the like, we must usually assume previous or present
infection by these common organisms. It may have been of such
minute proportion that we have not been aware of it. That such

676 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

has occurred and has remained local, presupposes that there has been
a specific reaction. On the whole, therefore, it is justifiable to con-
clude that protective inoculation merely raises to a higher level
immunity already, in some degree, possessed.

In therapeutic inoculation we start with the knowledge of infec-
tion that already exists. As Theobald Smith^ puts it, when we in-
duce immunity we simply stimulate the body to a higher resistance
rather than put into it something that was not there before. Pro-
tective inoculation and therapeutic inoculation do not diflfer, there-
fore, in principle.

The problem of therapeutic inoculation, in raising the immunity
when definite local infection exists, is obviously much greater and
more complicated than that of protective inoculation. It is easy to
see wherein the preparedness against invasion by specific micro-
organisms, afforded by protective inoculation, may destroy invading
bacteria before disease can be produced. That therapeutic inocula-
tion in the actual presence of infection is efficient in raising the im-
munity to the extent of curing the disease, or even of benefiting the
patient, is not so easy to see at first, and certainly requires both
laboratory and clinical evidence to support it. Interpretation of
Pasteur's success in antirabic inoculation after infection is per-
haps the first clinical evidence of the efficiency of therapeutic in-
oculation after disease organisms have entered the body. From the
researches of Prof. Sir A. E. Wright we find not only laboratory evi-
dence of increased bacterial resistance following therapeutic inocula-
tion, but also clinical evidence of the effect of this increased antibac-
terial power upon bacterial lesions, as leading to their control and
oftentimes their cure when more or less localized in their type.

The Study of the Immune Response to Infection as Indi-
cated by Opsonic Index Determinations. — The opsonic index
is no measure of the total degree of immunity of the patient. Its
variations, under varying conditions of health, disease, and after
therapeutic inoculation, are merely to be taken as indication of
whether or not the antibody forming mechanism is giving evidence
of response in ^he production of specific antibacterial substances.
Indication may be obtained through opsonic index determinations,
in conjunction with clinical observation, as to whether there is too
great or too little bacterial stimulus, and what the conditions are which
govern the acquisition of this bacterial stimulus.

Opsonic Power in Health. — The opsonic power of healthy

* Medical Communications, Mass. Med. Soc., vol. xxi, No. 3, 1910, p. 766.

THERAPEUTIC INOCULATION

677

individuals conforms to a certain mean, the variation being slight in
the same individual from day to day or in different individuals com-
pared to each other, as against any microorganism with which none
of them is infected.

Fleming* has reported observations made in Wright's laboratory
on the opsonic power in individuals whose blood has been used as
normals in the routine opsonic technique in Wright's laboratory.
Between 600 and 700 indices were determined upon these normal
individuals, and it was found that in 97.5 per cent, of the cases the
extreme variation was between 0.90 and i.io, but that in only 2.5
per cent, of the determinations the indices were either above i.io

Fig. 226. — Vasiation of the Opsonic Index in Normal Individuals. Based on 63s Determinations.

This chart shows graphically the results of 635 tuberculo-opsonic index determinations on the blood of a
number of individuals clinically uninfected by tubercle. These individuals were, for the most part, laboratory
workers whose sera were constantly being used as "normals" in opsonic index determination. These observa-
tions were collected by Fleming and reported in the "Practitioner," London, May, igo8, all from the records
of Sir A. E. Wright's laboratory. It will be seen that 76.7 per cent, of the indices fell within 0.95 to 1.05; lo.i
per cent, between 0.90 and 0.95; 10.7 per cent, between 1.05 and i.io; and 2.5 per cent, below 0.90 or above
I.IO. Hence it may be concluded that the variation of the tuberculo-opsonic indices in normal individuals is
within comparatively small limits, 94.5 per cent, being between 0.90 and i.io.

or below 0.90. In three-fourths of the cases there was a variation
between 0.95 and 1.05; that is, a range of variation of o.io.

Bulloch^ showed that the opsonic indices of 34 medical students
compared to his own serum, which was considered normal against the
tubercle bacillus, showed extreme variation from 0.8 to 1.2. But three
of these cases showed indices above i.io or below 0.90, or about 12
per cent. The remaining cases — 31 — or 87.5 per cent. — were between
0.90 and I. The average normal opsonic index was 0.965. The
index obtained in the same way from 32 healthy hospital nurses

* Practitioner, London, May, 1908.

* Trans. Path. Soc, London, 1905, vol. Ivi, part 3.

678 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

showed a variation between 0.80 and i.io. Again, he found that
about 87.5 per cent, fell between 0.90 and i.io, with the average
normal opsonic index as 0.969.

Urwick, in 20 cases, found about 80 per cent, between 0.90 and
1. 10.*

It appears, then, that the opsonic indices of normal individuals
practically all fall within a certain definite range of variation. This
holds true against other pathogenic bacteria as it does against the
tubercle bacillus. The reason for this variation is probably partly
due to unavoidable error in opsonic technique. We see that the
extreme limit of variation is 0.20 in from 87 to 97 per cent, of the
cases. This furnishes us a reasonable basis for the conclusion that,
if the opsonic technique is skilfully carried out, as these observations
would suggest, there is no reason why the experimental error should
be any greater in the determination of the opsonic indices of the serum
of infected individuals than it is in that of the normal.

The significance of these observations is that healthy individuals
may be considered as having equal ability invested in their phago-
cytic mechanism of ingesting bacteria as they enter the body. In the
absence of any definite knowledge of other means of ready attack, it
is certainly suggestive that the opsonin, in conjunction with the leuko-
cytes, constitutes the early and active defense against any and all
invading bacteria.

Opsonic Power as Influenced by Presence of an Infectious
Process. — After infection has taken place variations in the opsonic
index against the infecting microorganism are found, depending on the
character of the infection, as to whether it is localized, fulminating,
or general. The variation may be above or below normal and the
excursion wide, from day to day or from hour to hour, in infections
of the acute fulminating type. The important point to be noted is
that, whatever the variations in the opsonic power, they are specific
against the microorganism producing the infection. If the blood be
tested against some microorganisms with which the patient is not
infected no striking variations in the opsonic power will be found.

The fact of these variations after infection suggests a possible
difference between the normal opsonin and that which is developed
specifically after infection. There are certain differences between
immune opsonin (that developed subsequent to specific infection)
and the normal opsonin found in the blood of healthy individuals.
So far as the present discussion is concerned, however, whether this

* Studies on Immunization, Wright, p. 145.

THERAPEUTIC INOCULATION 679

difference be in amount or in character is unimportant. The effect
in making phagocytosis possible is the same.

I<ocalized Infections. — Localized tuberculosis may be taken as
a type of strictly local infection, though, of course, in no case can one
say that bacilli are not entering the blood-stream. However, from
the condition of apparent health, the absence of temperature asso-
ciated, we conclude that the process is essentially local. In this
group of infections we include local tuberculous lesions, acne, furun-
culosis, carbuncle, and traumatic infections that have passed the
acute stage and have become indolent.

In these local pyogenic and tubercular infections the opsonic
power of the blood is found to be characteristically below normal.
The more chronic and localized the disease, the more constant the
finding of low opsonic power of the blood-stream.

Systemic Infections. — Passing on to the condition of the op-
sonic power of the blood in acute infections or infections associated
with systemic disturbance and temperature, we are struck at once
by the marked variations. Wright' reports opsonic indices upon
the blood of a child suffering from tuberculous caries of the fibula,
associated with constitutional disturbance. There were seven in-
dices determined at from one- to nine-day intervals. The extreme
limits of variation were from 0.98 to 1.73. It should be noted
that on the two days following a scraping operation the index,
which two days before the operation was 0.98, was increased to 1.73.
As a note, in explanation of this elevated index, Wright states:-
'^ A rise in the opsonic power similar to this here registered has been
repeatedly observed by us in connection with the stirring up, by
surgical interference, of tuberculous foci.'' A case of tuberculous
caries of spine with constitutional disturbance gave five indices, de-
termined at from one- to two-day intervals, ranging from 0.65 to 1.4.
A case of the same kind gave three indices ranging from 0.6 to 2.4,
taken at one- and two-day intervals. Other observers have con-
firmed these wide fluctuations in the opsonic power in pulmonary
tuberculosis and tuberculosis of the non-localized type.

In acute fulminating infections and the so-called septicemias due
to pyogenic organisms, wide variations in the opsonic power of the
blood have been observed, and are to be considered characteristic.

Associated with various diseases which undermine the patient's
health we sometimes find a condition of furunculosis. During

* Proceedings of the Royal Society, 1906, vol. xxvii.

* Studies in Immunization, p. 153.

68o THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

systemic infections like typhoid it is common. In cases of diabetes
patients are conspicuously subject to staphylococcic infections. A
series of i6 cases of diabetes mellitus were studied with reference to
the condition of the opsonic index, suspecting that a condition of
lowered opsonic power accounted for the susceptibility to staphylo-
coccic infection. This study, made by DaCosta, and reported in
the American Journal of Medical Sciences, July, 1907, p. 57, showed
that the average opsonic index was 0.62 and the range from 0.34 to
0.72.

A reason for the low opsonic power of the blood-stream in the pres-
ence of localized infection is. suggested by the laboratory experiment
of adding large numbers of bacteria to a highly immune serum taken
from an animal immunized by injection with corresponding bacteria.
If sufficient bacteria are added the serum will be found to be almost
totally depleted of its specific antibacterial power. It is easy to
show that this loss is due to combination with the bacterial cell.
Blood fluids lose their antibacterial power by combination of their
immune substances with bacteria, at the stimulus of which these
substances were developed. It seems reasonable, therefore, in the
case of localized infections that the antibacterial power of the blood-
stream should be subnormal, and that this should be due to gradual
abstraction by combination with bacteria and bacterial substances in
and about a focus of infection.

The usual walled-off condition of localized infection produces a
more or less restricted blood-supply. This is to be taken as a reason
for the inability of the blood-stream to receive bacterial substance
which should constitute stimulus to the formation of antibacterial
substances. Hence, segregation of a focus of infection is an im-
portant factor in producing a low antibacterial power of the blood-
stream.

The significance of wide fluctuations in opsonic power in non-
localized or systemic infections is that the blood-stream must be
receiving bacteria from the focus of infection, and possibly may be the
seat of actual growth. Otherwise there would be no such evidence
of immunizing respjonse.

The Antibacterial Power of the Blood-stream Compared with that
of the Tissues in a Condition of Health. — Bacteria entering the blood-
stream have arrayed against them practically all the defensive forces
of the body in the antibacterial elements of the serum and its phago-
cytic cells. They stand but little chance against this formidable
first defence. Bacteria entering the tissues, however, meet with a

THERAPEUTIC INOCULATION 68 1

defense which is much weaker, in that at the point of entrance there
can be only limited numbers of phagocytic cells, and such opsonin
as the fluids in the immediate vicinity contain. This defence is in-
finitesimal compared to that which the blood-stream, with its whole
force of leukocytes, entire concentration of opsonin, and possibly
other protective substances, presents.

Should bacteria enter directly into the blood-stream, therefore,
the chances of their resisting the phagocytic attack are obviously
much less than in the case of their entrance into cellular tissue.
The rarity of septicemia compared with the frequency of local infec-
tion bears this out clinically. The tendency of local infection to
remain local is also clinical evidence of the high antibacterial efficiency
of the blood-stream, as compared with that of the tissues and their
fluids in which the bacteria have been able to gain a foothold.

When bacteria penetrate the protective barrier of the skin or
mucous membrane they meet with the first active defence in the op-
sonin and phagocytic cells of the immediate vicinity. The fact that
infectious disease is comparatively rare, while minute infection is
suggestively a daily occurrence, leads to the conclusion that the body
is capable of furnishing a defence that is efficient beyond the degree
that would be expected of the few phagocytic cells and opsonin in the
tissue at the point of infection.

The body's means of strengthening the local antibacterial attack
is through the early reaction of inflammation, active hyperemia.
Through this phenomenon the protective mechanism is enabled to
bring into contact with the infected focus a continuously fresh supply
of antibacterial substances and fresh replacement of leukocytes.
To this automatic response we must ascribe, to a large degree, freedom
from infectious disease.

Failure in this initial defence is signalized by the development of
actual infectious disease. That bacteria have been able to overcome
the normal defence may be due to extreme virulence, to their numbers,
to their entrance where blood circulation is deficient, or, finally, to a
blood-stream deficient in protective substances.

Virulence, — It has been shown by Rosenow^ that, when virulent
pneumococci are added to a normal serum, in vitro y and then brought
into contact with living active phagocytes, they are not ingested.
This indicates that these virulent pneumococci are not acted upon
by the opsonin in normal serum in a manner effective enough to render
them phagocytable. They may contain some substance having an

* Illinois Med. Jour., iqo8, xiii.

682 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

antiopsonic effect. The same phenomenon occurs in the case of
virulent streptococci. In the case of the pneumococcus, Rosenow
found that this resistance to phagocytosis was due to a quality which
they possess when virulent, but lose after growth on culture-media.
He was able to extract from virulent pneumococci a substance which,
when brought into contact with non-virulent pneumococci for a
number of hours, rendered them insusceptible, relatively, to phago-
cytosis.

In the above, we have laboratory proof of resistance of bacteria
to phagocytosis, probably due to resistance to opsonification, in the
case of the streptococcus and pneumococcus. It is readily con-
ceivable that in actual infection by these organisms, and possibly
others, no matter how effective the opsonin or the phagocytic cells
may be under ordinary conditions, they may, in the manner sug-
gested in Rosenow's experiment, render the phagocytic attack almost
powerless through extreme virulence.

Entrance of Excessive Numbers of Bacteria, — It is easy to con-
ceive how excessive numbers of bacteria entering at one point may
cause immediate abstraction of local antibacterial substances and
thus many may escape the phagocytic attack. Such will be apt to
find conditions suitable for growth in fluids of low antibacterial power.
Beyond the production of local conditions suitable for growth through
abstraction of antibodies, if considerable numbers of bacteria enter
the blood-stream there will also occur a lowering of the antibacterial
power through combination with the bacterial cells, and this deple-
tion may be accentuated conceivably if the numbers of bacteria that
enter the blood-stream are sufficient to so overstimulate the anti-
body forming cells that protective response temporarily fails. The
condition of lowered antibacterial power of the blood-stream thus
brought about not only makes possible the spread of the disease
locally, but also the development of secondary foci of infection.

Infection at Points of Deficient Circulation. — Theoretically, parts
of the body which are poorly vascularized should be favorable points
for bacteria to lodge and grow. The skin is mechanically a good
protection. Its vascularity is a most excellent secondary defense.
Bacteria getting beyond the limits of a superficial infection run a very
good chance of being destroyed in the blood-stream if normal in its
antibacterial efficiency. If, for reasons above stated or others, as will
be suggested later, the opsonic power of the blood is below normal
or defective, bacteria may exist long enough in the blood to reach
points of more or less sluggish circulation, such as the tendinous in-

THERAPEUTIC INOCULATION 683

sertion of muscle about the joints, the joint capsules, and bone.
The sluggish capillary circulation may conceivably result in a few
bacteria lodging in the tissues and causing depletion of the lymph in
the immediate vicinity in its antibodies. The possibilities of this
focus receiving suflScient quantum of antibodies to replace those de-
pleted by growth of bacteria is limited by the fundamental defi-
ciency of the blood-supply. The bacteria find suitable conditions
for growth.

The development of tuberculous and other bone diseases following
trauma which does not produce any abrasion of the skin indicates
infection from within; that the trauma has produced a condition of
local susceptibility to infection. It is reasonable to ascribe this
local susceptibility to the disturbance of circulation by rupture of
capillaries and exudation of blood fluid, a resulting stagnant condition
of lymph, and difl&culty in the replacement of this lymph by fluid of
higher antibacterial power. Thus are afforded to microorganisms
that chance to reach such a focus comparatively unrestrained op-
portunities for growth.

Entrance of Bacteria Into the Blood-stream Deficient in Its Protec-
tive Power. — In diabetes clinical experience indicates an increased sus-
ceptibility. DaCosta has shown the reason in the low opsonic power
of the blood-stream. Further clinical experience has shown that
patients suffering from generalized infections may be unusually sus-
ceptible to infections of other types. In wasting diseases, such as
typhoid, it is not uncommon to have furunculosis as a complicating
infection.

In endeavoring to account for infectious disease other than acci-
dental traumatic infection, we must bear in mind that human beings
are, most of them, subject to minute infections by the common
pyogenic microorganisms, such as streptococcus, pneumococcus,
staphylococcus, and possibly colon bacillus, almost constantly. The
difference between infection and infectious disease is merely one of
proportion. In the first case the infection may not be noticeable;
in the second, it produces signs and symptoms. That these infec-
tions continue to be minute means a well-grounded immunity of the
blood-stream. If anything happens, however, to disturb this favor-
able balance of immunity the bacteria are there to take advantage.
The conditions which affect the normal immunity of the blood-stream,
rendering it less efficient, are known only in a general way. Lack
of food, physical exhaustion, and lowering of the body temperature
may be mentioned as possible factors.

684 THERAPEUTIC IMMUNIZATION AND VACaNE THERAPY

The retention in the body, through inefficient excretion of toxic
substances from faulty metabolism, may conceivably limit antibody
production, or neutralize antibodies after they are produced, or,
finally, paralyze the phagocytic cells. Thus, the normal antibac-
terial efficiency of the blood-stream conceivably may be seriously
depleted by conditions concerning which we have no knowledge and
for which we have no remedy.

It is inconceivable that the use of bacterial vaccine should have
anything but temporary efficiency in the case of localized infections
developing as a result of generally lowered antibacterial power of the
blood-stream from such obscure causes. It may be that the opsonic
power of the blood may be temporarily increased by exhibition of
vaccine, but the fundamental process at the basis will maintain
itself in spite of bacterial stimulation.

It is reaosnable to make use of bacterial vaccines when it is
found that the opsonic power of the blood-stream is low, or in the
case of infections comparatively localized in type in which we know
it to be low, but, with the above considerations in mind, it is folly
to assume that bacterial vaccine should fulfil the indications in all
cases.

The Significance of a Localized Infection, — The development of
a focus of infection signalizes the failure of the immunizing mech-
anism, through the early phenomenon of hyperemia, to focus at the
point of infection blood fluids of sufficiently high bacteriotropic
power and, possibly, phagocytes in sufficient numbers to destroy the
bacteria before an actual disease focus is produced. When the focus
of infection becomes localized we see in this success of the secondary
defence, which consists essentially of an efficient walling off of the
infected area, a blood-stream of specifically elevated antibacterial
power as against the infecting bacteria, and probably an increased
circulation in the tissues adjacent to the disease focus.

The Conditions in the Focus of Infection. — When toxins have been
produced in sufficient amount, the circulation sufficiently cut off by
exudation and swelling, and there has been a pouring out of leuko-
cytes and liquefaction of tissues, there is thus produced an abscess-
cavity surrounded by a wall of tissue infiltrated, swollen, and full of
bacteria. The interchange of blood and lymph through this wall
must necessarily be deficient and the fluids in it more or less stagnant.
The antibacterial content of the lymph becomes depleted by com-
bination of antibodies with the bacteria present, and offers consider-
ably less obstruction to bacterial growth than the normal fluids of the

THERAPEUTIC INOCULATION 685

blood-stream. The actual pus may be almost entirely deprived of
its opsonic power, as shown by Wright.^

A tryptic ferment derived from broken-down leukocytes is a con-
tent of pus in the case of pyogenic infections. When pus is under
pressure its effect is to dissolve connective tissue and probably to
afford new channels for bacterial extension.

The antibacterial content of fluids in a focus of infection has been
shown conclusively to be subnormal. This is due to abstraction of
protective substances of stagnant lymph by combination with bac-
teria, and Wright has shown that apparently healthy leukocytes de-
rived from pus, even when in contact with healthy serum, have lost
their power of phagocytosis.

The conditions, therefore, in the focus of infection, stagnant
lymph of low antibacterial power, impossibility of sufficient inter-
change of fluid from the focus of infection with the highly protective
fluid of the circulating blood (this dependent upon the obstruction to
circulation through swelling and the walling off process) , are such as
to supply conditions suitable for bacterial growth, and favor a per-
sistence of infection locally.

Brawny infiltration, such as carbuncle, is an example of the
condition in which bacteria cultivate themselves, to a considerable
degree safeguarded from the circulating blood through swelling, exu-
dation, and walling ofT about the focus of disease.

The Effect of the Existence of a Localized Infection on the Anti-
bacterial Power of the Blood- stream. — While the opsonic power of the
blood-stream has always been found to be much higher than the fluid
in the focus of infection in a given case, it is generally found, in the
case of chronic localized infection, such as local tuberculosis, lupus,
and acne, that the opsonic power of the blood-stream is depleted
much below the normal. This is due, on the one hand, to the lack
of bacterial stimulus to be obtained from the focus of infection on
account of its comparatively segregated condition; second, because
of gradual loss of opsonin which it should normally possess through
continuous contact with bacteria and toxin in the outskirts of the
focus of infection.

Physiology of the Protective Response. — In the normal
individual the blood-stream is to be considered the reservoir of anti-
bacterial power. Its fluids contain opsonin and phagocytic cells,
together of sufficient antibacterial power to destroy microorganisms
that enter. The blood is capable of being directed in abnormally

^ Proc. Roy. Soc., 1904, vol. Ixxiv.

686 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

large amount, through the reaction of inflammation, to any part of
the tissue that becomes a point of bacterial invasion.

The reaction of inflammation is, from beginning to end, essentially
a protective process. One of its earliest phenomena, active hyperemia,
indicates the endeavor of the immunizing mechanism to render the
bacteriotropic pressure at the point of bacterial invasion as nearly
as possible equivalent to that of the circulating blood.

The wide distribution of pathogenic bacteria on the skin and
mucous surfaces of the body suggests that the condition of health is
the outcome of constant strife between the bacteria endeavoring to
enter the tissues and the repelling forces of the opsonins and phago-
cytes reinforced constantly from the blood-stream.

The fact of infectious disease registers not only the failure of the
phagocytic attack, but also of the reinforcement derived from the
blood-stream through the early reaction of inflammation, hyperemia.
Numbers of bacteria, having avoided the initial phagocytic attack^
deplete fluids locally of their opsonin, multiply, and may fairly soon
give evidence of entrance into the blood-stream by the production of
temperature. The clinical evidence locally is that of a spreading
infection. Opsonic measurements of the blood-stream at this acute
stage show evidence of depletion in antibacterial power.

Bacteria when entering the blood-stream in this depleted condi-
tion find a less active phagocytic attack, and may conceivably exist
long enough to be carried to some other part of the body and pos-
sibly produce secondary foci of disease. The extension of the dis-
ease locally is evidence of and seems to be the result of this depletion
in the antibacterial power of the blood-stream.

This stage is also one of stimulation of the antibody-forming
mechanism through the bacteria which leave the focus of infection
and enter the blood-stream or lymphatics. Sooner or later, as a
result of this bacterial stimulus, examination of the blood may reveal
the presence of new protective substances and increased power of
the normally present opsonin.

This entrance of bacteria into the blood-stream, constituting as
it does the stimulus to the protective mechanism, and followed, as it
is, by evidence of protective response, presence of newly developed
specific antibodies, is termed auto-inoculaiion. As a result of it the
blood-stream becomes more highly protective. This constitutes
the secondary defence, the fortification of the blood-stream through
the acquisition of new means of bacterial attack, specific antibacterial
substances, such as increased opsonic power, and, depending on the

THERAPEUTIC INOCULATION 687

kind of infecting organism, specific agglutinating, bactericidal, and
bacteriolytic power.

If the secondary defence is successful the result should be de-
struction of the bacteria present in the blood-stream and a more
vigorous attack upon those on the outskirts of the spreading infec-
tion. Evidence of final success is localization of the infection,
subsidence of temperature, and abatement of symptoms of general
toxemia.

Failure in the Development of Secondary Defence, — It is not diffi-
cult to imagine the effect of continuous entrance of excessive numbers
of bacteria into the blood-stream as auto-inoculating stimuli. We
should expect that the antibody-forming mechanism might not only
be so over stimulated that it would fail to respond in sufficient produc-
tion of antibodies, but also that such antibodies as were produced
would soon be absorbed by the auto-inoculating bacteria. It is prob-
able that both of these factors are active in rendering the blood-stream
low in its antibacterial efficiency when auto-inoculation is excessive.
Associated with this failure in the secondary defence we should ex-
pect, clinically, spreading of the infection locally, lymphangitis,
involvement of glands, high temperature, and presence of bacteria
in the blood-stream. These are exactly the conditions met with in
acute fulminating infections.

Spontaneous cure of such an infection must obviously derive itself
in part from some event which shall eliminate excessive auto-inocula-
tion if it is taking place. In liquefaction of the tissues in the focus
of infection, discharge of the infected pus and bacteria, the elimina-
tion of the tryptic burrowing effect of the pus and more efficient
cellular walling off, we have phenomena of the normal immunizing
mechanism which lead to the elimination of excessive auto-inoculation.
The result is that the antibody-forming cells are relieved of the toxic
stimulus, finally recover from toxic overstimulation, and the blood-
stream is in a condition to receive new antibodies and retain them,
since it contains no longer excess of bacterial toxins to neutralize them.

The liquefaction and discharge of pus is an important factor in the
immune reaction not only because it accomplishes the elimination of
auto-inoculation, but also because it makes way for the entrance
into what was the pus-cavity of lymph of higher bacterial power than
the pus, and, what is perhaps quite as important, lymph which has
the power of neutralizing the tryptic or dissolving action of pus. It,
therefore, contributes to cure of the disease locally, in that it makes
possible improvement in the local antibacterial attack.

688 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

Septicemia. — If excessive auto-inoculation is not normally or arti-
ficially checked, conditions for unrestricted growth in the blood-
stream and in the tissues may be afforded.

We may conceive that the antibody-forming cells become subject
to excessive stimulus and functionating is interfered with. The
blood-stream fails, therefore, to receive a sufficient quantum of anti-
bodies and its proper antibacterial efficiency is depleted through
absorption by excessive amount of bacterial substance. In the blood-
stream thus depleted it is conceivable that bacteria may exist long
enough to be deposited at points of low resistance locally and to pro-
duce new foci. Each new focus will have its effect in depleting the
blood-stream further of its antibacterial power, so that, finally, actual
multiplication may be possible in the blood-stream itself and true
septicemia develop.

The Walling-ojff Process. — The development of the secondary de-
fence— ^in other words, of specific antibacterial substances in the blood
— obviously cannot take place excepting through the presence of spe-
cific bacterial stimulus derived from the focus of infection. Exces-
sive stimulus during the fulminating stages of an infection may fail
in producing an efficient protective response through overstimula-
tion of the antibody- forming cells. Elimination of this excessive
auto-inoculation is the first requisite, both from the standpoint of
freeing the blood from toxins which deplete it of its antibodies and
freeing the cells of the toxic stress which renders them temporarily
deficient in their ability to produce antibodies or to functionate
properly otherwise. The closing up of avenues by which bacteria may
leave the focus of infection through swelling, exudation, and, finally,
by cellular proliferation, is one of nature's methods of automatically
eliminating excessive auto-inoculation.

It is easy to see how this normal protective process may go to the
extreme of such complete segregation that, finally, almost no auto-
inoculating stimuli will emanate from the focus. And, for quite the
same reason, it is clear that the antibacterial substances which the
blood possesses cannot come into contact with the bacteria in the focus.
Under these conditions we do not expect to find in the blood-stream any
evidence of protective response, and, in fact, as has been shown, we
do not find it. We also have to consider gradual abstraction of the
normally possessed antibodies through continuous slight contact
with the outskirts of one or more chronic bacterial foci.

Interpretation of the above considerations leads to the conclusion
that the persistence of localized infection registers the success of the

THERAPEUTIC INOCULATION 689

immunizing mechanism, in protecting the body by the segregation of
the infection, that the more complete the segregation the better the
body is safeguarded. In like measure, the more complete the segre-
gation of the bacteria in the focus of infection, the better protected
are they from the action of the blood fluids, and, to the same degree,
are the antibody-forming cells denied the stimulus to the formation of
specific antibodies. With these considerations in mind, we are justi-
fied in assuming that in the case of chronic localized infection the im-
munizing mechanism may, in some cases, have overreached itself, as it
were, and have brought about conditions conducive to the persistence
of the infection locally.

Determination of Antibodies to the Focus of Infection, — When
bacteria and bacterial substances are entering the blood-stream we
may find evidence that such is taking place by detecting the presence
of new sp>ecific antibacterial substances in the blood-stream, which we
know are to be found only subsequent to the entrance of auto-inocu-
lating bacterial stimuli. Detection of the increase in one antibody
is sufiicient evidence that auto-inoculation has taken place in suffi-
cient amount to stimulate the antibody-forming mechanism and to
result in immunizing response. A succession of positive and nega-
tive phases, as indicated by fluctuations in the opsonic power, are
indicative of response to a succession of auto-inoculating stimuli.
Supposing that this series of auto-inoculations is not so excessive as
to maintain the blood-stream in a condition of low antibacterial
power, that the final result is rather to increase its antibacterial effi-
ciency than to lower it, there is still another requirement of the
greatest importance, that these newly produced antibodies may, in
addition to their effect in sterilizing the blood-stream, also be en-
abled to direct themselves against the bacteria in the local focus
of disease.

The application of new antibodies locally depends obviously
upon conditions in the focus of infection, which will allow free circu-
lation of blood and lymph. If the free interchange of antibodies to
and from the focus is interfered with, the protective elements which
the blood possesses cannot be efficiently applied. This is commonly
the condition met within chronic localized infections, and is obviously
one of the reasons for their chronicity.

As previously suggested, conditions may spontaneously develop

as a part of the normal immune reaction which provide for a more

free circulation through liquefaction and discharge. Thus, stagnant

lymph in the walls of the cavity which has been thus produced may

690 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

flow outward and allow for fresh inflow of the fluid from the blood-
stream of higher antibacterial power.

As long as discharge into the abscess-cavity and outward main-
tains itself, so long will a continuously fresh supply of antibodies and
phagocytic cells from the blood-stream exert as nearly as possible the
maximum immimizing effect that the blood-stream has to offer.
This is nature's method of finally extinguishing infection by bringing
about this evening up of the bacteriotropic pressure.

It should be clear that if anything takes place to block the dis-
charge from such an abscess-cavity, the fluids in the walls will again
stagnate and gradually be depleted of their specific antibodies by
combination with the bacteria present. Conditions suitable for fur-
ther multiplication of bacteria in the walls of the abscess-cavity are
thus brought about. In the normal course of events, unless provi-
sion is made to obviate it, coagulation of lymph takes place, and
pretty soon closes fairly effectually the channels for outflow of lymph
into the abscess-cavity. That conditions suitable for the persistence
of bacterial growth may in this way be produced there is sufficient
clinical evidence to be found in the frequency of exacerbations in local
foci, in which there has developed a crust, or in which, through the
coagulation of discharge and the drying of a gauze wick, the exit for
the discharge is sealed.

Coagulation of lymph, then, is one of the natural phenomena which
leads to chronicity and spread of the disease, in that it prevents the
efficient application of antibacterial substance locally.

Iftduced Auto-inoculation. — Without dispersion of sufficient num-
bers of bacteria from an infected focus, so that unpoisoned cellular
tissue may derive stimulus for specific antibody formation, the im-
munizing mechanism cannot reach its highest efficiency as against
the infecting microorganisms. Sufficient spontaneous inoculation, in
other words, is essential to the development of the body's secondary
defence, the array of specific antibacterial substances in the blood-
stream. We have considered conditions occurring in the natural
course of infectious disease to render auto-inoculation possible and
effective; which prevent or limit auto-inoculation, and the effect of
the consequent denial to the antibody-forming cells of specific bac-
terial stimulus; which allow excessive auto-inoculation, and its effect
in the depletion of the antibacterial power of the blood-stream; and,
finally, conditions which, under the natural conditions, tend to
eliminate excessive or toxic auto-inoculation. As evidence of auto-
inoculation, we find response in the production of specific antibac-

THERAPEUTIC INOCULATION

691

terial substances. We take an elevation in the opsonic power as
indicating that efficient auto-inoculation has taken place; a series of
fluctuations in opsonic power as indicating a series of protective re-
sponses to a like series of auto-inoculating stimuli; consistently low,

ZtSSmc
fnon

ffiEi,:i3]aHnaDnanncmEEn^!niEcni?niF^fifi~TT]TE-:;:[i

ItOS OCT.

NOV.

Fig. 227.— Induced Auto-inoculation.

The effect of massage of a gonorrheal joint upon the opsonic content of the blood (Wright, Lancet, November

2, 1907, 1227).

non-fluctuating opsonic power, as indicating absence of bacterial
stimulus. Without this conception of the mechanism of auto-
inoculation, and its effect upon the protective response, a proper con-
ception of the mechanism of the immune reaction is not to be ob-

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OPERATION CURVE.— T.B.SALPINGITI&

Fig. 228. — Auto-inoculation as Registered by the Opsonic Index Following Operative Procedusx

IN A Case of Tuberculous Salpingitis.

tained, nor will it be possible in the treatment to so select and corre-
late measures that they may have the effect of rendering normal
physiologic immunizing process efficient at points where its failure
is obvious.

692

THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

Massage of a gland or joint, passive or active motion of a joint,
surgical operation, increase in the active blood-supply to an affected
part, by heat or other means, Bier's passive hyperemia, walking and
deep breathing in pulmonary tuberculosis, shouting in laryngeal
tuberculosis, all were shown to be followed by an immunizing re-
sponse registered by elevation of the opsonic power of the blood.

Iff* MY

-.iiJUUIJUUUHLJLllIiaCMbJCJLJJDaQja'ifn

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Aus. inhaaaitu

Fig. 229. — Induced Auto-inoculation.
Tuberculous bone disease — ankle. The effect of walking (Wright, Lancet, November 2, 1907, 1229).

The charts shown (Figs. 227, 228, 229, 230, 231,) are very important,
as indicating the nature of auto-inoculation and its effect upon the
antibacterial power of the blood-stream.

Having studied the features of the immune reaction against in-
fection, and having seen that the whole is physiologic in its nature,

TU8ERCUL0

OPSONIC

INDEX

14
I 2
NORMAL 10
08
0-6

Fig. 230. — Induced Auto-inoculation.
The effect of fomentations as shown by variation in the opsonic index (Wright, Lancet, November 2, 1907. 1 232).

FOM£MTATtOMS\ \

ti^

I "

25 1

it should be clear that the largest factor in recovery from any infection
is the body's own self-immunizing power. It should be clear that
the measures we use in treatment must first be directed to secure the
efficient functionating of all the body cells through proper feeding
and hygiene; to avoid the use of any measure which will interfere

THERAPEUTIC INOCULATION

693

with the normal immunizing process in any of its phases; to render
any phase of this process more eflScient where possible; when failure
is evidenced by persistence of disease, to endeavor to make this
failure good by some artificial measure. The endeavor should be
to allow the immunizing process to take place so far as is possible by
nature's own methods. This entails the use of a number of methods,
and, more important still, a proper correlation of these methods.

Early Stages of Local Infection.— Clin\ca\ observation has indi-
cated that the application of heat in the form of soaks and poultices
is valuable at this stage. When properly applied, their effect is to
increase the local hyperemia, and thus to enhance the efficiency of the
normal process by which the antibacterial forces, the phagocytes and

GONOCCXiCUS KNEE.

Fig. 231. — Induced Auto-inoculation.
Here is registered by a fall in the gono-opsonic power an auto-inoculation due to the tapping of a gonorrheal joint.

serum, are focused against the invading bacteria. The apparent at-
tempt of the immunizing mechanism to even up the bacteriotropic
pressure in the focus of infection with that of the blood-stream is
furthered through the increasing rapidity of the interchange of fluids
from one to the other. Lymph depleted of its opsonin and phagocytic
cells filled to repletion with bacteria in the focus are replaced by
fluid of higher opsonic power and fresh phagocytic cells.

Bier^s passive hyperemia has been applied to all sorts of infec-
tions at all stages where the physical conditions were such as to
allow of it The objection to passive hyperemia in the early stages
of an infection is quite the same as against the Gamgee dressing,
namely, the induction of stasis of lymph flow in the focus of infection
at a period when the introduction and replacement of fresh lymph should

694 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

be as rapidly carried out as possible. Upon general principles, then,
this measure is contraindicated, because it obstructs the development
of a normally efficient means of antibacterial attack. Apart from
this contraindication, as interfering with the normal immunizing
process, it may have the particular effect, in case the infection is
extensive, of inducing excessive auto-inoculation, consequent lowering
the opsonic power of the blood-stream, and making it possible not
only for bacteria to exist therein long enough to lodge in other parts
of the body and possibly to produce new foci of disease, but also
making the resistance to the local spread of the infection less active.
The actual effect of Bier's bandage in inducing auto-inoculation is
well shown in one of the charts. The mechanism of such auto-
inoculation is that blood fluid is forced from the vessels into the
tissues, and there probably takes up bacteria and bacterial poison
which, when the bandage is released, enters the blood-current. The
application of Bier's bandage never can be without its danger where
the infectious process is extensive and there is no local exit for dis-
charge.

Exception to the rule against Bier's passive hyperemia for use in
acute closed infections is in the case of slight, limited infectious
processes, the fingers, for instance. Here alternation of active and
passive hyperemia may be more efficient than the active hyperemia
that is normal or artificially induced. For instance, Bier's bandage is
applied for ten minutes, the finger then immersed in a hot soak for
half an hour, and the same repeated a number of times. The mechan-
ism is something as follows: The fluid is forced from the vessels
into the focus, producing swelling. It reinforces that which is pres-
ent by its opsonin and phagocytes. Early release of pressure does
not allow it to remain there long enough to lose its opsonin and be-
come a culture-media. The focus being small, when the bandage is
removed and the fluid returned to the blood-stream, auto-inoculation
should not be excessive. On the contrary, it might be expected to
be an efficient stimulus for immunizing response without excessive
reduction in the bacteriotropic power of the blood. In the induc-
tion of more intense hyperemia by heat we derive at once a more in-
creased active circulation in channels that have been dilated as a result
of the passive hyperemia. These procedures, if used judiciously,
not only should not interfere with the natural hyperemic reaction,
but should render it more efficient.

Indications in Fulminating or Spreading Infection. — In the later
stages of infection, when involvement of tissue locally is extensive

THERAPEUTIC INOCULATION 695

and spread of the infection is unchecked, we see in this condition
failure in the initial hyperemic attack of the immunizing mechan-
ism. Temperature and constitutional symptoms indicate that
auto-inoculation is taking place in toxic amount. This is clinical
evidence of the depleted antibacterial power of the blood-stream.
The indication, obviously, is artificially to eliminate this toxic auto-
inoculation. This is the rationale of surgical measures. Opening up
the focus of infection accomplishes this in the following manner:
Discharge of fluid greatly deficient in opsonic power and trj^ptic
in its action upon connective tissue, dissolving it and opening up
channels for extension of bacterial growth; of leukocytes incapable of
ingesting bacteria even in the presence of opsonin; finally, elimination
of the pressure within the focus, which renders spread more easy.
Thus the blood-stream is freed from toxic auto-inoculation and the
antibody-forming mechanism from overstimulation.

The effect of surgery upon the focus of infection is to allow dis-
charge of the stagnant fluid, its replacement by fluid of higher anti-
bacterial power, and unpoisoned leukocytes. The blood-stream is
relieved of auto-inoculating numbers of bacteria, depleting it of its
antibodies. The antibody-forming cells are relieved of overstimula-
tion and, in favorable cases, finally react in the formation of new
antibacterial substances. The blood-stream thus reinforced at once
offers not only a barrier to the spread of the focus, but also, if the
discharge continues, furnishes decided reinforcement to the anti-
bacterial attack within the walls of the focus of disease, through con-
stant circulation into the focus and outward as discharge.

The surgical operation then owes its efficiency to the elimination of
auto-inoculation y and to the production of conditions allowing of the
application of fresh blood fluids of high protective power against the
bacteria existing in the focus of infection, in stagnant fluid of very little
protective power. The rationale of the surgical measure, therefore,
lies in the fact that, by rendering the secondary defence efficient, it
at least leads to localization of the infected area.

Antiseptics. — There is nothing more natural than to attempt, by
frequent irrigation and by wet antiseptic dressings, to destroy the
bacteria remaining in the operative cavity by means of antiseptic
solutions. Clinical experience has shown that strong antiseptics are
not efficient; in fact, retard rather than accelerate the immunizing
process locally. Consequently, practice is gravitated toward the use
of irrigations merely for mechanical cleansing, either of normal salt
solution or some clean solution, such as boric acid. Strong antisep-

696 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

tics are inefficient because they are not only parasitropic, but histo-
tropic. When sufficiently strong to kill bacteria they also destroy
tissue cells. The antiseptic cannot come into contact with all bac-
teria in the focus. Those which continue to exist may conceivably find
a more or less suitable medium for growth in the tissue devitalized
by the antiseptic. The effect of devitalized tissue in the walls of such
a cavity may conceivably be to seal the natural avenues of exit for
the lymph, and result finally in stagnation of fluid in the walls and the
redevelopment of conditions in the focus of infection which the
operation temporarily removed. Further, it is difficult to imagine
that serum and phagocytic cells have an efficient antibacterial power
when in contact with strong antiseptics. We know that strong anti-
septics interfere with the normal immunizing process. The reason
is probably somewhat as suggested.

Drainage is commonly understood to mean the evacuation of pus
and the maintenance of free openings, so that any pus may continue
to find exit. The mechanical process of removing pus is responsible
for efficient localization and its probable mechanism has been indi-
cated. In order, however, to destroy the bacteria remaining in the
walls of the focus it is obviously necessary that the blood fluids should
not be allowed to stagnate, should be replaced by fluid from the blood-
stream continuously. This is only possible on condition that a con-
tinuously free discharge from the walls of the cavity and outward is
taking place. As has previously been shown, the tendency to the
formation of crust through lymph coagulation in the walls of the
cavity is evident within a few hours after operation. The effect is to
seal channels for exit of lymph; in fact, to cause stagnation and ineffi-
cient replacement of lymph in the walls. It is certain that measures
should be sought to make possible this interchange of fluid.

Wicks, — Dry gauze wicks are efficient until they become thor-
oughly soaked. They are apt soon to become dry or, if not, coagula-
tion soon renders them more as plugs than drains. An illustrative
case, among a number seen by the writer, had cellulitis of the neck
in which there had been two operative wounds which had, on the pre-
vious day, been connected by continuous gauze wick. The condition
had shown no tendency to improve during more than a week. The
wick was dry and stiff, and upon removal several drams of pus were
evacuated. This case progressed rapidly to resolution in a few days
after the use of the wick was abolished, and the lesions covered by a
pad kept continuously wet with a solution of sodium citrate (i per cent)
and sodium chlorid (4 per cent.).

THERAPEUTIC INOCULATION 697

Sodium Citrate and Sodium Chlorid Solution. — ^To render the im-
munizing mechanism more efficient when it fails through inefficient
local application of antibodies, Wright devised this solution, which
is calculated to prevent coagulation of lymph, crust formation, and
consequent cessation of discharge. The effect of the sodium citrate
is to produce precipitation of calcium salts and thus to prevent coagu-
lation. If constantly applied to the woimd-cavity, exit for lymph
discharge is rendered continuously open. The sodium chlorid con-
tent renders the solution hypertonic, and tends by osmosis to draw
lymph through the walls of the cavity. This solution, then, forestalls
plugging of the capillaries and lymph spaces, and by chemical means
induces a continuously free discharge. Thus, there is brought about
a continuous circulation of lymph of antibacterial power, as nearly as
possible equal to that of the blood-stream through the infected walls
of the cavity. The writer has found proof of the efficacy of this
measure through its use for the last five years. If the opening does
not mechanically close itself, neither wicks nor drains are neces-
sary. If, through contraction of muscle, the opening mechanically
closes itself, rubber dam or rubber tubing should be used.

Bie/s Suction, — One can forcibly drain the walls of a focus of
infection of their fluids by applying Bier's cup. When used in con-
nection with sodium citrate and chlorid solution, its occasional use
will produce more rapid drainage, and, hence, more rapid replenish-
ment with fluid of a higher antibacterial power from the blood-
stream. Bier's cup should not be used unless the sodium citrate
and chlorid solution has been applied for several hours, and then with
extreme care. Several cases have come to the writer's notice of
local exacerbation developing after too frequent or too forcible Bier
suction. Suction is a rational measure because it may aid in the
application of immune substances locally, but, if a sodium citrate
and chlorid solution is used, it is generally unnecessary.

Tuberculous Abscess, — Indications. — In the case of an abscess-
cavity due to the breaking down of a tuberculous focus, such as a
lymph-node, conditions are not quite the same as in an abscess due
to pyogenic organisms. This is due to the fact that the pus, in its
low content of polymorphonuclear leukocytes, from the breaking
down of which tryptic ferment is obtained, would not be expected
to exert and, in fact, does not exert much of a dissolving action upon
the connective tissue. There is to be observed no tendency to spread,
as is found in the case of tryptic pus of pyogenic organisms. Further,
the walling off of the limiting membrane of the node is active in pre-

698 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

venting extension. It is possible, therefore, if desirable, to postpone
the evacuation of such a cavity without danger to the patient, and, as
will be seen later, in the treatment of tuberculosis, it may be of advan-
tage to postpone evacuation for certain reasons.

The danger of secondary infection in tuberculous processes makes
it desirable to evacuate the pus through as small an opening as pos-
sible. Where wide incision is used, the chance of secondary infec-
tion is much greater than if pus be aspirated or drained through a
minute incision. The absence of tryptic action renders it possible
to abstract the pus by means of an aspirating needle and syringe
when necessary. Such aspiration may have to be repeated fre-
quently, but the final result will commonly be quite as good as that
obtained where incision is made, so far as efficient drainage goes;
there will be no sizable scar and the chance of secondary infection
will be minimized.

Where bacteria are growing in a serous cavity, clinical improve-
ment is known to follow evacuation of the contents of such a cavity.
We have seen that the opsonic power of the blood, in contact with
bacteria growing in this manner, is much lower than that of the
circulating blood. The excellent results which sometimes occur in
the case of tuberculous peritonitis, which have been attributed to
opening up of the abdomen and allowing air to enter, are readily
explained by the fact that the abstraction of fluid of low antibacterial
power has been followed by an inflow of lymph from the blood-stream
with considerably higher antibacterial power. Thus we have rationale
for tapping when more extensive operation is contraindicated.

Chronic Discharging Sinus. — Persistence of a discharging sinus
depends primarily on the presence of a focus of disease at its base.
When this is removed, however, so far as possible, the discharge is
still apt to continue on account of infection of the sinus walls by
pyogenic organisms. The persistence of bacterial growth is due to
the diflSculty of blood fluid and leukocytes penetrating the con-
nective-tissue walls of the sinus and coming into contact with the
bacteria in effective amount to destroy them. Coagulation of lymph
at the exit of the sinus tends further to obstruct free interchange of
fluid in the infected sinus.

Fundamental to the cure of these conditions, therefore, is the use
of measures which will induce a stream of lymph through the walls of
the sinus into contact with the bacteria. The use of sodium citrate
and salt solution as an irrigation, in association with cupping, may pro-
duce the desired effect. The use of wicks to keep such sinuses open is

THERAPEUTIC INOCULATION 699

inefficient, for the reason stated previously. Frequent probing does
more harm than good, m that by trauma to the tissue it is apt to
produce hemorrhage, and through clotting the sinus is obstructed;
abstraction of the protective substances in the effused blood rapidly
takes place, the result being that an excellent culture-medium is
produced for the further growth of the bacteria. Where the situa-
tion admits of it, the laying open of a sinus by operative procedure,
the application of iodin, etc., proves in practice, particularly in the
fistulous sinuses about the rectum, to be the most rapidly efficient
procedure, in that the whole length of the sinus is opened up and it
granulates from the bottom.

Indications for Treatment in Chronic Localized Infections, —
Bacterial Vaccine. — When surgery has, in the manner suggested,
reduced a spreading pyogenic infection to a localized process, and
when, by the methods suggested, as full a lymph-stream as possible
is caused to flow through the walls of the focus; in other words,
when efficient drainage is maintained, we may still at times meet
with a process which, in spite of these favorable conditions, becomes
indolent and chronic. The measures already used have been di-
rected toward safeguarding the rest of the body and toward pro-
ducing efficient application of the antibacterial substances which
the blood-stream contains against the bacteria locally. We must
here recognize that this localization may be a reason for chronicity,
in that through the elimination of auto-inoculation the stimulus
to the formation of specific antibodies is denied to the cells involved
in their production. This, in connection with abstraction of anti-
bacterial substances by constant slight contact with the focus of
infection, renders the blood-stream low in its total antibacterial
power, as has been previously shown.

The blood-stream has been shown to be higher in antibacterial
power than any other body fluid and is many times higher than fluid
in an infected focus. It is obvious that a blood-stream low in its anti-
bacterial content cannot be as efficient locally as a destructive agent
as if its protective power were greater. We have seen that in chronic
localized infections the opsonic power of the blood is consistently
subnormal, and in many cases not more than two- or three-tenths of
the normal. Bulloch^ showed that in cases of lupus, where opsonic
power of the blood was subnormal, the determination of blood to the
focus produced by exposure to o^r-ray and Finsen ray was not as
efficient as in cases where the opsonic power was normal or above.

^ Trans. Path. Soc. of London, 1905, Ivi, part 3.

700 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

On similar consideration, Wright based the fundamental principle that
in cases where the antibacterial power of the blood is below the standard
necessary for the most efficient response to infection , measures to in-
crease the antibacterial power of the blood should be used.

We have seen that it is possible by the injection of bacterial
vaccine corresponding to the bacterial character of the infection
to bring about an immunizing response in the achievement of a
heightened bacteriotropic power of the circulating blood, and if the
dosage of vaccine be of proper size and given at proper intervals, the
high bacteriotropic power may be more or less constantly main-
tained. The result of such inoculation will be, as Wright puts it,
that the citadel of the circulating blood will be more secure against
septicemic invasion. Bacteria entering the blood will be more apt
to be killed instead of being carried from point to point unharmed
and in a condition to establish new foci. The blood will have at its
disposal a reservoir of antibacterial fluid of satisfactory potency and
available for flushing any bacterial nidus in the tissue, wherever it
may be.

Induced Auto-inoculation Instead of Bacterial Vaccine in Local-
ized Infections, — The surgeon's work, therefore, is not always com-
pleted when he has secured free drainage and conditions necessary
for application of antibodies locally. It may be that the infection
will persist through low antibacterial power of the blood-stream.
It is rational, therefore, in cases that do not show tendency to im-
prove consistently to make use of bacterial vaccines to secure a
blood-stream of higher specific protective power.

Vaccine in Generalized Infections. — It is easy to see the rationale
of vaccine in localized infections in which the low antibacterial
power is known to be due to inefficient bacterial stimulus to the
antibody mechanism. It is more difficult, however, to see wherein
it can be of value in cases where there is no lack of bacterial stimulus.
In generalized infections there is no absence of auto-inoculation, in
fact, it is continuous. The struggle is taking place in the blood-
stream, the immunizing mechanism is receiving all the stimulus
necessary, and such antibodies as are produced are applied against
the bacteria in an unobstructed manner. The immunizing mechan-
ism is rendered inefficient through toxic overstimulation, and such
antibodies as are produced are rapidly absorbed by excessive bac-
terial poison in the blood. The obvious indication is to eliminate
auto-inoculation. Absolute rest is the only measure we have to
favor this. The only basis for giving vaccines is a supposition that

THERAPEUTIC INOCULATION 701

the bacterial stimulus is not efficiently applied. That vaccine applied
in concentrated form in connection with comparatively uninjured
cellular tissue may cause the local elaboration of protective sub-
stances when the stimulus applied through the blood-stream, being
not so concentrated, is less eflicient. To the objection that vaccine
might aggravate intoxication, Wright suggests that there is reason
to beUeve that vaccine injected is held back in the tissues for a cer-
tain length of time before being taken into the blood-stream. How-
ever, the fact remains that in septicemic cases judicious injection of
vaccine may produce an immunizing response, registered by the
opsonic index/

Clinical evidence comes from Thompson^ in his report of 7 cases
of septicemia treated by vaccine derived from organisms obtained
from the blood-stream: 3 cases recovered and 4 died. In 2 of the
fatal cases the efifect of the vaccine was strikingly but temporarily
beneficial; in 2 others the benefit was slight, but demonstrable; in the
others immediate and continued improvement followed the use of the
vaccine.

Vaccine When Auto-inoculation Cannot be Checked. — Sometimes,
in persisting local infections, we have evidence that auto-inoculation
is taking place, in irregular temperature, symptoms of toxemia,
and fluctuations in the opsonic index as so consistent. Very often
a careful search will reveal in pocketing of pus a redevelopment of
the condition of acute abscess formation, though possibly of small
proportions. Drainage in such a case is usually efficient. Occa-
sionally, however, drainage is found to be good, but in spite of it
auto-inoculation takes place, temperature and clinical symptoms
persist. In such a case, the auto-inoculation may be either too ex-
cessive or too frequent, or the blood-stream inefficient in offering
sufficient reinforcement to the antibacterial power of the fluids in
the focus of infection. At any rate, the auto-inoculations are not
followed by response that is effective. Exhibition of a proper vac-
cine is indicated in these cases not because auto-inoculation is lack-
ing, but because of the possibility that it is inefficient.

It would at once suggest itself that we should find in Bier's passive
hyperemia, as applied to certain infections, as tuberculous joints, ul-
cerations, etc., where such can be applied, a measure which would not
only increase the antibacterial power of the blood, but at the same
time cause a determination of lymph to the focus of disease. Such

^ Lancet, Nov. 2, 1907, Charts 14, 15, etc.
' Amer. Jour, of Med. Sci., Aug., 1908.

702 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

treatment is advantageous, perhaps, in certain ways, in that we are
always using the correct vaccine; in that we are not confronted with
the difficulty of isolating organisms and preparing vaccine; that there
is no delay in its application ; that stagnant lymph may be replaced by
lymph of higher bacteriotropic power and which will exert a beneficial
action. The disadvantages are, however, that auto-inoculations
consist of living bacteria, as well as their products, carried into the
blood-stream; that auto-inoculations constitute unmeasured doses of
bacteria; that the dose may at any time be excessive in the case of
an infected focus of considerable size; that in the case of a small
focus the auto-inoculation may be too small to be beneficial, and
where bacterial growth is gradually lessened by immunizing response
to previous auto-inoculation, the size of the auto-inoculations will be
considerably lessened; in cases where there is actually required a
gradual increase in the amount of auto-inoculation in order to pro-
duce adequate immunizing response; that auto-inoculations cannot
be made use of in infections where the location is unsuitable. The
use of bacterial vaccines, on the other hand, are more advantageous
in most cases, because the dose can be accurately measured and can
be increased at will; it is not so time-consuming in its application for
both the patient and the practitioner as the procedure of auto-
inoculation. It is infinitely safer, because it does not depend for its
usefulness upon the entrance into the blood-stream of living organisms.

Summary of Indications for Vaccine.— The exhibition of vac-
cine we have, therefore, found to be indicated, first, in localized infec-
tions; second, in infections which, by various procedures, have been
rendered local in character; third, in infections subject to intermittent
auto-inoculation which cannot be checked; fourth, we have con-
sidered the question of their indication in generalized infections; in
other words, where the blood-stream is subject to continuous auto-
inoculation.

Guidance to Correct Dosage. — Vaccine is a poison, and we
must in our use of it consider it to be such first and last. It has
absolutely no resemblance in its constitution or its mode of action
within the body to antitoxins, such as diphtheria antitoxin. In
consideration of its being a poison or a toxin, we have at once a
decided reason for careful consideration of the dosage that we should
use in treatment. That it is, when properly used, a powerful factor
in control of some diseases is beginning to be generally recognized.
That it is also equally powerful in doing harm is realized by the few
who, by inordinate dosage, have produced unfortunate results, and

THERAPEUTIC INOCULATION 703

by those within whose observations these cases have come. That
killed bacteria can, when injected into the normal individual, produce
nausea, malaise, rigors, vomiting, etc., and localized inflammatory
condition at the point of inoculation, the extensive experience of
Wright in protective typhoid inoculation has clearly shown. In
other words, the injection of bacterial poison may produce the same
train of symptoms as living bacteria of the same sort.

A dose of vaccine containing 100,000,000 killed staphylococcus
pyogenes aureus, when injected into a patient suffering from furun-
culosis, is commonly followed by improvement in the local conditions
during the next twenty-four hours. A dosage of 500,000,000 of the
same organism in a similar case is also commonly followed by local
exacerbations in the furuncles already present, and very probably will
be followed by the development of new lesions. Temperature and
generalized symptoms may or may not be produced. It is further
well known that if, in a patient suffering from pulmonary tuberculosis,
a dose of yV c.mm. O. T. is given subcutaneously, it is apt to be fol-
lowed by a febrile reaction in the subsequent few hours, associated
with signs of increased activity in the focus of disease. The injec-
tion of this dosage of tuberculin in an uninfected individual is with-
out constitutional effect. The same may be said about the injection
of killed staphylococci in case the patient is not infected.

From these facts it would appear that the effect produced by these
agents is not primarily due to the amount of toxin they contain y other-
wise we should have produced the same symptoms in normal individ-
uals. Rather, it would appear to be that the exacerbations of the
infected individuals are due, not to the inherent toxic power of the
dose employed, but to some effect which it exerts only when the
organism is infected.

The knowledge that it is possible to secure an adequate immuniz-
ing response on the part of the body from the inoculation of bacterial
vaccine, without the previous induction of symptoms of toxemia, and
that, by consistently increasing the dosage of vaccine, likewise guarding
ourselves against such toxic symptoms, we may maintain the protective
mechanism at a high level of efficiency correlated with improve^ient
and final cure of the disease process, is derived absolutely and entirely
from the study which Wright has made of the body reaction against
infection, and subsequent to inoculation, by means of the opsonic index.

In Fig. 232 is shown a curve representing daily variations in the
phagocytic power of the blood, as registered by opsonic index deter-
minations, in a case of tuberculosis after an inoculation of ^-^^j^ mg. of

704

THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

tuberculin R. This curve, while not typical, illustrates a certain se-
quence of events in the production of opsonins which will follow the
inoculation of any vaccine if given in sufficient dosage.

At the start we have two opsonic mdices, which represent a low
normal phagocytic power, consistent with that to be found in chronic
localized tuberculosis. Immediately following inoculation there is
recorded a slight rise in the phagocytic power, which, though in any
case possibly due to error in estimation, occurs so frequently that it may
have some significance. It is possible that it represents an immediate
response to the stimulus furnished by the absorption of a minute amount
of the inoculum. A very important feature is the marked decrease in
phagocytic power which continues low until the third day. This per-

TUBERCULO-
OPSONIC

INDEX

■^

f.A

i*o

1-6

1*4

nik

•

1*2

nohmali-o

o-s

h[1

li"

O'tt.

)

V o

0-4

OCT.

A 1

L&j

Fig. 232. — Opsonic Curv'e Illustrating the Variations in the Opsonic Index of the Blood Follow-
ing Inoculation (A. E. Wright, Lancet, 1907, 1218).

iod of diminished phagocytic power constitutes the negative phase, and
represents a period in which the phagocytic defense to the tubercle
bacillus is obviously weakened. Following this negative phase comes
a wave-like increase in the phagocytic power, registered by a consider-
ably and continuously elevated opsonic index. During this period,
termed by Wright the positive phase, the offense which the phagocytes
are able to offer should be at its best. The next feature to be noted is
the gradual sinking away of the opsonic power, followed subsequently
by a gradual rise to a condition somewhat slightly more elevated than at
the start.

In describing the features of this curve, Wright terms the negative
phase the ebb, the positive phase the flow, the subsequent decline as
the back flow, and the final condition, in which the curve is slightly

THERAPEUTIC INOCULATION 705

more elevated than at the start, he terms the sustained high tide of
immunity. The form of the curve produced, and consequently the
sequence of events in the immunizing response, depends on the dosage
cf vaccine injected. If the dose be small, that is, insufficient perhaps to
produce clinical improvement, there may be an immediate rise in the
opsonic index without any preceding fall or negative phase. The
positive phase or increased phagocytic power under these conditions,
however, will be of short duration, a few hours perhaps, and the height
of the rise may not be very great. If a larger dose be given, that is, a
dose which produces a satisfactory immunizing response, as would be
consistent with improvement in the condition of the patient, a sequence
of events similar to Fig. 232 may be obtained; that is, there will be a
fall for a longer or shorter time, followed by a rise of the phagocytic power
above normal, and then a gradual fall again. The effect of an exces-
sive dose of vaccine, that is, a dose of sufficient size to produce toxic
symptoms, would be to induce an immediate fall in the phagocytic
power and a more or less continued depression, depending on the size of
the dose. The continuation of this phase of depression may be for a
number of days. If no further inoculation is given, there may occur a
spontaneous recovery of opsonic power.

Wright states^ that, where an excessive dose of vaccine has been
given, a reinoculation, as soon as constitutional symptoms have dis-
appeared, of a minimum dose of vaccine would practically always re-
sult in a desirable rise in the phagocytic power. The changes in the
phagocytic power of the blood-stream induced by inoculation, as above
sketched, will apply to chronic localized infectious disease, as well
as to generalized infections, but the use of sufficient dose to induce a
persistence of negative phase is, in this latter, as we shall see later, a
dangerous procedure.

It is obviously desirable in treatment to maintain, for as long a
period as possible, a high level of phagocytic resistance. The proper
time for repeating inoculations would naturally be at the time when
the phagocytic power is falling, marking the end of the positive phase.
A negative phase of short duration is commonly followed by a positive
phase of correspondingly short duration and slight elevation. An ac-
centuated negative phase of moderate duration, say, thirty-six hours,
may be followed by a positive phase, lasting several days. An excessive
dose may be followed by merely a prolonged negative phase; henee the
dose is an extremely important factor.

* Lancet, August 24, 1907, p. 493.
45

7o6 THERAPEUTIC IMMUNIZATION AND VACCINE THER.4PY

A repetition of the condition repeated in Fig. 232 is desirable. To
produce this, inoculations must be given at the end of the positive
phase. If the inoculations are given too frequently, the effect is to pro-
duce a partial failure in response and an elision of a portion of the posi-
tive phase. It is impossible, by frequent inoculation of tuberculin,
superimposing one dose upon another, to produce a continuous increase
in the opsonic power.^ Each inoculation must be treated as an independ-
ent event, and should be followed by another inoculation as soon as its
effect is wearing off.

Correlation of These Variations with Clinical Symptoms.

— It does not matter, for practical purposes, whether the opsonic index is or
is not a measure of the protective response to inoculation, if it can be
shown that it corresponds in its rise and in its fall to conditions of im-
provement and aggravation in the clinical symptoms of the patient and
in the activity or non-activity of the focus of disease. The correlation
between the clinical symptoms and the condition of the opsonic power
of the blood has been definitely shown as follows: First, in cases of
chronic localized staphylococcic and tuberculous infections we have
seen that the opsonic power as against the infecting organism is in-
variably low. Secondly, as a result of thousands of opsonic obser-
vations, Wright states that he has satisfied himself that in all infections
a low opsonic index is correlated with an unsatisfactory clinical con-
dition, while a high opsonic iildex is correlated with a clinical condition
which shows improvement for the time being. Exception to this is
found to be occasional, and is accounted for by the supposition that
the lack of improvement is due to a walled-off condition of the focus of
disease, and to the impossibility of the circulating blood coming thor-
oughly in contact with the infecting organisms.

Hektoen states^ that in the early stages of pneumonia, diphtheria^
and erysipelas, when the symptoms are most pronounced, we have a
condition of negative phase or lowered opsonic power, and that when the
symptoms begin to subside, such subsidence is associated with a rising
opsonic power. This variation also applies to the streptococcus in
scarlet fever. In fatal cases of pneumonia the opsonic curve may not
recover from its primary depression, but sinks lower and lower. He
refers to the clear and close association between recovery and the wave-
like rise of opsonin, and to the similar correlation of improvement in

^ Wright, Studies in Immunization, p. 273.
2 Cleveland Med. Jour., May, 1909.

THERAPEUTIC INOCULATION

707

symptoms and conditions associated with a rise in opsonic power Jol-
lowing immunization by vaccine.

sag^ss^g^gjssasi^s

. 0

•M

S §

^ i-i

^ :^

K
<

•u

0; u

b 4)

>> s

T 0

tf)

0 y

= S

0 ^

rt Sf

.- D

c -0
0 c

c '^

0 5

- c

t: e

R ii

55 n

a. -^

fl- «-

u -^

< 0

0 ;s

^ s

^:s

tfl

n ts

3 I»

"O ?i

- :i3

1 .T

= a

l-H

Si.H

0 a

-^ Q

^ Cn

>» "^

= 0

— &4

a 0

■* H

C/i

•¥•

*-•

-n

-«»i

«-<

■

«-<

Recognizing in the negative phase following inoculation a phase
of lowered resistance, and in the positive phase a period of increased

THEKAPEUTIC IMMUKIZATION AND VACCINE THERAPY

resistance, it is the endeavor, by means of vaccines, to secure,
associated with as brief a period as possible of lowered phagocj tic
power, as prolonged a period as possible of elevated phagocytic
power.

Finally, we are led to the conclusion that the negative phase, as
measured by the opsonic index, in that it is associated with aggrava-
tion of the disease or at least a condition of stasis, is a thing to he
avoided, and that any therapeutic measure which may induce such a
condition might be dangerous to the life of the patient in some ca;
or inimical to progress toward recovery. We see in furunculo;
following the inoculation of a large dose of vaccine, indications of this
aggravation during the period in which the opsonic index is subnormal,
in the fact of increased tenderness, discharge, and the development
of fresh furuncles. In the case of gonorrheal joints, associated with
the negative phase after inoculation, we find commonly increased
pain , tenderness, and possibly swelling in the joint. _

THERAPEUTIC INOCULATION 709

it Stood before inoculation, in the absence of constitutional disturbance
on the part of the patient, he considers that a larger dose could have been
administered. The ideal dosage is one which will induce a slight initial
fall after inoculation, and after from seven to ten days will be found to be
higher than it w^as at the outset. The duration of the initial fall de-
pends, of course, on the dosage, and should not be longer than from
twenty-four to forty-eight hours. The question of increasing the
dosage is decided entirely upon the manner of the immunizing response
obtained. Wright's rule is never to increase to a larger dose until one
fails to obtain a satisfactory elevation in the opsonic index with the dose
used. The question of superimposing one dose upon another before
the opsonic index has begun to show signs of falling is an important one.
It would appear at first glance to be best to derive the full effect from
the past dose before injecting the next, and this seems to be actually
the case. Wright has shown that, in a case of tuberculosis, it is impos-
sible to cause a cumulation in the direction of a positive phase; that is,
one cannot, by injecting tuberculin frequently, produce a gradually in-
creasing opsonic power.* He, therefore, considers each inoculation inde-
pendently, and does not attempt to produce a gradually increasing ele-
vation in the opsonic power.

The difficulty of obtaining accurately estimated opsonic indices,
and the large amount of time necessary for their correct determination,
has rendered it desirable to find some more simple method of giving
vaccine than that based on the determination of the opsonic index as a
guide in every case. In consideration of the fact that the opsonic
index has a definite correlation with the clinical symptoms, it is possible,
in those cases in which signs and symptoms may be easily observable,
to make use of them as guides to dosage of vaccine. In the case of
furunculosis the development of new furuncles and their continued
aggravation for several days would be evidence of lowered phagocytic
power; in other words, of a pronounced and continued negative phase.
It may be taken as evidence that the dosage of vaccine was too large. If,
on the following day after inoculation, in such cases, there is a slight ex-
acerbation in the furuncles already present, but on the subsequent day
a marked improvement and a continued improvement over the several
following days, the dosage may be taken as correct. In the case of a
sinus or abscess, a marked increase in the discharge may indicate the
induction of a marked negative phase from too large dosage. In the
case of an ulcer, the increase in discharge and extension may mean the

* See Trans. Med. Chir. Soc., vol. Ixxxix, 1906, Chart 5.

THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

same thing. In the case of a gonorrheal joint, local exacerbations may
continue for several days, and in such a case the dosage has been too
large. In the case of bladder infections, we may take pain, frequency of
micturition, the condition of the urine, and possibly temperature, as
indications.

In glandular tuberculosis a single excessive dose may or may not
produce increased swelling and pain. Such walled-ofif infections are not
as immediately susceptible to lowered resistance, because of their walled-
off condition, and because the conditions in the focus are of much less
antibacterial efficiency than that of the circulating blood in an un-
treated case. Where a series of excessive doses, however, are given,
we may, after a long time, find a lack of progress, or in extension of the
process to other glands, that, instead of increasing the patient's resist-
ance, we have, by our injections, induced a condition of predominating
negative phase. It is in these conditions particularly that occasional
opsonic index determinations may be necessary to determine whether
or not our dosage is successful in producing satisfactory phagocytic re-
sponse. In fact, in this type of case the opsonic index is the only ready
method for determining whether the tuberculin used is of satisfactory
potency. In localized infections, therefore, where it is possible to ob-
serve the symptoms and conditions following vaccine, we are able at
once to say whether or not our dosage is efficient or harmful. In the
treatment of generalized infections, such as the septicemias, and in ery-
sipelas, cellulitis, uterine sepsis, etc., infections characterized by tem-
perature and generalized symptoms, much more care is necessary in using
vaccine than in the localized infections, and much smaller doses must be
used, with the idea of producing an immediate positive phase. In spite
of the fact that the opsonic power may be low, and that the amount of
vaccine introduced would seem infinitesimal compared to that already in
the body, it is impossible to conceive that large doses could do anything
but maintain a lowered state of resistance. We know that a minute dose
of streptococcus, for instance, of 5,000,000, may produce in septicemia an
immediate elevation in opsonic power. We further know that such an
elevation will persist for but a few hours only, hence such dosage must
be repeated more frequently than if larger doses were given. Hence
in septicemia the dose should be repeated every day or more often. We
cannot aflford in these cases to diminish the phagocytic power or other
factors in resistance even for a few hours, because during that time the
bacteria will find conditions more suitable for unbridled growth.
In infectious processes with temperature, a drop during the few hours

THERAPEUTIC INOCULATION 7 II

following inoculation would indicate that the dosage used was not harm-
ful, while a rise might or might not indicate that the effect was toxic.
Temperature and subjective symptoms appear to be the best clinical
guide.

A good rule to follow in the use of vaccine is, the sicker the patient^ the
smaller the dose that should be given.

When it is impossible to obtain guidance from clinical symptoms,
as in tuberculous glands, as to the dosage necessary, one must fall back
on experience in giving tuberculin to these cases under guidance of the
opsonic index. The initial dosage should be so small that symptoms are
out of question, and every increase should be likewise minute enough
to entirely avoid them.

There is no rule as to the period that is to elapse between doses.
The vaccinating qualities of the vaccine, and the ability of the patient
to respond to its action, are variable factors. Hence no interval has
been laid down as the proper one. A minute dose which may produce a
rise in the opsonic power almost at once will be followed by a brief
positive phase, and hence reinoculation is soon necessary. A dosage
might be arrived at which could be repeated every four hours, everyday,
or less often. There can be no fixed rule. In septicemia and like con-
ditions small doses must be used and hence they must be given daily
or more often.

In starting inoculation after operative procedures, the fact that the
operation has induced an autoinoculation should be borne in mind, and
no vaccine given until the full effect of it has worn off. In carbuncle two
or three days may elapse, in tubercle a week perhaps, depending on the
amount of autoinoculation which the extent of the surgical procedures
would lead one to suspect.

Dangers in Overdosage. — It is obviously most desirable in the
exhibition of vaccine to avoid producing anything in the way of severe
subjective symptoms. The future of vaccine therapy will be much
more secure if satisfactory results can be achieved without production
of unpleasant symptoms immediately following inoculation. We may
take, of course, production of subjective symptoms as danger-signals,
that the dosage is producing a negative phase and may well be smaller.
If inoculation be given, using signs of intolerance of vaccine as a guide,
there must be reached in almost every case treated a point when intoler-
ance will be manifested. The so-called clinical method of giving
vaccine gradually increases the dosage, with the idea of securing eventu-
ally tolerance to large doses of vaccine. In contrast, the method that

712 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

Wright has developed, using the opsonic index as a guide, does not in-
crease the dose until there is evidence that the last dose has not been
efficient in raising the opsonic power of the blood. Increase, there-
fore, has been gradual. During five months' service in Wright's
clinic, at St. Mary's Hospital, the writer remembers but one or two
instances where severe subjective symptoms, focal or general, were
produced by inoculations. In cases treated by the writer in the
past four years, opsonic index determinations have not been used
as a guide to treatment. The initial dose has always been sufficiently
small to make it certain that no serious negative phase will be induced.
The doses. have been increased gradually, in accordance with the ex-
perience gained in treating cases with the opsonic index as a guide,
and in infections other than localized staphylococcic there has been
but rare instance in which tolerance has been noted. The final dosage
of tuberculin, after a year's treatment, has invariably been smaller
than that reached after a like period by those using the clinical method.
The results have been satisfactory, and the patients in all cases have
continued to accept treatment without any fear of being made ill. In
the case of furunculosis, however, it has been the custom to give some-
what larger doses than those calculated not to produce subjective symp-
toms, as it appears that more rapid improvement will take place follow-
ing a dosage, such as may produce temporary exacerbation without
doing the patient harm.

Glandular tuberculosis is noteworthy, in that, even though pro-
longed negative phase may follow a tuberculin injection, there may be
no evidence in the condition of the patient or in the focus of disease
that such is the case. A series of excessive doses may be thus given
over a long period, and the sum total of the effect may be in the direc-
tion of reducing the patient's resistance instead of increasing it. In
some cases, where no improvement is shown from month to month, it
is impossible to determine whether or not the scheme of dosage has been
such as to produce a heightened opsonic power consistent with improve-
ment. In these cases the opsonic index, occasionally determined, will
indicate as to whether the tuberculin as given is efficient.

It has been shown by Wright and others that excessive doses or too
frequent dosage induces a more or less continuous condition of negative
phase and lack of resistance. While such a condition might not be of
serious import to the life of the patient, in glandular tuberculosis, in
furunculosis, or in strictly localized infections, it is certainly not the
case where bacteria are multiplying in or gaining entrance into the

THERAPEUTIC INOCULATION 713

blood through autolnoculation. It is perfectly evident that if, in such
cases, the ability of the blood-stream to destroy bacteria is lessened,
there will be offered a much better opportunity for living bacteria to
exist in the blood-stream for a suflScient length of time to be transferred
to other parts of the body, and possibly to produce new foci of disease.
In addition to this, the size of the autoinoculation, that is, the number
of bacteria introduced into the blood, may be definitely increased on
account of the increased activity in the focus, which is known to ac-
company the negative phase immediately following excessive auto-
inoculations. This stirring up of the focus after excessive inoculation,
and its effect in inducing autoinoculation, is perfectly well illustrated
in pulmonary tuberculosis following diagnostic dosage of tuberculin.
Here, the focal signs and the temperature induced can mean nothing
else than that bacteria are being taken in excessive numbers into the
blood-stream. In pulmonary tuberculosis, the harm which an excessive
dose of tuberculin may produce is evidenced by the unfortunate results
which occurred following the first use of tuberculin after its discovery
by Koch, and since that time, by the induction of generalized tubercu-
lous infections and the production of other foci of disease following its
excessive use.

A case of extensive furunculosis of the neck of several months'
duration is illustrative of the harmful effect of injudicious dosage of
vaccine in localized infections. The case was referred to the writer for
decision of the question as to why the vaccine as injected had not been
followed by a cure. Patient had been receiving 400,000,000 staphylo-
coccus aureus vaccine daily for about a week, and, previous to this, the
same dosage had been given every two or three days for a month. The
condition showed no improvement. Following the writer's suggestion,
no vaccine was injected for five days. Then the same dosage was given
and repeated four days later. At the end of two weeks the patient was
entirely well, and, so far as is known, has since remained so. This
would appear to be clinical evidence of a more or less continuous nega-
tive phase produced by too large and too frequent dosage, and of its result
in leading to chronicity rather than to recovery. Such cases are not
serious in their outcome, but their frequent occurrence cannot be of
any advantage to the welfare of vaccine therapy.

The really serious results of overdosage of vaccine would appear to
be in the generalized infections and in those subject to autoinoculation.
Here the maintenance of a lowered antibacterial power in the blood-stream
may most certainly be conducive to unbridled growth of bacteria in the

714 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

blood, and to the induction, in acute cases of severe toxemia. In septi-
cemias, such lowering of the antibacterial power obviously should not be
produced even for a few hours. In cases subject to intermittent auto-
inoculation, excessive dosage of vaccine, occasionally given, might con-
ceivably do no harm, but if given sufficiently often to cause a persistent
lowering of the antibacterial power of the blood, although conceivable
that the patient may recover in spite of it, he cannot recover on account
of it, A case in point, indicating probably disastrous results from over
dosage of vaccine, is one which came to the writer's attention after it
had been treated for over a month with injections of colon vaccine.
Following appendectomy a discharging sinus persisted. That auto-
inoculation was taking place irregular temperature indicated. For some
time colon vaccine had been injected every few days, and for the week
before the patient was seen by the writer, inoculations of 200,000,000
organisms had been given approximately every four hours. It was
stated that the idea in giving such frequent and excessive dosage was
based on the supposition that opsonins are produced locally; that a
localized inflammatory reaction at the point of inoculation is indicative
that the vaccine is efifective in production of antibodies; that hence,
the more local reactions that are produced, the greater the production of
antibacterial substances.

Without discussing the fallacy of this reasoning it may be stated that
the patient gradually lost ground, became emaciated, and finally reached
an extremely critical condition. Physical examination suggested that
the condition might be due to an abscess in the vicinity of the diaphragm.
Operation revealed that there was no such condition. Smears on agar
were made from the blood at the time of operation, and on being incu-
bated showed a solid growth of colon over the whole surface of the
culture-medium. The patient died several days later. In the absence
of any evidence of local condition which might have produced death, it
is to be assumed that it was due to colon septicemia.

In treating septicemic cases, a scheme of dosage that will induce re-
peated slight elevations of the opsonic power, without previous nega-
tive phase, must be used. Elision of negative phase is possible if we hold
to minute dosage. The rise in opsonic power obtained is of short dura-
tion. Hence reinoculation is necessary at short intervals. The same
rule holds in all cases subject to autoinoculation.

The size and frequency of dosage depend on the character of the
autoinoculation: small, if it be continuous and excessive, as indicated
by temperature and toxemia; larger, if intermittent and less in amount.

THERAPEUTIC INOCULATION 715

The rule that "the sicker the patient the smaller the dose of vaccine"
cannot be repeated too often or too strongly emphasized.

Site for Inoculation. — That commonly used, because most con-
venient to get at, is the upper posterior portion of the arm. The back
or abdomen is quite as satisfactory, but cannot be reached so easily.

The probability that antibacterial substances are produced at the
point of inoculation would suggest that advantage might be gained by
placing the inoculation at such a point, in relation to the lesion, that
the lymph-stream may at once carry the newly formed protective sub-
stances into contact with the bacteria therein, before they become diluted
by the whole blood-stream. Wright states that by thus inoculating
"up stream," as it were, better results have been obtained in certain
cases than by the usual method.

I/Ocal Reaction. — Inoculation of vaccine, using dosage of ser-
viceable proportions, commonly produces at the point of injection an
inflanmiatory reaction. This is dependent partly upon the size of the
dose, partly on the condition of sensitization of the patient to the
poison of the infecting bacterium. Ordinary therapeutic doses do not
produce a reaction in the case of individuals uninfected by the corre-
sponding organism. In infected individuals the reaction varies
somewhat according to the size of the dose. As the patient recovers
from the infection, the reaction becomes less marked and finally may
not appear after very large doses. The reaction consists of redness,
swelling, tenderness over an area of varying size. It may involve
the skin of the whole posterior portion of the upper arm. Its onset
is commonly within a few hours after inoculation, and it reaches a
maximum within thirty-six hours. If the inoculation be given deeply,
the reaction is less apparent. Associated with a marked local reaction
may also occur a focal reaction, manifested by increased signs of
activity in the lesion. Experience has shown that, in general, those
cases which develop the more active local reactions react best to the
vaccine in their protective response, and are most apt to do well.

These local reactions are specific. They do not appear unless the
vaccine used is derived from the organism that is the infecting agent.
In localized infections the absence of reactions after a moderate dose
indicates that the vaccine is probably not the proper one; in other
words, the diagnosis of the actual infecting agent is in error. Ex-
ception to this rule is found in some individuals who have apparently
not the powej: to react. In some grave septicemias local reactions
may be absent. A properly small dose in septicemia may produce
only the slightest local reaction, or none at all if injected deeply.

7l6 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

Untoward local effects are rarely seen. It is conceivable that a re-
action might be so acute that the tissues might break down. This
actually occurred in one of the writer's cases. Culture from the pus
proved sterile. The vaccine, which had been used in treating many
patients with good results, also proved sterile.

In tuberculous conditions therapeutic doses of vaccine, if injected
deeply, commonly produce no demonstrable local reaction. A small,
hard nodule may, however, develop. If injected into the skin, or just
below it, a reaction similar to that of von Pirquet may be produced.
Local reactions have not been prominent in cases treated by the writer.

Skin reactions, in that they appear to be specific, are valuable as
indicating whether or not the proper vaccine is being used, and their
intensity indicates to some degree the power of protective response of the
individual. The gradual loss of ability to react locally to increasing
doses may mean increasing immunity to the organism in question.

Focal Reaction. — This is best seen in the treatment of furunculosis.
If the dose of vaccine be of suflScient size, associated with the local re-
action and the negative phase, increased tenderness, possibly swelling,
increased discharge, and possibly a new lesion, may appear at the seat
of infection. In pulmonary tuberculosis focal reaction consists in in-
creased r^les, both in number and extent, and possibly increased ex-
pectoration.

In gonorrheal joints a dose of 10,000,000 bacteria may be followed by
increase in pain, swelling, and tenderness in any or all joints affected.
If a larger dose is used, the symptoms become more pronounced. These
focal reactions give evidence of increased activity of the bacteria in the
focus of infection. The period in which they develop corresponds to
that of the local reaction, and to the phase of diminished resistances,
as indicated by the opsonic index.

Focal reactions are made use of in diagnosis of pulmonary tuberculo-
sis, and Irons * has made use of the focal reaction in diagnosis of gonor-
rheal joints. In some cases of localized tuberculosis focal reaction may
follow a dosage of -^^-^ mg. or less of tuberculin, and thus localizing
diagnoses may sometimes be made.

Preparation of Bacterial Vaccine

The successful application of bacterial vaccine in the treatment of
infectious processes depends fundamentally upon a properly prepared
and constituted vaccine. There is required for the production of such a
vaccine a well-equipped laboratory, separate and apart from routine

^ Arch, of Int. Med., 1908, i, p. 432.

LABORATORY TECHNIQUE 717

pathologic work, kept clean and as free as possible from dust, and de-
voted exclusively to the purpose. Test-tubes and other glass receptacles
which maybe used as containers at any stage in the preparation of vaccine
should be used exclusively for these purposes. Animals used in inocula-
tion experiments should be kept apart from those used in routine patho-
logic work. Certain special apparatus will be convenient, and will later
be described. Of importance equal to that of a laboratory is the use of a
carefully elaborated technique, which shall offer every possible safeguard
to the end of securing vaccines that shall be accurately standardized,
sterile, and free from any contaminating growth.

The constitution of the bacterial vaccine is suggested by the com-
monly accepted definition, which is as follows: The bacterial vaccine is
a suspension of killed bacteria, which, wlien introduced into the animal
body in sufficient dosage, induces an elaboration of antibacterial or
protective substances, specific in their action against the variety of bacteria
injected. A properly constituted vaccine for any particular case is,
therefore, one that is made up of the specific bacteria that are the
causal agents in the condition to be treated. There may be a number
of bacteria of different kinds found coexistent in a given lesion. In
mixed infections of this sort it will be necessary to determine which
variety is the disease producer. In case the responsibility cannot be
fixed, it will be necessary to use coinciden tally two or three differently
constituted vaccines to properly meet a mixed infection. If investiga-
tion shows infection to be due to a staphylococcus, pneumococcus,
gonococcus, or to the tubercle bacillus, it is commonly satisfactory
to make use of corresponding stock vaccine. In most of the other
infections the infecting organism should be derived from the lesion and
grown in pure culture, and from this culture the vaccine prepared.

LABORATORY TECHNIQUE

The technique to be followed in the preparation of vaccine varies somewhat accord-
ing to the nature of the organism dealt with. The preparation of a staphylococcus vaccine
will be described as a type, and modifications necessary in dealing with other species will
ht later noted.

The water of condensation in three or four tut)es of nutrient agar is inoculated from
a pure culture, the surfaces thickly inseminated, and incubated for a period of from twenty-
four to forty-eight hours. The contents of a test-tube containing 10 cc. of 0.85 sterile salt
solution, made up in distilled water, is poured into one of these tubes, and the growth
rubbed off by means of a sterile platinum wire (Fig. 235). The opalescent emulsion thus
produced is poured into the second, then into the third, and finally into the sterile tube
which originally contained the salt solution. In pouring the emulsion from one tube to
another great care must be taken thoroughly to burn off and heat the open ends of the
tubes. They must be held slanted, at as small an angle as possible from the horizontal,
at all times while being manipulated, in order to prevent air contamination. If, during

718 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

the (viurse iif ihe prtjiaraliiin an open tube is umporarily sit asidt, il should he ^lanlcd Itj
Iht sanif manner and for the samt |mriiosc The final lulie ninlainint; tht- emulsion is
Ihvn hualtd in thf bimv-pipe iiame, drawn uul and iloscd, and shaktn vigoruusly for from

in order to produce a homogeneous
uircs some skill, ihe result of jirai
n the left hand, ihc ripen tml is i

laon. The sealing of a test-ttibe

The lutie, held at an angle of

usly heated in the yellow flame

LABORATORY TECHNIQUE 71Q

unlil it is tiry, U>:h inside and nut, up 10 iiv.i nr ihrre inches from its optn end. Air U
Ihcn lurncd on, ami "Uh thi' lilue flame Ihi' [■Mlrcmv tiid cif ihi: lulu- is mc,lu>d and a shert
piece (if (jiass luliini; is made to adhere lo it, "hii h shall strvc as a handle "hi-n ihe lube
isdraivniiul (Fig. 137). Thi.- lulx: is thin miatcd tominuously in the llamc, which impinges

as near ihe en.l as j->ssible. U hen the wall »[ ihe Hibc is moUen, ihf Rlass ■nails of ihc
tube are allowed lo rtin tcigether. in urder to ihitkcii ihc "all of ihc ]>'irti<in that is to be
drawn oul. If ihls im)riss of thickening is nr>t accomplished, the 'vall of ihe mrtion drawn

720

THERAPEUTIC IMMrXIZATION AND VACX^INE THERAPY

oul may be t..o ihin I.. !«■ si-rv
(lra« II ..ul «hile slill in ih,- l1am.
ihc nxil portion, li is ihin u
Ihc laix-Tt^l portion is i in. nr si
Ihcn allowtd lo cool, htaLiii sulistquin
riRhl unlilciH'l (Fif!. J40).

il.k- {Fin. i,l8). "hin ipn>p,Tly ihirkom-ii, ih.' IuIk>
mil thu iliami'Ur of iho mulU'Ti pari is iwo-ihirds that
ivicl fmm iht llami.', and imnu'dialfly .Iran n iiul uii
I (liamiicr an.) 1 or 4 in. long [Vie,. 231)). Thi- tuliu

Standardization.— .A fiiT ihomugh shaking (lifietn minutes is sufTirient), ihi- ia(>crtii
■ml is dteply scratched with a file or glassnrulting knife, J in. from the end (Vig. ^^l),
jnikcn off, sttrilized in the Biinsen llamt. cooled, a few <lro()S ON|irr.'Ssi,d into a clean « otch-
■lass or other receptacle (Fij;. i4i). and the open end of the tulie irsealed. It will coni-
nonly 1>e found thai the shaking has not 1>roki.'n up the clumps of lacteria. and thai, there-
ore, further manipulation is necessary, that the portion of the emulsion (i> 1>c standardized
nay contain as few and as small clumps of liacteria as possible. For this purifse, a small

pipit is drawn oul wiih a capillary jmriion aliut 1 mm. in diameter, and cut off sijuarcly
aliout 1 in. from the stub. .\ rublwr teat is a Hi Ned to this iiijiei, the emulsion is drawn in
and out forcibly, the pi[)et l)eing held at right angles to the lalile against the Ixitlom of
the ivatch-glass (Fig. 14,!). By this mean^ further breaking u|i is elTecled. The emul-
sion should then contain liacleria singly, in |iairs. or in very small groups.

,\ capillary pipit, drawn fn)m i-in. glass tubing, evactly the same as the pipet
used for ops.>mr index determination, the capillary end lieing aUiui ; in. hmg. cut S(|uarely,

LABORATORY TECHNIQUE

is marked uiih a plass markiiiK-i>cndl } m. from the tip. A linaturc is Ismnd rnund the
thumb of ihc Ml hand, the dorsum is pricked near the nail "iih a blunt glass nteclle (Tig.

having \x-en fitted iii the pi|itl, three or four viiiumes of 0.85 salt
I, ihen one volume iif blood, one of laclerial ttnulsion. and again

722

THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

three or four volumes of sail solulion (Fig. 245). The volumes of blood and emulsion
must be scparalcd from each i thcr and fmm the sail siilution in the pipel by air-bubbles;
ibat is, as each volume is asiiirated, it is allowed to run upward in iho pi|:i'l. so that a
space is left before the nexl \iilume is aa|iirated. The "volume" referred lo is the amount
of fluid between the end if the pipet and the pendl-mark. The amt>unl of sail solulion
used does nut aller the final results and need not be atcura

of ihe capillary arc then lhfm)ughlj- miscd on a glass slide by alternately presang and
releasing the rubber feat (Fig. 246), in order that in Ihe mixture there shall be an even
distribution of bacfena and red corpuscles. A small drop is then expressed on each of
lw<i or three clean glass slides (Fig. 147), and with the end of a fresh slide a smear is
made (Fig. 248) and alloned 10 dry. These smeared slides are ihcn Immersed in a satu-
rated solutiiin iif mcriunc chlorid for three minutes, and stained with carbollhionin blue

tor about one minute cold (ihionin pure, (Iriihlcr, J per lem., rarl-.lic acid, i
If stained pn>pcr1v, the red corpuscles will have a liijbi green and ihe bacti
jnirpie tint.

The actual standardization consists in cnun
bacteria contained in a series of fields of e'|ual •
corpuscles and the number of bacteria met with h:
counling easier, a more restricted field than that 0

I lo this

d foL

. adher

LABORATORY TECHNIQUE

723

portion that a small square field will be marked off and projected on the slide for a counting
area. The number ii£ cells and bacteria in each field ate noted, added, and when 500
cells have been counted, the following projjortion is worked out. Supposing that in count-
ing 500 cells 600 bacteria have been encountered, the proportion is as (olloivs: 500 (red
cells) : 600 (tjacteria) as 5,000,000.000 (the number of red cells in 1 cc. of normal blood)
is to^. X — 6,ooo,ooo,ooQ of bacteria lo Ihc cubit centimeter.

i|uirtmcnls t-it accuracy in ibis method of slandanlization are that the indi-
so ci>rpuscles are used shall have an apiin>\imately normal red count; that the
nulsion shall be free from clumps; that where fields containing suggestions of
red cells are met with, ihcy should be cxeludtii; fields should be counted in
iraled piirliims of the slide to insure fair average. At its best, this numerical
m, but it is (]uite accurate enough for use. Quite as
is their virulence, which cannot be measured except

by the method o'

e doses ot

t in the i:

ndardizatio

ie of any vaci ine that has nei cr been tried. The actual numcr-
.cine, then, by Ihtst methods, has liecn satisfactorily arrived at.
is possible, and much easier accomplished, if on the slide to
be counted the numIxT of red cells al«jul equal that of the bacteria. Hence, if before
(tiding the blood and emulsion for standardizaiion the vaccine appears to be extremely

724

THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

lur. ic as volumes i>( emulsion should lie used ti) one of ihe blood. Expcrienci.- teaches
one tr> judge Ihe jiniliabli' content of a baiterial umulskm jm-t oc. from its ofarily, s-i thai
the pro()er adjustment can In' made from )ns|ifclii>n.

Sterilization.— As SKin as the f™ iln)i,s of cmulsi.m art cspressed frnm the IuIh:. for
slandar.lizalion, the lulx- i^ waled and at once immorse<i in a ualer-lraih at 60^ V.. in ivhich

il is allowed to remain for one hour. The shorter the exi-tsure to heat, the less ihe vac-
tinaling quality of the vaccine should suffer. Afler the [jeriod of slcrilizalion, care haiing
been taken that the temperature of the balh has remainj''' ct>nBlanl, and that the tube has
been ciim])lettl\- immersed, il is removed friim ihe halh, ihe end broken off, and, with

slam (figs. 350. 251). This, incubalcd twelve hour^. will show nlielher or not ihe vac-
cine has Ijeen successfully sterilized. After slerilizalion, a lalx/l is affixed to the lulx* ctm-
lainer slating the kind "f *-accinc, iis ilerivation, number of bacteria per cubic ceminieier,
the lenglh of lime sterilized, and Ihe dale. The vaccine shoukl not lie used tor inocula-
tion until the test culture has l>een incubalcd at least liielve hours and is i)roved to be

LABORATORY TECHNIQUE

725

Keeping qualities of vaccine n

It is probaMe that ihtrc is some ric:
luberculin, appears not to retain its
liiled. Tulierculin K, and the sural
efficiency in the various dilutions, t

I- be insured by storing ihc slticks in a rool plate,
ioration month bi- month. A luxin, such as old
ccinating power for mnre than a few weeks 1/ di-
I baiillen cmulsinn, apparently lose none of iheir
n after several months. The ".riler has used a

Fio. ISI —Ex

staphylococcic vaccine which he (irejared in Wright's laUiraloty tor over a y
noted very little diminution in ils vaccinating riualitits, even though it has 1

within two or three months.

S'by .*

called; D. Iy>

If ()ne desires lo prepare large amounts of v
houses may be employed. In dealing with a large
that the preparation of considerable t|uantilies at 01
mass cultures, grown on the surface of agar in Roi
ounce bottles with wide necks, furnish the

Tine, mclhoils used by commercial
orulalion clinic, the writer has found
lime is desirable. For (his purpose
flasks, or large flat eight or sinteen-
ilate such bottles i

is jioureil over the surface of the receptacle

726 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

and stood upright in the incubator. The sterile sail ailution used in ihc prcparalion may
amount to 50 re. or more, and it is, therefore, convenient 10 use as containers 8 by i inch
extra heavy test-tubes, which will be the final containers [or Ihc slock vaccine. Care must
be used in burning off the neck of a bottle or dask, l>«h Inside and out, k^fore making any
transfers 0/ fluid by pouring. There is less danger of air contamination if the transfer
of emulsions is made by means of pi]M-ts. The method of sealing the large tubes is sim-
ilar to that where a smaller one is uwd. The oilier steps in the preparation of slock are

as Stated. It is well tr> have the hi

Bottling the Vaccine.— The n
in such strength and in such eonlai
trcalmeni of patients. In the case
desirable: one bottle conla-ning 200.

of It

of SI aphjlo coccus,

■accinc prepared,
nienl for actual use in the
-cincs, three strengths are
anolher 5oo,ooo,c>co, and

P^y

It-sized Untie for staphylococc
i are being Ireated, hotiles of

a third i, 000,000, oco. A conver
but where a small number of ci
saiisfaclory.

The mode of preparation of these vaccine lultles is as follows: A number of large-
mouthed i-ounce "French square" bottles arc washed with weak hydrochloric acid solu-
tion, rinsed with water, and dried out thoroughly by invertinf- over a heater. They are
then plugged lightly with cotton and placed in a dry sterilizer for one hour, in order to set

LABORATORY TECHNIQUE

727

the cotton plugs. With a large pipet there is added to each bottle 15 cc. of 0.S5 per cent,
silt solution, made up with distilled water, and the cmton plugs replaicd. These bottles
are then autoclaved for one-half hour at fifteen ix>un(l5 pressure. To earh bottle is
then added 35 c.mm. of pure lysol, and the cotton plug replaced {Fig. ^54). The method
of adding this lysol is as follows: By means of a standard millimeter pi)iet, 35 cmm. of

mercury arc measured out

mercury arc measurea out ann ciraivn into a pLpet similar to that used for standard
purposes. This pipet is markeii oR, sii that the alun'e quantity of lysol ran !v mer
The pipet is then sterilized in the flame and used for the abo'f niinui
will then contain 8; percent, sterile salt solution, »ith J of i pe

Each bottle
(apj.roxiraately) of

Fro. 2s6.

These bottles are then to be covered nilh sterile rublx^r ra|is, such as those used in
Wright's laljoratory. The rubber should be thick and of pure gum, and of such con-
sistency that it will heal after each puncture of the hypodermic needle.

This cap should be rinsed in water anil lioiled ten to fifteen minutes in a 10 per cent,
lysol solution. The bottles should be taken one at a lime, held at an angle of 45 degrees
or leas, the neck burned cil in a Bunscn tlame, with sterile forceps the caji removed from
the tysol solution, and stretched over the neck of the buttle aseptically. .\s each Isittle

THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

728

is capped, wilh ihc thumb pressed tighilv agaii

order ihuroughly u, dislribule Ihc I)-*;!, nlhcnv

small flocculi later. After all the Imlllea are thus eapp"! an

and the cap dippi^d into mcUed i»raffin in order thoroughly

Imtlles may lie termed "blanks," and are 10 be used as conla

the individual yiatienl.

The method of transferring the vaccine from the sMi k tu
pared ifi as follows; if

lop (Fig. 256). it is at o

is apt to be stringy and

lI shaken they

we necii incur ijce. I"illle a total of 15, 000.000, 000 organ isms. There tting *
organisms (in this case) in each cc. of our stock. sini]ile calculation »ih sh
necessary to add 3} cc. of the stoik to the solution in the b)tlle. Before adi
cine, howe\er, «e must abstract an e(|ual amount of iluiil from the IkjIIIc. T1
are made, using a 2 cc. syringe graduated to ^\ cc. A dro]) of pure lysol is
the nibl«r cai> of the "blank" b"itlle, the sterile needle is insirti-d through t

hitlie inverted, and the amount withdrawn. Tfic tube romaininj; the slock vaccine is
vigorouslv shaken for a minute or two. the end of ihe tapered rftlion is broken olT, flamed,
and the tube held in the left hand inverted. If the fiuid does not enter the tapered ]!<Jnit>n
far enough for the needle to reach it, the heat of the hand, plus a little shaking, will often
suffice to effect this. If not, the Imt end of (he tulie may !*■ held near a Bunsen flame.
The proper amount of emulsion, in this case rj cc, Is 10 be "ithdrawn and injected Ihnmgh
the rublx.-r ca;> inio ihe bottle fFii;. 258I. The l«>tllc will n.-w ,ontaln 15 ic, ,ach cubic

LABORATORY TECHNIQUE

729

o of organisms. This botlle, aller l>cing labeled
0 be o]>ened frequently, it

r which will hold i,ooo,ooc
properly and shaken, is ready for us

If the vaccine stock be a large 01
as a preservative before closing, \ per cent, lysol. If the amount of emulsion 10 Ite added
to each bottle is more than iq per cent, of its total bulk, the slock should always preiiously
receive J per cent, lysiil, in order that Ihe completed vaccine may siill have the full i per
cent, of lysol. To eslimale riiughly the amount of vaccine in a tube, in order to determine
the proper amount of lysol to add, Ihe tube is immersed, up lo the level of the vaccine, m
a graduated beaker with some water in il and ihe rise in the water noted. Allowance of
the thickness of ihe vaccine container must be made and subtracted.

Carliolic acid, J per cent, lo J ]ier cent, or more, may be usi-d as a preservative instead
of Ivsol. The advantage of the former is that the vaccine is less opalescent and does not

3
i

' J

B-0 =

(SB Taking UtooD C

rlBunsenl; D.d.mpfot I

develop a flocruient prerijiiiate, which occasionally forms when lysiil is used. li appears
to tht- writer that lysiilized vaccines are more efficient than those preserved by carbolic arid.
Method of Sterilizing Syringes. — The syringe is so continuously in use in making
vaccines and in inoculating patients, that some more ready and effectual method for in-
stantaneous sterilizaibn than b-iiling affords is of great aiUaniage. Sterilization by bail-
ing is slow, inefficient, and causes the syringe to deteriorate. The method introduced by
Wright for sterilizing sjTinges, by filling and refilling seieral times with rotlon-seed oil,
kepi at a temperature of i.^o" to 150° C, meets every reijuiremcnl. These temperatures
at once kill bacteria or s|K>reE^ that is, they give us an inslanlaneous auloclaving effect.
Besides, the oil keeps Ihe syringe always in easy working order. Syringes of the Rous-

730 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

Collin or the Ermold type will stand these temperatures with rare breakage. The writer
has used a single Ermold syringe for four months without replacement of any part save
the needle. A simple and satisfactory oil bath is here illustrated (Fig. 241). A more
satisfactor)' oil bath, however, is one having a de\ice for regulating the temperature con-
stantly at the desired point (Fig. 260).

The preparation of a streptococcus vaccine requires the cultures to be grown for from
one to three days, and that once or twice during this time a sterile platinum wire be carried
over the surface in order to cause thick insemination. One or two bouillon cultures planted
at the same time should be used to wash off the agar growth instead of salt solution, in order
to fortify the emulsion. The breaking up of the chains of streptococcus for standardiza-
tion purposes is difficult, and a more prolonged shaking and pipeting than in the case
of staphylococcus and some other bacteria v.ill always be required. A streptococcus
emulsion may contain from 200,000,000 to 1,000,000,000 per cubic centimeter, and, con-
sequently, in standardizing one must take from three to six times as much emulsion as
blood, according to one's estimate as to the probable content of the emulsion from gross
appearances. Streptococcus vaccines should be bottled for actual use in strengths of from
50,000,000 to 200,000,000 of bacteria per cc.

Pneumococcus and gonococcus vaccines differ from the staphylococcic vaccine in the
mode of preparation only in their difficulty in growth, and in their requirement that special
culture-media should be used; i cc. of hydrocele fluid or human serum for each tube.
For the pneumococcus sheep serum may be used. For this purpose 50 cc. of clear sheep
serum is added to 100 cc. of distilled water, and sterilized for fifteen minutes at 10 pounds
pressure in an autoclave. The resulting fluid will be quite opalescent, but they will con-
tain no flocculi. One or 2 cc. of this added to each tube of nutrient agar makes a fair
medium. Emulsification of pneumococcus is somewhat more difficult than of staphylo-
coccus. Fifteen minutes' shaking, plus five minutes' pipeting, will be necessar}-.

Colon and typhoid vaccines may be sterilized in forty-five minutes, and at a temperature
of 58 ° C, or for seventy minutes at 53 ® C. Emulsification is ver}' easy and very little pipet-
ing is required. In standardization of typhcid vaccine a blood should be used which does
not agglutinate typhoid bacilli. For curative inoculation, typhoid vaccine should be bottled
in strengths of 100,000,000 to 200,000,000 per cc.

THE TUBERCULINS

Tuberculin R and tuberculin O are the results of a process of
grinding the bodies of virulent tubercle bacilli into a fine powder. The
bacilli are finely comminuted, suspended in water, and centrifugalized.
The deposit is called tuberculin R, the supernatant cloudy fluid tuber-
culin O. The former is, then, bacillary substance with some soluble
portions of the bacilli removed; the latter is an opalescent solution of
the substances soluble in water.

Bacillary emulsion, or B. E., is a suspension of the comminuted bodies
of tubercle bacilli. It, therefore, contains all the immunizing substances
of the bacilli, whereas tuberculin R is minus certain soluble constitu-
ents. Although there are many other tuberculin preparations, the three
mentioned are the most commonly used in the treatment of the types of
tuberculosis with which this article deals.

The preparation of these tuberculins for actual use on the patient consists in making
proper dilutions of the concentrated preparations obtained from manufacturers. Tuber-

THE TUBERCULINS 731

culLn R is commonly sold in vials rontaining ! oc. of fluid in which iherc aro 2 ms. of
vacdnaling substance (Mieslet, Lucius, and Bruning), Bacillan- cmulsiim may lie
oUained in 5 cc. vials, each cubic centimeler ccinlaining s mg. of bacillary substance.

It is convenient to prepare for actual use Ihrce strengths of luberculin R and of bacillary
emulsion, one to contain sic rag- per cc. another , An mg. [>crcc.,and a third njfei] n.g. per
cc, in order that ihe dosage may be accurately administered. Before making dilutions of
the German product it has been found best 10 sterilize the original preparation tor one
hour at 60° C. If sterilization is to be done, it "ill U- necessary to make two of %\'right"3
so-called " curly pipets." For this puniose a jiiect of ^\ or J-imh tubing, 6 in. long, is
healed in its middle and drawn out into a t-in. h capillary, and cut off so thai the lapcred
end of each tube will l)e 4 or 5 in. lung. The undrawn end is then heated at a (mint such
ihal will allow at least [ cc. of fluid 10 be drawn inlo the tube, .■\fier Ihe glass is thor-
oughly molten at this ix)int, it is drawn out so that there will be a conslriclcd portiim a
little over an inch long, and while still pliable, Ihe end of the tube is rotated in its long diam-
eter or twisted so thai the drawn-out portion is given a com[ileie recurve (Fig. 161). This
tube is sleriliied in the tlame. A second is prepared in the same way, and likewise sleril-
iicd. The (ial containing tuberculin is unstopjwred, the mouth flamed, and the contents
drawn up inlo Ihe curly pipel and the end sealed; i cc. of sterile sail solution is poured
inlo the \ial to completely wash out the tuberculin which may have been adherent 10 Ihe
interior of Ihe vial. This is drawn u\i inlo the second pi[iel, which is likewise sealed.
These two pii>els are then sus])encled for one hour in a water! alh al <)o° C. We then
have 1 cc. of tuberculin R, in which there is a lolal of 2 mg. of solid substance. To an

Fio, itt.—Wsic.HT-i ■■CcELV P[PKi" Used a? * Costai\-er fos Tvbebcclin Dibisg Siipilij.iion.

8 by 1 test -tube, containing c.^acily 4S cc, of sterile 85 per cent, salt solution, the contents of
these two pipets are added, and the tube drawn out in the flame and sealed as previously
described. We then haic a solution of tuberculin R whiih contains s"^ mg. per cc. The
bacillary emulsion should be slcrilized and prepared in the same manner. In this case,
however, but i cc. of ihe fluid is withdrawn from the original vial under sterile jirecauiions,
the stopper replaced, and the remainder saved for future use. Certain .American prepara-
tions of tuberculin do not require sterilization, acci>rding lo the slatcment of the manu-
facturers. The technique of diluting these preparations may l;c as follows: To an 8 by 1
tube, containing 48 cc. of sterile salt solution, i cc. of tuberculin R is added, using a sterile
syringe. The vial is then washed out with 1 cc. of sierile sail solution and (his added. We
then haie a solution containing ^ mg. per cc. The tube is sealed and labeled. The
dilutions made in this manner arc kepi as stocks, and from ihem further dilutions arc made
lor actual use— 125 c.mm. of lys.1l should be added to each 50 cc. stock solution. To
prepare a solution to contain ylo mg. per cc, we find that, uang a is cc bollle of Ij-solized
salt solution, we require a total of [jSj mg. of bacillary suljslance. There being ^ mg. in
every cubic centimeter of the stock, we find that we require o.j7 cc. of the stock. This
amount haling been extracted from a blank lysol salt vaccine bi>tlle with a sterile syringe,
the same amount o£ the slock is injected through the rublier cap and Ihe liottle well shaken.
To prepare a bollle lo contain jjo mg. )>er cc. twice this amount of ihe slock musi be added.
To prepare a bollle lo contain snVo mg. per cc. we must transfer ^ cc. from the bottle con-
taining ^ifan mg. per cc. Before these additions arc made, equal quanta of the cc
of the blank vaccine botlles must be abstracted.

Tuberculin O is used fir the von Pirqucl lubcrculucutaneous lest. ii

732 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

for use to have old tuberculin in sealed capillary tubes, each one containing sufficient un-
diluted tuberculin for a single test. Three-eighth inch glass tubing is drawn out into a
fine capillary, the long tube thus made is cut into 2-inch lengths, one end of each steril-
ized, and inserted into the tuberculin container. The fluid readily runs into these tubes
by capillary traction. Both ends are then sealed in the flame.

THE STERILIZATION OF VACCINES

At the present time the only method that can be recommended for every-day use in
killing bacteria for vaccines is the use of heat. The temperature of 60° C. for one hour
can be depended on to kill any species of bacteria which are at present used in the prepara-
tion of vaccine. It is the temperature most commonly used.

There is sufficient evidence that this amount of heating injures the vaccinating quali-
ties of certain bacteria. It is, therefore, desirable to subject the vaccine to as short an
exposure as possible to this degree of temperature. In the case of staphylococcus albus,
citreus, colon, and Friedlander's bacillus, exposing in a water-bath at 60° C. for fifteen
minutes, and immediately following the addition of { of i per cent, (of the total bulk)
of lysol, has been found sufficient to destroy these bacteria. In the case of staphylo-
coccus aureus, however, from twenty to twenty-five minutes will common^ be required.
In the case of gonococcus the addition of } of i per cent, lysol to the bacteiial emulsion,
thorough shaking, and exposure to a temperature of 37^° C. in an ordinary incubator
for a period of twelve hours have been found to kill the organisms. In the case of typhoid
the present method of sterilization used in Wright's laboratory, London, is exposure to a
temperature of 53° C. for seventy minutes. In the case of streptococcus and pneumo-
coccus heating for thirty minutes is ordinarily sufficient. In all cases it is wise to add
lysol immediately after sterilization. In every case the vaccine should be tested culturally
to prove its sterility. Other methods of destroying bacteria in the preparation of vaccine
to the end of rendering it a more efficient immunizing agent will be discussed later.

NEW METHODS OF KILLING BACTERLA FOR VACQNES

There is considerable evidence that vaccines composed of bacteria killed by heat are
not so efficient, so far as their vaccinating qualities are concerned, as those killed by some
other methods. It appears that heat in some manner modifies the particular toxic sub-
stances contained in the bacterial cell in such a manner as to render them less efficient
in inducing the formation of corresponding specific protective substances. It would be
desirable, if possible, to make use of bacterial protoplasm as vaccine without subjecting
it to the modification of heat.

We have good evidence, in the work of Weaver and Tunncliffe,^ that a streptococcic
vaccine, composed of organisms killed by a solution of galactose, has superior vaccinating
qualities to the same killed by heat. By inoculating animals they compared the im-
munizing effect of vaccines prepared by these two methods. Their experience in using
streptococcic vaccine, prepared in the ordinary manner by heating, is consistent with
that obtained by many workers, in that they found that the results were not so good as
had been obtained in the use of vaccines of other types of organisms.

Their technique was as follows: They washed off in a sterile 25 per cent, galactose
solution a twenty-four-hour growth of streptococcus on blood-agar, 2 cc. of the solution
being employed for each agar slant. This suspension of bacteria in galactose solution
was incubated for from forty-eight to seventy-two hours, and during this period was
shaken several times. The emulsion obtained from each agar tube was centrifugalized,
the supernatant fluid pi|>eted off, and the residue desiccated in vacuum over calcium
chlorid at room temperature and sealed. Usually the bacteria were found to have been

* Jour. Infec. Dis., Dec. 18, 1908.

NEW METHODS OF KILLING BACTERIA FOR VACCINES 733

killed in twenty-four hours. One strain of streptococcus was not killed in forty-eight
hours, but was sterile after seventy-two hours. The killed organisms were then suspended
in 2 or 3 cc. of sterile normal salt solution. The vaccines which they used for comparison
were prepared in the usual nanner, and killed by thirty minutes' exposure to a tempera-
ture of 60° C. They found that galactose-killed streptococci induced in rabbits more or
less immunity to the living streptococcus. It required five to seven days after the
inoculation for this immunity to appear. Protection afforded by two doses was greater
than that of a single dose. They found that the opsonic index was elevated after injec-
tions and followed a more or less regular course. The negative phase was more marked
after the first dose than after the second. The index was usually highest on the second or
the third, fourth, and fifth days after injection. The larger the dose, the higher the
indices. Two guinea-pigs were protected, each by the injection of 500,000,000 galactose-
killed streptococci, and six days later each was inoculated with a living streptococcus
culture intraperitoneally. Both were well a month after inoculation. The control,
unprotected animal died in eighteen hours. As a part of the same experiment, guinea-
pigs were inoculated by the same doses of heat-killed bacteria, and after the same period
were inoculated with a living broth culture intraperitoneally. All these animals died.

Again, one rabbit was inoculated with 500,000,000 galactose-killed streptococci,
four days later the same dose was repeated, and after ten days 3 cc. of a twenty-four-hour
living broth culture of streptococcus was injected intraperitoneally. The rabbit did not
become sick and was well a month later. A second rabbit, inoculated in the same manner,
but with heat-killed streptococci, and later injected with the same amount of a living
streptococcus culture intraperitoneally, died twelve hours after inoculation.

The advantage of the galactose-killed vaccine over that killed by heat appears to be
perfectly definite. In one of the rabbits treated by galactose-killed vaccine the opsonic
index six days after inoculation was 6. In the rabbit of the same group, treated by heat-
killed vaccine, the opsonic index remained approximately i.^

They conclude that subcutaneous injections of galactose-killed streptococci all pro-
duce definite phenomena, in the fact of a very great rise in the opsonin, as indicated by
the increased phagocytic power; that hand in hand with this rise in opsonic power the
animals developed a considerable degree of immunity to living virulent streptococci, of
sufl5cient degree to protect the animal against doses of living culture that killed normal
animals. The protection may be complete, or it may delay and modify the infection.

In marked contrast are the effects of the injection of heat-killed streptococci, in that
they did not produce any pronounced increase ift opsonin; the animals thus treated, when
injected with living cultures, later appear to have had even less resistance than normal

^ The clinical results in the use of heat-killed streptococci would more or less confirm
this view. Certainly the use of streptococcus vaccine is not commonly followed by the
consistently good effects seen in the case of vaccines prepared from other organisms. A
reasonable explanation is that particular endotoxins of the streptococcus are much more
easily altered by heat than those of some other bacteria commonly and successfully used.
In general accord with these observations, as to the comparative inefficiency of strep-
tococcus vaccine when killed by exposure to a temperature of 60° C. for one hour, is the
experience of Leary (Boston Med. and Surg. Jour., 1909, clxi, 716). He states that
"clinical results from the use of such vaccine were unsatisfactory." Consequently, he
shortened the time of sterilization to fifteen minutes at 60° C. and obtained better re-
sults. "Positive cultures of the streptococcus may be obtained from the suspension"
at the end of exposure. He adds J per cent, carbolic acid after heating. He states
that "this small amount of carbolic acid . . . results in killing or further attenuation
of the organism, so that infection is not possible. We have now used such vaccine on
several hundred cases without any infections and with results markedly superior to those
obtained when Wright's rule was followed."

734 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

animals. They report excellent results in the treatment of patients. First, a case of
suppurative otitis media and mastoiditis, the second, of chronic erysipelas. They con-
clude that, in view of the results in attempts in protecting rabbits against virulent strep-
tococci by heat-killed vaccine, it is doubtful if one gains any advantage in the thera-
peutic use of streptococci killed by heat.

Clinical Practice
acute fulminating infections

A constant protection against the invasion of pathogenic organisms
is the unbroken skin in health. The hair-follicles and the openings of
the sebaceous and sweat-glands, however, become avenues of entrance
for bacteria at times and localized infections may result. Excessive
activity in the secretion of sebaceous material renders the skin oily
and more apt to harbor bacteria on its surface. The tendency of these
glands to become occluded, resulting in the formation of sebaceous
cysts and comedones, offers opportunities for the surface bacteria to
grow in a medium which is more or less out of contact with the circulat-
ing blood. Thus we have conditions which predispose to acne and
furunculosis. A perfectly healthy skin is more or less proof against
such infections, unless the organisms be inadvertently rubbed into
these minute openings, or some injury impairs the blood-supply.

Infections taking place through the normal openings of the skin
are commonlv localized. We have, as a result, acne and furunculosis.
This, however> depends largely on the virulence and character of the
infecting organisms. When lymphangitis and temperature develop,
the infection may be termed acute and fulminating in type, because
in these cases the bacteria are unquestionably being taken into the
blood-stream. The most serious of these fulminating infections are
obviously those which originate from the entrance of bacteria through
some traumatic break in the skin. The most common and least serious
under ordinary conditions are those due to the staphylococcus. The
graver infections resiJt from the entrance of streptococcus, pneumococcus,
and occasionally to some other bacteria. The gravity of the infection
depends upon the number of organisms that gain entrance, the depth
to which they penetrate, and the character of the tissues in which they
find their initial seat. It is obvious, if large numbers of virulent bacteria
suddenly find their entrance into the subcutaneous tissue, they will find
opposed to them only few leukocytes and only a certain quantum
of lymph. Although certain of the bacteria may be destroyed at once,
an excess of organisms will immediately absorb the antibacterial sub-
stances that are at the locus of entrance. Trauma to the tissues at this

ACUTE FULMINATING INFECTIONS 735

point and a lymph of lowered antibacterial power would furnish a
good medium on which bacteria which are not killed, will j&nd more
or less unbridled opportunity for growth.

If the locus of infection be superficial, tissue necrosis may take place
in such a manner that the pus may point, and either evacuate itself or
be readily evacuated by surgical procedure; further applications of
heat will be efficient in inducing a more free blood-supply. The deep
infection may be beyond the scope of ordinary therapeusis. Any collec-
tion of fluid which later will develop will necessarily be under greater
tension; excessive autoinoculation will be apt to take place, because of
this tension and of the impossibility of the pus to discharge itself. We
have considered previously the characteristics of the pus of pyogenic
bacteria, and have noted that it has a distinct tendency to dissolve
connective tissue on account of the tryptic ferment it contains. In a
deep infection this solution of tissues will take place in all directions
under excessive tension.

If infection enters a tendon-sheath, there is nothing to prevent a
severe infectious process, as the conditions are such in these sheaths
as to prevent any rapid replacement of lymph, exhausted of its anti-
bacterial power, by fresh lymph from the blood and leukocytes. The
same may be said of serous cavities, such as the joints. There are but
t\vo types of localized infection which can be treated successfully by
specific antitoxins. They are diphtheria and tetanus. Success in the
treatment of the former depends on the addition of antitoxin during
the early period of the disease, before it has appeared in the normal
course of events in the blood. The success in the treatment of tetanus
by antitoxin is nowhere near so great. In order to be efficient it must
be administered immediately after infection has taken place, in large
doses, at least every eight up to twelve hours.

In the treatment of superficial fulminating infections, in their very
early stages, clinical practice appears to be overwhelmingly in favor
of the application of heat by poultices and hot soaks where they can be
applied. The application of these measures is unquestionably the first
indication, for the reason that it tends to further the efficiency of the
process which the body first makes use of in its struggle against infec-
tion, in that it increases the supply of blood to the part and thus aids in
rendering conditions in the focus of infection, so far as opsonin and
leukocytes are concerned, as nearly like that to be found in the circulating
blood as possible. It is a rational procedure, because it tends to render
more effective the initial protective reaction of the immunizing mechan-
ism. Any therapeutic measure which might inhibit in any way the

736 THERAPECmC IMMUNIZATION AND VACCINE THERAPY

initial hyperemic reaction must be considered, on the grounds stated, an
improper procedure. Bier's passive hyperemia and Gamgee dressings
are instances of therapeutic measures misapplied if used at this early
stage of the infection. They induce a condition of stasis of circulation
in the infected focus, whereas the clear indication is a rapid interchange
of lymph into and out of, the focus, and a continuous supply of fresh
leukocytes, such as active hyperemia brings about. (See Principles of
Immunization.)

Although any measure to obstruct free hyperemia is thoroughly
irrational in general, superficial infections, in which the blood-supply
appears to be deficient, particularly when the infection is of very slight
dimension, may be sometimes excepted. In some of these cases inter-
mittent passive hyperemia, as described on p. 265, would appear more
advantageous than an endeavor to increase hyperemia by heat. This
is seen in slight uifections of the fingers.

Where the infected area is large, as in phlegmon, passive hyperemia
may be decidedly dangerouSy because the blood-stream may recei\e exces-
sive autoinoculation from the lymph which has been forced throughout
the infected area, and has been taken into the blood again bearing ex-
cessive numbers of bacilli.

The use of vaccines at this stage, even supposing that accurate
bacteriologic diagnosis can be readily made, is generally contra-
indicated, because the failure of the body to immunize itself is not due
to any deficiency in bacterial stimulus.

The breaking down of the tissues, the formation of a pus-pocket,
attest the failure of the initial attempt to destroy the bacteria. We
have seen that pus under pressure not only furnishes conditions favor-
able to local growth of bacteria, but also, by its tryptic ferment, leads
to the spread of the infection by solution of the connective tissue.

At this point, surgical measures have always found their rational
application, and removing the pus, relieving the pressure, nullifying
the tendency of the infection to spread, and allowing fresh lymph from
the blood to take the place of lymph which has lost its antibacterial
power by its long contact with bacteria. The fresh lymph not only
exerts its effect against the bacteria, but neutralizes the tryptic ferment
of the pus and prevents further solution of the tissue.

One of the most important and eflScient therapeutic measures that
have been offered in the treatment of localized infections Wright has
given us in the sodium citrate and chlorid solution which he advises.
This solution is composed of 4 per cent, sodium chlorid and i per cent.

ACUTE FULMINATING INFECTIONS 737

sodium citrate in water. It is used as an irrigation and as a constant
dressing in the case of abscesses and infected wounds. Its action, as
has been previously stated, by means of its sodium citrate content, is
to decalcify the lymph and prevent its clotting in the walls of the cavity,
to prevent the formation of crusts in the same manner; and of the salt
content, in that it furnishes a hypertonic solution, to induce a flow
of lymph from the tissues into the abscess cavity. Thus, by the constant
application of this solution after operative procedure, free circulation
of fresh lymph is secured and maintained in the focus. When this
solution is used, wicks become totally unnecessary; an exception may
be found in the case of wounds which mechanically close themselves
and obstruct the exit of fluid. In this case rubber dam should be used
for its mechanical effect in keeping the wound open.

Contraindication to sodium citrate and salt solution is to be found
in cases where there is a tendency to hemorrhage.

The salt content of this solution is very irritating to the skin, and
may, if necessary, be diminished to a 2 per cent, solution. The skin
should always be protected by means of boric ointment, in order to
prevent pustulation, which may result from irritation of the salt.

Having secured by surgical measures the evacuation of pus and
consequent elimination of excessive autoinoculation, by means of the
citrate and salt solution the maintenance of free drainage, and conse-
quent furtherance of conditions necessary for destruction of the bac-
teria, we have next to consider the condition of the blood-stream as
to its antibacterial eflSciency. Following the elimination of autoinocu-
lation, the opsonic power of the blood rises sooner or later to above
normal. If the opsonic power maintains itself above normal, such
may be taken as evidence of a proper immunizing response to bacterial
stimulus. Clinical evidence of such a favorable response is to be seen
in the subsidence of local and general symptoms and improvement in
local conditions. Vaccine may be reasonably withheld so long as the
conditions suggest that the immunizing response is sufficient. In the
majority of cases incision, coupled with maintenance of free drainage by
the use of citrate and salt solution, is followed by resolution. In those
cases that do not readily clear up, opsonic determinations generally in-
dicate a low antibacterial power of the blood-stream. Consideration
shows that the surgical measures have changed what bade fair to be-
come a generalized infection into a localized process. Autoinoculation
has been entirely eliminated, and the blood receives no impulse leading
to the production of specific antibodies. Hence we should furnish the
stimulus by injection of corresponding vaccine. The failure of these

738 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

processes to resolve is suflBcient reason for the exhibition of vaccine
without resorting to opsonic determinations.

In every localized infection a culture should be obtained at the time oj
operation^ not only for record as to the nature of the infect iony but also to
enable one to furnish a vaccine if later needed.

Vaccine is indicated when these processes give evidence of becoming
indolent, to take the place of autoinoculation, which is found to be lacking
in such conditions. Vaccine should be withheld until it is evident
that the beneficial effects of previous autoinoculation, either natural or
induced by the operative procedure, have worn off. Indolence of the
lesion may be taken to indicate this state of affairs.

Where temperature persists, it usually means that there is some
pocket that has not been drained. If, in spite of apparent good drainage,
temperature persists irregularly, whatever autoinoculation that may be
responsible for the temperature is probably not efficient in the produc-
tion of antibodies. In such cases vaccine should be given regularly,
with the hope of producing a continuous elevation in the opsonic power.

The dosag^e must be small, eliminating, so far as possible, the period
of negative phase — therefore, frequent. In the case of streptococcus and
pneumococcus initial dosage of from 2,000,000 to 5,000,000; colon,
10,000,000; staphylococcus, 25,000,000, should be injected daily and
gradually increased by from 2,000,000 to 10,000,000, always avoiding
any increase in temperature or subjective symptoms. As the dosage
is increased, a greater period must elapse before the next is given.

Satisfactory response is indicated by a drop in temperature. If
temperature does not fall within the next twelve hours, and if the patient
shows no signs of increased toxemia, the dose may be guardedly in-
creased.

Where the infection produces no temperature, but is indolent in
resolution, larger doses may be given from the first, as the lesion now has
the characteristics of a localized infection. The initial dosage of pneu-
mococcus and streptococcus may be 10,000,000, increased by the same
amount two days later, and gradually increased further up to 100,000,000
or more every three or four days. The other local measures, as suggested,
to cause determination of the blood to the focus, must be used. Initial
dose of staphylococcus may be from 50,000,000 to 100,000,000; of colon,
10,000,000 to 20,000,000. The smaller doses in these cases may be
repeated every two days, the larger, every three or four days. Every
dose should be allowed to exert its full effect before the next is given.
Opsonic index determinations furnish evidence as to the time when the
effect of a dose of vaccine is wearing off.

ACUTE FULMINATING INFECTIONS 739

The suggestions here offered as to dosage are based on study of re-
quirements by means of the opsonic index; generalized reaction, asso-
ciated with fever following vaccine, in the localized infections, may
take place if too large dosage be given. This indicates that living
bacteria are in the blood-stream, and that conditions favoring spread
of the infection have been produced. This condition should be entirely
avoided, and can be if the dosage be increased very gradually.

In the absence of generalized reaction following vaccine we have
local evidence in an increased discharge, swelling, tenderness, etc.,
that the dosage is too large. The writer has made it a point, in the
exhibition of vaccine, to seek to avoid any local or general reaction.
In that excellent therapeutic effect may be produced, w ith total absence
of toxic symptoms or local exacerbation, except in rare cases, the writer's
experience entirely corroborates that of Wright.

Treatment of deep punctured wounds should be surgical, and should
not be delayed, particularly if tendon-sheath involvement is suspected.
The development of pus should not be awaited. The other measures
referred to should then be applied as indicated to induce determination
of blood to the lesion.

In all cases an infected member should be held in an elevated or
horizontal position, in order that there may be no obstruction to the
free return of venous blood, to the end of securing free interchange of
blood fluids.

In the writer's experience, the use of vaccine when the acute infections
have become indolent has fulfilled a distinct indication, and has been
followed by excellent results in the majority of cases treated. There
has been, apparently, no advantage gained when vaccines have been
used during the acute febrile period. Vaccine has seemed to be less
efficient in streptococcic infections than in others. The results have
improved since the adoption of better methods for steriUzing the vaccine.

Vaccine should be prepared from cultures obtained from the patient
if possible. Until such can be prepared, corresponding stock vaccines
should be used.

Some most striking results have been obtained in treatment of infected
laparotomy wounds, when the colon bacillus has been the causal agent.
A type of this case, treated by the writer, is a girl of ten years, who for
two months after appendectomy had a septic temperature, associated with
a fistulous opening discharging pus and feces. Reoperated twice, in search
for some undischarged pocket of pus, but none was found. When seen, the
patient was much emaciated, was unable to retain food by mouth, was running
an elevated temperature, discharging feces and much pus from the operative
wound. A bad prognosis had been given. The colon bacillus was isolated

740 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

from the pus and vaccine injected as follows: First day, 10,000,000; second,
20,000,000; fourth, 40,000,000; fifth, 80,000,000. The temperature had
begun to drop after the second dose, and at the end of a week became normal
and remained so. Discharge of pus ceased; the child was able to take food
by mouth. Some weeks later, after the fecal fistula had closed, patient was
discharged well.

GENERALIZED INFECTIONS

The Septicemias. — Septicemias may be divided into two classes:
first, those which derive their bacteria from some active focus of infec-
tion, such as uterine sepsis; and, second, those in which the bacteria
appear to be cultivating themselves in the blood-stream, or cultivating
themselves in some part of the endarterial system, as in malignant endo-
carditis. In the first, there is a condition of more or less continuous
autoinoculation, and possibly also growth of bacteria in the blood itself;
in the second, the preponderance of growth of bacteria appears to be
in the blood.

In the first class we must include acute fulminating infections when
associated with temperature, and likewise carbuncle, phlegmon, erysipe-
las, uterine sepsis, and other infections which start locally, but which
are characterized by continuous or intermittent autoinoculation; in the
second class would naturally be included those septicemias in which
the atrium of infection is not demonstrable or in which the locus of
infection cannot be extirpated or drained.

At once the difference in prognosis between these two classes of cases
is apparent, when we consider that in the former it is possible commonly,
by means of operative measures, to eliminate autoinoculation in varying
degree, and thus diminish the numbers of bacteria that are being sent
into the blood-stream, while in the latter, the true septicemias, we have
no control over autoinoculation, because it appears the bacteria find in
the blood-stream a suitable medium for growth, or continually find
entrance from some focus that cannot be eradicated, as, for instance,
vegetations in the endocardium.

In septicemia dependent on local infections the fact of the immediate
amelioration in symptoms, drop in temperature, and disappearance of
bacteria in the blood-stream, after operation, indicates that the blood-
stream has the inherent power of destroying the bacteria present, pro-
vided that constantly new invasions of bacteria from the focus of infec-
tion be inhibited. It suggests that the presence of bacteria in the
blood-stream is largely due to autoinoculation, and that if growth does
occur in the blood-stream itself, it may be accounted for by diminished
antibacterial power, produced by a combination of antibacterial sub-

GENERALIZED INFECTIONS 741

stances as soon as they enter the blood-stream with the bacteria already
present.

We have obviously no control over the bacterial content of the blood
in the true septicemias, save by making use of measures to increase the
power of the blood-stream itself to destroy the bacteria.

Uterine Sepsis and Similar Conditions.— Treatment should
be directed first to the elimination of autoinoculation by absolute rest and
such local measures as may cause free drainage. By such methods,
abstraction of antibacterial substances from the blood-stream, by con-
tinued fresh invasion of bacteria, will be lessened. Fresh increments
of antibodies in the blood-stream, instead of being immediately ab-
sorbed by the bacteria, will be applied in the circulating blood against
the bacteria in the focus and lead to its final localization.

Where temperature persists after these procedures, opsonic index
determinations have shown that autoinoculation has not been thor-
oughly eliminated. The continuance of symptoms and temperature
shows that the autoinoculation is not effective in the production of
suflScient antibodies to destroy the bacteria that enter the blood, that
the focus has not become localized. If it is impossible to secure better
drainage, the next indication is to endeavor to fortify the blood-stream
by means of bacterial vaccines.

In treating septicemias we cannot afford, even for a few hours, to
break down, in the smallest degree, or maintain in a condition of
depression, any barrier offered against the growth of bacteria. We,
therefore, have immediate reason for the use of sufficiently small dosage
to cause complete elimination of the negative phase or phase of dimin-
ished resistance. In the giving of vaccines in febrile cases it is the desire
to produce, by subcutaneous inoculation, a reaction followed by raised
immunity and no preceding negative phase. This is particularly the
case in septicemias. The best way to prevent the taking of large
amounts of vaccine into the circulation is by reducing the dosage.
The opsonic index has pro\dded a method for testing the effect of
inoculation, and by its use it was found possible to produce an im-
mediate reaction in the production of antibacterial substances without
any previous diminution. Wright has shown it possible in tubercu-
losis to produce a rise in opsonic power within one hour after inocu-
lation. Haffkine, referred to by Wright,^ was the first to obtain a
condition of immunity twenty-four hours after inoculation of plague
vaccine. Wright lat©r showed the same was possible, using a typhoid
vaccine.

^ Lancet, August 24, 1Q07.

742 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

Based on the supposition that, in spite of the fact that the blood-
stream contains toxic numbers of bacteria and toxic substances in large
amount, these do not furnish a sufficiently concentrated stimulus, because
they are diluted by the whole blood-stream, to the cells responsible for
the formation of antibacterial substances, we are justified in expecting
that a concentrated dose of vaccine, incorporated in the subcutaneous
tissue, might be efficient at this point.

That it is possible in septicemia to induce a rise in the opsonic power
of the blood without any previous induction of negative phase we have
a sufficiency of laboratory evidence. This rise, however, is necessarily
fleeting, and the stimulus in the way of vaccine must be repeatedly and
frequently given.

We not only have the laboratory evidence of the efficiency of vac-
cine in producing a rise in the opsonic power in septicemia, but also
evidence of associated clinical improvement, which renders this rise
more significant. Purely clinical evidence as to the efficacy of vaccine
in septicemias has been furnished by several writers, among them
Thompson.*

He reports 7 cases of streptococcic endocarditis in which, following the
use of homologous vaccine, 3 recovered; in 2 of the fatal cases the eflfect of
vaccine was strikingly but temporarily beneficial, and in 2 other cases the
benefit was slight but demonstrable. He reports i case of advanced pyemia
as cured. In all cases striking eflfect was noted in the decline in temperature
following vaccine, and there was associated clinical improvement.

Hartwell, Streeter, and Green' report 9 septicemias treated, 4 due to the
staphylococcus aureus, 5 to streptococcus, of which 4 died. Their opinion
was that in those that recovered successful outcome was no more due to the
vaccine than to the surgical treatment. In 18 cases of puerperal sepsis, 15
of which were due to the streptococcus, they state that the effect of the vaccine
on the temperature was at times striking.

Thompson's method of treatment consisted of fairly large and
infrequent dosage. In one case 50,000,000, 100,000,000, and 200,000,000,
twice, of killed streptococci, were given at six-day intervals. In another
10 inoculations were given, varying from 100,000,000 to 300,000,000, at
intervals of four or five days. In another, 13,000,000 to 20,000,000
were given on account of the feebleness of the patient — 24 inoculations
in all — at first every other day and later every day.

* Amer. Jour. Med. Sci., August, 1909.

* Surg., Gyn., and Obst., September, 1909.

GENERALIZED INFECTIONS 743

The writer has treated one case of staphylococcus septicemia for a period
of three weeks, giving from 25,000,000 to 100,000,000 every day at first, and
later every other day. The patient recovered several months after inoculations
were stopped. One case of malignant endocarditis due to the streptococcus:
This patient was in a critical condition when seen; history and the condition
of the heart indicated an endocarditis of long standing. Vaccine was given in
dosage of from 10,000,000 to 25,000,000 every other day. There were abso-
lutely no untoward results, and there was a distinct average lowering of tem-
perature. The patient died of cardiac failure after about two weeks. One
case of pyemia due to staphylococcus was apparently temporarily benefited by
vaccine, but finally succumbed. Six cases of septicemia, following localized
infections, some of them of joints, were treated after surgical measures had
been exhausted and bad prognosis had been given, ^^ith ultimate recovery of 4.

These citations suggest that vaccine may fulfil a distinct indication
in generalized infections. That its use is productive of a rise in the
opsonic power of the blood, if properly given, is certain; that, associated
with this, amelioration in symptoms is produced, seems apparent. It is
entirely too much to expect of the exhibition of vaccine that it should
be a cure-all for these serious cases. There are unquestionably many
factors to be considered which make for life or death of the patient,
and over which vaccine can have no control. For instance, it has been
clearly shown by Rosenow and others that bacteria have the power
of immunizing themselves against the blood fluid. Further, it has
been shown by Rosenow that \'irulent pneumococci resist phagocytosis.
Even though the antibacterial power of the blood were raised to a very
high degree, it might not be able to cope with such conditions. We
have further to consider the effect of the poison upon the functions of
certain organs which may be injured beyond repair, and which, in spite
of the efficient response of the immunizing mechanism to vaccine, would,
nevertheless, lead to an ultimately fatal outcome.

Diagnosis. — It is not within the scope of this chapter to enter into
details of bacteriologic diagnosis. As in the case of every infection of
importance, accurate bacteriologic diagnosis should be made for record,
this being of particular importance when specific treatment by vaccine
may be required.

When possible to obtain a discharge, diagnosis may be readily made,
otherwise blood-culture will be necessary. The obser\ation of Rosenow
(loc. cit,) that the use of agar as a medium for blood-cultures yielded
positive growth repeatedly where cultures in broth remained sterile,
indicates that the accepted idea that fluid media are always preferable
to solid media for blood-cultures is erroneous. The use of both solid

744 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

and liquid media will not only tend to secure greater average success,
but also will give a fair idea of the relative numbers of bacteria in the
blood.

Dosag^e. — ^While it is desirable, if possible, to guide the dosage by
means of the opsonic index, it is possible to treat this type of case de-
pending upon clinical symptoms alone. It should be borne in mind
that we must avoid the lowering of the patient^s resistance by using
excessive dosage. While the opsonic power may be continuously low,
and apparently it would seem that even large doses of vaccine could
not further lower it, theoretically we should expect large dosage to
do nothing else than to increase the condition of overexcitation under
which the protective mechanism is struggling. Clinically, we find that
sometimes even small dosage will be followed by alarming symptoms
and evidence of increased toxemia. This would not appear to be due
to the amount of toxin administered, but to the effect it has upon the
protective mechanism. It does not seem that this toxic effect is always
registered by the lowering of the opsonic power, because it is already
much reduced perhaps, but, nevertheless, clinical experience would
indicate that we have in some manner broken down the barriers of
resistance which the patient normally possesses. We should not, even
after a few hours, allow this to take place. We can, by the exhibition
of minute doses at short intervals, achieve a slight and repeated rise
in the opsonic power, and, associated with this, we can see improvement
without any injurious effect upon the patient. Until it can be definitely
shown that large doses can be given without harm, we must in practice
hold to such amounts of vaccine as will be effective and without danger.

In the case of streptococcus, from 1,000,000 to 5,000,000 may be an
initial dose. Two millions is practically always safe. This should
be repeated in from twelve to t^venty-four hours, and, if there are no
imtoward effects, may be increased on the following day. Inasmuch
as the dosage depends upon the virulence of the vaccine and the condition
of the patient, no absolute rule can be given. It may be possible to
repeat these minute doses every six or eight hours with nothing but
benefit. A maximum dosage might be said to be 25,000,000 daily,
though this will not always apply. Where the blood infection emanates
from a local focus, the increase in dosage may be rapid and the amount
given finally larger. As the dosage is increased and the patient improves,
one- or two-day intervals between the doses may be desirable. In the
case of pneumococcus the dosage is practically the same. In the case
of staphylococcus it is sometimes found that the organism is of low
virulence, and it may be found that even from 100,000,000 to 200,000,000

SUPPURATIVE ARTHRITIS 745

may be given every two or three days. Much care must be taken in
giving initial doses of colon vaccine, the dosage being from 5,000,000.
The virulence of all vaccine varies, and is not to be measured by the number
of bacteria in the dose given. In one instance an inoculum of 5,000,000
streptococci of one strain might conceivably have the virulence of five
times or more that dose in the case of another strain. The dosage
should always be increased in such a manner that no exacerbation will
be produced. The sicker the patient, the s)naller the dose that should be
given.

A sudden rise in temperature and increase in toxic symptoms suggest
that the dosage may have been too large. These signs may, however,
have been produced in the normal course of events and have no relation
to the vaccine. If the dose that has been followed by such signs is
minute, there is no contraindication to repetition on the next day. If
the dose was of larger proportions, it would be well to reduce its size next
day.

While in the case of pneumococcus, streptococcus, and staphylococcus,
the most common causes of the septicemias, immunity appears to be
largely due to the opsonin and the phagocytes, in the case of colon and
typhoid we see in the agglutinins, bactericidins, etc., additional factors
of equal or greater importance. The de\'elopment of these substances
is by no means parallel to that of opsonin, but in the case of a given
dose of vaccine, these substances make their appearance usually later
than the increase in opsonins. Hence, we may have an elevated opsonic
index, and at the same time a low agglutinating power in these infections.
A dose of sufficient size to cause a decided increase in opsonin may be
inefficient in producing agglutinins in large amount. It is desirable, of
course, to induce formation of these substances, and hence in colon
infections a more rapid increase in dosage is advisable. At the very
start, however, dosage must be small, in order not temporarily to lower
the opsonic resistance. Later, it would appear that, at least clinically,
within certain limits, these other antibodies more than balance tempor-
ary lowering of the opsonic index after good-sized dosage. In the case
of a child with colon septicemia following appendectomy the writer
gave as an initial dose 10,000,000, on the following day 20,000,000, two
days later 40,000,000, and again, two days after, 80,000,000, with im-
mediate fall in temperature and recovery.

INFECTIOUS ARTHRITIS

Suppurative conditions are most frequently due to the strep-
tococcus, staphylococcus, or pneumococcus, but in the case of trau-

746 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

ma tic infections following punctured wounds, other organisms may be
found. After thorough drainage by surgical measures, the most im-
portant indication is to render drainage permanently effective. The
inefficiency of gauze wicks to allow of good drainage has been considered.
Their action is commonly more effective in preventing efficient discharge
than in promoting it. Where mechanical conditions are such that the
operative wound naturally closes itself, the insertion of a rubber dam
is effective in preventing this closure. The uselessness of antiseptics
as irrigations of joints, and, in fact, their positive harm, needs little
comment.

The prime indication in these infections, as w ell as in all others, is
to produce a free and continuous streaming of lymph from the blood
into the infected focus, in order that, as nearly as possible, the sum total
of its antibacterial power can be exerted against the bacteria as they
cultivate themselves in the tissues. In order that this shall take place,
evacuation of the pus and elimination of pressure is the first necessity;
the second is to perpetuate a free and clear external opening.

The usefulness of the sodium citrate and chlorid solution in meeting
these requirements has been sufficiently considered. In practice it is
possible, by use of this solution, to prevent any tendency to crust forma-
tion, to produce a discharge as long as is desirable, and to maintain an
unobstructed opening for as long a period as desired, subject, of course,
to the gradual closure that will take place through the process of healing.
It appears, in general, that operative wounds heal less rapidly if this
solution is kept constantly applied.

When, in spite of these measures, the infection becomes indolent,
either with or without temperature, the use of appropriate vaccine is
indicated. Where there is a temperature, the dose, of course, should be
small, and under all conditions considerably smaller than in most other
localized infections.

Vaccine, always in association with the other measures indicated,
has, in the wTiter's hands, appeared to be efficient in a number of cases
of suppurative joint infection. Two cases should be cited in which,
following operation, a septicemic condition developed, streptococci were
isolated from the blood, and vaccine given, with ultimate recovery and
good functionating joint.

It has been usually the case, w^here temperature has again de\'eloped
after once having reached normal, that some pocket of pus has developed.
Vaccine cannot, of course, be expected to cope with such a complication,
and is contraindicated until it is clear that foci of pus are satisfactorily
evacuated.

GONORRHEAL ARTHRITIS 747

Gonorrheal Arthritis. — These infections in their acute stage
present a condition of more or less contmuous autoinoculation, as
evidenced by the temperature. The ordinary treatment by fixation
of the part affected commonly is sufficient to satisfy the primary indica-
tion in all infections associated with autoinoculation and temperature,
namely, the elimination of such automoculation and thus the production
of a strictly localized infection.

Inasmuch as in the ordinary course of e\'ents elimination of auto-
inoculation is secured after a few days of treatment, it does not appear
necessary to use vaccines during this acute stage.

When temperature subsides and autoinoculation consequently ceases,
we usually find a condition of lowered opsonic power for reasons previ-
ously discussed. The indication is, therefore, to furnish a stimulus, by
means of vaccine, that shall set in motion the protective mechanism and
result in the elaboration of protective substances in increased amount.

Although certain cases of gonorrheal arthritis gradually progress
toward complete recovery, the frequency with which they become chronic
and resist all the ordinary measures of treatment attests the failure of the
immunizing mechanism in these cases.

We see in the low antibacterial content of the blood-stream, and the
obstruction to circulation produced by the local swelling, factors which
render this chronicity possible.

The consensus of opinion among those who have treated a con-
siderable number of cases of this type by injections of gonococcic vac-
cine appears to be that vaccine is a valuable therapeutic measure.

Hartwell^ reports the treatment of 31 cases of gonorrheal arthritis. These
cases were first treated at periods varying from one month to one year after
the acute attack. In 27 of these cases the end-results were completely func-
tionating joints without disability. Those which did not entirely clear up,
so far as function is concerned, had already, when treatment was started,
become ankylosed. Dosage, in Hartweirs chronic cases, reached as high as
500,000,000 to 600,000,000. Interval between dosage was from five days to
a week. Subjective symptoms, such as malaise, nausea, and vomiting, were
occasionally produced, but no untoward event occurred which was ultimately
serious. He prepared his vaccine by two methods — the first exposure to 60^
C, and in the second he exposed his vaccine in an ice-box over night, added
i of I per cent, of lysol, and allowed it to stand twelve hours before using.
There appeared to be no differences in the vaccinating qualities of these dif-
ferently prepared vaccines. He used autogenous vaccine in 21 cases, mth
what he considers better results than where stock vaccine was used. His
method was gradually to increase the dosage, with the idea of overcoming
tolerance already produced by previous dosage.

^ Ann. Surg., November, 1909, p. 939.

748 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

In 20 acute cases treated he thought the vaccine diminished pain and
hastened resolution. Nine of these cases recovered with free motion of the
joint affected. He found that in the acute cases other joints became in-
fected after the first few inoculations. He thinks these were due to the or-
dinary course of the disease, and not to the effect of the vaccine. His dosage
in acute cases was from 25,000,000 to 100,000,000, and the interval two to
four days.

Hartwell concludes that gonococcal vaccine is a valuable therapeutic
agent in gonorrheal arthritis in all stages except where ankylosis has
occurred. It does not prevent extension to other joints, nor does it pro-
duce lasting immunity sufficient to prevent recurrence after a new attack
of acute urethritis.

Thirty-one cases of gonococcal arthritis were treated by means of vaccine
by Irons.* His conclusions are conservative when he states that in certain
cases of gonococcal arthritis recovery can be hastened by injection of dead
gonococci, and that the chronic ambulatory cases showed better response to
inoculation than the more acute cases. Improvement, however, in the acute
cases often seems more rapid after inoculation than by other treatment. In
15 cases he found that the opsonic index was low at first. His guidance in
the use of vaccine was by clinical syniptoms, and the vaccine used was of
various kinds, varying from one to a number of combined strains.

The dosage employed by him at first was 20,000,000 to 50,000,000, and
later, and in other cases, the dosage was increased to 100,000,000 and rarely
to 1,000,000,000, with an interval of three to seven days. No harm was done
by using these large doses, beyond production of clinical symptoms during
the next twenty-four hours, associated with the negative phase, such as joint
pain, tenderness, fever, and malaise when large doses were given.

Cole and Meakins^ report the treatment of 15 cases. They used the
opsonic index as a guide for treatment and found that in each case inocula-
tions were followed by a rise in the opsonic index during the first week; that
by the tenth day the index fell again; their dosage was large, varying from
200,000,000 to 1,000,000,000. They state that constitutional disturbance
was met with rarely and was severe in but one case. They repeated their
inoculations every seven to ten days. They conclude that the chronic cases
show better results than the acute. Cases that have progressed slowly under
other treatment show almost immediate improvement soon after vaccine is
given.

Considerable numbers of cases have been reported by other observers,
with approximately the same conclusions. The writer has had, or has
at present under treatment, 20 cases of chronic gonorrheal arthritis.

^ Arch. Int. Med., i, No. 4, 433.

* Bull. Johns Hopkins Hospital, June, July, 1907, p. 223.

INFECTIOUS ARTHRITIS 749

In 1 6 treatment was begun at from one month to hvo years after the
acute attack. All these cases had resisted other forms of treatment.
Twelve of these cases recovered completely after from one to four months'
treatment, with complete functionating joints. In all cases stock vaccine
was used. The initial dosage was always small — from 5,000,000 to
10,000,000, injected at intervals of three to five days.

The attempt was made, as in the treatment of all other infections,
to so gradually increase the dose that the general symptoms should be
entirely avoided and focal symptoms so far as possible. In no case
were generalized symptoms produced. In chronic cases the dosage has
rarely exceeded 50,000,000. In 4 acute cases treated the dosage has
been from 5,000,000 to 25,000,000. The longest period of treatment
in acute cases was two months. There was no fresh joint involvement
after the treatment had begun. In these cases the inoculations appeared
to have some control over the pain.

One case, which is particularly striking, is that of a man twenty-fi\^e
years old, who had several joints affected for over two years. The con-
dition remained more or less active in the ankles, and there was con-
siderable tenderness and swelling in the plantar surfaces of the feet.
Walking was extremely painful, and the patient had been unable to
go about his work for a long time. An inoculation of 5,000,000 was
given, and five days later 10,000,000. Two days after the first dose the
patient stated that he could walk with less pain, and after the second
dose he walked into the clinic without any perceptible limp. In this
case there was complete recovery after eight inoculations.

So far as is known there has been no recurrence. Treatment has
been started on a number of cases with such immediately beneficial
results that the patients have ceased attending the clinic, and, therefore,
the outcome is unknown.

Other Types of Infectious Arthritis.— There are certain non-
suppurative inflammatory processes occurring in and about the joints
the characteristics of which are decidedly in favor of their being of
bacterial origin. Until recently many acute and subacute inflammatory
conditions of the joints and periarticular tissues have been grouped
under the general heading of rheumatism. Based on the character of the
disease, the typical so-called articular rheumatism has been for some
time placed in the group of bacterial infections, although no definite
organism has as yet been proved conclusively to be the cause of this
disease. There are, however, beyond the typical rheumatic fever, non-
suppurative inflammatory conditions of the joints which are associated
with similar constitutional and local symptoms and signs, characteristics

750 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

which are quite as much in favor of their being considered infectious
processes as the same are in favor of the infectious nature of acute articu-
lar rheumatism. These arthritic conditions very commonly follow
apparently localized infections, such as tonsillitis, pharyngitis, and
rhinitis. They are rather common sequela? of scarlet fever. The fact
that these conditions often follow acute local infections suggests that the
infective material has been transferred to the blood-stream and the
bacteria have lodged and grown in and about the joint.

It would appear, as has been previously suggested, that local in-
fections associated with temperature are not really local, but are more
or less continuously sending bacteria into the blood-stream. Decidedly
in favor of this is the fact of wide fluctuation in the opsonic power of the
blood, which can be due to nothing else than the taking up of bacteria
and their products by the blood-stream.

Sequence of events in scarlet fever often furnishes evidence that
bacteria exist in the circulating blood, derived originally from the throat
infection as an atrium. In severe cases streptococci can commonly
be obtained by blood culture. In postscarlatinal nephritis they are to
be found in large numbers in the kidney. In the writer's observation
of scarlet-fever cases at the Boston City Hospital, South Department,
during a period of over two years, scarlatinal arthritis was frequently
seen. It was of all degrees, varying from slight periarticular inflamma-
tion, associated with a little temperature, to a condition of suppuration in
one or more joints. In every case (6) of this kind that came to opera-
tion the streptococcus was demonstrated in pure culture in the pus.
It would seem reasonable, therefore, to attribute these arthritic condi-
tions in scarlet fever to streptococcus infection, varying in intensity
according to the protective reaction which they induce in the patient.
It is quite as reasonable to attribute the acute arthritic conditions fol-
lowing tonsillitis to entrance of bacteria into the blood-stream and
localization in and about the joint, in tissues which are normally poor
in vessels, where the supply of protective substances, therefore, must
be correspondingly less than in better vascularized tissue.

The bacteria, having been transferred into the blood-stream and
lodged in such poorly vascularized tissues as those about the joints,
soon render the local conditions more suitable for their growth. They
accomplish this by abstraction of antibacterial substances from the
lymph in the immediate vicinity of the locus, and through swelling and
exudation which ensue it becomes more and more difficult for an inter-
change between the fluid in the locus and fresh lymph from the blood-
stream to take place. The bacteria, then, have most excellent condi-

INFECTIOUS ARTHRITIS 751

tions for growth in a more or less stagnant fluid of continuously low anti-
bacterial power. The blood-stream has been able to ward off infection
of a generalized type, but the fact that infection has taken place clearly
indicates that it has not been able to exert its full power against the
bacteria in the tissues.

As a result of the development of localized infection, the blood-
stream itself suffers in a decided manner a loss of a considerable por-
tion of its antibacterial power. The opsonic index in these localized
infections is consistently subnormal. A reasonable explanation of this
fact would appear to be, first, that the blood is unable to derive sufficient
autoinoculation to induce formation of protective substances, because the
localized condition shuts it off from anything like a free circulation,
and it consequently takes up but few bacteria; secondly, the blood
suffers a gradual loss of opsonin and other antibodies which it would
otherwise have by continuous slight contact with the outskirts of the
bacterial focus.

We can justifiably ascribe the chronicity of some of these infections
to the same conditions that apply to all chronic infections; namely, a
low opsonic power of the blood-stream, and the difficulty of its coming
into contact intimately with the bacteria in the focus in sufficient amount
to cause their destruction. We need no better confirmation of this
than the sequence of events which follows the forced entrance of fresh
lymph into the focus, by means of Bier^s bandage, and the subsequent
drainage of this lymph into the circulation. Clinically, such procedure
is commonly followed by marked amelioration in local signs and symp-
toms, not only in the joint to which the bandage was applied, but to
other infected joints if there be any. By means of opsonic determinations
we find variations quite similar to those produced by an inoculation of
a vaccine derived from a corresponding organism. First there may be
a negative phase and subsequently a positive phase. This can mean
nothing else than that these variations register an immunizing response,
and indicate that the increased supply of blood-fluid has abstracted
from the focus sufficient bacteria and toxin to constitute an autoinoculat-
ing ictus, thus leading to the increased formation of antibacterial sub-
stances. We can also see, as a reason for the improvement in the local
focus, the replacement of the stagnant lymph in the focus of infection
by fresh lymph from the blood of higher antibacterial power. In these
considerations we can derive indications for treatment.

The question of using Bier's bandage as a therapeutic measure has
been discussed. Its advantage lies in the fact that no diagnosis is
necessary; its disadvantage, in the fact that the dosage of living vaccine

752 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

that is sent into the body cannot be measured, and always there is the
possible danger of the development of new foci in other parts of the
body. Unquestionably the response to a living vaccine of exactly the
infecting organism is of more efficiency than that following the use of
a killed corresponding vaccme. It is a very much safer procedure to
make use of vaccine.

The question of bacteriologic diagnosis is the most important and
the most difficult one to settle. The difficulty of obtaining a positive
blood-culture, even in some cases of septicemia, indicates that in these
cases positive results from blood-culture are not to be expected, except
possibly in cases where there is temperature.

Bearing in mind the possibility that the condition may have
started from a localized infection, a history of tonsillitis, laryngitis, or
pharyngitis should be sought, and cultures taken from the tonsils or
nasopharynx or nasal cavity, as may be suggested by the history or
by the local conditions. It would appear to be justifiable in the case
of pure culture of pneumococcus, for instance, obtained from the
tonsils, to prepare an autogenous vaccine and make use of it as a
therapeutic test. In febrile cases dosage should run from 5,000,000
to 25,000,000; in afebrile cases from 10,000,000 to 100,000,000 or
more. Where the dose is small, the interval should be short. As the
dose is increased in the chronic cases, three days to a week may elapse
between the doses. The initial dose is always the minimal.

Before vaccine is given, the first indication is the elimination of auto-
inoculation by fixation of the joint, or, in case several are affected,
absolute rest will be advisable to accomplish this end.

There have been reported but a few cases of treatment by vaccines
of these non-suppurative joint conditions. Two interesting cases of
this type have been seen by the writer, and one of them was successfully
treated.

Case I. — The patient, a woman of fort}'-five years, suffered with so-called
rheumatism for a period of ten years. She was referred to the wTiter to settle
the question of diagnosis and treatment. During this time different joints
became successively involved, and each attack was associated with some
fever, malaise, pain, tenderness, and swelling about the infected joint. After
two or three weeks the condition would begin to quiet down, leaving stiffness,
slight swelling, and some disability. Rarely were two joints affected at the
same time. The knees, the ankles, the elbows, and shoulders have been
successively involved. The general condition of the patient was very good,
and there has been no special loss of weight. She had been subject to attacks
of tonsillitis, although the throat showed nothing but moderately enlarged
tonsils. The question of the tonsils being the atrium of infection was, of course,

LOCALIZED STAPHYLOCOCCIC INFECTIONS 753

immediately considered, and cultures were planted on acetic agar. A pure
growth of pneumococcus was obtained.

It was impossible at the time to prove by opsonic indices whether this
pneumococcus was the actual cause of the arthritis, but it was thought wise
to prepare an autogenous vaccine and to give it for therapeutic test. After a
few inoculations of from 5,000,000 to 25,000,000, given at three- to five-day
intervals, the most marked changes took place. In the recently involved joint
the process quieted down almost immediately, and in the joints that had been
affected for some time there was immediate and progressive improvement.
The patient has since gone on to practically complete recovery, with very little
disability, and in eight months has had no recurrence.

There is, theoretically, no class of cases that offer any clearer indica-
tion for specific treatment by bacterial vaccine than infectious, non-
suppurative arthritis or periarthritic infections if accurate bacteriologic
diamosis can be made.

There is no danger in the use of bacterial vaccine if dosage is so
carefully graded that no symptoms are produced.

There is ah^•ays a positive danger of over-autoinoculation and the
possible development of other foci if Bier's bandage is used. Bier's
bandage furnishes the exact requirement in the way of supplying vaccine
to stimulate the protective mechanism; it also pro\ides for increased
interchange of lymph in the focus. But it is clear that, as the focus of
infection begins to clear up, the bacteria become fewer, the size of the
autoinoculations become smaller and smaller, and hence less and less
effective in raising the antibacterial power of the blood. In other words,
when large dosage of vaccine is clearly indicated, the dosage obtained in
this way is progressively smaller and less effective.

LOCALIZED STAPHYLOCOCCIC INFECTIONS

Furuncle. — When the patient appears for the first time with a
small furuncle, originating perhaps from an infected hair-follicle, which
is red, painful, and tender, to a degree depending on the location and the
tenseness of the tissue, the treatment should be regulated according to
the stage of the infective process. If there is as yet no e\idence of lique-
faction or slough, a single dose of 100,000,000 Staphylococcus pyogenes
aureus stock vaccine will ordinarily suflSce to abort it. After a few
hours of somewhat increased local tenderness and swelling a marked
improvement in the appearance and symptoms will become apjmrent,
and twenty-four hours later the tenderness may have practically disap-
peared. An inoculation of 100,000,000 to 200,000,000 at the end of
forty-eight hours, followed by a repetition after two or three days, may
be necessary, but these two or three inoculations will generally suffice.

754 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

As an adjuvant to the vaccine, heat may be applied locally by means of
a hot- water bag. It is applied with the greatest advantage during the
positive phase when the blood is at its best, that is to say, six or eight
hours after the first inoculation or more, depending on the size of the
dose.

If, when first seen, the furuncle shows a tendency to point, and lique-
faction of the tissue is in evidence, a minute incision should be made
at such a point that it will drain readily. This should be more in the
nature of a puncture than an incision. The pus should be expressed,
so far as possible, and then a pad of gauze, thoroughly wet in Wright's
solution of sodium citrate and sodium chlorid, previously described,
should be applied and kept wet so long as any discharge is maintained.
The action of the sodium citrate will be, of course, to prevent crusting,
and of the sodium chlorid, to draw fresh serum through the opening,
thus insuring a continuously acting free drainage and a consequent free
bathing of the infected focus in a continuously fresh stream of serum
from the circulating blood. We have, in the stream of fresh anti-
tryptic serum, the best agent for the neutralization of the tryptic pus and
an adjuvant to the destruction of the bacteria by the leukocytes. Wide
incision, such as might break through the walling-off tissue, is in these
cases bad, because it opens up fresh channels for the extension of infec-
tion. The dosage of vaccine under these conditions should be as given
above. On the second day the drainage will ordinarily be found to be
free through the opening, and there will be improvement in every sign
and symptom. The application of heat will hasten the process of
separation or liquefaction of the slough, and in forty-eight hours the
furuncle should be well discharged. Subsequent dosage of 200,000,000
after two days, and 300,000,000 to 400,000,000 after a similar or slightly
longer period, practically always effects a rapid cure. It should be
remembered that in all cases where Wright's citrate and salt solution
is used, the skin about the lesion should be protected at every dressing
by the application of boric ointment in order to prevent pustulation,
which the concentrated salt solution commonly induces.

A localized abscess of larger proportions will require an immediate
and adequate incision, which should, at the same time, be as small as
conditions will allow. Sodium citrate and salt solution should be applied
as a dressing.

In all cases the patient should be given a cathartic, preferably calomel,
followed in twelve hours by a Seidlitz powder if the bowels are at all
constipated.

Purunctilosis. — 'WTien the patient gives a history of recurrence of
furuncles over a longer or shorter period, the problem for vaccine be-

FURUNCULOSIS 755

comes more complicated. It has been the writer's experience that
furunculosis commonly follows any change in diet or in mode of life,
such as would be consequent to a railroad journey, to a camping trip,
or residence in summer hotels. Overwork, overstudy, and over-
exercise as well seem to predispose to furunculosis. Skin of a certain
type is often associated with a tendency toward infection by pyogenic
cocci. Such a skin is apt to be oily and pale, indicating poor circula-
tion, and subject to comedones.

Every practitioner of medicine has had impressed upon him by
experience the difficulty in the cure of these cases by ordinary methods.
No sooner will one furuncle be incised and begin to heal than others
develop. A repetition of surgical operation is associated with a repetition
of furuncle. The patient complains often of headache, of being easily
excited, of indefinite pains and exhaustion, malaise, or poor appetite,
besides the irritation and pain consequent to the furuncles, repeated
operative procedures, and the inconvenience of the constant application
of dressings to the different parts of the body. There is no class of
cases that is more satisfactory in the results achieved by vaccine therapy,
and none in which the patient is himself better convinced of the efficacy
of such measures.

It is always best in cases of this chronic type to isolate from the pus
the particular organism that is causing the trouble, and to prepare a
vaccine at once. In the majority of cases stock vaccine, composed of
three or four virulent strains of staphylococcus aureus, will be satisfactory,
and should always be used until an autogenous vaccine can be prepared.
Better results will be obtained in the long run by using the vaccine
prepared from the particular infecting organism. The first dose should
be 100,000,000 to 150,000,000. It should be repeated on the third day,
increased to perhaps 200,000,000, and four days later about 300,000,000
should be administered. After a few trials one will be able to judge
efficiently as to the size of dose that is best borne. The following
clinical data will be of assistance.

If, on the day following inoculation, the present funmcles become
more inflamed and one or two new furuncles develop, and there is some
general malaise, it is probable that a smaller dose will be more advantage-
ous. If, however, on the day following inoculation there is a slight
exacerbation, but on the next day marked improvement is evident in
the patient's general condition, and no new furuncles put in their appear-
ance, and if this improvement is maintained for two or three days longer,
the proper dose has been arrived at. This dose can be repeated, and
may be slightly increased, four or five days after the first injection.
New furuncles may continue to come at intervals for some weeks, but

756 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

they will be less acute, they will disappear more quickly, and will give
much less trouble than the original crop.

Duration of treatment depends on the previous chronicity of the
case and on the location of the furuncles. If they are situated chiefly
on the back of the neck and many comedones are present, the outlook
for immediate cure is not good. The writer has treated several cases of
this kind for three or four months before the heck has entirely healed
up. If the furuncles are scattered over the body, they w^ill be found
to be much more rapidly amenable to treatment than if localized on the
neck.

Duration of Immunity, — ^Where treatment is being applied for the
cure of a single boil or furuncle, and there is no history of previous at-
tacks, usuallv there will be no recurrence within some months. In cases
of recurrent furuncle, after a sufficiently prolonged course of treatment,
it has been the writer's experience that, as a rule, there is no recurrence
within at least six months following the cessation of treatment.

In chronic furunculosis of the back of the neck, with a duration,
as often happens, of months or years, there will persist a chronic indur-
ated condition of the tissues, often of considerable depth, and one or
more small discharging sinuses. The prognosis after treatment with
autogenous vaccine should be eventually favorable. The occasional
development of a furuncle is to be expected, but its duration will be
shorter, the tenderness less, and solution and resolution more rapid.
A moderate dose of vaccine is sufficient to abort a new furuncle if given
at the opportune moment.

In the course of the last two years the writer has had under treatment
something less than 200 cases of localized staphylococcus infections,
and feels able to speak with confidence of the efficacy of appropriate
bacterial vaccines properly applied in the control of these infectious
processes.

Guidance of Treatment. — ^The use of the opsonic index is generally
unnecessary, if one has a thorough appreciation of what Wright terms
the correlation that is known to exist between the condition of the
opsonic resistance and the clinical condition of the patient and his lesions.
The induction of a negative phase, that is, a period of lowered opsonic
power, of lowered resistance, in fact, by the use of improperly large doses
of vaccine, is signalized almost at once by local changes in the lesions,
which give information that the process is on the increase. We find
that local tenderness increases, inflammation extends, discharge becomes
increased in amount, and there may be malaise, headache, and local pain.
New furuncles may start within a few hours of the inoculation. The

FURUNCULOSIS 757

presence of these manifestations means that a condition of lowered
opsonic resistance has been induced by the injection, as has been suf-
ficiently well shown by many observers. The opsonic index gives a
cue to the efficiency of the antibacterial substances in the circulating
blood, but the clinical conditions just described give one about as efficient
information as to the state of antibacterial resistance.

If the condition of lowered resistance gives e\idence of continuance
by persistence of the local manifestations described for over t^venty-
four hours, the dosage given was too large. This does not mean that
if the patient is left alone the antibacterial mechanism will not recover
itself and improvement become manifest after a few days. It does
mean, however, that if another injection is given too soon, the same
condition may again supervene. We must in such a case await the
oncome of spontaneous improvement, as shown by local conditions,
and then start with a much smaller dose. There should be such proper
adjustment, size, and interval of dose as to produce a slight exacerbation,
if any, in the first twelve hours after inoculation, followed by some
improvement in the next twenty-four hours, and considerably more
improvement in the following day. By the third day a slightly larger
dose may be given, and three or four days later, perhaps, a still larger
dose; then, if consistent improvement is taking place, the interval may
be increased to four or five days, being careful not to use a dose of such
a size as will produce an exacerbation of long duration.

Local Effects of Inoculation, — If the proper vaccine is used, and it
may be either autogenous or a commercial vaccine of exactly the same
character as the infecting organism, there will, in a few hours, develop
at the point of inoculation an area of redness and slight induration
and tenderness. The duration and severity of this reaction de})end
to some extent on the size of the dosage. It is always more marked in
the early stages of treatment, and as the lesion improves and the dosage
is pushed higher, the reaction may disappear altogether, only to reap-
pear if excessively large doses are used. In the absence of any local
reaction after repeated inoculation of a sufficient dose of vaccine one
is almost justified in concluding that the infective process is due to some
other organism than that which his vaccine contains.

What harm can large doses of vaccine do in these cases? If we
desire to obtain from our treatment the maximum good, with the mini-
mum of discomfort and unpleasant symptoms in our patients, we should
guard against using large doses when smaller ones will accomplish the
same results. If, being ourselves convinced, it is our desire to further
the interests of specific therapy, we can ill afford, by injudicious use

758 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

of vaccines, to furnish a foundation in the lay mind for the idea that
vaccines are often brilliant in their results, but that one never can tell
how much good they will do; that they will certainly make one sick
before they make him well, as some of the victims of ill-conducted
vaccine therapy have confided to the writer. We cannot always avoid
the mistakes of too large doses, but we can make it a rare occurrence.

If the dose is not too large, it may be given too frequently. The
patient may not suffer any great increase in discomfort, and the lesions
may not grow much worse, but remain about stationary from day to
day. To illustrate: A patient was referred to the writer because he
had failed to recover completely from a carbuncle on the neck and
scalp. Vaccine had been given for two months, but there was still a
large area of induration and some discharge of deep-lying pus. Inquiry
revealed the fact that 400,000,000 of staphylococcus aureus had been
given every other day for a long period and daily for two weeks. Vac-
cines were withheld for five days, and then the same dosage given less
frequendy. In two weeks the induration had cleared up, and, except
for a superficial pustule, was well. In this case, and in others where
dosage is too large and too frequent, the clinical picture is corroborative
of what would naturally be expected — f. e,, an almost continuous negative
phase or condition of lowered resistance to the infection. It is a con-
dition of hyperexcitation of the antibody-forming mechanism, from
which the organism does not recover until the exciting agent is removed.

There can be no hard-and-fast rule as to the interval between dosage;
it depends on the size of the dosage, the vaccinating qualities of the
vaccine, and the manner in which the patient responds. Some writers
whose experience has been large say that an interval of three days is
proper. No doubt there is a dose which, if given at three-day intervals
in a given case, will be followed by satisfactory results, but the size of the
dose efficient at this interval will differ in different patients and with
different vaccines. It should be the desire to so adjust the dosage that
there should be as short a period of negative phase — with its lowered
resistance — ^as possible, consistent with the production of a positive
phase — the period of elevated resistance — of as long duration as possible.
Patients and the vaccines are variable factors, and the doses must be
adjusted so that the maximum benefit may be derived during the period,
whatever it may be, between inoculations. In the early treatment of
cases the interval may be one or two days, because, in order to avoid
the exacerbation which would result from a long-continued negative
phase, the early dosage is small. The smaller the dose, the shorter
the duration of the negative phase. At the same time, the positive

ACNE 759

phase will be of brief duration. Hence, at first, to avoid exacerbation,
small doses should be given frequently, and as improvement becomes
evident, the doses are made larger and less frequent. In furunculosis
the interval of dosage in a given case may vary from one to six or more
days, depending on the stage of treatment.

Acne* — The pustular type of acne may be compared to a chronic
furunculosis of the face, and is commonly amenable to vaccine treatment
if properly conducted. The etiologic factor is the staphylococcus
aureus or albus; if together, the albus usually predominates; more
commonly, the albus will be found singly in practically pure culture in
the pus from the lesions.

Kind of Vaccine, — A vaccine prepared of equal parts of Staphylo-
coccus aureus and albus from virulent stocks is commonly satisfactory
in the treatment of these cases, but it will be found that an autogenous
vaccine frequently gives better results than such a stock vaccine.

Duration of Treatment, — Some cases will clear up after two or three
months of careful treatment, and with only occasional subsequent de-
velopment of new lesions. A few cases will be absolutely cured. One
should not be discouraged if, after two or three months' treatment, there
is definite improvement, but not a cure. Persistence will often bring
final success.

Dosage, — At first 100,000,000 to 200,000,000 may be given, and re-
peated in five or six days. An increase of from 50,000,000 to 100,000,000
at each dose should be made up to the limit of 1,000,000,000, although
the writer has only rarely found it necessary to give more than 500,000,000.
Quite as good results have been achieved with such a dose given once
in five or six days. A smaller dose, however, given twice a week, has
oftentimes improved the condition where a larger dose, given once in
six days, was followed each time by an exacerbation.

If the vaccine is given properly, a gradual improvement should be
evident. Relapses are very common, however. The result of treat-
ment depends fundamentally on the proper adjustment of size and
interval of dose. A given dose would seem to be correct if, on the day
following its administration, one or two new lesions begin to appear,
but in the next few days disappear, with an accompanying improvement
in the other older lesions. Such a dose may be continued until it is
found that, on the day following the dose — i, e,, in the period of negative
phase, which is characterized, of course, by diminished phagocytic resis-
tance— there are no new lesions, but that an immediate improvement
follows, and then, in the two days before the next dose, new lesions appear.
Under such conditions it is evident that the patient is becoming tolerant;

760 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

that the vaccine is producing an immediate positive phase, but that
the continuance of the positive phase is consequently short. We must»
therefore, increase the dose until it will produce a negative phase.

Whitfield* says, concerning acne, "The treatment is uncertain; in
some cases most brilliant, in others without the slightest avail." This
appears to be the consensus of opinion among those who are dealing
with considerable numbers of these cases, particularly in the chronic
type of acne vulgaris, which runs for years, accompanied by comedone
formation, deep-lying nodules, pustules, and areas of induration. Fre-
quently there is temporary improvement, but relapses are common, and
the fundamental nodular inflammatory condition may continue un-
abated. In view of this fact it seems probable that the staphylococcus
may not be in all cases the etiologic factor. Unna, in 1893, found in
smears from comedones and pustules a bacillus in large numbers.
Sabouraud was able to grow it, and later Gilchrist expressed the opinion
that it was the cause of acne vulgaris.

Pioneer work in the treatment of acne by this bacillus has been
done by Fleming ^ in Wright's clinic in London. Perusal of his investiga-
tions would lead one to believe that the so-called acne bacillus is the
probable cause of the disease; that it is an important factor in producing
all types of the lesions; that staphylococcus may be associated with it
in the production of pustules; and that treatment by vaccine derived
from the acne bacillus, used in association with staphylococcic vaccine,
promises better results than have heretofore been obtained.

Carbuncle. — The proper use of vaccines in the treatment of car-
buncle can in almost every case be relied upon decidedly to modify
the surgical necessities, and sometimes even to render surgical inter-
vention unnecessary; in almost all cases (the exceptions being aged
people or others who, for one reason or another, do not react to the in-
oculations of vaccine) the use of vaccines will distinctly modify and
limit the course of the disease after operation.

The problem of treatment is more complicated than that of simple
furuncle, for the following reasons: First, carbuncle of considerable
size is commonly associated with fever, which, of course, indicates that
bacteria and their poisons are being taken up by the blood-stream;
that is, there is more or less continuous autoinoculation taking place.
Second, whereas in furuncle the pus and necrotic material is ordinarily
localized in a single pocket, and may be given efficient vent by a simple
incision, in carbuncle we have a more generalized necrosis and infiltra-

* Trans. Sixth International Dermatological Congress, 1907.

* Lancet, April 10, 1909; Brit. Med. Jour., August, 1909.

CARBUNCLE OF THE NECK 76 1

tion of the tissues with pus; incision drains the immediate vicinity, but
only that. Third, the tissues seem to offer little resistance to the ex-
tension of the process downward and laterally; in other words, there is
apparently an absence of the tendency toward walling off which is so
evident in furuncle. This may be due to the virulence of the infecting
organisms and to the tryptic or dissolving power of the pus (a product
of the broken-down leukocytes), by w^hich it dissolves the fat and connec-
tive tissue and thus extends. Fourth, the circulation of the blood,
upon which the body depends for the destruction of invading organisms,
is cut off everywhere excepting at the extreme limits of the extending
process, but even here the coagulation of lymph and the exudation
tend to nullify the attempts of the body to furnish a suitably
increased blood-supply.

These factors are particularly notable in certain locations, such as
the back of the neck, where the columnae adiposa^, by their anatomic
relations, divide the subcutaneous tissue into numerous cells with
connective-tissue walls. We should, therefore, expect that where a
carbuncle exists in this location, extensive surgical measures would be
more necessary than in other parts of the body, and this is actually the
case. If, wherever the carbuncle is located, there is shown by elevation
of the infected area above the normal skin surface a tendency toward
walling off, the extent of the surgical requirements will be consider-
ably lessened. If the infection is infiltrating and the tissue is brawny
and not raised above the surface, thus indicating a defective wall-
ing off, surgical measures are of immediate and paramount impor-
tance.

If, in carbuncle of the neck, w^hen first seen, the infection is extensive,
without any discharging opening, the indications are surgical, namely,
excision or crucial incision and removal of necrotic tissue, and the pack-
ing of the wound with gauze wet in Wright's sodium citrate and sodium
chlorid solution. A culture should be immediately taken with the in-
tention of preparing an autogenous vaccine. There will usually be an
exacerbation in temperature following the operation, due, of course, to
the autoinoculation which the operative procedure has induced. The
dressing should be kept continuously moist and changed every few
hours. There will be, in a few hours, a profuse purulent discharge. A
flaxseed poultice, constantly applied over the citrate dressing, will be
found distinctly advantageous in that it increases the blood-supply
to the part. After twenty-four hours the tenderness at the edges of the
carbuncle should be considerably less and the temperature should be
somew^hat lower.

762 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

The injection of vaccine should be delayed until the effect of the
surgical autoinoculation has worn itself out. Ordinarily, by the third
day after operation, the temperature will have become practically
normal, and the opsonic index, if determined, will be found normal or
elevated. At this time a small dose of vaccine, perhaps 100,000,000,
is indicated; tw^o days later it should be repeated, and three to four
days subsequently increased to 200,000,000. If, on the third day
following operation, the temperature is still elevated, it means that
the opsonic power is deficient, but suggests that the dose of
vaccine should be made small, in order not further to depress
the resistance. In a febrile case the dosage would ordinarily be
50,000,000, repeated daily until the temperature is normal, then increased
to 100,000,000 every other day, and then further mcreased, as indicated,
with an accompanying increase in the interval between the doses. The
sodium citrate dressings should be continued only until the wound is
clean and has begun to granulate; thereafter the wound may be packed
with sterile gauze or with gauze impregnated with balsam of Peru or
some antiseptic powder. The urine, of course, must be examined for
sugar, the presence of which is commonly accompanied by a lowered
opsonic resistance to staphylococcus and with a predisposition toward
such infection. Inoculation may properly be continued every four or
five days until the wound is clean. The patient should be advised on
discharge to report for inoculation whenever the slightest suspicion of
recurrence develops.

On the face, the ideal to be aimed at is to produce as little disfigure-
ment as possible. In the writer's experience, carbuncles on the face have
never required excision. There is commonly found one or more small
pustules where the pus has burrowed toward the surface; the necrotic
skin covering these pustules should be cut away, that the discharge
may be free. A sodium citrate solution is applied in the usual manner,
and over it a hot flaxseed poultice. An immediate inoculation is usually
given of from 25,000,000 to 50,000,000 staphylococci (aureus). This is
followed in twenty-four hours by a dose of equal size, and on the follow-
ing day 75,000,000 or 100,000,000 may be injected. After twenty-four
hours ordinarily there will appear, in addition to the discharging open-
ings seen at first, a considerable number of small, superficial pustules,
corresponding with the mouths of the hair-follicles. These are each
pricked, and as much discharge expressed as possible. Each day this
procedure is carried out. By the third day the temperature may have
reached normal, and the discharge have increased. At this stage it will
be possible to provide for a larger opening by cutting some of the epi-

EMPYEMA 763

thelial bridges with scissors and thus give exit to the slough. At the
end of five or six days the wound should be clean and granulating.
The vaccines are given every other day, after the first three or four days,
and then at longer intervals until the crater is entirely closed in. After
the first four doses, generally given daily, one or two doses may be
skipped. Rarely is it necessary to administer more than 200,000,000 or
300,000,000 at a dose as the recovery progresses. In a half-dozen cases
of facial carbuncle that the writer has treated the resulting scar has been
scarcelv noticeable.

Empyema* — The commonest causes of empyema are pneumococcus
and streptococcus. Where drainage is free in adults, there is commonly
little need of offering assistance to the patient in immunizing himself.
If the discharge continues, it is very often due to poor drainage. Certain
cases, however, continue to have a discharge which may be attributed
to a lack of immunizing power. Such cases will be apt to show elevation
of temperature, considerable discharge, and an opsonic index to the
organism present v/hich is below normal. In such cases bacterial
vaccines are indicated.

Although several cases of pneumococcous empyema have come to
the writer's attention with a question of the advisability of vaccine,
it was found in all cases that the patient finally, in a fairly short time,
immunized himself and vaccines were unnecessary, although they might
have hastened the result. The dosage of pneumococcous vaccine in
such cases may be from 10,000,000 to 100,000,000 or more, bearing
in mind the axiom that the sicker the patient, the smaller the dosage
that should be used. This means that if there is a temperature the
minimal dose, repeated in twelve to twenty-four hours, will be indicated.
If there is no temperature, and the general condition of the patient is
good, slighdy larger doses may be gi\'en every day, or every other day,
with a gradual increase in dosage and in hiterval. Where the empyema
is due to other organisms, such as streptococcus, or where a mixed
infection is found, appropriate autogenous vaccines should be made and
used if indicated. About one-half the cases of empyema in adults are
said to be due to streptococcus.

Dr. Cleaveland Floyd^ reports 6 cases of empyema in children, in which
he considers that extremely favorable results were obtained. He has noted
an immediate control over the course of the disease and a decided improve-
ment in the condition of the patient.

Briscoe and Williams^ report a case of empyema in a child of two, in

* Boston Med. and Surg. Jour., 1908, clviii, 5.

* Pract., London, May, 1908, 675.

764 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

which pneumococcus was the cause and to which vaccine therapy was applied;
io,ocx5,ooo killed organisms were given, and eight days later 40,000,000.
Their opinion was that the temperature was diminished and the general con-
dition improved.

Allen states that good results may be anticipated in empyemata when
vaccine therapy is directed against organisms found present; that there is
apt to be a mixed infection and that a mixed vaccine should be employed;
that improvement may be slow and prolonged treatment necessary. If
streptococcus is found, the dose will be from 10,000,000, as a minimum, to
50,000,000 or 100,000,000.

Empyemata of the accessory air-cavities, where they do not respond
to ordinary treatment, would naturally come within the scope of vac-
cine therapy.

Osteomyelitis. — In acute osteomyelitis, after drainage has been
assured and the temperature reaches normal, there may be advantage
in giving staphylococcus or other vaccine as indicated by culture. There
are no statistics by w^hich one can prove that a continuously elevated
opsonic index after such condition will hasten cure, but it seems reason-
able that such w^ould be the case.

In certain cases the tendency of the infection is to continue in the soft
tissues, producing a profuse discharge. Such infections may be definitely
controlled by vaccine. As an example of such a case I may cite one referred
by the author of this volume, who had osteomyelitis of the terminal phalanx
of the thumb. Incision had been made and dead bone found, but was not,
however, removed. For a month there were two discharging sinuses and
a very severe infection of the soft tissues of the thumb. Inoculations of
100,000,000 were given ever}' three or four days, gradually increasing to
300,000,000 at five-day intervals. At the end of two weeks the thumb had
decreased remarkably in size and the discharge was much less. After three
months' treatment about one-half of the terminal phalanx was discharged, and
within ten days the sinuses healed.

Where discharging sinuses are all that is left of the disease, the use
of vaccine, associated with measures to produce a determination of lymph
into the sinuses (as described under Treatment of Sinus), has proved
a reliable means of hastening recovery.

It has always seemed best to the writer, in this as well as other ful-
minating infections, to interfere as little as possible during the active
febrile period; that persisting temperature in most cases means insuf-
ficient drainage or new foci forming in other parts. Certainly, in these

» Vaccine Therapy and Opsonic Treatment, 1908, 170.

INFECTED SINUSES 765

conditions, vaccine cannot hope to compete with the measures calculated
to produce free drainage. Vaccine may be given during the febrile period
if it is held down to extremely minute doses, as 10,000,000 to 50,000,000
staphylococci daily, or 1,000,000 to 10,000,000 streptococci, as the case
may be, but in the writer's experience it is a better course to rely on free
drainage and the patient's own powers to immunize himself at first, and
then, if conditions indicate that he is incompetent to do so, the ex-
hibition of vaccine is decidedly indicated.

Infected Sinuses. — A successful outcome in the treatment of tu-
berculous lesions associated with discharging sinuses depends often upon
the way in which any secondary infection of the sinus itself is treated.
There are many cases in which the sinus is infected by Staphylococcus
pyogenes albus, which is apparently of little virulence, and which the
writer has been in the habit of neglecting, unless it is evident that its
growth produces irritation and increases the discharge. The use of
the opsonic index will give one a cue as to whether such an infection
needs treatment. If the opsonic index is found to be repeatedly low —
that is, below 0.75 — it is reasonable to endeavor, by means of an auto-
genous vaccine, to elevate the index to above normal and maintain it so
for as long as possible. Where staphylococcus pyogenes aureus, or
streptococcus, or other pathogenic organisms are found, it is practically
certain that a vaccine will be the best method of treatment. An auto-
genous vaccine should always be used, particularly in the case of strepto-
coccus or colon bacillus.

Oftentimes, although the lesion at the base of the sinus may be dis-
charging little, there may be a copious discharge, originating in an infec-
tion of its walls. The organisms in the sinus walls have decidedly
suitable culture ground for their growth. They are walled off from
active blood-supply by the fact that they are located within a tube, as
it were, of rather dense connective tissue, in the interior of which there
is plenty of such food material as coagulated fibrin and broken-down
tissue and detritus. It is obviously necessary, in the first place, to do what
we can to bring a supply of fresh serum to the part, and, in the second
place, to provide for its free exit, in order that continuously fresh serum
may come into contact with the bacteria. Wright's treatment of such
a sinus is irrigation with the solution of salt and citrate, previously
described, which prevents coagulation of lymph and secondary plugging
of the sinus, and will, by osmosis, draw serum to the part and bring
it into contact with the bacteria which it is our purpose to destroy.
Besides the syringing, it will be best in many cases to apply to
the opening of the sinus gauze pressings, wet in the same solu-

766 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

tion, being careful first to cover the normal skin thickly with boric
ointment.

The dosage of vaccine in these cases often exceeds that of the other
lesions infected by corresponding bacteria, because the organisms are
so well walled off from the circulation, and it may be necessary to prolong
treatment over a considerable period. Sinuses that lead to glands which
have been infected with streptococcus, even if the glands have been
removed, are apt to discharge for a long time.

As an illustration, a woman twenty-five years of age had a furuncle in the
auricle excised. She developed subsequently enlarged glands in the neck,
several of which suppurated, requiring a number of incisions for sufficient
drainaga. For three months, in spite of autogenous streptococcus vaccine in
moderate dosage up to 100,000,000, only slight improvement in the discharge
was obtained. A sudden attack of erysipelas facialis developed, lasting a week.
On recovery from this attack every sinus immediately closed and the patient
has been well ever since.

This would seem to indicate that in dealing with chronic infected
sinuses, at any rate those infected with streptococcus, we have an indica-
tion for large dosage so long as no constitutional symptoms develop.
Apparently in this case the high degree of immunity to the streptococcus,
which developed accompanying the recovery from erysipelas, was sufl5-
cient to eradicate the streptococci which had been active in the perpetu-
ation of the infection, and upon which the vaccine in ordinary dosage
had practically no effect.

Erysipelas. — The ordinary type of facial erysipelas is of so short
duration, and the temperature is so likely to fall at almost any time,
that observations as to the eflBcacy of vaccine until a great many more
cases have been reported will be of litde value. When, however, in a
case of erysipelas of the spreading type, we find that a series of inocula-
tions will stop the progress of the disease, we must give vaccine perhaps
a certain amount of credit.

If possible, an autogenous vaccine should be prepared, but until it
can be obtained, a stock vaccine of several strains obtained from erysipelas
cases is indicated.

So long as the temperature is elevated, we have a condition of auto-
inoculation which contraindicates the use of large doses of vaccines.
Such dosage would tend further to depress the antibacterial power of
the blood or to maintain it in a lowered condition. We must, therefore,
grade our dosage exactly as we would in a septicemia, and be satisfied
with a slight rise in the antibacterial power and a repetition of this rise

SYCOSIS 767

as often as possible. The writer's method has been to give daily inocu-
lations of from 2,000,000 to 25,000,000 organisms.

The writer has treated four cases of the migrating type. One of them, in
spite of the vaccine, developed patches in various parts of the body successively,
practically cleared up twice, and finally had a third relapse. We cannot in
this case say that the vaccine did no good, but certainly it did not effect a cure.
The other three cases, of exactiy the same type, previous to inoculation had
shown no tendency to limit themselves, but after several inoculations, at one-
and two-day intervals, the process in each case absolutely ceased. The
dosage in these cases may be at daily intervals at first. If more minute
doses are given, say 1,000,000 or 10,000,000, inoculations may be given once
in twelve hours. Large doses are decidedly contraindicated, as they are in
any active spreading infection associated with temperature.

Sycosis. — This infection, which is due to the staphylococcus aureus,
has always been resistant to the usual methods of treatment. Scham-
berg and others^ say that no treatment, save possibly the x-ray, has
given in their hands as good results in cases of obstinate sycosis as vac-
cine therapy. They report i case entirely cured; 2 not improved; i
greatly improved; 2 slightly improved; 3 almost well. When these cases
are seen, they have been generally of long standing, and a condition of
pustulation is commonly superimposed upon thickened and chronically
inflamed skin.

In the writer's experience, early cases are very amenable to vaccine
treatment. Measures must first be taken to prevent crusting, to provide
for a free discharge from the pustules, and in some active manner to draw
as much blood to the part as possible. The face should be kept as free
as possible from crusts. The pustules should be pricked, and the pustu-
lar area washed frequently with ^ per cent, sodium citrate and 2 per cent,
sodium chlorid solution, and hot applications made continuously as
possible for two or three hours twice a day.

Vaccine should be prepared from the patient's own organism, which
is usually staphylococcus aureus alone or mixed with staphylococcus
albus. The aureus, however, is always the offending organism, and
the vaccine should be prepared from this. The dosage in an adult
should be at the start 200,000,000 or 250,000,000, and should be repeated
in four or five days. Treatment may have to be continued for from
one to two months, although the early cases may clear up in half the
time. The dosage need not be pushed higher than 400,000,000 or
500,000,000.

The immediate improvement, after the first one or two doses, is so
marked that oftentimes the patient will feel that he is immediately on

* Trans. Sixth International Derma tological Congress, 1907.

768 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

the road to recovery and will stop treatment. He will be fairly sure
to relapse sooner or later, and wall then show up for one or two doses
and again disappear. If the treatment is persisted in, and every measure
taken to improve the local condition, to provide for local blood-supply, and
to raise the antibacterial power of the blood by vaccine, nearly all cases
should be improved and all but a few cured.

Bczeina. — Eczema will often be found associated with the presence
of staphylococcus in the skin, either as a cause or as a secondary invader.
In either case, appropriate vaccine treatment is indicated. Chronic
eczema in cases of long-standing furunculosis have done extremely well
under treatment by autogenous vaccines. The locations of the lesions
have been indifferently in the axilla, sides of the neck, groins, and flexures
of the knees and elbows, situations where irritation or increased bodily
heat and skin moisture have induced a condition of lessened resistance
to bacterial growth. In eight well-marked cases of spreading eczema of
long standing, after a treatment varying from three weeks to two months,
a cure resulted which, in each case, so far as the writer knows, has been
permanent.

Varicose Ulcer. — Varicose ulcers are most commonly infected by
staphylococcus, although other organisms may be found. If the condi-
tions indicate infection, cultures should always be taken and the organ-
ism determined. If staphylococcic vaccine is used, the dosage should
be carried on as usual in localized infections, and may be increased as
the treatment progresses. In several cases treated by the writer a stock
vaccine was used to advantage. The inflammatory condition about the
ulcer cleared up after two or three inoculations, and the tendency to
close in became immediatelv evident. The ulcer was washed several
times a day with Wright's citrate and salt solution, in order to promote
free discharge and bring as much serum as possible to the part. When
this solution irritates and causes pain, it' is necessary to dilute it one
half; that is, ^ per cent, sodium citrate and 2 per cent, sodium chlorid.
Infection, of course, is only one factor in these cases, and unless other
conditions are properly met, recurrence is likely.

LOCALIZED TUBERCULOSIS

Diagnosis. — Before specific treatment by tuberculin is applied in
any case, clinical diagnosis should be, if possible, supplemented by exact
laboratory diagnosis or by means of certain tuberculin tests. In the
case of nodes especially, it is impossible to say, from clinical appearance
and conditions, that the etiology is definitely tuberculous. In the ques-
tion of tuberculosis of the genito-urinary tract, the absence of bacilli in

LOCALIZED TUBERCULOSIS 769

microscopic examination of the sediment should lead one to further
effort for diagnosis by inoculation of guinea-pigs. The diagnosis of
cystitis or pyelitis is frequently made as being due to the colon bacillus,
because of its presence in the urine in large numbers. In these cases
tuberculosis should always be suspected and guinea-pigs inoculated.
Where it is possible to obtain pus, such specimens should likewise be
injected into animals if no bacilli are found in smears. In the case of
fistula or sinus, scrapings from the wall or bits of tissue should be ex-
amined histologically. Where there is extensive involvement of nodes
of the neck without suppuration, and operative procedures on account
of the extent of involvement may not be deemed wise, a small portion of
a single node may be excised for the purpose of diagnosis. In the case
of closed infection, where it is impossible to obtain discharge or a specimen
of the organ infected for histologic examination, some of the newer
methods, such as von Pirquet's tuberculocutaneous test, the eye reaction
of Calmette and Wolf-Eisner, and diagnosis by means of variations of
the opsonic index following induced autoinoculation, may be used.

The Technique of the Ophthahnic Reaction. — ^The eye should be
inspected to ascertain if it is perfectly sound. It should be irrigated
with 2 per cent, boric-acid solution, then two or three drops of a
sterile i or 2 per cent, solution of old tuberculin introduced.

Precautions and Dangers in the Application of the Eye Reaction. — ^The
eye must be in good condition, the tuberculin sterile and pure; the patient
must keep his fingers out of his eyes.

Untoward Results. — Calmette mentions 20,000 observations, in
which he found but 80 relating to the production of ulcerative keratitis
or serious conjunctivitis attributable to this test.

Delayed Reaction. — ^If, when there is no reaction at first, it develops
some days later, Calmette believes that such patients are bearers of
tuberculous lesions, though perhaps very minute; that proof of this
can be furnished by subcutaneous injection and noting resulting thermic
reaction.

In tuberculous patients the reaction becomes more intense sometimes
when repeated.

Where neither the conjunctival nor the von Pirquet reaction appears,
it may be necessary, if diagnosis is important, to use the inoculation
method.

Von Pirquet*s Tuberculocutaneous Reaction. — Technique. — ^The

ventral surface of the forearm is sterilized, dried, and two minute

drops of pure old tuberculin are placed three inches apart. The point

of a sterile scalpel is then rotated, using slight pressure, in such a manner
49

770 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

as to introduce some of the tuberculin into the skin. The knife may be
rotated perhaps one-half dozen times. The excess of tuberculin is
wiped ofiF after five minutes. The patient is told to report in twenty-four
hours. A positive reaction may be described as anything between a
small, dull-red papule, perhaps | in. in diameter, to an inflamed papule,
^ in. in diameter, with a red areola, and swollen. After two or three days,
in case of the severe reaction, the superficial layers of skin may become
necrotic and whitened, and in this type there may persist for some
months a brownish discoloration. In the writer's experience, the dull
reactions unassociated with areola have been associated with tuberculous
conditions of considerable previous duration, and the more brilliant
reactions with the earlier processes. The points of inoculation need
not be protected. I have never seen any untoward happenings following
this method of diagnosis.

The interpretation of the different degrees of the von Pirquet skin
reaction, as to the sort of lesion with which they are consistent, is more
or less uncertain. The writer has, during the past two years, used the
test in several hundred cases. In the last stages of pulmonary tuber-
culosis it has been in some cases either very slight or absent. In early
pulmonary tuberculosis it has been commonly very intense. In active
tuberculosis elsewhere it has been also quite intense. In localized lesions
of long standing the reaction is commonly slight, dull in color, and the
papule of small dimensions and without areola.

In the case of an otherwise healthy individual, the development of
an acute adenitis associated with a negative skin reaction, or one of
very slight degree, is strongly suggestive that the lesion is non-tuberculous.
If the reaction be brilliant, in the absence of any demonstrable focus
elsewhere, the lesion may be considered to be presumably tuberculous.
It has been shown that 55 in 100 healthy adults give a positive reac-
tion. In healthy children under three years there were reported but
4 positive reactions per 100. Given, therefore, a suspicious lesion in
a child under three, the positive reaction would furnish confirmatory
evidence of the tubercular nature of the process. In adults a positive
reaction would by no means be so confirmatory. In the case of glands
of long duration, a dull reaction would be consistent with a tuberculous
nature. The same may be said of joints and bone disease of long
standing. Cases of healed pulmonary tuberculosis commonly react
with very slight intensity. Fresh tuberculous glands developing in these
apparently arrested pulmonary cases has been, in the writer's experience,
associated with an intense reaction.

It would appear that the ophthalmic reaction is being generally given

METHODS OF GIVING TUBERCULIN 77 1

up in favor of the reaction of von Pirquet. It is not at all certain that
the former furnishes any more information than the latter. The skin
reaction certainly has in its application no element of danger. This
cannot be said of the eye reaction.

Given a clinical diagnosis of tuberculosis, and a skin reaction consist-
ent in its character to that which would be expected to accompany the
lesion, we are justified in the use of tuberculin as a therapeutic measure
if other methods of diagnosis are contraindicated or not decisive.

If more accurate diagnosis is required, some one of the inoculation
methods may be used. If the question is one of pulmonary tuberculosis,
and the temperature is normal, an injection of yq ^g' ^^ more of old
tuberculin will commonly produce elevation in temperature, a few
hours after inoculation, and increase in the number of riles to be heard
in the lungs, if the case is one of tuberculosis. In localized tuberculosis
the same focal reaction in a gland, in a joint, or elsewhere in the soft
tissues may be obtained and manifested by swelling, tenderness, local
pain, and discomfort if the infection is tuberculous. The dosage in an
adult which might be expected to produce such a focal reaction should
be from yoW ^^ ToT ^S- tuberculin B. E. or T. R. The reaction ob-
tained is comparable to that obtained in the lung from the injection of
old tuberculin. In many cases of localized tuberculosis, even though
large doses are given, no focal reaction is obtained.

Choice of Tuberculin. — In the treatment of localized tuberculosis,
we are commonly not dealing with a general condition of toxemia,
because there is an absence of autoinoculation. It would seem, there-
fore, that we desire, above all, to produce an antibacterial immunity.
We should, therefore, choose a tuberculin composed of bacterial sub-
stance. The bacillus emulsion, being composed of bacterial substance
from which nothing has been extracted, would appear to offer all the
effective stimulus w^hich the bacteria are capable of affording. Tuber-
culin R. may be used with good results, but it has not, in the writer's
hands, been as efficient as the bacillus emulsion (Tuberculin B. E.).

Methods of Giving Tuberculin.— C/mit a/ Method, — Tuberculin
is given, according to this method, with the idea of securing tolerance to
very large doses. It takes for its guidance the production of toxic symp-
toms. When marked local or general reactions are produced, the dosage
is considered to be too large, and the subsequent injection is always of a
smaller amount. Amount of dosage is again gradually increased until
toxic symptoms are again produced or the patient recovers. The increase
in dosage is, of course, gradual, but, inasmuch as symptoms of intoler-
ance are taken as an indication that the maximum dose has temporarily

772 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

been reached, it would seem that production of toxic symptoms must
be a common occurrence. We know that, associated with a condition
of toxemia produced by an excessive dose of tuberculin, there is a con-
dition of lowered antibacterial power of the blood-stream or a negative
phase. We suspect, even in localized tuberculosis, associated with
symptoms of toxemia, that living bacteria are actually being taken into
the blood-stream, which fact, taken in connection with its low anti-
bacterial power, may conceivably be a menace to the patient, in rendering
the development of other foci of infection possible.

It appears to be a fact that tuberculin may be given by the clinical
method with more rapid improvement and cure than when the opsonic
method is used. SuflScient numbers of cases have not been reported to
determine whether or not the general or focal reaction produced by
large doses may be dangerous to the patient in the case of localized
tuberculosis.

The use that Wright has made of the opsonic index in studying the
bodily reaction against infection has formed a basis for the rational
application of specific immunization methods. One of the most im-
portant conceptions that Wright has given us is that efficient immunizing
response to minute doses of tuberculin can be achieved, and that when
tuberculin is given in such a manner as to secure a sequence of such
immunizing responses, clinical improvement and cure commonly result,
without the usual toxic symptoms that have hitherto characterized
attempts at immunization with tuberculin.

The treatment of large numbers of cases under guidance of the
opsonic index has furnished a scheme of treatment that can be followed
without the need of the opsonic index, and with approximately the same
end accomplishment. Such a scheme differs from the clinical method
of giving tuberculin in that it does not seek tolerance of large doses,
but rather a succession of immunizing responses; it never reaches a
dose of toxic proportions except by error, and it attempts to carry out
the treatment from beginning to end without the production of toxic
symptoms. Such a method is certainly the most conservative that could
be used. It is to be commended as against any method that takes for its
guide to dosage intolerance, as indicated by local or general toxic reaction
following inoculation.

In practice, it means that the initial dose of tuberculin is always
minute enough not to produce any symptoms; that the increase in dose
is so gradual that any symptoms which might be associated with negative
phase are avoided.

During the past two years the writer has treated over loo cases of

TUBERCULOUS LYMPHNODITIS 773

localized tuberculosis without the use of the opsonic index as a guide.
The dosage has been increased as nearly as possible in the manner
that Wright has used when guided with the opsonic index. The pro-
duction of anything suggestive of toxic symptoms after inoculation with
tuberculin has been almost entirely absent.

I/Ocal Measures Calculated to Render the Immunizing
Response Bfficient. — A condition of restricted blood-supply often-
times renders the inoculation treatment of tuberculosis inefficient, because,
no matter how much elevated the opsonic power of the blood becomes
following inoculation, the new antibacterial substances can obviously
only become effective in the lesion when the blood-supply is unobstructed.
It is, therefore, quite as important in such cases to use measures to in-
crease the local blood-supply in the focus of infection as it is to raise
the antibacterial power of the blood-stream itself. The majority of
cases of localized tuberculosis do not require the application of local
measures, but, the absence of improvement after several months of
treatment with tuberculin would suggest that measures must be taken
to cause determination of blood actively to the focus; application
of heat, of Bier^s suction, and, if the location of the lesions makes it
applicable, the guarded use of Bier's passive hyperemia by means of
bandage.

. Tuberculous I/ymphnoditis.— Before treatment is started, care-
ful physical examination should be made, in order to determine if there
are other lesions which would lead one to modify the dosage of tuberculin.
If there is an active pulmonary lesion, associated with temperature, the
treatment should be directed toward the cure of this condition and the
node temporarily neglected. If there is a tuberculous lesion found else-
where, as, for instance, in the eye, in the bladder, testicle, etc., if the
tuberculin be given according to the principles of Wright, treatment need
not be modified or the dosage lessened on account of these conditions.

Surgical Indications. — In the case of a single encapsulated node
without surrounding induration, in a locality where the scar resulting
from operation would not matter, the quickest and best procedure would
be to excise. If the same sort of node has been existant for a long time,
and if the condition suggests that it be caseated, excision would always
be the best treatment. The :v-ray will often furnish evidence, if the node
is favorably situated, as to whether or not caseation or calcification has
taken place. It is obvious that against caseated and calcified nodes
tuberculin can accomplish nothing. If the glands are very extensive,
and still seem to offer assurance that extirpation, more or less complete,
may be obtained, surgical measures would again seem to be indicated,

774 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

inasmuch as tuberculin, if used postoperatively, is usually efficient in
preventing extensive recurrence, even if all the infected tissue is not
removed. When liquefaction has taken place, the pus should be drained.
Drainage should be put off, if tuberculin is used, until as much of the
node as is possible has been liquefied, in order that the problem for
tuberculin may be less. We, therefore, should postpone incision until
the skin shows evidence of thinning out and spontaneous rupture. In
most conditions of this kind incision is quite unnecessary, and, if used
at all, should be more of a puncture than an incision, as it is, with a small
opening, much easier to prevent secondary infection than if a wide incision
were made. Quite as satisfactory as incision, however, is puncture with
a large aspirating needle and removal of pus by aspiration. In this
way the pus is removed and the resulting scar is minute. Aspiration
may be necessary repeatedly, but is ordinarily efficient. The resulting
scar is in the form of a depression or dimple, which gradually smooths
out and becomes less noticeable.

This leaves for tuberculin, then, cases of node involvement which are
obviously too extensive in which to expect complete extirpation; in
which the resulting scar would be undesirable; in which the nodes are
too scattered to render anything but several incisions sufficient; for the
after-treatment of cases where the attempt has been made completely to
extirpate, partiy to extirpate; and for those in which there has already
been recurrence beneath the skin, or in which there is a chronic dis-
charging sinus. Based on statistics of results in these glandular cases
which are available, the surgeon may do much less extensive operation,
and at the same time feel reasonably sure, if after treatment with tuber-
culin is conscientiously carried out, that, even though small nodes have
been missed, the average ultimate results in the cases will be much bet-
ter than in the past when attempts have been made to complete extirpa-
tion, and it has not been achieved on account of extensive involvement.
At the same time, in the majority of cases, the surgeon may limit him-
self to the excision of the most prominent masses if this be deemed
expedient, and trust to the efficacy of tuberculin to complete the cure.

The R61e of Tuberculin. — The tuberculous lymph-node is, as a
rule, so well walled off from the circulating blood that febrile conditions
are uncommon. We may conclude that, as a result of this walling off, the
blood does not take up in any amount tubercle bacilli or toxin from the
focus of infection as it does in febrile cases of pulmonary, renal, or certain
other forms of tuberculosis. We should expect, therefore, that, in the
enforced absence of the specific poison of the disease, the blood would
lack in specific antibacterial substances on account of this lack of stimulus

THE ROLE OF TUBERCULIN 775

to their formation. Corroborative of this are the observations of Wright,
Bullock, and many others, that the opsonic index is subnormal in local-
ized tuberculosis as in other local infections where the blood-supply is
deficient. The opsonic power in these cases does not show fluctuation,
because there is no stimulus to produce immunizing response, and the
blood itself, by its continuous, although slight, contact with the lesion,
gradually loses by combination with the bacterial substance and toxin
the opsonic power which it normally has. Thus is explained the absence
of fluctuation and also the low opsonic power found in localized tuber-
culosis.

We are here dealing with lowered antibacterial power, because there
is a lack of excitation for the formation of antibacterial substances. We
step into the breach, and furnish this exciting ictus by means of inocula-
tion with the specific poison which the body needs for the formation
of these substances.

The determination of the opsonic index before and after inoculation
has shown that minute doses of tuberculin may be calculated upon to
cause an immediate rise in the opsonic power, but the continuance of
this elevated opsonic power may be of brief duration; that slightly larger
doses will be followed on the day succeeding inoculation by a diminution
in the opsonic pow er, varying in its degree and duration upon the size
of the dosage; that a slight fall, lasting a few hours, though indicating
a temporarily diminished phagocytic resistance, still does not commonly
produce anything apparent in the way of subjective symptoms, locally
or generally; that, following this stage of diminished resistance or
negative phase, there will succeed a stage characterized by increased
opsonic power, lasting for a longer period than when a smaller dose was
used which did not produce a negative phase. If a still larger dose be
injected, the negative phase may be considerably prolonged and as-
sociated with constitutional disturbance, such as headache, malaise,
and possibly a febrile reaction, and locally characterized possibly by
tenderness, slight swelling, and pain. The febrile reaction can mean
nothing but the presence in the blood of bacilli and toxin which have
been liberated from the iocu» of disease. This is uncommon in lymph-
nodular tuberculosis, even though large doses are used, but where there
is a great involvement of tissue and less complete walling off, it may
be readily conceived that sufficient bacilli may be thrown into the cir-
culation to constitute a menace to the individual from the possible
production of new foci in other parts of the body. Clinically, we have
instances of generalized tuberculosis, tuberculous meningitis, etc., fol-
lowing inoculation of large doses of tuberculin in some local infections.

776 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

We obviously desire to avoid the slightest danger to the patient as the
result of our treatment, and our aim is, therefore, to achieve the maxi-
mum immunizing response, with as brief a period as possible of low-
ered resistance and its attendant danger. This danger is certainly less
in lymphnodular tuberculosis than in any other type, excepting perhaps
lupus. As a means of registering the response of the organism to tuber-
culin inoculation, in order to guide the dosage, Wright has used the
opsonic index. It is not to be taken as a measure of anything but the
opsonic power. It may be considered as an indicator of the state of
excitation of the antibody-forming mechanism, showing whether or not
it is or has been favorably stimulated in the production of antibodies
by the vaccine or autoinoculation.

The giv'ing of tuberculin, with the opsonic idea in mind, is the most
conservative method that can possibly be devised, because it safeguards
the patient against the effects of excessive dosage. The treatment of
large numbers of cases with careful opsonic measurements have fur-
nished those who have worked under these most favorable conditions
with a scheme for the giving of tuberculin which may be calculated
to do no harm, and to achieve consistent results without the labor neces-
sary in the estimation of large numbers of opsonic indices.

Method of Treatment. — In the case of adults the initial dosage of
tuberculin R. or B. E. may be g^-L to 20^ ^g- The increase should
be very gradual, and may at the end of six months to a year reach as high
as T^ mg. The interval between doses should be approximately one
week. No dose should be increased until one feels satisfied that the
patient is not improving under it. Ordinarily, three or four doses of
20^ mg. may be given, four or five of i^^ mg., the same number of

12^' ^^ 10m' ^^ mb^ ^^^ 5^> ^^^ ^^ ^^- I^ '^ "^* ^^ ^'^ uncommon,
if dosage is too large, for the patient to complain of swelling and tender-
ness in the gland being treated. If this is not severe, the same dosage
may be repeated, and this commonly without any exacerbation. If
such occurs, a longer period may be allowed to elapse before the next
dose. If after one month's treatment there is no evidence of improve-
ment, the dose may be more rapidly incrtased. It should always fall
short of producing local or general symptoms. Some patients will
require much larger doses than others even at first. The largest dose
that I am giving, among about fifty glandular cases treated over a
period varying from three months to eighteen months, is -^^ mg.
weekly.

It is rather common after the first few doses of tuberculin for some
of the nodes to break down. This is, in a way, a favorable happening,

TUBERCULOUS SINUSES 777

because it renders the problem for tuberculin of much less magnitude.
The pus is never evacuated until there is danger of spontaneous rupture.
We delay interference, with the hope that as much of the node will break
down as is possible. Aspiration is much more satisfactory than incision,
because there is less danger of secondary infection. It meets every
indication that surgical measures can meet, because it produces free
drainage, admits of free circulation of lymph into the cavity, than which
extensive surgical measures cannot furnish more. The resulting scar
is commonly negligible.

Sinuses. — Secondary infection is common. The most serious, and
the least amenable to treatment, is the streptococcus. Vaccine treat-
ment of any infected sinus is commonly unsatisfactory, unless certain
active measures are used to promote antibacterial action locally, because
the blood-supply is deficient, and even though the antibacterial power
of the blood is high, it may not be effective, since it does not come into
contact properly with the bacteria in the sinus. We must promote
discharge in order to bring about free and rapid replacement of lymph.
This is accomplished by means of syringing and local application of
the sodium citrate and salt solution. These secondary infections must
be treated ordinarily if results are to be obtained. I have, however, neg-
lected in several cases these secondary infections and given tuberculin
alone with satisfactory results.

Several cases that I have treated have only healed after treatment extending
over at least a year. One case is interesting, in that it would indicate that much
larger doses of streptococcus vaccine may be necessary in order to achieve
results, and possibly that some modification in the method of preparing the
vaccine may be necessary. This patient had several discharging sinuses in
the neck, which failed to improve after several months' treatment with strepto-
coccus vaccine. She suddenly developed an acute erysipelas, and coincident
with recovery all the sinuses healed.

Lymph-nodes Developing in Supposedly Arrested Cases of Pulmonary
Tuberculosis, — Examination of the lungs in these cases may show no
activity in the focus. Nevertheless, the patient is apt to give a history
of having lost some weight, and of not having felt as well during the
period in which he has noticed the development of a node in the axilla
possibly, or in the neck. There commonly will be found to be no
temperature associated. We may find the development of nodes as-
sociated with extension of the process in the lungs. If this is the case,
the nodes should not be treated, but the pulmonary condition should
receive attention.

778 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

Where the node has developed in an apparently arrested case, with
no increase in pulmonary signs and without temperature, tuberculin
must be given more guardedly and in smaller doses at first, on account
of the possible danger of lighting up the pulmonary lesion. In the
cases the writer has treated he has found the von Pirquet cutaneous
test gave a brilliant reaction, whereas in supposedly arrested cases,
without new glandular involvement, we commonly find a dull and limited
reaction to this test. It is the writer's custom to start such cases with a

^^^^ ^^ 50^ ^8- ^- ^•' ^^^ gradually work up in the course of six
months to j^ nig., given at weekly intervals. At first the patient's
activity should be extremely moderate and absolutely under control.
For the twenty-four hours after inoculation the patient should rest. If
possible, during the first few doses of tuberculin, examination of the
lungs on the following day should be made. Temperature observations
three times a day should be required, and as soon as the patient is allowed
to exercise or walk about, temperature should be taken before and after
such exercise. If this activity causes a rise in temperature of a degree
or even less, the patient should be kept absolutely quiet while the tuber-
culin is gradually being increased in dosage, realizing that febrile reaction
at any time means autoinoculation induced by exercise or as a result of
the tuberculin. Some of the most brilliant results the writer has ever
seen in the treatment of glands by tuberculin have been accomplished
in this type of case. Treatment extending over one or two years may be
necessary.

Prognosis in Tuberculous Lymph-nodes. — In the group of about
50 cases the writer has treated in the past twenty months about 25 have
been cured. The minimum of treatment in cured cases was three
months, the maximum, eighteen months. The nodes in children under
ten yielded more readily than between ten and fifteen years, and those
in young adults have yielded better than in the older. The nodes of
short previous duration yielded better than those of long duration.
Nodes that are caseated do not yield at all to treatment, excepting so
far as perinodular inflammation is concerned. Cure is taken to mean
total disappearance of the node or diminution in size to that of a pea or
slightly larger. Ten per cent, of this group of cases have shown very
little improvement during this period of treatment. The rest have all
shown definite gain in that the nodes have become smaller. In nearly
all cases there has been an improvement in the general condition, and
reasonable gain in weight, in spite of the fact that in most of them
the conditions of hygiene have not been ideal, and have been improved
very little over the conditions before treatment was begun.

PROGNOSIS IN TUBERCULOUS LYMPH-NODES 779

Human tuberculin has been used in all cases; in several that did not
improve after six months' treatment with tuberculin R. a like preparation
of the bovine bacillus was used without any apparent improvement in
results. In the early part of the treatment of this group of cases tuber-
culin R. was used in all cases. While improvement was distinct, it has
been found that since bacillus emulsion has been used improvement has
been much more rapid and definite.

A very careful and unbiased account of the tuberculous cases treated in
Wright's clinic, St. Mary's Hospital, London, has been published in the
British Medical Journal, August 28, 1909, by Dr. Carmalt Jones. There were
367 cases of all types treated in the out-patient department. The treatment
was carried on under the disadvantage of lack of control over the conditions
of life of the patients, irregularity of their attendance, and poverty. It was
extremely common for patients to cease in their attendance when improved.
Under these conditions he states that the method that achieves good results
deserves full credit. Of 155 cases of adenitis end-results were obtained in
87. Tuberculin B. E. was used in minimal doses at the outset, repeated
every ten days, and dosage not increased until it ceased to have therapeutic
effect. The minimal dose was from ys^ to ^5^000 "^g-» ^^^ latter always in
the case of children. The maximal dose for children under five was 1^^,
and for adults rarely exceeding ^. Of 79 cases treated without surgical
measures, 27 were cured, 22 much better, 18 improved, 8 unchanged, and
4 worse. Cure is defined as either disappearance of the gland or reduction to
the size of cherry-stones. Forty-three in 79 cases had been previously oper-
ated. Of the cured cases, 9 out of 27 had been operated; of the much
better class, 14 of the 22 had been operated; of the improved, 14 out of 18
had been operated; of those worse or unchanged, 9 out of 12.

Prognosis, based on these results, will be that in 8 cases treated 5 will show
marked improvement and 2 or 3 will be cured, 2 improved slightly, and i or
2 will fail. We must anticipate the best results in young children and young
adults from fifteen to twenty-five years of age. After this time results are not
so good. The worst results are ordinarily between ten and fifteen years of
age, or about puberty. Success depends upon treatment of secondary infec-
tions. In the first five years of life the results are satisfactory, in the next less
satisfactory, and so on, until after the age of puberty, when there is apparently
a rise in the resistance or in the ability to react favorably to tuberculin. During
the period from ten to fifteen years the numbers of cases of improvement are
low, and there were more failures than at any other age.

In II cases the nodes disappeared; these were, with four exceptions, between
eighteen and twenty-three years. The most favorable age for recovery would
seem to be about twenty. Where the nodes are of short duration, recovery
may take place within a few months. In only 3 cases did treatment at this
age exceed a year. Relapses after improvement occurred in 1 1 cases.

Hartwell and Streeter* report the treatment of 20 cases of glandular
* Boston Med. and Surg. Jour., January 6, 1910, p. 5.

780 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

tuberculosis, using the method of Trudeau, which seeks to gain tolerance to
tuberculin by giving fair initial doses and constantly increasing by minimal
amounts. Initial dosage was ^ mg. B. E., increased by adding the same
decimal at each successive inoculation at weekly intervals. The maximal
dose in this group was 3 mg. ; duration of treatment was from two months to
twenty-one months. Five were nine years or less of age, the rest were thirteen
to twenty-five years. Ten cases showed as end-results good palpable glands;
the others were described variously as pea-, hazel-nut, and almond sized. The
patients were seen at periods from six months to one year treatment. They
state that tolerance to tuberculin was obtained in most cases uneventfully. In
a few instances intolerance was manifested by constitutional disturbance a
few hours after inoculation, associated with apathy and lassitude, accompanied
by headache and backache. No temperature observations were made. No
focal reaction was noted associated with constitutional disturbance. Their
guide as to intolerance has been the general reaction. When this occurs, the
dose is diminished considerably and gradually increased again. They saw
no ill effects in uncomplicated glandular tuberculosis. A tuberculous epidid-
ymitis was observed, however, to flare up under treatment. They gave as
a period for curative treatment of moderately enlarged glands a year, in the
massively enlarged, a longer time.

In this group of cases excellent results were secured by the use of
tuberculin, without reference to its action upon the opsonic power of
the blood, although attempt was made to avoid systemic reactions.
Although such were at times produced, they do not appear to have been
of serious consequence. According to Jones' statistics of cases treated
by Wright, using the opsonic index as a guide, at best 3 out of 8 cases
were cured. Applying the same criteria of cure in HartwelPs smaller
group of cases, we should have approximately 95 per cent, of cures
against 7 *} ^ per cent, by the opsonic method. If this record of cure can
be kept up in a larger series of cases, and if our requirements are rapid
results, irrespective of occasional unavoidable production of constitu-
tional disturbance due to intolerance, the use of larger doses than w ould
be allowable under the opsonic method of treatment might be justified.
Realizing the significance of constitutional disturbance in indicating
a period of lowered resistance to the infecting organism, it w ould seem
possible that in a larger series of cases some untoward results might
reasonably develop in association with these periods of lowered re-
sistance. If the results of a larger series of cases indicate that glandular
tuberculosis can be treated with approximately 100 per cent, of cure,
and with no untoward results, we may consider that we have in tuber-
culin, applied by the clinical method, by all odds the most remark-
able and efficient medy that has yet been offered for the cure of
disease.

TUBERCULOSIS OF BONE 78 1

In comparing the dosage of tuberculin, as given by different workers,
we must consider certain fundamental differences in the preparation of
the tuberculin. The dosage of tuberculin, as indicated by the writer,
is based upon the fact that in the case of bacillus emulsion the content
of each cubic centimeter is stated by the manufacturers to be 5 mg. of
bacillary substance. A dosage of j^^ mg., therefore, would mean that
fraction of a milligram of actual bacterial substance. In the case
of Tuberculin R., the original solution, as put out by the manufacturers,
commonly contains 2 mg. of bacillary substance per cubic centimeter,
and on this content dosage is based. Certain workers, however, do not
base their dosage on the content of the original tuberculin solution in
bacillary substance, but give certain fractions of a milligram of the orig-
inal solution as a dose. It is obvious, then, that a maximum dose of 3
mg., as Hartwell has used, would be equivalent to a dosage of -^ mg.
of solid bacillary substance. This maximum dose of 3 mg., compared
to the maximum dose used by the writer of -g-J-Q mg., is, therefore,
not so widely different as the figures would make it appear It would
appear at first sight to be 1800 times the writer^s maximal dose, but it
is actually only 10 times that dose.

In order that easy comparison of dosage may be obtainable, it would
seem advantageous to base the dosage upon the actual content of the
fluid preparations of tuberculin, as sent out by the manufacturers, in
bacterial substance.

Hawes and Floyd^ report the treatment of 20 nodular cases, of which 18
were improved, 2 not improved. They used a combination of bacillus emul-
sion and bouillon filtrate.

The method used was that of Trudeau.^ They state that larger doses of
tuberculin can be used in lymphnodular tuberculosis than in any other form
of the disease. They agree with Jones and others that improvement is apt
to be faiore rapid in children, while in adults they do not disappear so rapidly
but seem to become encapsulated.

Tuberculosis of Bone. — Unless as much of the diseased bone is
removed as is possible, the problem for tuberculin is extremely difl5cult.
With the dead bone cleared away, this form of tuberculosis is amenable
to prolonged treatment with tuberculin in a large majority of cases.
Here infected sinuses often complicate and require appropriate vaccines
before the discharge will cease. In caries of the spine, where the disease
is extensive and drainage is imperfect, and there is temperature associ-

^ Boston Med. and Surg. Jour., January 6, 1910, p. 5.
^Amer. Jour. Med. Sci., June, 1907, p. 18.

782 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

ated, the results cannot be expected to be satisfactory unless auto-
inoculation is eliminated by operation. Cases reported from Wright's
clinic by Jones Qoc. cit.) consist of 2 which were cured and 3 w^ere
much improved. Western ^ reports 15 cases, 7 of which were cured,.
5 showed improvement, and 3 no improvement. Hawes and Floyd
{loc. cit,) report 3 cases of bone and joint infection, in which 2 were
improved, i not improved. I have treated 6 cases of bone disease,
of which 4 completely healed after from nine to eighteen months'
treatment. One case, tuberculous ribs, still has .very slight discharge
from one sinus, previously having had profuse discharge from eight or
ten. In all these cases there has been a definite improvement in general
condition and most have gained weight. The maximum dosage of
tuberculin B. E. used was y^jVlT "^8- ^^ ^o\\d substance. The sixth case
was one of tuberculosis of the lumbar vertebrae, in which it is impossible
to maintain good drainage. The temperature continued elevated, and
after six months' treatment there was apparently no change in the con-
dition for the better.

The dosage of tuberculin in bone and joint cases is generally about
the same as that used where lymph-nodes are treated. In the case of
joints of short duration the initial dosage should be a little smaller.
Supplementary treatment, such as fixation, is usually imperative. The
duration of treatment depends upon the previous chronicity and extent
of the involvement and the age of the patient. In the case of bone in-
volvement, removal of carious bone renders the problem for tuberculin
much more simple.

Tuberculous Joints. — The problem for tuberculin in these cases
depends largely upon the character of the tissues involved. If it be
merely the soft tissues, without extensive necrosis and without much
bone involvement, the expectation of improvement wull be much greater
than in cases of long duration with bone involvement. Improvement
or lack of improvement in these conditions depends largely upon the
state of the blood-supply to the infected part. If the blood-supply is
cut off by fibrous or caseated tissue or pus from coming into contact
with the bacteria in the focus, it is obvious that, even though the
blood-stream be fortified in its content of antibodies, results will not
be forthcoming. Tuberculin should only be used in conjunction wuth
other measures which have proved themselves clinically valuable in
the conduct of these cases. Western reports 14 cases cured, 5 cases
improved, 5 cases with no improvement, and 2 cases with slight im-
provement, in 26 cases treated. Of the 5 cases showing no improve-
ment, 2 were over sixty years of age.

* Lancet, November 23, 1907, p. 1450-

GENITO-URINARY TUBERCULOSIS 7^3

Raw * reports 27 cases which were chronic or subacute, and ob-
tained the best results where there were suppuration and sinuses. My
own experience has been limited to the treatment of 4 cases, in i of
which there was decided improvement after six months' treatment, in
a second there was complete cure and function was apparently obtained,
and the other 2 were lost sight of.

There is not the slightest question but that tuberculin has distinct
value in many cases of joint infection. Its curative value is limited by
the condition of the focus as to whether or not the blood-supply can be
made sufficient. Methods for diagnosis and for decision of cure by
means of the opsonic index have been discussed.

GENITaURINARY TUBERCULOSIS

Renal Tuberculosis. — It is decidedly unwise for any one, no
matter how expert in the giving of tuberculin, to institute treatment in
any case of genito-urinary tuberculosis until the question of extent of
involvement of the kidneys and other structures, and the question of
extirpation, has been thoroughly investigated and considered by the
surgeon trained in the special methods of genito-urinary diagnosis and
treatment.

Expectation that the exhibition of tuberculin in extensive renal
involvement, associated with disintegration and extensive caseation of
the kidney, will take the place of extirpation of the organ is entirely
unfounded. It may reasonably be expected that the proper use of tuber-
culin may maintain the blood-stream in a condition of increased resist-
ance to the tubercle bacillus, but, both in theory and in practice, it is
unjustifiable to risk the patient's life by leaving unmolested a disinte-
grated useless kidney, on the expectation that the blood-stream will, by
means of its high antituberculous power, be able to produce resolution.
It is obviously impossible to transfer the antibacterial elements of the
blood-stream into a mass of caseated material, or even to conceive of a
sufficiently active circulation in the infected tissue surrounding such a
mass of caseous material to cause the destruction of the tubercle bacilli
present.

Involvement of both kidneys, if extensive, may contraindicate ex-
tirpation of either. The use of tuberculin in such cases has been found
to produce distinct amelioration in the pain, frequency of micturition
and temperature, and may be considered a decidedly useful measure for
the temporary relief, although from the start such cases are beyond hope
of cure.

^Lancet, February 15, 1908, p. 480.

784 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

A case of this type is reported by Walker/ and briefly is as follows :
After three weeks' treatment with tuberculin, pain and hematuria dis-
appeared, and frequency of micturition diminished. Temperature fell
to 99^ F.; weight increased. After six weeks, no bacilli were found in
the urine. After three months, the patient died of renal failure.

He states that renal tuberculosis with occlusion of the ureter, pro-
ducing a resulting accumulation of caseous material, offers no expecta-
tion of cure under tuberculin. The frequent involvement of the ureter
in the tuberculous process renders possible in such cases occlusion and
accumulation of pus under pressure. Walker {loc, ciL) refers to Fen-
wick's statement that actual harm may result from administration of
tuberculin when the ureter is involved, on account of the swelling in the
mucous membrane which may follow its use with possible occlusion
resulting.

Such increase in swelling might result from a ^^focaV^ reaction in an
already infected and swollen mucous membrane of the ureter, induced by
a large dose of tuberculin. These considerations furnish earnest reason
for the use of small dosage of tuberculin, and of an increase in dosage
so gradual that nothing in the way of reaction, local or general, is pro-
duced in the treatment of any case of renal tuberculosis.

Tuberculin should be of the most advantage in the early stages of
renal tuberculosis. It is uncommon, however, to arrive at a diagnosis at
this early period, because the first evidence noted by the patient, such as
cystitis, may not appear until long after the disease has gained consider-
able headway in the kidney.

Given a diagnosis of tuberculous kidney in its early stage, the ques-
tion of tuberculin as against extirpation cannot be settled until more
cases are reported with ultimate results, and compared to those obtained
by extirpation. A trial of tuberculin cannot be dangerous if it be ad-
ministered carefully.

Walker reports the treatment of an apparently early case as follows:

A history of sudden attack of pain in kidney, shooting into groin and testicle, followed
by dull renal ache. Passed blood. No bladder symptoms. Pott's disease twelve years
before with cold abscess. At about the same time amputation of left foot for tuberculous
disease. Kidneys not tender; right slightly enlarged. Tuberculin jj mg. once a month,
gradually increased to J mg. "Almost from the first weight increased. Blood has not
appeared in the urine ance treatment commenced." For eight months the pain in the
kidney continued troublesome. After that, it suddenly diminished, until January, 1906
(seventeen months* treatment), when it disapj)eared. Reduction in the dosage of 1^0 mg.
was followed by a noticably increased pain. In July, 1906, dose was raised, and in Feb-
ruary, 1907, patient stated he had had no pain since the increased dose. There was less
pain with larger doses.

* Practitioner, London, May, 1908, p. 723.

VESICAL AND RENAL TUBERCULOSIS 785

Carmalt Jones reports the cases of renal tuberculosis treated in
Wright's clinic. Of the cases treated, 2 were considered cured, 2
"better," 2 "somewhat better," and i dead.

The writer has used tuberculin in i case of renal disease in which
the organ was considered to be not sufl5ciently disintegrated to demand
extirpation.

The patient, a man of about fifty, had suffered from cystitis for over a year. His
ureters had been catheterized. The urine from the right kidney was cloudy, due to colon
bacilli and pus. That from the left kidney was more clear. The writer was advised that no
tubercle bacilli had been found in the sediment, and he was asked to treat the case as one
of colon pyelitis and cystitis. In order to rule out tuberculosis he inoculated a guinea-pig,
which died six weeks later, from generalized tuberculosis. During this period colon
vaccine was given, with some temporary improvement, manifested by lessened frequency
in micturition, almost total disappearance of colon bacilli, and diminution in the amount
of pus. The von Pirquet skin reaction was intense.

Tuberculin was given at weekly intervals as soon as a diagnosis had been made for
a period of four months. Dosage from 2o7)oo "^* °^ bacillus emulsion to ^^ mg. Al
the end of the fourth month's treatment the patient complained of dull pain and a sensa-
tion of fulness in the right side of the abdomen, high up. There was suggestion of a mass
to the right of the umbilicus, deeply situated. He was referred back to the surgeon,
operated, a large collection of pus, involving pelvis of the kidney and ureter, was found.
He soon after died of pneumonia. Dosage of colon vaccine was from 10,000,000 to
100,000,000 every four or five days.

This case is of interest for several reasons: First, in diagnosis, the
presence of colon bacilli in large numbers in catheter specimens of
urine from the ureter should suggest the possibility of tuberculosis as a
fundamental cause, inasmuch as the two organisms are so commonly
associated in these infections; second, the absence of tubercle bacilli
in the smears should lead one to inoculate a guinea-pig with the sediment
in order to secure final evidence for or against tuberculosis; third, it
suggests the difficulty of determining the extent of the tuberculous process
in the kidney; fourth, it illustrates the possibility of occlusion of the ureter
in any case where the same is involved in the diseased process.

We may have, therefore, at the outset, through disintegration, with-
out any definite evidence one way or another, or we may have developed
later, through occlusion of the ureter, an impossible problem for tuber-
culin, which could in no way be foreseen.

Vesical Tuberculosis Associated with Renal Involve-
ment.— Renal tuberculosis is commonly complicated by secondary
bladder infection by the same organism. It may be difficult to say which
is the original seat of infection, bladder or kidney. Cystitis, associated
with renal disease, may clear up after extirpation of the diseased organ.
Walker {loc, cit.) states that in some cases the cystitis appears to be due.

786 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

not to actual tuberculous infection of the bladder, but to the irritation
caused by the deposit from the kidney. In claiming cure of tuberculous
cystitis by removal of the kidney, this possibility must be borne in mind.
When, in spite of extirpation, the cystitis persists, the use of tuber-
culin is indicated. Walker concludes that it is a valuable adjunct to
operation. He reports the following case (loc. cit.) :

Patient had constantly aching left kidney eight months. Worse in morning, aggra-
vated by exercise. Nocturnal micturition for six months. Blood in urine. Frequency,
half houriy in day, two houriy at night. Left kidney large and tender. Cystoscope showed
general tuberculous cystitis, left ureter retracted. One month later large tuberculous
left kidney removed and a month later tuberculin begun. During twelve months' treat-
ment there was increase in weight, frequency of micturition became hourly instead of
half hourly, pain less; improvement was slow but undoubted.

A brief summary of a case of this type treated by the writer is as fol-
lows:

Increased frequency for over five years. Three months before operation cystitis
became severe; incontinence of urine. Much pus and many tubercle bacilli found.

At operation right kidney and ureter were found to be extensively tuberculous and were
removed.

When seen by the writer, two months ofter operation, there was a free discharge from
two operative wounds. Urine foul, cloudy, contained pus and tubercle bacilli, and large
numbers of colon bacilli. Micturition during the day every twenty minutes, at night ten
or fifteen times. Excessive vesical pain. Temperature ioo° to 102° F. Prostration,
emaciation. Bad prognosis given by the attending surgeon.

Tuberculin R was given at weekly intervals, beginning wdth 7^^^^ nig. (bacillary

substance). Temperature normal after two weeks. Dosage of ^^^ mg. at end of two
months. General condition, strength, weight, appetite, showed at this time a decided gain.
Pain and frequency did not improve commensurately. A colon bacillus, isolated from
urine, was agglutinated by the patient's serum at a dilution of i: 128. Colon vaccine
prepared and injected twice a week at first. Initial dose, 10,000,000.

Before the end of two weeks there was less pain and frequency, the urine appeared a
little less cloudy and less foul. In the second month of treatment, with the combined vac-
cine, the urine became comparatively clear. After six months from the start, the wounds
had healed, the urine, no longer foul, contained very little sediment. Urination every
two hours in day, less often at night, associated with very slight burning. At this time
patient had been up and about increasingly for two months; had gained considerable
weight.

At the time of writing (March, 19 10), the patient had received tuberculin weekly
twenty-one months with occasional breaks. The maximum dosage, ^oVu n^g* For six
months colon vaccine was given, at first twice weekly and later once a week. Maximum
dosage, 60,000,000. It was omitted about a year ago. The urine sediment was sHght, and
few colon bacilli were to be found on recent examination. It still contains tubercle bacilli,
as recent inoculation experiment proved. Micturition every three to five hours, occasion-
ally once or twdce at night. No pain. Gain in weight approximated at 30 pounds. Is
able to attend to household duties and to go about without discomfort. She states that
she feels better than she has for several years.

VESICAL TUBERCULOSIS 787

There are certain features of this case that are worthy of note:
First, the immediate improvement in the cystitis following the ad-
ministration of colon vaccine, there having been no improvement in
this regard during the tAvo months of exclusive tuberculin treatment;
second, the fact that the colon bacilli were but few in the
urine after six months of treatment with colon vaccine; third, that,
although the maximum dosage of colon vaccine was but 60,000,000, and
the last dose was given approximately a year ago, the immunity estab-
lished has apparently continued to the present time; fourth, the presence
of liWng tubercle bacilli in the urine indicates that the process is still
active somewhere, but the patient's excellent condition, the absence of
temperature, indicates that she has at present a well-defined degree of
immunity; fifth, the presence of these bacilli indicates that every possible
measure should be made use of to increase the patient's resistance, and,
particularly, that we must maintain the antituberculous power of the
blood-stream at as high a degree as possible by the use of tuberculin;
sixth, it is interesting to note that the patient is able to say, based on her
subjective symptoms of well-being, or the opposite, following a dosage of
vaccine, as to whether the dose as given is increased or diminished. It
has been found in every instance in which the dosage has reached 20^0
mg. the patient does not feel as well for three or four days after in-
oculation. It has been found that a dosage of from -§-5^ to ^-qVo ^S-
(bacillary substance) is the most satisfactory dosage with which to main-
tain the present excellent condition. It is planned gradually to increase
the dose by minute increments, that is, from -g^jVcr ^^ ToVrr^ ^^^ ^^^^ ^^
^f^Q-^ mg. and so on, with the expectation that in the next six months a
dosage of y^jVlT "^o- ^^'^^kly may be well borne. There has been in the
treatment of this case at no time any suspicion of severe subjective
symptoms following either the colon vaccine or the tuberculin.

Vesical Tuberculosis Without Apparent Renal Invc^ve-
ment. — There may occur, according to Walker (loc. cit.), a considerable
number of cases of tuberculous cystitis, unaccompanied by demonstrable
renal involvement. Of 42 cases, he found 10 in which the disease was
apparently confined to the bladder, and 32 in which foci w^ere found in
other parts of the urogenital system. In 22, of these 32 the other involve-
ment was in the genital system.

When, as a result of the application of the usual methods of diag-
nosis, it is concluded that the bladder is the chief seat of involvement,
we have a condition unsuitable for surgical treatment and unsatisfactory
with other usual methods.

We have to deal with a tubercular infection of a mucous membrane,

788 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

ulcerated and indurated. Such lesions are definitely known to be
amenable to tuberculin.

Again quoting Walker (loc, ciL) :

"In such cases the best results may be obtained from tuberculin treatment." He
states that sometimes, after two or three injections, the patient will report improvement.
Less often the symptoms persist in increased or lessened severity, and improvement is only
obtained after many months of treatment. The patient first experiences increased vigor,
pain diminishes and disappears, and calls to micturition become less troublesome. From
a frequency of fifteen minutes during the day and incontinence at night, improvement
to two hours through the day and once or twice at night may be obtained in several months.
Hematuria gradually ceases. The urine remains for a long time without change, but may
eventually become clear, and the urinary pigment, which was deficient, increased. The
patient puts on weight.

He selects the following case from a few in which the tuberculous
process has apparently been arrested:

Man, thirty-one, in July, 1903, had hematuria and hemoptysis. For four years
cystitis symptoms had increased gradually. Cystoscope showed ulceration left side of
bladder. Groups of fine tubercles found. Four months treated with drugs. Symptoms
the same. Steadily lost weight. Tuberculin begun November, 1903, slu n^g-> repeated
every two weeks. January, 1904, urine unchanged. He ceased to lose flesh, held his
urine four hours during the day, rose once at night. Much stronger, and had regained former
figure. Cystoscope showed groups of tubercles, but less ulceration. Hemoptysis in March,
1904, and about weekly during the early part of the year. He began to gain flesh, and
appearance showed improvement. In 1904 burst of hemoptysis and hematuria. September,

1904, to Januar}', 1905, had gained one stone and a half in weight. Cystoscope, June,

1905, showed few fine tubercles; ulceration had healed. September, 1905, no pain or
hematuria. Urinated three or four times a day, not at all at night. Urine still hazy,
trace of pus. January, 1906, injection reduced to ttAth mg. for three weeks. Blood ap-
peared in urine and was present some weeks. It disappeared and the urine gradually
cleared, with increased doses of tuberculin. Urine became absolutely clear, remained so
several months. July, 1907, attack of cystitis. Urine cloudy, no T. B. found, numerous
staphylococci. Recovered from this attack of staphylococcus cystitis and feels well,

Jones reports the cases of tuberculous cystitis treated in Wright's
clinic as follows:

Two cases cured, 4 much better, 8 better, meaning either some relief from pain or
frequency of micturition. One case was no better, i worse, and i unknown. There
were relapses in 5 cases. In 13 cases there was secondary colon infection. In 10 of the
successful cases initial dose was less than j^^y ^"^ oiten ^^—^ mg. After a time it
was raised gradually to ^oVo* Serious results may follow large initial doses. Treatment of
successful cases averaged one year two months. Five or 6 were treated six months or less.

The writer has treated a case of genito-urinary tuberculosis, which
in its early history furnishes an excellent illustration of the course of an
untreated case of tuberculous bladder, apparently unassociated with
renal disease:

VESICAL TUBERCULOSIS 789

In early October, 1908, "F. G.," male, about twenty-eight years old, was referred for
treatment. For ten years he had suffered from frequent micturition, generally every two
or three hours. For three or four years had passed a little blood once or twice each year.
At times there was considerable pain and burning on micturition, but this was not constant.
Four years before the above date the symptoms of cystitis became marked, and when blood
appeared, he was referred to a surgeon for observation. Cystoscopy was at the time per-
formed by J. H. Cunningham, Jr., who found several ulcerated areas in the mucous mem-
brane and made a positive diagnosis of tuberculosis. During the following four years he
occasionally passed blood, had some pain on micturition. Frequency, every two or three
hours, once or twice at night. Urine generally not cloudy. His general health continued
to be fairly good although untreated. In October, 1908, he developed a swollen testicle,
which was, when the writer saw it, the size of a clenched fist. It had become swollen
in a few days; was only slightly tender. His physician believed it to be due to the gono-
coccus, but there was no history of exposure or clinical evidence of the disease. The
von Pirquet cutaneous reaction was intensely positive. In a short time the tissues broke
down, fluctuation was made out, and considerable thick pus was aspirated. No pyogenic
organisms were present. A guinea-pig inoculated, killed after four weeks, showed tubercle
bacilli in the mesenteric glands, inguinal glands, and tubercles were found studding the
peritoneum.

The sequence of events in this case and the observations furnish
clean-cut evidence of a tuberculous cystitis extending over a period of
years and final extension to the testicle.

It indicates that in an apparently healthy individual tuberculosis
may exist in the bladder for a long time, and illustrates the tendency of
bladder tuberculosis to extend to other organs of the genital system.
It is particularly interesting, because of the sequence of events in the
same case following the use of tuberculin as treatment over a consider-
able period. The treatment of this case will be considered under the
next heading.

Vesical Tuberculosis Associated with Tuberculosis of
the Genital System. — In 23 cases cited by Walker {loc. ciL) tuber-
culosis was found to be coexistent in the bladder and in some of the
genital organs. This association is very commonly met with.

He states that his patients steadily lost ground under various local
and general treatment, and that he considered them eminently suited
for tuberculin treatment; that in none of them was he able to bring about
a cure, though he treated them over long periods. In most cases a con-
siderable amelioration of symptoms was obtained. The distressing
frequent and urgent micturition is sometimes diminished to a remarkable
degree.

One illustrative case, a mai\ of thirty-eight, when seen had symptoms of cystitis for
eighteen months. Left seminal vesicle was hard, and in the left lobe of the prostate was a
large, hard nodule. Tubercle bacilli found in the urine. Cystoscope showed a cystitis
without definite tubercles. During six months tuberculin was given. Dosage, ^^^j to
jjjy mg. He gained weight; there was no blood in his urine since the early part of the
treatment. Micturition less frequent.

7QO THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

A second case for four months urinated every ten minutes and was incontinent at night.
Urine thick and milky, prostate and seminal vesicle affected. After four months there was
a gain of weight, lessened pain, urination every one and a half hours during the day,
every two hours at night. After twenty-one months' treatment urination was every three
hours and twice at night, still milky. At the end of twenty-eight months' treatment the
urine was clear, frequency every three hours in the day time, once at night.

The case " F. G/' will be here continued as one of tuberculous cvstitis
with secondary testicular involvement:

Beginning October 7, 1908, tuberculin R. was injected once a week, initial dosage
mg. (bacillary substance), the second | mg., the third ir~^ mg., the latter

20.000 ° ^ -^ ^^ ^^n "- - \5M}0 ^•' 10.000

repeated weekly until December 22, when it was increased slightly to ^^^ mg. After
the pus was aspirated from the testicle, a sinus continued to discharge until the last
of December. The testicle gradually lessened in size, and the epididymis could be felt
as a somewhat enlarged, hard mass. After the first four doses of tuberculin, micturition
became less frequent (for several years it had averaged ever}' two or three hours). On
December 22, 1908, after about three months' treatment, the patient stated that for the past
week he had several times held his urine seven hours without much discomfort, and had
not been up at night to micturate for some time. June 15, 1909, the dosage had reached
j^{j^ mg. T. R. Urination every four or five hours and not at all at night. August 3,
tuberculin B. E. was substituted for T. R., inasmuch as results in other cases appeared to

be superior than those obtained by the use of T. R. Initial dose — 1 — mg, December
^ "^ 20,000 °

24, 1909, dosage had reached n^jj mg. B. E., and the last dose, March 4, 19 10, was ^Jo mg.

The testicle is now of practically normal size, the epididymis hard, but smaller than at
first, micturition three or four times a day, never at night; pain after micturition, as ex-
perienced at first, has almost disappeared; no blood in the urine since treatment was begun;
weight about as usual; general condition excellent; subjectively and objectively perfectly
well; has been able to attend to business from the start of treatment as he had previously,
but with less discomfort. He has received no local cr general treatment other than tuber-
culin and advice as to hygiene.

There has been no suspicion of constitutional or focal reaction following injection of
vaccine.

This case is of interest in the matter of diagnosis. The finding of
tuberculous ulceration in the bladder in 1904 indicates that the bladder
symptoms, extending over from five to ten years, were within reasonable
probability due to a condition of tuberculous cystitis; the testicular in-
volvement, which occurred four years after the ulcerations were found,
and proved to be tuberculous by animal inoculation, confirms the ac-
curacy of the cystoscopic diagnosis.

The case is further valuable as indicating the eflSciency of tuberculin
so far as indications may be obtained from the study of any one case.
The symptoms had gradually gotten worse over a long period previous
to the beginning of tuberculin treatment, and the involvement of the
testicle came as evidence of unfavorable progression of the tuberculous
process. The improvement associated with the exhibition of tuberculin
may not only be taken as evidence of its efficiency in cystitis, but also
in an early tuberculous process in the epididymis.

GENITO-URINARY TUBERCULOSIS 791

The outcome of the case also shows that tuberculin may be given
successfully without the production of any symptoms of intolerance of
either a general or a local nature.

The question of when to stop tuberculin treatment in a case of this
kind can be determined only by the method of trial and error. The
writer proposes to inoculate a guinea-pig with the centrifugalized sedi-
ment of the urine. If bacilli are to be found in the urine, the treatment
will be continued; if not found, tuberculin will be stopped for a month or
t^vo and the patient kept under careful observation. Tuberculin will be
started again if increased frequency of micturition, pain, or other symp-
toms of cystitis develop.

Tuberculosis of the Genital System.— The chief danger of
tuberculous infection of the genital system is that it may infect the
bladder. Walker {loc, cit.) considers the onset of cystitis to indicate
extirpation, if possible, of the organ involved, but otherwise does not
make use of extensive operative procedures, this because of the tendency
of these lesions to contract and become walled off as a result of the
benefit of tuberculin and general hygienic measures.

He reports a case of tuberculous epididymitis, prostatitis, and vesicu-
litis, in which decided improvement took place after four years' treatment.
The lesion in the epididymis in this case was of nineteen years' duration.

Jones {loc. cit,) reports the following cases of tuberculous testicle
treated in Wright's clinic — 3 cases were cured, 2 "much better," 2
"better," and 2 doubtful as to the result.

Jones sums up 34 cases of genito-urinary tuberculosis treated with
tuberculin in Wright's clinic as follows: The results would indicate that
great improvement may be obtained in 3 out of 7 cases, and slight im-
provement in 2 more cases; treatment may last a year or more. There
were secondary infections in one-half the cases.

Genito-urinary Tuberculosis Associated with Tubercu-
losis Blsewhere. — If the complicating tuberculous lesion is other
than pulmonary, there is no contraindication to the use of tuberculin in
the dosage which consideration of the genito-urinary condition would
indicate.

If there is an active pulmonary lesion, the dosage of tuberculin must
be modified according to the special requirements for treatment of a case
of the pulmonary type. If there is pulmonary involvement of a more or
less inactive character, tuberculin may be guardedly given. We must,
at first, insist that the patient be kept quiet during the twenty-four
hours after inoculation, in order to eliminate the possibility of superim-
posing an autoinoculation upon the inoculation already given, and thus
avoid what might constitute a toxic dose of tuberculin.

792 therapeutic immunization and vaccine therapy

Tuberculin Treatment

There is no form of tuberculosis, except the pulmonary, which
requires more careful attention to dosage than renal tuberculosis. In
febrile cases we are dealing with autoinoculation. Extremely minute
doses, of course, must be given. The initial dose may be ~^^ mg.
(B. E. solid substance) or less, repeated in from five to ten days for several
inoculations, when it may be increased to ^^^ mg. The next gradation
will be to 3^ooQ, and hereafter the increase must be more gradual, using
several doses of 25:^0 > 20;^ ^^^ 15:^)0 before any further increase.
The safest method of giving tuberculin is to bear in mind that the aim
should always be to fall short of the production of clinical symptoms.
That this will be in some cases impossible at some stage of the treatment
is evident. We have in the clinical symptoms a guide which indicates
when any dose is too large. There may be rise in temperature, increased
frequency in micturition, increased pain or tenderness, headache,
malaise, nausea, etc., during the twenty-four hours after inoculation,
which are known to be correlated with any marked reduction in the op-
sonic index. If such symptoms occur, we should always await spon-
taneous improvement before again inoculating, and at the same time give
a considerably smaller dosage. We must use greater care in further
increase of dosage as the treatment progresses.

In afebrile cases, in the absence of subjective evidence which indi-
cates that the antibacterial resistance is being unnecessarily lowered by
the dosage of tuberculin used, we may have positive e\idence that the
tuberculin is doing good in the sense of well-being that the patients
frequently experience for several days after each inoculation.

Where it is impossible to observe any local changes, as in tubercu-
losis of the kidney or in the seminal vesicle, prostate, or testicle, following
single inoculations, when there is no temperature, we can begin with the
usual minimal dose, and gradually increase at about the same pace which
would be used in the case of bladder tuberculosis when signs would
manifest themselves if the dosage were too large. In the same way,
based on experience in treating cases of this type, using the opsonic index
as a guide, we are able to obtain a scheme which, if used consistently,
will gradually promote tolerance to tuberculin by a very gradual increase
in dosage, and at the same time will not provoke any extended period of
lowered opsonic power with its attendant lack in progress or retrogres-
sion which may be associated with a series of prolonged negative phases.

The danger of producing constitutional disturbances following in-
oculation in cases of extensive tuberculosis of soft tissues, such as we are
here dealing w^ith, is much greater than the danger from such reactions

TUBERCULIN TREATMENT 793

which may beproduced in glandular cases. Severe constitutional symp-
toms, following inoculation with tuberculin, mean nothing else than the
presence in the blood of living bacilli and poisons, and are associated with
a period of diminished tuberculotropic power of the blood-stream.
Dissemination of bacteria with the blood-stream at such a period cannot
be anything but dangerous to the patient, not only from the standpoint
of the possibility of the development of new foci elsewhere, but also
through the extension of the process locally, when the local and general
barriers of resistance are temporarily partially broken down. If we
take the signs of intolerance to tuberculin as a guide for dosage, we shall
have no guide unless intolerance is produced. That repeated consti-
tutional disturbances following the inoculation are consistent with more
or less rapid recovery in a large number of cases is well known. That
the use of large doses of tuberculin with production of constitutional
reactions has been repeatedly followed by disaster is quite as well known.
It no doubt takes a somewhat longer course of treatment to arrive at
tolerance to the same amount of tuberculin if we use the opsonic method
of treatment than when the clinical method is used, but, theoretically
and practically, there is no reason to think that the results of treatment
will be less good if the same dose is finally arrived at. By the opsonic
method we arrive at the large doses only after a considerable space of
time, and during this time we have produced no periods of constitutional
disturbance and attending dangers. The largest dose of tuberculin that
the writer is giving in geni to-urinary cases is ^ mg. B. E. after two years*
treatment.

Extirpation of tuberculous organs in the genito-urinary system is,
in the majority of cases, palliative, because the process is apt to involve
other tissues that cannot be removed. These cases are rendered diffi-
cult and often impossible as surgical problems because of the many
avenues for extension of the process; because, in the case of the kidney,
the proper functioning is interfered with; where the ureter is involved,
it may become occluded and render useless the corresponding kidney;
where symptoms of cystitis are intense, surgery may offer no relief.

There is no doubt that some patients recover after removal of some
seriously involved organ and that the body is, by its removal, enabled to
hold in check lesions elsewhere. But we know that it is through the
specific antibacterial power of the blood fluids and through cellular re-
action in walling off the lesions that this takes place. We know that
the blood-stream itself is, in the vast majority of cases, deficient in tuber-
culotropic power, and have seen the reason for this in the segregation
of these foci from the circulation and the consequent lack of effective

794 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

bacterial stimulus to induce the formation of a sufficiency of tuberculo-
tropic substances. It does not seem an irrational procedure to make
use of an agent, tuberculin, to furnish an artificial stimulus to the im-
munizing mechanism when it gives every evidence of being in default
for lack of this stimulus. In fact, the knowledge that it is possible to
increase the power of the blood-stream to destroy tubercle bacilli, and
thus better safeguard the rest of the body and, perhaps, prevent further
extension of lesions already under way, would appear to render the use
of tuberculin imperative when operative procedures have accomplished
all that is to be expected or when they are contra-indicated. Clinical
evidence derived from the treatment of other localized infections with
tuberculin is overwhelmingly in support of this view.

It has been the unfortunate custom in medicine to base on brilliant
results achieved by new methods in certain types of infection extrava-
gant expectations as to their efficiency in others. That it is unreason-
able to anticipate that masses of tuberculous tissue should suddenly melt
away under tuberculin treatment should be evident from consideration
of the conditions in tuberculous foci. We cannot expect the leukocytes
or antibacterial substances to have any effect upon bacteria that they
cannot reach. In fact, clinically, tuberculin may not appear to reduce
the size of a tuberculous prostate or seminal vesicle to a marked degree,
even though given for several years. It may be reasonably assumed,
however, that with a blood-stream high in protective substances the
danger of extension of the tuberculous process will be lessened. On
the other hand, in tuberculous conditions of mucous membranes, as that
of the bladder, we should anticipate more rapid disappearance of lesions,
and this appears clinically to be a fact.

Theoretically and practically, the indications for the use of vaccine
in chronic localized infections, of tuberculin in chronic localized tuber-
culosis, when surgical conditions have been efficiently met and cure is not
forthcoming, are insistent and essential in a degree no less than the sur-
gical procedure as leading to the immunization and cure of the patient.

DOSAGE TABLE

The vaccinating qualities of different vaccines, composed of the same
species of organisms, but of different derivations, may vary to a consider-
able degree. The dosage of one may necessarily be twice that of the
other, to produce the same immunizing response. Hence, numerical
standardization, although it must be accurate, is only tentative. The
final standardization is that derived from clinical use.

INJECTION OF VACCINE

796 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY

Dosage of tuberculin B. E. and T. R. is based on content of each
cubic centimeter of the original solution in actual bacterial substances.

The following table represents dosage as has been used by Wright
at St. Mary^s Hospital, London:

Dosage of Vaccines

Minimum. Maximum. Average.

Tuberculin R. or B. E —1^ -A-

50.000 4000

Staphylococcus 25 m. 1000 m. 250 m.

Streptococcus i m. 300 m. 10 m.

Gonococcus J m. 10 m. J m.

Pneumococcus i m. 300 m. 10 m.

Diplococcus intracellularis meningitidis 10 m. 100 m.

Micrococcus catarrhalis i m. 300 m. 10 m.

Micrococcus neoformans 10 m. 50 m. 25 m.

Bacillus coli 2 m. 1000 m. 100 m.

Bacillus typhosus ■ . 5 m.

Bacillus pyocyaneus 2 m. 1000 m. 100 m.

Bacillus of Friedlander 4 m. ' 8 m. 6 m.

The writer has varied the dosage in his own practice:

Initial Dosage (Febrile Cases)

Tuberculin R. or B. E V^ mg. in children;

sdiuo ""8- i" adults.

Streptococcus 1,000,000 to 5,000,000.

Gonococcus 1,000,000 to 5,000,000.

Pneumococcus 1,000,000 to 10,000,000.

Bacillus coli 2,000,000 to 10,000,000.

Bacillus typhosus 5,000,000 to 10,000,000.

Staphylococcus 20,000,000 to 50,000,000.

Initial Dosage (Afebrile Cases)

Tuberculin R. or B. E ^ to ^^ mg.

Staphylococcus 100,000,000 to 250,000,000.

Streptococcus 10,000,000.

Pneumococcus 10,000,000.

Gonococcus 10,000,000.

Bacillus coli 10,000,000.

CHAPTER Lin

COLEY SERUM FOR MALIGNANT TUMORS

Dr. William B. Coley, after long and careful experimentation,
described in 1891* a method of treatment for sarcoma which is familiarly
known as the subcutaneous treatment with Coley toxins. The agent
employed is a filtrate of the combined toxins of the streptococcus of
erysipelas and the Bacillus prodigiosus. Its use was suggested by the
fact that certain malignant tumors, which had been partially removed
by operation, were observed to be at least temporarily inhibited if in-
oculated with erysipelas. In the original cases this inoculation was, of
course, accidental. Coley determined to use this clinical observation
as the basis for accurate treatment with small but continued doses of
the erysipelas toxin, and, to make this possible, sought to procure a
filtrate of unvarying strength. This he has succeeded in doing, and
has made it more effective by adding the toxin of the Bacillus pro-
digiosus. These combined toxins, as made by Dr. Martha Tracy
(now at the Huntington Institute for Cancer Research, Germantown,
Pennsylvania) from Dr. Coley's directions, are much more powerful
than the original liquid or the preparations offered by manufacturing
chemists.

The initial dose should never be more than \ minim; it may be
put into the tumor or under the skin in any convenient part of the
body; it is, at least theoretically, safer to give the early injections
away from the growth, as injections given into the tumor mass itself
may be absorbed irregularly, either slowly or very rapidly, and it,
therefore, seems better to give the early injections at least into normal
tissues. If there is no reaction following the initial injection, J minim
may be given on the following day, and the amount gradually in-
creased on successive days until a reaction is obtained. The reaction
consists, subjectively, in a feeling of malaise, with headache, chill,
fever, general pain, nausea, and, if the dose be excessive, vomiting
and collapse, and the objective signs of rapid pulse, small in volume,
temperature elevation to 103° to 105° F., sweating — all the signs of an
intense intoxication. Death has been reported in several instances
and has occurred once in our own hands.

^ Ann. Surg., 1891, xiv, 210.

797

798 COLEY SERUM FOR MALIGNANT TUMORS

The gradually increasing dose will ultimately produce a reac-
tion of moderate severity, which may present all the symptoms
enumerated or emphasize one or two of them particularly; after a
reaction, one or two days should intervene before another injection is
made, and the amount should be only very slightly increased. Oc-
casionally a moderate increase of the amount injected may make a
terrific increase in the character of the reaction, as in the case cited below.
The object should be to produce reactions as powerful as the patient
can withstand without too great subsequent prostration, and to continue
these at two- or three-day Intervals, until either the growth begins to
disappear or it becomes obvious that toxins will not affect the disease.
In successful cases the treatment may continue two or three months, and,
after an interval of rest, be again instituted if signs of the disease still
remain or reappear.

Results. — It would seem, from Coley's paper,^ that rather more than
10 per cent, of otherwise hopeless cases have been cured subsequent to
this treatment. Among the cases treated immediately under Coley's
observation the percentage is higher.

It seems only justice to the patient to recommend i thorough trial of
this method in every case of sarcoma in which it is known or suspected
that operation has failed to remove the disease in toto; and in every
operative case in which there is recurrence or the suspicion of recurrence.
Operation should be done in every case in which there is prospect of
removing all or almost all of the growth without serious danger to the
patient's life, and the Coley toxins should follov/. Occasionally a
course of the toxins has been instituted before operation, and perhaps
with some benefit, but it should ne\'er be prolonged in the face of an
advancing disease. It would seem indisputable that some cases, other-
wise certainly and rapidly fatal, have been restored to health after the
thorough use of Coley toxin and without other medication or treatment.

Fatal Ca^e.— Within three years a reputable practitioner, residing in the
suburbs of Boston, reported (orally) the case of an individual past middle age
with a large sarcoma, upon whom the toxin treatment was to be used. The
first dose was \ minim of the toxins, given by the physician himself. Almost
immediately after the injection the patient went into sudden collapse, and in
spite of all efforts died within a few minutes. No autopsy.

A patient suffering from so-called Hodgkin's disease, with extensively en-
larged cervical, axillary, and inguinal nodes, was being treated with slowly
increasing doses of the toxins. Immediately following an injection of less
than I minim more than the previous dose, after which little or no reaction

1 Boston Med. and Surg. Jour., 1908, clviii, 175.

COLEY SERUM FOR SARCOMA 799

occurred, there was a sudden collapse, with extreme weakness — ^pulse i6o
and almost imperceptible; nausea and vomiting, cold sweat, sighing respira-
tion, and diarrhea. This improved slowly, but left the patient very weak for
forty-eight hours. It is fair to say that this patient was one in whom the
normal resistance was greatly diminished.

In conclusion, it seems certain that the spindle-cell sarcoma is most
likely to be benefited by the toxins; the large round-cell to a lesser degree,
the small round-cell, with many mitotic figures, least of all.

Dr. Leo Loeb^ says, "I have written to a number of prominent surgeons,
asking for a statement concerning their experience with Coley's fluid. Four-
teen of these surgeons had had personal experience with this mode of treat-
ment. The majority state, without, giving the number of patients treated,
that they have not seen any successful cases. From some surgeons I obtained
the number of cases treated, and the result was as follows: Among 78 cases
of sarcoma, in 4 cases a cure was obtained; therefore, in not quite 5 per cent,
of the cases treated a positive result was obsers'ed. On the other hand, in
a number of cases in which no cure was obtained, the injection of the toxins
seemed to have a marked weakening influence on the patient, and sometimes it
produced a sloughing of the tumor.

^^ It is, therefore, likely that the treatment of inoperable sarcoma \\ith the
toxins of streptococcus and Bacillus prodigiosus leads to a cure in approxi-
mately 4 to 9 per cent, of cases, and some results obtained so far suggest that
this method of treatment may prove of value as a postoperative procedure in
diminishing the number of recurrences, and that in a certain number of cases
it might limit the necessity for amputation of the limb in cases of sarcoma of
the long bones. As to its mode of action, nothing definite can be stated, but
it is likely that the toxins themselves, as well as the local and general reactions
they produce, frequently affect the life of the sarcoma cells unfavorably."

We have had several cases where no improvement followed treat-
ment. One case has been encouraging:

R. A. H., nineteen, single, was referred to us by Dr. D. H. Judd, of
Boston, with a soft, movable, nodulated tumor of the left parotid.

June 12, 1909, operation removed all the tumor, which was grossly visible,
amounting in volume to the size of an egg, more or less encapsulated. Patho-
logic examination showed this to be a small round-cell sarcoma. Coley
serum was begun at the first sign of recurrence about six weeks later, and has
been continued every alternate six weeks since (two and one-half years).
The quickest result in the way of diminution of the recurring tumor in this
case seems to follow local injection, rather than that given at some remote
place.

^ Jour. Amer. Med. Assoc, 1910, liv, 263.

APPENDIX

SOME INVALID AND CONVALESCENT FOOD RECIPES

Many times a surgeon is asked, ** Doctor, what may I have to eat?'*
or, ^'Doctor, I am getting so tired of this, or that, can't you let me have
something different?" He will find that, in the long run, it will be
an asset of no mean value to be able to direct whoever is in charge in
the making of a few simple and tasty dishes. With a trained nurse
on the case, he can usually relegate the responsibility in this matter to
her, but even under these circumstances it is sometimes unwise to
allow too much latitude in the choice and construction of dishes, and
in serious cases the surgeon should know exactly what the patient is
getting and how it is being prepared. It is for the purpose of supplying
a number of nutritious and appetizing recipes, simple to make, and of
proved value, to which the doctor may refer, that this section is added.

Apple Meringue. — Stew i pound of apples until soft, beat thoroughly
until quite smooth. Beat in the yolk of i egg and sugar to taste. Turn
the mixture into a glass dish. Beat up the white of i egg stiffly and add
to it a little sugar. Pile the meringue over the fruit.

Apple-water. — Slice into a pitcher 6 juicy sour apples. Add a table-
spoonful of sugar, and pour over them i quart of boiling water. Cover
closely until cold, then strain. Slightly laxative.

Arrowroot. — Mix a teaspoonful of Bermuda arrowroot with 4 teaspoon-
fuls of cold milk. Stir this slowly into i pint of boiling water, and let it
simmer for five minutes. Keep stirring all the time, to prevent lumps and
keep it from burning. Add i teaspoonful of sugar, a pinch of salt, and
one of cinnamon, if desired. (In place of the cinnamon, half a teaspoonful
of brandy may be used, or a dozen large raisins may be boiled in the water.
If the raisins are preferred, they should be stoned, and the sugar may be
omitted.)

Cornstarch or rice-flour gruel is made in the same way.

Baked Custard Pudding. — Beat 2 eggs, add to them i dessertspoon-
ful of castor sugar and i pint of milk, and stir until the sugar is dissolved.
Strain into a buttered pie-dish and bake in a slow oven until set.

Barley-water. — Wash thoroughly 2 ounces of pearl barley in cold
water. Add 2 quarts of boiling water and boil until reduced to i quart

800

SOME INVALID AND CONVALESCENT FOOD RECIPES 8oi

about two hours — stirring frequently. Strain, add the juice of a lemon, and
sweeten. For infants omit the lemon.

Beef-essence. — Mince finely i p)ound of lean, juicy beef from which
all the fat has been removed; put into a wide-mouthed bottle or fruit-jar,
and cork tightly. Set the jar into a kettle of cold water over a slow fire, bring
the water to a boil,. and let it boil for three hours. Strain and season with
salt and red pepper.

Beef-juice. — Place ^ pound of lean, juicy beef on a broiler over a clear
hot fire, and scorch each side. Press out the juice with a lemon-squeezer
into a hot cup, add salt, and serve hot with toast or crackers.

Beef-tea Jelly. — Scrape i pound of beefsteak with a sharp knife, having
first carefully removed all the fat. Soak in 2 gills of water for a short time,
then place in a saucepan with seasoning and J ounce of gelatin. Put over
a slow heat until the meat changes color, but do not allow to boil. Stir
until it commences to set at the sides. Pour into a mold and allow to set,
then serve.

Beef-tea, Peptonized. — To J pound of raw beef, free from fat and
finely minced, add 10 gr. of pepsin and 2 drops of hydrochloric acid. Put
in a large tumbler and cover with cold water. Let it stand for two hours
at a temperature of 90° F., stirring frequently. Strain and serve in a red
glass, ice cold. Peptonized food does not keep well, and should not be
used more than twelve hours old.

Beef-tea with Oatmeal. — Mix i tablespoonful of well-cooked oatmeal
with 2 of boiling water. Add i cupful of strong beef-tea and bring to the
boiling-point. Salt and pepper to taste, and serve with toast or crackers.
Rice may be used in place of the oatmeal.

Blanc-mange. — Put i pint of milk into a saucepan with J ounce of castor
sugar, the rind of half a lemon, and \ ounce of gelatin. Let this mixture
stand by the fire until the milk is well flavored and the gelatin dissolved.
Stir until beginning to set at the sides. Pour into a mold. When it is quite
set, turn it out and serve.

Broth, Chicken. — An old fowl will make a more nutritious broth than a
young chicken. Skin, cut it into small pieces, and break the bones with a
mallet. Add the washed neck, gizzard, and liver. Cover with 2 quarts of
cold water, add i tablespoonful of salt and i small onion, and boil slowly for
three or four hours. Strain, return to the stewpan, bring to a boil, sprinkle
in I tablespoonful of rice, and simmer for twenty minutes. Add i teaspoon-
ful of finely chopped parsley and season to taste.

Broth, Clam. — Take 3 large clams, washed clean, and let them stand
in enough boiling water to cover them till the shells begin to open. Drain
out the liquor, add an equal quantity of boiling water, i teaspoonful of finely
pulverized cracker crumbs, a little butter, and salt to taste.

Broth, Mutton. — Cut up fine 2 pounds of lean mutton, without fat or
skin. Add i tablespoonful of pearl barley, i guart of cold water, and a

8o2 APPENDIX

teaspoonful of salt. Bring to a boil, skim well, then cover, and allow to
simmer gently for three hours. When ready, take out the meat and bones,
cut the meat into tiny dice, replace in the broth, allow to cool slightly, and
add i teaspoonful of chopped parsley. Season to taste and serve.

If preferred, the broth may be strained and served simply with the
chopped parsley. If rice is used in place of the barley, it will not need to be
put in until half an hour before the broth is done.

Broth, Oyster. — Cut into small pieces i pint of oysters; put them into
i pint of cold water, and let them simmer gently for ten minutes over a slow
fire. Skim, strain, add salt and pepper.

Chicken Omelette. — Put i ounce of butter into an omelette pan and
allow to become hot without browning. Skim well, add 3 eggs well beaten
and 2 tablespoonsfuls of finely chopped chicken. Stir well and turn the mix-
ture into the pan. When lightly set, fold into two parts. Have ready a hot
dish, decorate with parsley, and serve at once.

Chicken Panada. — Pound the white meat of a chicken to a cream, stir
in I teaspoonful of bread-crumbs. Season and simmer slowly in a little white
stock for a few minutes, allow to cool slightly. Serve with toast.

Chicken, Potted. — Pound 4 ounces of boiled chicken to a paste in a
mortar with i ounce of butter. Add i dessertspoonful of chicken stock.
Press into a jar and pour over it a little melted butter. When required for
use, spread between thin slices of bread and butter, sprinkle a little salt over
it, and cut into dainty shapes.

Chocolate. — Scrape fine i ounce of chocolate, add 2 tablespoonfuls of
sugar and i tablespoonful of hot water; stir over a hot fire for a minute or
two until it makes a smooth paste, then pour into it i pint of boiling milk,
mix thoroughly and serve at once. If allowed to boil after the chocolate is
added to the milk, it becomes oily, and loses flavor.

Coffee. — Stir together 2 tablespoonfuls of freshly ground coffee, 4 of
cold water, and half an egg. Pour upon them i pint of freshly boiled
water, and let them boil for five minutes. Stir down the grounds, and let it
stand where it will keep hot, but not boil, for five minutes longer. In serving
put sugar and cream in the cup first, and pour the coffee upon them.

Coffee, Crust. — ^Take i pint of crusts — those of Indian bread are the
best — ^brown them well in a quick oven, but do not let them bum; pour over
them 3 pints of boiling water, and steep for ten minutes. Serve with cream.
This is a nutritious substitute for coffee.

Coffee and Egg. — Boil together for five minutes a tablespoonful of ground
coffee, J egg, J pint of milk, and J pint of boiling water. Beat the rest of
the egg and 4 teaspoonfuls of sugar together until stiff and light, and strain
the boiling coffee into it, stirring all the time. Add 2 tablespoonfuls of hot
cream. This is only to be given in small quantities.

Coffee, Nutritious. — Dissolve a little gelatin in water. Put i ounce of
freshly ground coffee into a saucepan with i pint of new milk, which should

SOME INVALID AND CONVALESCENT FOOD RECIPES 803

be nearly boiling before the coflFee is added; boil together for three minutes;
clear it by pouring some of it into a cup and dashing it back again. Add
the gelatin, and leave the cofiFee on the back part of the range for a few
minutes to settle. If desired, beat up an egg in a breakfast-cup, and upon
it pour the coffee.

Coffee, Bice. — Parch, and grind like coffee, half a cupful of rice. Pour
over it a quart of boiling water, and let it stand where it will keep hot for a
quarter of an hour, then strain, and add boiled milk and sugar. This is nice
for children.

Cream of Tartar Lemonade.— To a quart of boiling water add J ounce
of cream of tartar, the juice of one lemon, and 2 tablespoonfuls of honey or
sugar. Let it stand on ice until cold. This is a widely used diuretic beverage.

Custard, Boiled. — Warm i pint of milk. Beat up 2 or 3 eggs, pour on
the milk, and add i ounce of sugar. Stir over a slow heat until thickened,
allow to cool slightly; add a flavoring of vanilla or lemon.

Custard, Soft. — Take 2 tablespoonfuls of cornstarch to i quart of
milk; mix the starch with a small quantity of the milk and flavor; beat up 2
eggs. Heat the remainder of the milk to n^^r boiling; then add separately
the mixed cornstarch, the eggs, 4 tablespoonfuls of sugar, a little butter,
and salt. Boil the custard two minutes, stirring briskly.

Egg Broth. — Beat together i egg and \ teaspoonful of sugar until
very light, and pour on i pint of boiling water, stirring well to keep it from
curdling. Add salt and serve hot.

Egg Jelly. — Put i ounce of liquid gelatin into a saucepan, add the
strained juice of i lemon and the rind thinly cut. Beat in i egg and
sugar to taste. Add i pint of water. Stir the mixture over a slow heat, and
then beat with an egg-beater until light and frothy. Strain and turn into
molds until set, and serve when required.

Egg-nog, No. 1. — Beat the white of an egg stiffly, then stir into it in
turn a lablespoonful of sugar, the yolk of the egg, a taWespoonful each of ice-
water, milk, and wine. Do not beat, but stir very lightly.

Egg-nog, No. 2. — Beat up i egg with a tablespoonful of sugar. Stir
into this a cup of fresh milk, i ounce of sherry, or J ounce of brandy, and add a
dash of nutmeg.

Egg-nog, Hot. — Beat together the yolk of an egg and a tablespoonful
of sugar, and stir into it a pint of milk at the boiling-point. Add a tablespoon-
ful of brandy or whisky, and grate a little nutmeg over the top.

Eggs, Scrambled. — Take 4 eggs, half a teaspoonful of salt, one pinch
of pepper, one-quarter cupful of milk, one tablespoonful of butter. Put the
butter into a saucepan; when melted and hot, add the other ingredients.
Stir over hot water until of a soft, creamy consistency. Serve on buttered
toast.

Eggs, Soft-boiled. — Drop 2 eggs into enough boiling water to cover
them. Let them stand on the back of the stove where the water will keep hot.

804 APPENDIX

but not boil, for eight minutes. An egg to be properly cooked should never
be boiled in boiling water, as the white hardens unevenly before the yolk is
cooked. The yolk and white should be of a jelly-like consistency.

Omel, Cracker. — Pour i pint of boiling milk over 3 tablespoonfuls
of fine cracker-crumbs. Butter-crackers are the best to use. Add half a
teaspoonful of salt, boil up once all together, and serve immediately. Do not
sweeten.

Gruel) Flour. — Mix a tablespoouful of flour with milk enough to make
a smooth paste, and stir it into a quart of boiling milk. Boil for half an hour,
being careful not to let it bum. Salt and strain. This is good in cases of
diarrhea.

Gruel, Indian-meal. — Mix a scant tablespoonful of Indian-meal with
a little cold water, and stir into i pint of boiling water. Boil for half an
hour. Strain and season with salt. Sugar and cream may be added, if
desired.

Gruel, Indian-meal and Flour.— Mix 4 tablespoonfuls of Indian-
meal and 2 tablespoonfuls of flour and stir into a little cold water. Add
this slowly to 2 quarts of boiling water. Boil slowly three hours, adding
water from time to time to keep up the quantity to 2 quarts. Salt to taste.
To serve, mix a portion of this with an equal quantity of milk, and warm to
taste.

Gruel, Oatmeal. — Boil a tablespoonful of oatmeal in a pint of water for
three-quarters of an hour, then put it through a strainer. If too thick, reduce
with boiling water to the desired consistency.

Gruel, Oatmeal, with Milk. — Soak i pint of oatmeal in i quart of water
over night. In the morning, add more water, if necessary, and boil for an
hour. Squeeze through a fine strainer as much as you can, and blend it
thoroughly with a pint of boiling milk. Boil the mixture for five minutes,
and salt to taste.

Irish Moss. — Wash thoroughly a handful of Carrageen moss, pour over
it 2 cups of boiling water, and let it stand where it will keep hot, but not
boil, for two hours. Strain, add the juice of one lemon, and sugar to taste.

Slippery-elm may be used in the same way, a teaspoonful of the powder
to each cup of boiling water.

Junket. — Put i pint of cold fresh milk into a clean saucepan and heat
it lukewarm (not over 100° F.) ; then add i teaspoonful of essence of pepsin,
and stir just enough to mix; divide quickly into small cups or glasses and let
stand until firmly jellied, when the junket is ready for use, just as it is, or with
sugar; or it may be placed on ice and taken cold.

Junket, Cocoa. — ^Put an even tablespoonful of any good cocoa and 2
teaspoonfuls of sugar into a saucepan; scald with 2 tablespoonfuls of boiling
water; rub this paste smooth; then stir in thoroughly J pint of cold fresh
milk; heat this mixture lukewarm (not over 100^ F.); add i teaspoonful of
essence of pepsin, and stir just enough to mix; divide quickly into small cups

SOME INVALID AND CONVALESCENT FOOD RECIPES 805

or glasses and let stand until firmly jellied, when the junket is ready for
use; or it may be placed on ice and taken cold; or it may be served with
whipped cream.

Junket, Egg. — ^Beat to a froth one strictly fresh egg; sweeten with 2
teaspoonfuls of sugar; then stir in thoroughly J pint of cold fresh milk; put
this mixture into a clean saucepan and heat it lukewarm (not over 100° F.) ;
stir in i teaspoonful of essence of pepsin, and divide quickly into small cups
or glasses and let stand until firmly jellied, when the egg-junket is ready for
use, just as it is, or with grated nutmeg; or it may be placed on ice and taken
cold.

Lemonade, Flaxseed. — Into i pint of hot water put 2 tablespoonfuls
of sugar and 3 of whole flaxseed. Steep for an hour, then strain, add the
juice of a lemon, and set on ice until required. This is an efficient bronchial
sedative.

Lemonade with Egg. — ^Beat i egg with 2 tablespoonfuls of sugar until
very light, then stir in 3 tablespoonfuls of cold water and the juice of a small
lemon. Fill the glass with pounded ice, and drink through a straw.

Lime-water. — Pour 2 quarts of hot water over fresh unslaked lime of
the size of a walnut; stir until slaked, and let it stand until clear, then bottle.
Lime-water is often ordered with milk to neutralize acidity of the stomach.

Milk and Albumen. — Put into a clean quart bottle a pint of milk, the
whites of 2 eggs, and a small pinch of salt. Cork and shake hard for five
minutes.

Milk-punch. — ^To J pint of fresh cold milk add 2 teaspoonfuls of sugar
and I ounce of brandy or sherry. Stir until the sugar is dissolved.

Milk and Water, Hot. — ^Boiling water and fresh milk, in equal parts,
compose a drink commended in cases of exhaustion, as it is quickly absorbed
into the system with very litde digestive effort.

Milk, Peptonized. — Immediate Process, — Put 2 tablespoonfuls (i oz.)
of cold water into a goblet or gkiss; dissolve in this one-quarter of the contents
of a peptonizing tube; add 8 tablespoonfuls (4 oz.) of warm milk — not
boiling; drink immediately, sipping slowly. If J pint of milk is required,
double the proportion of water, peptonizing powder, and milk. Cold milk
may be used instead of warm, if preferred.

Milk, Peptonized.— C(?/(/ Process,— Put a teacupful (gill) of cold water
into a clean quart botde and dissolve in it by shaking thoroughly the powder
contained in a peptonizing tube; add a pint of cold fresh milk, shake the bottle
again, and immediately place it on ice — directly in contact with the ice. Shake
the bottle before and after using. Peptonized milk prepared by this recipe
is especially appreciated by patients who dislike the taste of warmed or boiled
milk, and ordinarily it is readily digested and assimilated.

Milk, Sago. — Wash a tablespoonful of pearl sago and soak it over night
in 4 of cold water. Put it in a double kettle with a quart of milk, and boil until
the sago is nearly dissolved. Sweeten to taste, and serve either hot or cold.

8o6 APPENDIX

Orange Albumen. — To the juice of one sweet orange add the white of
one egg and stir the mixture thoroughly for two minutes, being careful not
to beat it. Add ice-water to fill the glass.

Possett, Treacle.— Bring a cupful of milk to the boiling-pomt and stir
into it a tablespoonful of molasses. Let it boil up well, strain, and serve.

Raw-meat Sandwich. — Scrape the pulp from a good steak, season to
taste, and spread on thin slices of bread. Sear the bread slightly and serve
as a sandwich.

Soup, Rice. — ^Take i pint of chicken stock and 2 tablespoonfuls of rice.
Let them simmer together for two hours, then strain and add i pint of
boiling cream and salt to taste. Boil up once and serve hot.

Soup, Tapioca Cream. — Remove all fat from J pint white soup stock
(or use milk and water instead), put into a saucepan and bring to a boil.
Sprinkle in \ ounce of fine tapioca and cook until clear. Beat up one yolk
of egg, add seasoning of salt and pepper, then stir in i gill of cream. When
the tapioca is quite clear, strain the egg and cream and add them; after this
addition the soup must not boil. It should be sufficiently thick to hold the
tapioca in suspension.

Soup, Tomato. — Peel and slice one onion, cut i pound of fresh tomatoes
into small slices. Fry the onion a nice light brown in i oz. butter, add the
tomatoes and fry them a little, then put in i pint of water and a small bunch
of mixed herbs. Allow all to cook till tender, rub through a hair sieve.
Return to the stew pan, season to taste with salt and pepper. When boiling,
gradually add { ounce of crushed tapioca and cook for ten minutes longer.
Serve with small croutons of fried bread.

Soup, White Celery. — To J pint of strong beef-tea add an equal quantity
of boiled milk, slightly and evenly thickened with flour. Flavor with celery
seed or pieces of celery, which are to be strained out before serving. Salt
to taste.

Sweetbreads. — Keep the sweetbreads in cold water until ready to use;
then remove the fat, ducts, and membranes. Put them into boiling salted
water, add one tablespoonful of lemon-juice, and cook twenty minutes. Drain
and cover with cold water. Let them stand a few minutes, then drain, and
they are ready for the tray.

Tamarind- water. — A very refreshing drink may be made by adding i
pint of hot water to i tablespoonful of preserved tamarinds, and setting
aside to cool.

Tea. — Tea should be made in an earthen pot, first rinsed with boiling
water. Allow a teaspoonful of tea to each half pint of water. Put in the tea,
and after letting it stand for a few minutes in the steaming pot, add the water
freshly boiling, and let it stand where it will keep hot, but not boil, for from
three to five minutes.

Tea, Com. — ^Parch brown a cupful of dry sweet com, grind or pound it in
a mortar. Pour over it two cups of boiling water, and steep for a quarter of an
hour.

SOME INVALID AND CONVALESCENT FOOD REaPES 807

Toast, Milk. — Take i cupful of milk, half a tablespoonful of corn-starch,
half a tablespoonful of butter, 2 slices of dry bread, i saltspoonful of salt
Scald the milk. Melt the butter in a saucepan ; when hot and bubbling add the
corn-starch. Pour in the hot milk slowly, beating all the time until smooth.
Let it boil up once. Then add the salt. Toast the slices of bread. Pour
the thickened milk over the slices. Let it stand five minutes; serve.

Toast, Peptonized Milk. — Over 2 slices of toast pour i gill of pep-
tonized milk (cold process); let stand on the back part of the range for
thirty minutes. Serve warm or strain and serve fluid portion alone. Plain
light sponge-cake may be similarly digested.

Toast-water. — Toast 3 rather thin slices of stale bread to a very dark
brown, but do not bum. Put into a pitcher and pour over them a quart
of boiling water. Cover closely, and let it stand on ice until cold. Strain.
A little wine and sugar may be added if desired. Good in diarrhea.

Vanilla Cream. — Rinse a mold in hot and cold water. Make a custard
of two eggs and i pint of milk, and when thickened strain into \ pint ot
whipped cream; add i teaspoonful of vanilla essence. Dissolve { ounce of
gelatin in i tablespoonful of water until it is quite smooth, add a little of
the mixture to the gelatin, and then add the remainder of the gelatin to
the mixture. Add i ounce of castor sugar. Beat out all lumps. Pour
into the mold and allow to set.

Veal Jelly. — Cut li pounds of veal, free from fat and skin, into small
pieces, put in 2 ounces of sago and season with salt. Pour on two teacups of
water, cover the pan and allow to simmer for five hours, then strain, boil up,
and allow to partially cool, and pour into a mold. When cold, it will turn
out a firm jelly.

Wine, Mulled. — Into half a cup of boiling water put 2 teaspoonfuls
of broken stick cinnamon and half a dozen whole cloves. Let them steep for
ten minutes and then strain. Beat together until very light 2 eggs and 2
tablespoonfuls of sugar, and stir into the spiced water. Pour into this, from
a height, a cupful of sweet wine, boiling hot. Pouring it several times from
one pitcher to another will make it light and foamy. Serve hot. The wine
should not be boiled in tin.

Wine Whey. — Heat i pint of milk to the boiling-point, and pour into
it a wineglass of sherry. Stir once round the edge, and as soon as the
curd separates, remove from the fire and strain. Sweeten if desired. The
whey can be similarly separated by lemon-juice, vinegar, or rennet. With
rennet whey, use salt instead of sugar.

INDEX OF AUTHORS

Abbe, R., 380, 621
Abel, 341
Abram, 201
Alamartine, H., 438
Allaben, J. E., 26
Allen, 280
AUport, W. H., 550
Alvensleben, 565
Amsden, 291
Anders, J. M., 502
Anderson, 601
Andrews, E. Wyllys, 330
Araaud, G., 492
Amsperger, L., 480
Ascoli, 297
Aspell, 293
Auer, 131

Babler, E. a., 48

Bacelli, 297

Baeyer, H. V., 412

Baillet, 484

Bainbridge, 203, 207

Baker, W. H., 531

Balch, F. G., 623

Baldwin, H., 202

Baldwin, J. F., 26

Baldy, J. M., 28, 544

Ballance, 628

Barker, 330

Bartlett, 120

Barton, 226

Bassett, 74

Bassini, E., 489

Baum, 305

Baumgarten, 147

Beach, 305

Beard, 367, 554

Beck, C, 411

Beck, Emil G., 274, 277, 453

Becker, E., 107 201

Beebe, S. P., 439

Benelli, E., 330

Berendes, 152

Berger, P., 490

Bemheim, 81

Bertelsmann, R., 519

Berthoumeau, 167

Bevan, A. D., 202, 204, 373

Bibergeil, E., 338

Bichat, X., 226

Bidwell, 121

Bier, A., 258, 263, 271, 619

Bircher, E., 438

Bischoff, 79

Blake, J. A., 466

Blake, J. B., 34, no, 298, 337, 458

Bland-Sutton, 114

Blanlaret, 37

Blasius, 79

Bloodgood, 458

Blundell, 79

Boas, W. F., 145, 168

Bolterrani, G., 520

Bolton, C, 459

Boothby, W. M., 85, 90, 105, 622, 623

Borchardt, 185, 188

Boudet, 390

Boudon, 492

Bougdan, A., 392

Boycott, 89

Bovee, 199

Boyd, 147

Brackett, 202, 204, 630

Bradford, E. H., 627

Brauer, 131

Brewer, W. H., 202

Brian, 621

Brieger, 675

Briggs, 280

Briggs, F. M., 441

Briggs, W. T., 603

Briscoe, J. C, 763

Broca, 304

Brockway, 633

Brown, F. T., 598

809

8io

INDEX OF AUTHORS

Brown, W. H., 439
Brown, W. J., 385
Brun, v., 204
Briinings, 46

Brunton, Sir Lauder, 136
Bryant, J. D., 619
Buck, 619
Bull, W. T., 491
Bulloch, W., 677
Bumm, E., 299, 544
Burrell, H. L., 619, 651
Busch, M., 122, 338, 632
Bush, C, 499
Busse, 40

Buxton, H. T., 26, 199
Byford, 339

Cabot, A. T., 316, 531, 603

Cabot, H., 387, 600

Cabot, R. C, 56, 57, 58

Ca6kovi6, M. von, 104, 293

Calmette, A., 769

Calot, 633

Campbell, R., 202

Cannady, J. E., 392

Cannon, W. B., 458

Caraven, 74

Carmalt, 192

Carrel, 80, 85, 621

Carri^re, 304

Cashing, E. W., 231

Cates, 206

Catz, 125

Cavallo, 367

Champneys, 423

Chapman, 196

Chavasse, 618

Cheever, D. W., 79, 308, 313, 652

Chopart, 347

Ciuffini, 77, 295

Clark, J. G., 553

Codivila, 655

Codman, E. A., 625

Cofifey, R. C, 26

Cole, R. I., 748

Coley, W. B., 373, 491, 797

Collins, C. v., 30

Connell, 474

Connor, 185

Conti, 201

Cooper, 619

Cornwall, A. P., 651

Cotton, F. J., 105, 633

Couvelaine, 205

Couvelaire, A., 559

Craig, A. B., 338

Craig, D. C, 177,336

Craig, D. H., 316

Crandon, 89, 171, 263, 385, 503, 622, 630

Crile, G. W., 30, 79, 80, 81, 132, 564

Croom, J. H., 40

Crouse, H., 553, 640

Crump, 338

Cullen, T. S., 553

Cunningham, J. H., Jr., 237, 487

Curtis, 81

Curtis, F., 465

Gushing, E. W., 506

Gushing, Harvey, 280

Gushing, Hayward W., 489, 652

Cutler, C. N., 89

Czemy, 196

Da Costa, 683

Daguin, 167

Dahlgren, 303

d'Amico, 46, 50, 152

David, 81, 131

Davis, E. P., 559

Dawson, J. B., 501

Deaver, 517

De Forrest, 280

De Garmo, 329

Delore, X., 438

de Normandie, R. L., 448, 559

Dent, 316

Denys, Jean, 79

Desault, 226

Dewey, 313

Dewey, G. G., 316

Dewitt, W. A., 47

Dickinson, W. H., 213

Doederlein, A., 538, 544, 559

Dorrance, 86

Dorsett, 293

Douglas, 89

Doyen, E., 534

Dudley, E. G., 526, 534

Duhrssen, A., 561

Duplay, 652

Dupuytren, 313

Duschinsky, 338

Dyball, 300

EcK, 621

Edebohls, G. M., 564

INDEX OF AUTHORS

8ll

Edsall, 204

Edwards, S., 501

Ehrenfest, H., 565

Ehrenfried, 85, 89, 131, 292, 622, 623, 633,

656
Ehrlich, P., 675
Eiselbserg, A. von, 40, 41
Eisendrath, D. N., 47
Eligagaray, 304
Elliot, J. W., 483
Ellis, A. G, 337, 33^
Elsberg, 80, 81
Emmet, T. A., 526
Englehardt, 316
Erlenmeyer, 295
Esmarch, 263
Evans, H. M., 433, 439
Ewald, 140, 146

Falconer, J. L., 202

Faraboeuf, 347

Faure, 628

Favill, 202, 204

Felch, L. P., 365

Fell, 131

Fen wick, W. S., 298

Finney, J. M. T., 180, 463

Finsen, 368

Fisberg, A. von, 438

Fleming, A., 677, 760

Floyd, C, 763

Forge, 310

Fowler, G. R., 26, 185, 517

Fowler, R. H., 26

Fox, 40, 296

Fraenkel, A., 119

Frank, F., 559

Frankel, A., 115

Freimd, 438

Friedenwald, 147

Friedman, L. V., 540, 559

Fulton, F. T., 298

Furstner, 313

Gangani, 305
Gatch, W. D., 27, 104
Gaub, 0. C., 584
Gaultier, 298, 300
Gellhorn, 338, 555
Geraghty, J. T., 387
Gerster, 124, 517, 651
Gibbon, 55
Gibson, 180, 392

Gibson, C. L., 119

Gibson, C. P., 475

Gigli, L., 544

Gilliam, D. T., 27, 544

Ginsburg, 86

Glimm, 338

Gocht, 619

Goldstein, M. A., 419

Goldthwait, J. E., 636

Goodman, E. H., 203, 305, 387

Gottheil, 292

Graff, 280

Graham, A., 38

Grant, 403

Grant, W. W., 403, 629

Graves, W. P., 196, 253, 554, 562

Green, 131

Green, C. M., 559

Grevan, 201

Grieg-Smith, 199, 247

Grossich, A., 392

Groves, E. W. H., 501

Griineisen, 515

Gunn, 293

Guthrie, 80, 207, 622

Guthrie, L., 203

Hadda, S., 611

Haddaeus, 293

Haffkine, W. M., 741

Hahn, E., 474

Haldane, 93

Hall, Rufus, 108

Hallowell, 621

Halsted, A. E., 193

Halsted, W. S., 433» 439) 489* 633

Hamilton, 654

Hammond, L. J., 162

Hanmer, G. P., 623

Hanssen, 184, 186

Hardouin, 188

Harrington, C, 391

Harris, M. C., 338

Harris, R. P., 544

Hartwell, H. F., 747, 748

Harvey, W. W., 452

Harvie, 463

Hatcher, R. A., 30

Haward, W., 407

Hawkes, F., 180, 251

Hay, 168

Hayem, 304

Hecker, 204

8l2

INDEX OF AUTHORS

Heiczel, 605

Heile, 336

Heinck, A. B., 476

Heineck, A. P., 540

Heinemann, 136

Heister, 231, 506

Hektoen, 706

Henderson, 174, 337

Henderson, M. S., 648

Henderson, Y., 93, 112

Hericourt, 134

Herry, 306

Herzog, 313

Hewitt, 196

Hiele, B., 660

Hildreth, R. D., 397

Hill, E. C, 48

Hilton, 258

Hirsch, M., 200

Hoehne, 338

Hofifa, 221

Hofmeier, M., 114, 553

Holding, 373

Holmes, 652

Homans, 196

Hopkins, 89

Horsley, 436

Horwitz, O., 580

Howe, W. C, 620

Howland, 203

Hubbard, J. C, 202, 500, 623

Humphry, R. E., 302

Hunner, G. L., 604

Hunter, John, 209

Hunter, W., 208

Hurd, 316

Hurwitz, 203

Hutchins, 295

Hutchins, Willard H., 296

Irons, E. E., 748

Jaboulay, 621

Jackson, D. D., 97

Jackson, H. B., 469

Jacobs, 502

Jacobson, S. D., 563

Jacobson, W. H. A., 154, 390, 408, 415, 423,

436, 469, 601
Jaeger, 563
Janeway, 81, 131
Jareis, 189
Jeanbrau, 310

Jianu, 465
Johnson, A. B., 373
Jones, C, 779
Jones, D. P., 301
Jorgensen, 675
Jottkowitz, 652
Judd, D. H., 799
Judd, E. S., 633

Kaisteller, 387

Kaltenbach, 189

Kappis, 182

Karu, Haruzo, 185

Kassabian, 367

Katz, 513

Kausch, 152, 277

Keen, W. W., 92

Keetley, 501

Keith, A., 130

Keller, 154

Kelling, 115

Kelly, Howard A., 161, 544, 548, 527, 553

Kelly, J. A., 201

Kemp, 47

Kendirdjy, 125, 513

Kennan, 187

Kennedy, 628

Kernig, 57

Kerr, LeGrand, 300

Klein, 114, 115

Kleinertz, R., 293

Klose, H., 302

Knapp, L., 204

Kochert, 438

Kolle, F. S., 412

Kottmann, 306

Kraske, 174, 613

Krebs, G., 400

Kridel, 290

Kronecker, 136

Kronlein, 196

Kuhn, F., 131

Kulka, 298

Kummer, 341

Laborde, 130
Ladd, W. E., 202
Laffer, 184
Lahey, F. H., 298
Lambert, A., 621
Lamm, 114
Landois, 79, 80
Lane, W. A., 408

INDEX OF AUTHORS

813

Langenbeck) 647

Lauenstein, C, 338

Leary, T. J., 305

Leathes, 263

Lecene, 118

Lederer, 177

Lee, 42

Lee, W. E., 40

Legal, 206

Lejars, 515

Leland, G. A., Jr., 454

Le Normant, 119

Leopold, C. G., 544

Lesser, L. V., 124

Leube, 140, 143

Levy, 199

Lewis, B., 606

Lichtenstein, 184

Lidsky, 306

Lindemann, 195

Link, G., 497

Lloyd, 316

Locke, 50

Loder, H. B., 388

Loeb, L., 799

Lommel, 304

Lossen, 313

Lothrop, H. A., 490

Lovett, R. W., 660

Low, H., 202, 204

Lowenthal, 438

Lower, 79

Ludwig, 153

Lund, F. B., 228, 279, 340, 550, 622, 649

Lusk, W. C, 616

Lyon, 92

MacDougall, 652
Madelung, 189
Madsen, 675
Mahler, 116
Mahoney, F. A,, 90
Maier, 554
Mann, 116

Mansell-Moullin, C. W., 40
Marcy, H. O., 492
Marpan, 204
Martin, 263
Martin, August, 337
Martin, E., 565, 648
Martin, W., 466
Marvel, E., 337

Mason, A. Lawrence, 125

Mason, N. H., 559

Mason, N. R., 397

Matas, R., 131, 294, 479

Mathieu, 185, 188

Mauclaire, 119

Mayo, C. H., 191, 433, 439, 624

Mayo, W. J., 458, 460, 462, 490

Mayo-Robson, A. W., 40

McArthur, A. N., 202

Mc Arthur, L. L., 479, 489

McBurney, 328, 503, 504

McCardie, \V. J., 302

McClure, 85

McCoUom, John H., 151

McCormack, Sir \V., 647

McDonald, E., 526

McGuire, S., 27

McKay, W. J. S., 40, 41, 108, 323

Meakins, J. C, 748

Melchoir, E., 607

Meltzer, S. J., 131, 296

Merkens, 97

MetchnikoflF, Elie, 135

Meyer, Willy, 131, 263, 268, 305, 517,

647
Mikulicz, 253, 417, 497
Mintz, 628
Mitchell, 278
Mitchell, J. K., 313, 316
Mitchell, S. Weir, 92, 314
Mocquot, 104
Moennighofif, 177
Monberg, 561
Monks, G. H., 504, 517
Monprofit, A., 462
Moore, F. C, 147
Moorehouse, C. W., 92
Morel, L., 645
Morris, R. T., 191, 389
Morrow, Prince A,, 292
Moschcowitz, 75, 124
Mosetig-Moorhof, 654
Moxom, P, W. T., 299
Moynihan, B. G. A., 481, 482, 483, 490
Miiller, 201, 337
Mumford, 316
Munro, J. C, 124, 513, 5^5
Munroe, 196
Murphy, F. T., 623
Murphy, J. B,, 46, 47, 122, 178, 474, 55o,

621
Murray, F. W., 645

8i4

INDEX OF AUTHORS

Naunyn, 185

Nauwerck, 195

Neri, v., 655

Neuber, 654

Neugebauer, F., 323

Newell, F. S., 22^, 556, 559, 564

Newman, S. E., 47

Nichols, E. H., 652

Nichols, J. B., 207

Nicolaysen, 647

Noble, C. P., 329, 526

Noguchi, 392

Nordman, O., 302

OcHSXER, A. T., 35, 274, 410, 453, 456, 461

O'Dwyer, 131, 426

O'Leary, C, 211

Oliver, 300

Oilier, 652

Olshausen, R., 189, 293, 534, 544

Or^, 79

Osgood, R. B., 89, 202, 636, 652

Pacanotti, G., 123
Packard, H., 587
Paget, 298

Painter, C. F., 636, 651
Pare, Ambroise, 313
Park, R., 292, 302
Parsons, 279
Paschkis, 390
Pasteur, 197
Paterson, H. J., 459
Paul, F. T., 181, 436
Payr, 81
Pean, J., 534
Pechowitsch, G., 598
Peckham, 628
Penrose, 198
Petersen, 619
Peterson, R., 293
Petters, 201
Pfahler, 373
Pfannenstiel, 329, 565
Pilcher, J. D., 260
Pilcher, L. S., 601
Pinard, A., 540
Pineles, F., 438
Pirogofif, 347
Place, E. H., 385
Polak, 184, 185
Pool, 85
Porter, C. A., 296

Porter, W. T., 92
Post, Abner, 298
Potter, G. E., 40
Powers, E. J., 90
Pozzi, S., 534, 535
Pratt, J. H., 298
Prescott, W. H., 196
Prince, 393
Provandie, P., 89
Pryor, W. R., 531, 534
Pusey, W. A., 381, 554

QUEIROLO, 81

Quimby, 92

Rabinova, S., 189

Ranzi, 119

Ransohoff, J., 496

Raw, N., 783

Redlich, 438

Reed, C. B., 544

Regis, 316

Reicher, K., 204

Reichmann, 300

Remak, 368

Reynolds, E., 229, 534, 559

Ricard, 651

Rice, A. G., 202

Richards, 203

Richardson, 339

Richardson, E. H., 333, 337

Richardson, M. H., 477, 497

Richardson, Oscar, 296

Richardson, W. G., 293

Rickard, 481

Riegel, 146

Ringer, 46, 50

Risley, 196, 197

Rives, 300

Roberts, W. H., 302

Robertson, S., 454

Robinson, 131

Rockwell, 367

Rodman, 373

Rodman, W. H., 373, 502

Rogers, J., 296, 439

Rogers, L., 484

Roh€, 313, 316

RoUeston, 300

Rollins, William, 379

Romberg, 92

Rokitanski, 185

Rose, Edmund, 293

INDEX OF AUTHORS

815

Rosenow, E. C, 681
Rosenstern, 46
Rosenthal, 116, 188
Rowlands, 502
Rowntree, L. G., 387
Royster, 250
Rugh, 304
Ruhrah, 147
Russell, 482

Saboxjraud, R., 760

Sachtleben, 661

Sahli, 305

Sampson, J. A., 553

Sanborn, G. P., 663

Sanger, 628

Sargent, 279

Sartoli, 114

Sauerbruch, 131

Saxon, G. J., 46, 47

Scannell, David D., 109, 503, 650

Schachner, 323

Schaefer, 129

Schanz, A., 123

Schede, 654

Schlatter, 462

Schmidt, 131

Schmieden, 263, 268

Scholten, 205

Schopf, 490

Schrack, K., 204

Schultze, 316

Schwellbach, 41

Schweninger, 114

Sears, G. G., 313, 316

Seelig, M., 92

Sellhein, 560

Sencert, L., 337

Sertoli, A., 517

Sever, J. W., 202

Shephard, 481

Shepherd, F. J., 292

Sherman, 622

Sichel, 313

Sick, 628

Sigault, J. R., 544

Simpson, F. F., 544

Sims, J. M., 251, 527

Sippel, A., 208

Skene, A. J. C, 546

Smith, H., 411

Smith, N. R., 643

Smith, T., 676

Soper, 141, 373

Soubeyran, 300

Soutter, 627

Spassokukotzky, 197

Spencer, 484

Spitzka, E. A., 132

Stanton, E. M., 480

Starling, 169

Stem, 338

Sternberg, 145

Stevenson, M. D., 413

Steward, F. T., 399, 408, 415, 436, 469

Stoerk, 417

Stone, 202, 204

Stone, A. K., 103

Stone, I. S., 292

Stowe, H. M., 540

Streeter, E. C, 779

Stretton, J. L., 394

Sutton, W. S., 48

Sylvester, 104, 128

Symes, W. L., 211, 347

Symmers, 297

Tait, Lawson, 54

Telford, 202

Tennant, C. E., 450

Thiriar, 298

Thomas, T. T., 651

Thompson, 120, 124, 147, 701, 742

Thompson, H., 295

Thomdike, Paul, 162, 298

Tinker, M. B., 393

Torbert, J. R., 185, 559

Torek, 204

Tracy, M., 797

Tracy, S. E., 548, 553

Trembur, 305

Trendelenburg, 121, 196, 199, 336

Treves, Sir F., 183, 404, 484

Trunecek, 46, 50

Tubby, A. H., 632

Unna, 760
Unterberger, 280
Urwick, 678

Van der Bogart, 290
Vander Veer, A., 456
Vandini, 277
Velpeau, 226
Vincent, 178
Vogel, 337

8i6

INDEX OF AUTHORS

Voit, 140
Volkmann, 437
von Courty, 313
von der Velden, 76
von Horoch, 621
von Mikulicz, 196

Walker, J. W. T., 602
Wallace, C. H., 191
Walthard, 316
Wandel, 295
Warren, J. C, 499
Wassermann, A., 305
Waterhouse, H. F., 271
Waterman, N., 97
Watkins, T. J., 526
Watson, C. M., 524
Watson, F, S., 568, 591
Webster, J. C, 340, 544
Wechsler, B, B., 47
Weil, 304, 305
Weir, R., 500, 615
Weiss, N., 437
Weiss, T., 337
Welch, 297, 305
Wells, H. G., 204
Wertheim, E., 553
Wesley, John. 367
Western, G. T., 782
Whipple, 203
White, Franklin W., 135
Whitehead, 174

Whitehouse, F. C, 90

Whitfield, A., 760

Wiebbrecht, 438

Wiener, T., 447, 491

Wilbur, 207

Williams, Francis H., 373, 379

Williams, J. B., 205

Williams, J. T., 559

Williams, J. W., 541, 556

Wilmoth, A. D., 56

Wilson, 323

Wilson, H. A,, 647

Winiwarter, 41, 42

Witherspoon, T. C, 191, 437

Witte, 306

Wolf, 306

Wood, 114, 605

Wood, H. C, 30

Woolsey, 181, 184

Wright, Sir A. E., 134, 262, 663, 668-675,

704, 706, 708, 741, 772, 780
Wroth, P., 517

Yankauer, 417
Young, E. B., 521, 550
Young, H., 387

Zacharius, 293
Zander, 364
Ziilzer, 170
Zweifel, P., 544

INDEX

Abdomen, gunshot wounds of, 484

operations on, 457
Abdominal drainage, posture for, 25

dressing, layout for, 241

hysterectomy, 550

incision in relation to hemia, 328

swathe, 486, 487
postoperative, 342

wall, abscess of, 511

wound, bursting of, 189
laced adhesive dressing for, 232
Abortion, 535
Abscess, alveolar, 410

breast, 558

ischiorectal, 609

of abdominal wall, 511

of breast, 448

of Gartner's canal, 562

of groin, 631

of liver, 475, 516

of lung, 454

ovarian, 546

pelvic, 529

peritonsillar, 418

prostatic, 589

psoas, 630

retropharyngeal, 418

stitch, 253

subdiaphragmatic, 125, 511

subphrenic, 511

tuberculous, 697

vulvovaginal, 528
Acetone for cancer, 555
Acetonemia, 201

treatment of, 207
Acid intoxication, 201
Acidosis, postoperative, symptoms of, 205
Acne, vaccine treatment, 759
Actinomycosis of pleura, 453
Active movements, 362
Acute dilatation of stomach, 177

gastric dilatation, 183

intestinal obstruction, 180
52

Acute urinary fever, 162
Adenoids, 414
Adhesions, 332

electricity in, 371

prophylaxis against, 335

treatment of, 339
Adhesive dressing, laced, 231

plaster suspensory, 237
Adrenalin in shock, 97
After-care in relation to hemia, 330

of anesthesia, 31
Agglutinins, 665
Air embolism, 124
Albumin- water, 134
Alcohol in convalescence, 318

in shock, 98
Alcoholic habits, effects of, 307
Alexander's operation, 562
Alveolar abscess, 410
Amputated limb, bandages of, 224
Amputation, 617

about ankle-joint, 347

at point of election, 348

in general, 350

of arm, 618

of fingers, 618

of forearm, 6i8

of hip, 618

of leg, 619

of shoulder, 618

'of shoulder-girdle, 618

of thigh, 349, 619

of tibia short of 4 inches, 348

of toes, 619

through hip, 350
knee-joint, 349
tarsus, 347
Anal fissure, 607

fistula, 607
Anastomosis, arteriovenous, 623

intestinal, 471

of nerve, 628
Anesthesia, sudden death from, 112

817

8i8

INDEX

Anesthesia, sequelae of, 192
Anesthetic, administration of, 28

care after administration of, 31
Anesthol for anesthesia, 29
Aneurysm of innominate artery, 619
Ankle, strapping of, 233
Ankle-joint amputations, 347
Ankylosis, electricity in, 371
Anteflexion, 541
Antipruritic lotion, 292
Antitropins, 665
Antrum of Highmore, 413
Anus, artificial, 282, 471

imperforate, 608

operations on, 607
Appendectomy, dressing after, 505
Appendicitis, 502

charts, 511, 512

distant suppuration in, 516

hepatic infections in, 511

lymphatic infections in, 511
Appendicostomy, 500
Appendix, abscess of, pulse in, 64

gangrenous, 508
Arc-light therapy, 376
Arsenic in convalescence, 318
Arterial suture, 621
Arteriosclerosis, electricity in, 373
Arteriovenous anastomosis, 623
Arthritis, gonorrheal, vaccine treatment, 747

infectious, vaccine treatment, 745, 749

purulent, 652
Artificial anus, 282, 471

feeding other than per rectum, 148

limbs, 347
for amputations about ankle-joint, 347
at point of election, 348
of tibia short of 4 inches, 348
through tarsus, 347

respiration, 127
Asafetida enema for distention, 176
Aseptic primary healing, rise of pulse in, 62

processes, rise of temperature in, 65

wounds, treatment of, 242
Assistive movements, 362
Asthenic state, electricity in, 372
Asthma, cardiac, posture for, 25
Atresia of uterus, 562

of vagina, 562
Atrophy, electricity in, 370

of testis, 573
Autocondensation currents of electricity, 375
Auto-inoculation, induced, 690

Bacillus fusiformis, 385
Bacterial diagnosis, 743

vaccine, 672
Bactericidins, 665
Bacteriolysins, 665
Baer's membrane, 652
Bandages, plaster-of -Paris, 221

removal of, 217

suspensory, 235
Bandaging, 216

pain caused by, 53
Banti's disease, 499
Barium sulphid as depilatory, 390
Bartholin's gland, cyst of, 529
Barton bandage, modified, 225
Bassini's operation, 489
Baths before operation, 385
Beard-area, preparation of, 395
Bed, changing the, 18
Bedside chart, 23
Bed-sores, 320

posture for, 26
Beebe's serum, 439
Beef-tea, 134
Benzin on skin, 393
Benzin-iodin preparation, 393
Bevan's incision, 477
Bier hyperemic treatment, 263, 693

suction, 697
Biliary passages, 477
Bismuth paste in chronic sinuses, 277
Bladder, exstrophy of, 605

injury to, 552

operations on, 590

preparation of, 397
Blood chart, 23

transfusion, 78
Blue screen, 376
Boils, vaccine treatment, 753
Bone peg, 648

plates, 646
Bones, operations on, 635

tuberculosis of, vaccine treatment, 781
Bowels, care of, 165
Bow-legs, 654

Brachial plexus, suture of, 628
Bradford frame, 644
Brain, hernia of, 399

operations, 398
anesthesia in, 399
Branchial cysts, 443

sinus, 443
Breast, abscess of, 448, 558

INDEX

819

Breast, amputation of, 446

bandage of, 229, 447

swathe, 446
Brigg's cannula, 442
Bronchitis, posture for, 2$
Brown tongue, 214
Bubo, inguinal, 631
Buck's extension, 643
Burns after anesthesia, 193
Bursitis, olecranon, 625

subacromial, 625

subdeltoid, 625
Bursting of abdominal wound, 189

of wound, 521
Button, Murphy, 475

Cabot wire-splint, 640
Cachexia, cancerous, 554
Caffein in shock, 98
Calcium lactate in hemophilia, 76
Calomel, administration of, 168
Calorimetric values of various foods, 135
Camphor in pubnonary embolism, 1 20
Cancer of lip, 403

of pelvis, 553

of rectum, 613

treated by acetone, 555

trypsin for, 554
Cancerous cachexia, 554
Cannula for transfusion, 80
Carbolic acid poisoning, 292
Carbon dioxid in shock, 104

snow, 381
Carbuncle of neck, 442

vaccine treatment, 760
Cardiac asthma, posture for, 25
Cardiorenal cases, excretion in, 388
Care of bowels, 165
Cargile membrane, 413
Carotid artery, ligation of, 619
Cartilage of knee, 650
Caruncle, urethral, 528
Castor oil, administration of, 167
Castration, 574

Catharsis before operation, 384
Cathartics, 167
Catheter chill, 162

fever, 161

held in penis, 577

lubrication of, 157

plugging of, 581
Catheterization, 154
Cautery operation for piles, 609

Cecostomy, 520
Celiotomies, posture for, 25
Cervix, operations on, 534

preparation of, 395
Cesarean section, 556
extraperitoneal, 559
vaginal, 561
Changing bed, 18
Chart, nurse's, 21

use of, 59
Chest, soreness of, after anesthesia, 192

stab wounds of, 454
Childbed, aseptic, temperature rise in, 65
Chloroform for anesthesia, 29

poisoning, delayed, 201
Cholecystenterostomy, 180
Cholecystgastrostomy, 481
Cholecystotomy, 478
Choledochectomy, 483
Choledochenterostomy, 483
Cholcdochoduodenostomy, 483
Choledochotomy, 482
Chorio-epithelioma, 541
Chronic urinary fever, 162
Cigarette wick drain, 252
Circular enterorrhaphy, 474
Circulatory system, action of massage on,

356
Circumcision, 570
Cleft-palate, 406

speech after, 407
Club-foot, 655
Coated tongue, 214
Cocain habit, effects of, 308
Coccyx, cyst of, 608
Coffee habit, effects of, 309
Coley serum for tumors, 797
Collapse after operation, 109
Colles' fracture, massage in, 358
Colostomy, 468

wound, routine care of, 471
Colpotomy, 529
Coma due to collapse, 109

postoperative, 106
Common duct operations, 482
Complete history, value of, 389
Compound fractures, 637
Congestion, hypostatic, of lungs, posture

for, 25
Conjunctivitis after anesthesia, 193
Continued shock, temperature in, 67
Contraction, Dupuytren's, 632
Contractures, electricity in, 371

820

INDEX

Convalescence, freedom of diet in, 138

general treatment in, 317
Convalescent diet, 800
Coxa vara, 654
Cradle for bed-clothes, 638
Cream-of-tartar lemonade, 567
Creolin, bums by, 397
Crile cannula, 80
Croton oil as purgative, 169
Cunningham's hernia dressing, 231
spica, 487

kidney table, 598
Curettage, 535
Cutaneous rashes, 287

caused by enemas, 292
Cyst, branchial, 443

of Bartholin's gland, 529

of coccyx, 608

of pancreas, 497

vaginal, 562
Cystitis, 157

prevention of, posture for, 25

treatment of, 159
operative, 161
Cystocele, 525
Cystocolostomy, 605
Cystotomy, lateral, 603

suprapubic, 600

vaginal, 604

Death, sudden, no
Decubitus, 320
Deformity of nose, 411
Delayed chloroform-poisoning, 201

hemorrhage, 71
Delirium tremens, 310

alcohol as prophylactic against, 139
Depilation vs. shaving, 389
Depilatory pastes, 390
Desault bandage, 226
De Witt's appliance for proctoclysis, 47
Diabetic coma, 107
Diagnosis, bacterial, 743
Diathesis in hemorrhage, 75
Diet, 133

after gastric ulcer, 467

before operation, 385

in inflammatory conditions, 137
Digital evacuation of rectum, 170
Digitalis in shock, 102
Dilatation, gastric, acute, 183
Direct current of electricity, 375
Dislocated cartilage of knee, 650

Dislocation of shoulder, 651

Distention of gastro-intestinal tract with

gas, 174
Diverticula, esophageal, 432
Doederlein tube, 538
Dorsal posture, 24
Dosage, guidance to correct, 702

of vaccines, tables, 794
Dotted tongue, 214
Double sling, 235
Douche before operation, 385

intra-uterine, 538

vaginal, 523
Drainage, 246

abdominal, posture for, 25

for empyema, 449

in relation to closure of abdominal wound,

343
of sinuses, 277

suprapubic, 587, 602
Drastic enemas, 172
Dressings, 241

pain caused by, 53

perineal, 570
Drop method of giving ether, 29
Drug poisoning, 290
Dry tongue, 214
Dubosc colorimeter, 387
Duodenal ulcer, perforated, 468
Duodenocholedochotomy, 483
Dupuytrcn's contraction, 632

Eau sucree as a stimulant, 136

Eclampsia, 562

Eczema, vaccine treatment, 768

Edema, malignant, 297

Effleurage, 357

Ehrenfried's intrathoracic apparatus, 456

club-foot plaster, 656
Elastic bandage for obstructive hyperemia,
265

suit of Crile in shock, 99
Elaterin as purgative, 169
Elbow, excision of, 635
Electric spark, 374

Electricity in artificial respiration, 131
Electrotherapeutic technique, 374
Electrotherapy, 367
Elephantiasis of vulva, 527
Elevated head and trunk posture, 26
Elsberg cannula, 82
Embolism after hemorrhoids, 611

air, 124

INDEX

821

Embolism, fat, 123

pulmonary, 118
operative treatment, 121
Emergency tracheotomy, 39
Emphysema, pulmonary, posture for, 25
Empyema, 449

bismuth paste in, 453

bottles for, 450

encapsulated, 451

pulse in, 63

vaccine treatment, 763
"En bloc" reduction, 495
Endometritis, 541
Enema, cleansing, administration of, 173

glycerin, 170

in constipation, 171

in shock, 105

nutrient, formulas for, 146
materials for, 143
technique of administering, 140

rashes following use of, 292
Enterorrhaphy, circular, 474
Enucleation of eye, 402
Epididymitis after urethrotomy, 583
Epigastric hernia, 490
Epispadias, 571
Equinovarus, 655
Eruptions caused by drugs, 290
Erysipelas, 288

vaccine treatment, 766
Esophageal diverticula, 432
Esophagotomy, 432
Estlander's operation, 454
Ether, administration of, 29

rash, 287
Ethyl chlorid for anesthesia, 29
Evacuation of rectum, 170
Excision of elbow, 635

of hip, 635

of knee, 636

of shoulder, 635

of tongue, 408

of vulva, 527

of wrist, 636
Exercise in empyema, 450
Exercises for flat-foot, 352
Exophthalmic goiter, 434
Exstrophy of bladder, 605
External iliac artery, ligation of, 621

urethrotomy, 575
Extra-uterine pregnancy, 555
Extravasation of urine, 584
Extubation, 428

Eye, enucleation of, 402
Eyebrows, preparation of, 395

Face, plastic operations on, 403

Faradic current, 378

Fat embolism, 123

Fatty degeneration of liver, 201

Fecal fistula, 280, 510

care of, 471
Feeding after laryngeal operations, 153

by gavage, 148

in gastric fistula, 152

nasal, 150

per rectum, 140
formulas for, 146

subcutaneous, 151
Feet, preparation of, 397
Female ambulatory urinal, 604

catheterization of, 155
Femoral artery, ligation of, 621

hernia, 489

thrombosis, 517
Femur, open fracture of, 643
Fenestrated rubber-tube drain, 252
Fever, catheter, 161

urinary, 162
Field of operation, preparation of, 389
Figure-of-8 bandage, 218
Finney's operations, 463
Fissure in ano, 607
Fistula, 273

after nephrotomy, 593

fecal, 280, 516
care of, 471

in ano, 6fe — [ ■

lymphatic, 279

perineal, 583

rectovaginal, 527

treatment of, 278

urethral, 583

vesico-uterine, 562

vesicovaginal, 526
Flap grafts, 634
Flat-foot after operation, 352
Flatus, 175

Flaxseed poultices, application of, 260
Flexible shank in shoeing, 355
Fomentations, 176

in sepsis, 259
Food receipts, 800

serving of, 138
Foot-shaped last in shoeing, 355
Force of pulse, significance of, 61

822

INDEX

Forced respiration, dangers of, 113
Foreign bodies left in abdominal cavity,

operation for, 326
Fossa of Treitz, 458
Fowler position, 518, 519
Fracture, Colics', massage in, 358

compound, 637

of external condyle of humerus, massage

in, 359
of femur, muscular treatment in, 363

of patella, 649

of spine, 661

of surgical neck of humerus, massage in,
360

open, 637

rise of pulse in, 62

operative fixation of, 646

Pott's massage in, 361

recent, treatment of, by massage, 358
Friction in massage, 357
Frontal sinus, 414
Fulminating infection, 694
Function of kidneys, test for, 388
Furred tongue, 214
Furuncle, vaccine treatment, 753
Furunculosis, vaccine treatment, 754

Gag, mouth-, 2>'^

Gall-bladder, 477

Gall-stone disease, posture for, 25

Galvanic current, 375

Gamgee dressing, 693

Ganglion, palmar, 631

Gangrene of testes, 491, 573

Gant's operation, 654

Gartner's canal, abscess of, 562

Gas-bacillus infection, 297

Gasserian ganglion, operation on, 400

Gastrectomy, 460

Gastric dilatation, acute, 183

fistula, feeding in, 152

lavage after anesthesia, 35

operations, posture for, 25

ulcer, diet after, 467
perforated, 465
Gastro-enterostomy, 457
Gastrojejunal ulcer, 459
Gastroplication, 465
Gastrostomy, 460
Gavage, 148
Gelatin as carrier of tetanus, 295

in hemophilia, 77

General peritonitis, 174, 465, 468, 508, 509,

510, 517
posture for, 26

Generalized infections, vaccine in, 700
Genital region, preparation of, 395
Genito-urinary tuberculosis, vaccine treat-
ment, 783
Geraghty test, 386

in acute nephritis, 388

in cardiorenal cases, 388

in chronic nephritis, 2>^d>

in prostatic cases, 388

in stricture cases, 388

in surgical kidney, 388
Gerlach, valve of, 501
Gersuny's method, 615
Glands of neck, 441
Glycerin enema, 170

suppository, 170
Goiter, exophthalmic, 434
Gravity in drainage, 251
Groin, abscess of, 631
Gums, preparation of, 395
Gunshot wounds of abdomen, 484

of chest, 454

Habits, effects of, in surgical conditions, 307
Hairy area, preparation of, 395
Hallux valgus, 659
Hammock suspensory, 235
Hand, bandage of, 224

preparation of. 397
Hare-Hp, 405
Harrington's solution, 391
Hartman's nasal forceps, 413
Head and face, operations on, 398

bandage of, 225

crown breeze of electricity, 374
Headache, 56
Healing, primary aseptic, rise of pulse in,

62
Heart-clot, 122
Heat for relief of pain, 55

in enemas, 172

in treatment of septic wounds, 258
Heat-stroke during operation, 109
Heel, bandage of, 220
Hellige hemoglobinometer, 387
Hematemesis, postoperative, 40

treatment of, 42
Hematoma of labium, 543

pelvic, 551
Hemophilia, 303

INDEX

823

Hemorrhage, constitutional treatment for,

77
delayed, 71

diathesis in, 75

diet after, 137

internal, 74

of nose, 412

primary, 71

secondary, 74

superficial, 73

temperature reaction affected by, 66
Hemorrhoids, 609

Hepatic infections in appendicitis, 511
Hepaticodocholithotripsy, 484
Hepaticodochostomy, 484
Hepaticodochotomy, 483
Hernia cerebri, 399

dressing, Cunningham's, 23 1

epigastric, 490

femoral, 489

incarcerated, 492

interstitial, 490

obturator, 490

operation, truss after, 491
use of swathes following, 344

postoperative, 328
treatment of, 331

radical cure of, 486

retroperitoneal, 490

spica, 487

strangulated, 494

umbilical, 490
posture for, 25
Hiccough, 209
High blood-pressure, electricity in, 373

frequency currents of electricity, 375
Highmore, antrum of, 413
Hip amputations, 350

excision of, 635
Hoffa table, 644

Hormones, action of, on peristalsis, 1 70
Hot air, application of, 270

soaks, 259
Humerus, open fracture of, 644
Hydatid cyst of liver, 476
Hydatiform mole, 540
Hydrocarbon prostheses, 411
Hydrocele, treatment of, by excision, 572

by injection, 572
Hymen, imperforate, 562
Hyperemic treatment in sepsis, 263
Hyperthyroidism, 435
Hypodermic injection, technique of, 55

Hypodermoclysis, 49

in shock, 99
Hypospadias, 571

Hypostatic pneumonia, posture for, 25
Hysterectomy, abdominal, 550

vaginal, 532

Ideal bandage, 624
Iliac thrombosis, 517, 553
Immunity, acquired, 671

artificial, 671
Immunization, principles of, 663

therapeutic, 633
Imj^erforate anus, 608

hymen, 562

rectum, 608
Incandescent light therapy, 376
Incarcerated hernia, 492
Incontinence of urine, 586
Indigo-camiin, 386
Induced current of electricity, 378
Infections, fulminating, vaccines in, 734
Inflammatory conditions, diet for, 137
Infusion, saline, 49
Ingrowing toe-nail, 63
Inguinal bubo, 631

Injection, hypodermic, technique of, 55
Innominate artery, ligation of, 619
Inoculation, site for, 715

therapeutic, 674
Inoperable malignant tumor of pelvis, 553
Insanity, postoperative, 313
Internal hemorrhage, operative treatment
of, 74

urethrotomy, 574
Interstitial hernia, 490
Intestinal anastomosis, 471

distention, 174

obstruction, acute, 180
Intrathoracic insufflation anesthesia, 456
Intra-uterine douche, 538
Intravenous infusion of salt solution, 49
in shock, 100
technique of, loi
Intubation, 424

instruments for, 427
Invalid feeding, 800
Inversion of uterus, 562
Inverted tube drain for large cavities, 252
lodin preparation of skin, 392
Iodoform emulsion in chronic sinuses, 277

poisoning, 291
Iron in convalescence, 318

824

INDEX

Irrigation of sinuses, 275
Irritable bladder, 158
Ischiorectal abscess, 609

Jaw, excision of lower, 400
of upper, 400

soreness of, after anesthesia, 192
Jejunal ulcer, 459
Jejunostomy, 474
Johns Hopkins operation, 489
Joints, operations on, 635

tuberculosis, vaccine treatment, 782

Keloids, treatment of, by x-ray, 374
Kidney efficiency, test for, 386

operations on, 590

surgical, 604

test, technique of, 387
Kneading in massage, 360
Knee, excision of, 636

operations on, 650

strapping of, 234
Knee-joint amputation, 349
Knock-knees, 654
Kollmann dilator, 575
Kraske's operation, 613
Kraurosis of vulva, 527

Labium, hematoma of, 543
Labor, early rising after, 565
Laced abdominal swathe, 506

adhesive dressing, 231
Laminectomy, 661
Lane's bone plate, 648
Laryngeal operations, feeding after, 153

stenosis, 425
Laryngotomy, 423
Larynx, operations on, 423
Late shock, temperature in, 67
Lavage, gastric, after anesthesia, 35

technique of, 148
Leg, bandage of, 220
Leonard tube, 538
Ligation of carotid artery, 619

of external iliac artery, 621

of general artery, 621

of innominate artery, 619

of subclavian, 620
Ligature for hemorrhoids, 612
Light therapy, 376
Limbs, artificial, 347
Lip, cancer of, 403
Lithiasis, pancreatic, 497

Lithotomy, perineal, 603

Liver, abscess of, 475, 516
fatty degeneration of, 201
hydatid cyst of, 476

Localized infections, 679

Locke's solution, formula for, 50

Low vacuum tubes of electricity, 375

Lubrication of catheters, 157

Lund swathe, 22S

Lung, abscess of, 454

Lymphatic fistula, 279

infections in appendicitis, 511

Lymph-nodes of neck, 441

Lymphnoditis, tuberculous, vaccine treat-
ment, 773

Macewen's operation, 654
Male ambulatory urinal; 586
Malignant disease, Rbntgen rays after
operation for, 373

edema, 297
Many-tailed bandage, 230
Massage, 356

dosage of, 365

general rules in, 364

in recent fractures, 358

of heart in shock, 103
Mastoid abscess, 443

operation, preparation for, 395
Mastoiditis, 443

dressing for, 444
Maydl's operation, 605
McBurney incision, 502, 504, 506

in relation to abdominal wound, 342
Meatotomy, 571
Median line incision in relation to abdominal

wound, 343
Menopause, 316
Methylene-blue test, 386
Micturition of women, 25
Mikulicz tampon for peritoneal drain, 253
Milk, dangers of, 134
Miscarriage, 535
Mixter tube, 468
Mole, hydatiform, 540
Monsell's solution as st>T)tic, 76
Morphin before the anesthetic, 30

habit, effects of, 308

in convalescence, 318

in relief of pain, 54

technique of hypodermic injection, 55
Mouth cleanliness, 385

nose, and pharynx, operations on, 405

INDEX

825

Mouth, preparation of, 395

Mouth-gag, 32

Movements, remedial, 362

Murphy button, 475
method for proctoclysis, 46

Muscle, suture of, 625

Muscle-splitting incision in relation to ab-
dominal wound, 342

Muscular system, action of massage on,

356
Myocarditis, 553
Myomectomy, 562

Nasal adhesions, 412

feeding, 150

hemorrhage, 412

polypi, 412

spurs, 412
Nausea and vomiting of anesthesia, 35
Neck, carbuncle of, 442
vaccine treatment, 761

glands of, 441

lymph-nodes of, 441

operations on, 420
Nephrectomy, 597
Nephritis, acute excretion in, 388

after anesthesia, 198

chronic, secretion in, 388
Nephrorrhaphy, 599
Nephrotomy, 590

double, 591

drainage apparatus, 593

fistula after, 593

uremia after, 593
Nerve anastomosis, 628

injuries, electricity in, 370

resections, 400

suture, 627
Nervous system, action of massage on,

356
Neurasthenia, postoperative, electricity in,

372
Neuroses, rise of temperature due to, 66
Nitrous oxid for anesthesia, 29
Noma, 385
Nose, adhesions of, 412

deformity of, 411

preparation of, 395
Nurse's chart, 21

Nutrient enemas, formulas for, 146
materials for, 143
technique of administering, 140

suppositories, 145

Obstruction, intestinal, acute, 180
Obturator hernia, 490
O'Dwyer cannula, 426
Olecranon bursitis, 625

suture of, 650
Omphalitis, 456
Open fractures, 637

rise of pulse in, 62
Operation, diet before, 385

Estlander, 454

for adenoids, 414

on abdomen, 457

on anus, 607

on bladder, 590

on bones, 635

on brain, 398

on cervix, 534

on Gasserian ganglion, 400

on joints, 635

on kidney, 590

on knee, 650

on larynx, 423

on mouth, nose, and pharynx, 405

on neck, 420

on penis, 566

on pericardium, 454

on prostate, 566

on rectum, 607

on scrotum, 566

on spleen, 499

on thorax, 446

on ureter, 590, 600

on urethra, 566

on uterus, 522

on vagina, 522

plastic, of face, 403

preparation for, 383

Schede's, 454
Operative fixation of fractures, 646

wound, treatment of, 241
Ophthalmic reaction, technique of, 769
Opsonic index, 669

power in health, 676
Opsonins, 665

actual role of, 666

and clinical symptoms, 706

importance of phagocytosis, 666

origin of, 667
Osteomyelitis, vaccine treatment, 764
Out-of-doors in convalescence, 318
Ovarian abscess, 546
Ovariotomy, 545
Overdosage of vaccines, 711

826

INDEX

Oxygen, administration of, 131

in anesthesia, 34
Ozone, 375

Packing of sinuses, 275

of wounds, pain due to, 51
Pain, 51

diet in, 137

relief of, 54

electricity in, 368
Painful stump, 617
Palmar ganglion, 631
Pancreas, 496

wounds of, 497
Pancreatic cyst, 497

lithiasis, 497
Pancreatitis, acute, 496

chronic, 497
Paraffin prosthesis, 411
Paralysis after anesthesia, 193
Parathyroid extract, 438
Parkhill clamp, 646
Paronychia, 631
Parotid fistula, 402

tumors of, 401

operations, facial paralysis after, 401
Parotitis after operation, 298

postoperative, 385
Passing a sound, 578
Passive movements, 362
Patella, fracture of, 649
Patient, preparation of, 383
Paul's tube, 468, 478
Pelvic abscess, 529

hematoma, 551

thrombosis, 553
Pelvis, cancer of, 553

inoperable malignant tumor of, 553
Penis, catheter in, 577

operations on, 566
Percussion in massage, 357
Perforated gastric ulcer, 465
Perforation of duodenal ulcer, 468

of uterus, 540
Pericardium, operations on, 454
Perineal drainage-tubes, 585

dressing bandage, 239

dressings, 580

fistula, 583
persistent, 586

lithotomy, 603

prostatectomy, 584
Perineorrhaphy, complete, 524

Perineorrhapy, incomplete, 522
Perionychia, 631
Peristalsis, stimulation of, 169
Peritoneal button, 576

drain, 253
Peritonitis, diffuse septic posture for, 26

general, 174, 465, 468, 508, 509, 510, 517

pulse in, 64

respiration in, 69

tuberculous, 520
Peritonsillar abscess, 418
Petrissage, 360
Pfannenstiel's incision, 560
Phagocytosis, 665
Phenol poisoning, 292
Phenolphthalein as laxative, 167
Phenolsulphonephthalein test, 387
Phlebitis, portal, 515

temperature in, 69
Phloridzin, 386

Physical examination, value of, 380
Physostigmin salicylate in intestinal dila-
tation, 177
Picric acid poisoning, 292
Piles, 609

Pillow and side splints, 642
Pilonidal sinus, 608
Plaster tongue, 214
Plaster-of-Paris bandages, 221
Plates, Lane's, 648
Pleura, actinomycosis of, 453
Pneumonia, hypostatic, posture for, 25

postanesthetic, 194
Poisoning by carbolic acid, 292

by iodoform, 291

by picric acid, 292
Polypi, nasal, 412
Portal phlebitis, 515
Position, Fowler, 518, 519
Postanesthetic pneumonia, 194
Postoperative acidosis, symptoms of, 205

coma, 106

flat-foot, 352

hernia, 328

treatment of, 331

insanity, 313

neurasthenia, electricity in, 372

psychoses, 310

reaction of pulse, normal aseptic, 61

swathes, 342

tetanus, 293
Posture, 24

in shock, 102

INDEX

827

Posture, Trendelenburg, dangers of, 199

in shock, 96, 102
Pott's fracture, massage in, 361
Poultice before operation, disadvantages of,

389
Poultices, 260

Pregnancy, extra-uterine, 555

Preparation of genital region, 395

of mouth, 395

of patient, 383

of skin by iodin, 392
complete technique, 393
Preparatory stimulation, 389
Primary healing, aseptic, rise of pulse in, 62

hemorrhage, 71
Proctectomy, vaginal, 616
Proctoclysis, 45
Prolapse of rectum, 612
Prone pressure method of artificial respira-
tion, 129
Prostate, operations on, 566
Prostatectomy, perineal, 584

suprapubic, 587
Prostatic abscess, 589

cases, excretion in, 388
Prostatotomy, 589
Prosthesis, paraffin, 411
Protective response, 685
Pruritus of vulva, 527
Psoas abscess, 630
Psychoses, postoperative, 310
Pubiotomy, 543
Puerperal salpingitis, 528
Pulmonary complications, posture for, 25

embolism, 118
operative treatment for, 121
Pulse, 59

chart, 23
Purgation, natural, 165
Purgatives, 167
Purulent arthritis, 652

conditions, chronic, diet in, 137
Pyemia, 284
Pylephlebitis, 124
Pylorectomy, 465

Pyloric spasm, Ringer's solution for, 46
Pyloroplasty, 463

QuAUTY of pulse, significance of, 61
Quinsy, 418

Radical cure of hernia, 486
Radium, 379

Raisin tea, 134

Ranula, 409

Rashes caused by drugs, 290

cutaneous, 287
caused by enemas, 292
Rate of pulse, significance of, 60
Reaction, von Pirquet's, 769
Recovery from anesthesia, 31
Rectal feeding, 140
formulas for, 146
materials for, 143

plug with drain, 252
Rectocele, 522
Rectovaginal fistula, 527
Rectum, cancer of, 613

evacuation of, digital, 170

imperforate, 608

operations on, 607

preparation of, 396

prolapse of, 612

stricture of, 611
Rectus incision, 509
Recurrent bandage, 224
Red screen, 377

tongue, 214
Reduction '*en bloc," 495
Relief of pain, 54

electricity in, 368

of tension in sepsis, temperature drop
after, 67
Remedial movements, 362
Removal of bandages, 217

of stitches, 242

of tonsils, 416
Renal activity, 566

impairment, test for, 386

tuberculosis, vaccine treatment, 783
Resections of nerves, 400
Resistive movements, 362
Respiration, 70

artificial, 127

chart, 21
Rest, 54

principles in treatment of wounds, 258
Restlessness after anesthesia, 42
Restraint, method of, for recovery from

anesthesia, 2i^
Retention of urine, 586
Retroperitoneal hernia, 490
Retropharyngeal abscess, 418
Retroversion, 544
Reverdin grafts, 634
Rhythm of pulse, significance of, 61

828

INDEX

Ribs, strapping of, 233
Right rectus incision in relation to abdomi-
nal wound, 342
Ringer's solution, formula for, 50

for proctoclysis, 46
Rise of temperature, interpretation of, 69
Rising early after labor, 565
Rogers' serum, 439
Roller bandages, 216
Rolling a bandage, 217
Rdntgen ray, 378

therapy, 373
Rosanilin test, 386
Rose position for tracheotomy, 39
Roux operation, 459
Ruptured urethra, 584

Sacroiliac disease, 543
Saline cathartics, 168

infusion, 49
in shock, 99
Salpingitis, 546

puerperal, 538

tuberculous, 549
Salpingo-obphorectomy, 546
Salt solution in shock, 99

subcutaneous injection of, 49
Saxon's apparatus for proctoclysis, 46
Scalp, preparation of, 394

wounds, 398
Scarlatina, surgical, 289
Schede's operation, 454
Scopolamin in anesthesia, 30
Scrotum, operations on, 566
Secondary hemorrhage, 74
Section, Cesarean, 556

vaginal, 529
Semiprone posture, 25
Semi reclining posture, 25
Sepsis as cause of hernia, 328

diet in, 137

drop of temperature after relief of tension
in, 67

pain due to, 54

temperature in, 68

uterine, vaccine treatment, 741
Septic intestinal obstruction, 181

peritonitis, posture for, 26

rash, 287

wounds, treatment of, 257
Septicemia, 284, 688
Septicometastasis, 285
Septicopyemia, 284

Sequelae of anesthesia, 192

Serum treatment in hemophilia, 304

Serving of food, 138

Shaggy tongue, 214

Shaving, disadvantages of, 389

vs. depilation, 389
Sheet- wadding in bandaging, 217
Shock, 91

diet in, 137

etiology of, 92

prophylaxis against, 95

symptoms of, 94

temperature and pulse in, 65

treatment of, 96

urethral, 162
Shoeing for flat-foot, 255
Shoulder, bandage of, 219

dislocation of, 651

excision of, 635
Sick room, 17
Sinus, branchial, 443

frontal, 414

pilonidal, 608

tuberculous, of abdomen, 550

vaccine treatment, 765
Sinuses, 273

treatment of, 275
Sinusoidal current, 378
Sipping as a stimulant, 136
Sitting posture, 25
Skin, complete preparation of, 393

preparation, benzin in, 394
Skin-grafts, 633
Sleep, 54
Sling, 234
Smith's splint, 642
Soap suppository, 170
Sodium citrate and sodium chlorid, 697
dressing for exudation, 262
in thrombophlebitis, 117
Solution, Harrington's, 391
Sore chest after anesthesia, 192

jaw after anesthesia, 192

tongue after anesthesia, 192
Sound-passing, 578
Speech after cleft-palate, 407
Sphincter, loss of, 609
Spica bandage, 219

for hernia, 487
Spina bifida, 660
Spine, fracture of, 661
Spiral drain, 252

reverse bandage, 219

INDEX

829

Spirochaeta gracilis, 385

Spleen, operations on, 499

Splenectomy, 499

Splint, Nathan R. Smith, 643

Split-rubber drain, 252

Sponges left in abdominal cavity, 324

operation for, 326
Spontaneous cure, 687
Spurs of nose, 412
Stab wounds of chest, 454
Static electricity, 374
Status lymphaticus, no, 301
Sterility, 604

Stimulation before operation, 389
Stippled tongue, 214
Stitch abscess, 253
Stitches, pain due to, 53

removal of, 242
Stomach, acute dilatation of, after operation,

177
Strangulated hernia, 494
Strapping, 233
Stricture of rectum, 611

of urethra, 575
excretion in, 388
Strophanthin in shock, 103
Strychnin in convalescence, 318

in shock, 98
Subacromial bursitis, 625
Subclavian, ligation of, 620
Subcutaneous feeding, 151

injection, technique of, 55
Subdeltoid bursitis, 625
Subdiaphragmatic abscess, 125, 511
Subphrenic abscess, 125, 511
Suction cups for hyperemia, 267
Sudden death, no
Suit of Crile in shock, 99
Sunlight in convalescence, 318
Superficial hemorrhage, operative treatment

of, 73
Superheated dry air, 377
Supine method of artificial respiration, 129
Suppositories, nutrient, 145
Suppression of urine, 566, 585
Suprapubic cystotomy, 600

prostatectomy, 587
Surgical kidney, 604

scarlatina, 289
Suspensory bandages, 235
Suture, arterial, 621

of brachial plexus, 628

of muscle, 625

Suture of nerve, 627

of tendon, 625
Suturing of fractures, 646
Swathes, 230

abdominal, 341, 486, 487
duration of wearing, 346
fitring of, 344

for breasts, 446

laced adhesive, 506

Lund, 228
Sweating after anesthesia, 43
Sycosis, vaccine treatment, 767
Symphysiotomy, 541
Synovial fringe, 650
Syringes, method of sterilizing, 729
Systemic infections, 679

Tapotement, 357
Tarsus amputations, 347
T-bandage, 231
Tea habit, effects of, 309
Temp)erature, 65

chart, 23

interpretation of rise of, 69
Tendon, sutures of, 625

transplantation, 627
Tenosynovitis, tuberculous, 631
Tension of pulse, significance of, 63
Testis, atrophy of, 573

gangrene of, 491,573

undescended, 574
Tetanus after operation, 293
Therapeutic immunization, 663
Thienhaus, 483
Thiersch grafts, 633
Thigh amputations, 349

bandage of, 219
Thirst, significance of, 44
Thoracic operations, posture for, 25
Thoracoplasty, 454
Thorax, operations on, 446
Thrombophlebitis, 114
Thrombosis, femoral, 517

pelvic, 553

iliac, 517, 553
Thyroidectomy, 433
Thyrotoxicosis, 434

cytotoxic seruni for, 439
Tibial amputations, 348
Time for dressings, 241
Tobacco habit, efifects of, 309
Toe-nail, ingrowing, 631
Tongue, excision of, 408

830

INDEX

Tongue, observation of, 212

soreness of, after anesthesia, 192
Tongue-forceps, s^
Tonsillar hemorrhage, instruments for,

tumors, 417
Tonsillectomy, 416
Tonsils, removal of, 416

tumors of, 417
Tracheotomy, 420

emergency, 39
Transfusion of blood, 78
Transplantation of tendon, 627
Treitz, fossa of, 458
Trendelenburg operation, 654

posture, dangers of, 199
in shock, 96, 102
Trephining, 398
Trunecek's serum for proctoclysis, 46

formula for, 50
Truss after hernia operation, 491

worsted, 491
Trypsin for cancer, 554
Tuberculin, administration of, 771
Tuberculins, 730
Tuberculosis of vulva, 527

vaccine treatment, 768
Tuberculous abdominal sinus, 550

abscess, 697

lymph-nodes, treatment of, by a;-ray,

peritonitis, 520

salpingitis, 549

tenosynovitis, 631
Tubes, vaginal, section for, 531
Turpentine enema, 172

stupes, 177
Tympanites, dangers from, 178

Ulcer, gastrojejunal, 459

jejunal, 459
Umbilical hernia, 490

posture for, 25
Undescended testis, 574
Urachus, persistent, 457
Uremia after operation, 108
Uremic coma after operation, 107
Ureter, accidental ligation of, 552

injury to, 552

kink in, 600

operations on, 590, 6c»
Urethra, operations on, 566

preparation of, 397

ruptured, 584

stricture of, 575

417

374

Urethral caruncle, 528

fistula, 583

oil injections, 569

shock, 162
Urethrotomy, external, 575

hemorrhage after, 582
Urinal, female ambulatory, 604

male ambulatory, 586
Urinalysis before operation, 386
Urinary fever, 162
• suppression, 566
Urine chart, 2^

extravasation of, 584

incontinence of, 586

retention of, 586

suppression of, 585
Uterine sepsis, vaccine treatment, 741
Uterus, atresia of, 562

inversion of, 562

operations on, 522

perforation of, 540

Vaccine defined, 672

dosage, 744
tables, 794

focal reaction of, 716

indications for, 782

laboratory technique, 717

local reaction of, 715

preparation of, 716

sterilization of, 732

therapy, 663
Vagina, atresia of, 562

operations on, 522

preparation of, 395
Vaginal Cesarean section, 561

cysts, 562

drainage, 251

douche, 523
an efficient, 396
apparatus for, 396

hysterectomy, 532

proctectomy, 616

section, 529, 531
Varicocele, 573
Varicose ulcer, vaccine treatment, 768

veins, 624
Veins, varicose, 624
Velpeau bandage, 226
Ventrosuspension, 544
Vesical tuberculosis, vaccine treatment, 785
Vesico-uterine fistula, 562
Vesicovaginal fistula, 526

INDEX

83^

Vibration, 377

in massage, 358
Vincent's angina, 385
Virulence, 681

Volume of pulse, significance of, 63
Vomiting in anesthesia, 33

p>ostanesthetic, not due to anesthesia, 37

protracted, after anesthesia, 38
von Pirquet's reaction, 769
Vulva, elephantiasis of, 527

excision of, 527

kraurosis of, 527

pruritis of, 527

tuberculosis of, 527
Vulvovaginal abscess, 528

Walling-off process, 688

Water before operation, 385

Water-bed, 18

Watson's apparatus for kidney drainage, 593

perineal drainage-tube, 585

peritoneal button, 576
Wave current of electricity, 374
Weir's operation, 615

Whitehead's operation, 612
Whitewash, formula for, 292
Wire nail for fractures, 647

splint, 640
Wiring of fractures, 646
Wirsung, duct of, 497
Wolfe grafts, 634
Worsted truss, 491
Wound, abdominal, bursting of, 189

bursting of, 521

closure in relation to hernia, 329

gunshot, of chest, 454

of pancreas, 497

of pericardium, 454

of scalp, 398

operative treatment of, 241

septic, treatment of, 257
Wrist, excision of, 636

flexion, measurement of degree obtained
after massage, 365

X-RAY therapy, 373

Zander apparatus, 364

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Kelly and CuUen's
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Myomata of the Uterus. By Howard A. Kelly, M. D.. Professor
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A Text-Book of Obstetrics. By Barton Cooke Hirst, M.D.,
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GYNECOLOGY AND OBSTETRICS n

Penrose's
Diseases of Women

Sixth Revised £dition

A Text-Book of Diseases of Women. By Charles B. Penrose,
M. D., Ph. D., formerly Professor of Gynecology in the University of
Pennsylvania ; Surgeon to the Gynecean Hospital, Philadelphia. Oc-
tavo volume of 550 pages, with 225 fine original illustrations. Cloth,
$3-75 i^et.

ILLUSTRATED

Regularly every year a new edition of this excellent text-book is called for,
and it appears to be in as great favor with physicians as with students. Indeed,
this book has taken its place as the ideal work for the general practitioner. The
author presents the best teaching of modern gynecology, untrammeled by anti-
quated ideas and methods. In every case the most modem and progressive
technique is adopted and made clear by excellent illustrations.

Howftrd A. Kelly, M.D.,

Professor of Gynecologic Surgery, Johns Hopkins University, Baltimore.

" I shall value very highly the copy of Penrose's * Diseases of Women * received. I have
already recommended it to my class as the best book.*'

Davis' Operative Obstetrics

Operative Obstetrics. By Edward P. Davis, M.D., Professor of
Obstetrics at Jefferson Medical College, Philadelphia. Octavo of 483
pages, with 264 illustrations. Cloth, $5.50 net; Half Morocco, $7.00 net.

JUST R£ADY— INCLUDING SURG£RY OF NEWBORN

Dr. Davis* new work is a most practical one, and no expense has been spared
to make it the handsomest work on the subject as well. Every step in every
operation is described minutely, and the technic shown by beautiful new illustra-
tions. Dr. Davis* name is sufficient guarantee for something above the mediocre.

'* SAUNDERS' BOOKS ON

Dorland's
Modern Obstetrics*

Modern Obstetrics: General and Operative. By W. A. Newman

DoRLAND, A. M.» M. D., Professor of Obstetrics at Loyola University,
Chicago, Illinois. Handsome octavo volume of 797 pages, with 201
illustrations. Cloth, ^.00 net.

Second Edition, Revised and Greatly Enlarged

In this edition the book has been entirely rewritten and very greatly enlarged.
Amongthe new subjects introduced are the surgical treatment of puerperal sepsis,
infant mortality, placental transmission of diseases, serum -therapy of puerperal
sepsis, etc. By new illustrations the text has been elucidated, and the subject pre-
sented in a most instructive and acceptable form.

Journal of the American Medical Assodaiion

" This work deserves commendation, and that it has received what it deserves at the hands
of the profession is attested by the fact that a second edition is called for within such a short
time. Especially deserving of praise is the chapter on puerperal sepsis."

Davis' Obstetric and
Gynecologic Nursing

Obstetric and Gynecologic Nursing. By Edward P. Davis, A. M.,
M. D., Professor of Obstetrics in the Jefferson Medical College and
Philadelphia Polyclinic ; Obstetrician and Gynecologist, Philadelphia
Hospital. i2mo of 436 pages, illustrated. Buckram, $1.7$ net.

THE NEW (3d) EDITION
Obstetric nursing demands some knowledge of natural pregnancy, and gyne-
cologic nursing, really a branch of surgical nursing, requires special instruction
and training. This volume presents this information in the most convenient
form. This third edition has been very carefully revised throughout, bringing the
subject down to date.

The Lancet, London

" Not only nurses, but even newly qualified medical men, would learn a great deal by a
perusal of this book. It is written in a clear and pleasant style, and is a work we can recom-
mend."

GYNECOLOGY AND OBSTETRICS.

Garrigues'
Diseases of Women

Third Edition, Thoroughly Revised

A Text-Book of Diseases of Women. By Henry J. Garrigues,
A. M., M. D., Gynecologist to St. Mark's Hospital and to the German
Dispensary, New York City. Handsome octavo, 756 pages, with 367
engravings and colored plates. Cloth, $^$0 net; Sheep or Half
Morocco, ;g6.oo net

The first two editions of this work met with a most appreciative reception by
the medical profession both in this country and abroad. In this edition "he entire
work has been carefully and thoroughly revised, and considerable new matter
added, bringing the work precisely'down to date. Many new illustrations have been
introduced, thus greatly increasing the value of the book both as a text-book and
book of reference.

Thad. A. Reamy, M. D., Professor of Clinical Gynecology, Medical College of Ohio.

"One of the best text-books for students and practitioners which has been published in the
English language; it is condensed, clear, and comprehensive. The profound learning and
gfreat clinical experience of the distinguished author find expression in this book."

American Text-Book qf Gynecolo^

Second Revised Edition
American Text-Book of Gynecology. Edited by J. M. Baldy,
M. D. Imperial octavo of 718 pages, with 341 text-illustrations and
38 plates. Cloth, ;g6.oo net.

American Text-Book qf Obstetrics

Second Revised Edition
The American Text-Book of Obstetrics, In two volumes. Edited
by Richard C. Norris, M. D. ; Art Editor, Robert L. Dickinson, M. D.
Two octavos of about 600 pages each ; nearly 900 illustrations, includ-
ing 49 colored and half-tone plates. Per volume : Cloth, ;^3.50 net.

((

As an authority, as a book of reference, as a * working book * for the student or practi-
tioner, we commend it because we believe there is no better." — American Journal of TiiB
Medical Sciences.

U SAUNDERS' BOOKS ON

Schaffer and Edgar's Labor and Operative Obstetrics

Atlas and Epitome of Lat>or and Operative Obstetrics. By Dr.

O. ScHAFFER, of Heidelberg. Edited, with additions, by J. Clifton Edgar,
M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University
Medical School, New York. With 14 lithographic plates in colors, 139 text-
cuts, and III pages of text. Cloth, $2.00 net. In Saunders* Hand-Atlases,

American Medicine

•* It would be difficult to find one hundred pages in better form or containing more
practical points for students or practitioners."

Schaffer and Edgar's Obstetric Diagnosis and
Treatment

Atlas and Epitome of Obstetric Diagnosis and Treatment. By Dr.

O. Schaffer, of Heidelberg. Edited, with additions, by J. Clifton Edgar,
M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University
Medical School, New York. With 122 colored figures on 56 plates, 38 text-
cuts, and 315 pages of text. Cloth, $3.00 net. Saunders Hand- Atlases,

New York Medical Journal

•* The illustrations are admirably executed, as they are in all of these atlases, and the text
can safely be commended."

Schaffer and Norris* Gynecology

Atlas and Epitome of Gynecology. By Dr. O. Schaffer, of Heidel-
berg. Edited, with additions, by Richard C. Norris, A. M., M. D.,
Gynecologist to Methodist Episcopal and Philadelphia Hospitals. With 207
colored figures on 90 plates, 65 text-cuts, and 308 pages of text. Clothe
J3. 50 net. In Saunders' Hand-Atlas Series,

AmericMi Journal of the Medical Sciences

" Of the illustrations it is difficult to speak in too high terms of approval. They are so
clear and true to nature that the accompanying explanations are almost superfluous."

Galbraith*s Four Epochs of Woman's Life

New (2d) Edition

The Four Epochs of Woman's Life : A Study in Hygiene. By Anna
M. Galbraith, M. D., Fellow of the New York Academy of Medicine, etc.
With an Introductory Note by John H. Musser, M. D., University of
Pennsylvania. i2mo of 247 pages. Cloth, $i.$o net.

Krmin^am Medical Review, Cnsrland

" We do not, as a rule, care for medical books written for the instruction of the public.
But we must admit that the advice in Dr. Galbraith's work is, in the main, wise and
wholesome."

G YNECOL OGY A ND OBSTE TRIGS. 1 5

Schaffer and Webster's
Operative Gynecology

Atlas and Epitome of Operative Gynecology. By Dr. O. Schaf-
fer, of Heidelberg. Edited, with additions, by J. Clarence Webster,
M.D. (Edin.), F.R.C.P.E., Professor of Obstetrics and Gynecology in
Rush Medical College, in affiliation with the University of Chicago.
42 colored lithographic plates, many text-cuts, a number in colors, and
138 pages of text. In Saunders' Hand- Atlas Series, Cloth, $3.00 net.

Much patient endeavor has been expended by the author, the artist, and the
lithographer in the preparation of the plates of this atlas. They are based on
hundreds of photographs taken from nature, and illustrate most faithfully the
various surgical situations. Dr. 8chaffer has made a specialty of demonstrating
by illustrations.

Medical Record, New York

" The volume should prove most helpful to students and others in grasping details usually
to be acquired only in the amphitheater itself."

De Lee's
Obstetrics for Nurses

Obstetrics for Nurses. By Joseph B. De Lee, M.D., Professor of
Obstetrics in the Northwestern University Medical School ; Lecturer
in the Nurses* Training Schools of Mercy, Wesley, Provident, Cook
County, and Chicago Lying-in Hospitals. i2mo volume of 5 12 pages,
fully illustrated. Cloth, $2.50 net.

THE NEW (3d) EDITION

While Dr. De Lee has written his work especially for nurses, yet the prac-
titioner will find it useful and instructive, since the duties of a nurse often devolve
upon him in the early years of his practice. The illustrations are nearly all
original, and represent photographs taken from actual scenes. The text is the
result of the author's many years' experience in lecturing to the nurses of five
different training schools.

J. Clifton Edgar, M. D..

Professor of Obstetrics and Clinical Midwifery, Cornell University, New York.
"It is far and away the best that has come to my notice, and I shall take great pleasure in
recommending it to my nurses, and students as well."

i6 SAUNDERS' BOOKS ON GYNECOLOGY AND OBSTETRICS.

American Pocket Dictionary ^^w (7th) edition

The American Pocket Medical Dictionary. Edited by W.
A. Newman Borland, A. M., M. D. 610 pages. ;^i.oo net; with
patent thumb index, $1.25 net.

James W. Holland, M. D.,

Professor of Medical Chemistry and Toxicology at tke Jeferson Medical College^
Philadelphia.

" I am struck at once with admiration at the compact size and attractive exterior. I
can recommend it to our students without reserve. "

Cra|^n*s Gynecology. N«w(7th)£dttioQ

Essentials of Gynecology. By Edwin B. Cragin, M. D.,
Professor of Obstetrics, College of Physicians and Surgeons, New
York. Crown octavo, 232 pages, 59 illustrations. Cloth, $1.00
net. In Saunders* Question- Conipend Series*

The Medical Record, New York

" A handy volume and a distinct improvement ot students* compends in general.
No author who was not himself a practical gynecologist could have consulted the
student's needs so thoroughly as Dr. Cragin has done."

Ashton*S Obstetrics. New (7th) Edidon

Essentials of Obstetrics. By W. Easterly Ashton, M.D.,
Professor of Gynecology in the Medico-Chirurgical College, Phila-
delphia. Revised by John A. McGlinn, M. D., Assistant Professor
of Obstetrics in the Medico-Chirurgical College of Philadelphia.
1 2mo of 287 pages, 109 illustrations. Cloth, $ i .00 net. In Saunders*
Question- Compend Series.

Southern Practitioner

"An excellent little volume containing correct and pracdcal knowledge. An admir-
able compend. and the best condensation we have seen."

Barton and Wells* Medical Thesaurus

A Thesaurus of Medical Words and Phrases. By Wilfred
M. Barton, M. D., Assistant to Professor of Materia Medica and
Therapeutics, Georgetown University, Washington, D. C. ; and
Walter A. Wells, M. D., Demonstrator of Laryngology, George-
town University, Washington, D. C. i2mo of 534 pages. Flex-
ible leather, II2.50 net ; with thumb index, II3.00 net.

Macfarlane's Gynecology for Nurses

A Reference Hand-Book of Gynecology for Nurses. By Cath-
arine Macfarlane, M. D., Gynecologist to the Woman's Hospital of
Philadelphia. 32010 of 150 pages, with 70 illustrations. Flexible
leather, $1.2^ net.

A. M. Seabrook, M. D.,

Woman's Medical College of Philadelphia.

*' It is a most admirable little book, covering in a concise but attractive way the subject
from the nurse's standpoint."

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