j/llaWu (i/p!W*«*v- r RD r> r* ^ r »^ » z o Q. UJ ye fo 35 30 25" 20 IS 10. 1 U u 1 Fig. 19. — Normal Reaction After Aseptic Operation. 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 60 on the record may have to be corrected to 120. The pulse may be irregular in force and rhythm. If irregular in PULSE 55 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. Mr P. G. Diagnosis Open Fracture Femur. If If //, '? n '? ,;p ^1 23 li jr 2i- 7t J- ?f 2^ ?i 3/ DAY OF ' 1 Tl MF JJ IT 5J il '-• \ r^ r* \ /• / s > w i 1 Mis',, E 1u I.T Mrs DiapTios.s p,.^y r,oT> kif,. MOM?Hr/ 5 1 31 1^ H ' sil 1-; ■■$ 1 .aac DISEASE. \ ? ^ 1 f, u li- TIM* 5 rrs: EE a -1 ^r \ y ^_> Q. < 7 97 ~ 1/,° /?« (20 / 1 /' / J / 9o ^ /^ >" ^ t-<^ i^ / 6o - _i / / i 25" / / / A ^ K-i' s r> =J= =L =M w" ^^^ = Fig. 22.— Peritonitis. Fig. 23. — Appendix Abscess. 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 diffuse 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. 58 PULSE, TEMPERATURE, AND RESPIRATION 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. Mrs; t. D.affTios.s ».hlldbed;Hetalned Membranes. mon?h3» '^1 AS 1^ .? .1 /- a. 3 -f 5 " 0/S£«SF / i. 3 * i (^ 7 ? TIMF 55 fS Cl !o i! «r <' <& rx .^i cc. -1 a z o h- < a Co LJ cr 107 /06' lOS 103" /Ol' /Ol' loo' ~53 ISO no no no 1.10 ICC 90 So 70 bo y« f5 fo 35 30 25 20 'S 10. c i;; e ,1 u. 1^ " r / /I / • t . / r<< I, 1 _/ Y (^ ]j « f , \ / / 4 / / / -^ ' ■ ■ / / y / / / / ►' r / ul Fig. 24. — Childbed. Rise of temperature and pulse on fourth day, aseptic absorption from retained membranes. Fig. 2S.^Perineal Prostatectomy (weight of prostate, 12 ounces). Marked shock shown by drop in tempera- ture and rise in pulse; then temperature, 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,, twenty-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. 19). The pulse, without altering its character, accelerates its rate simultaneously with and in proportion TEMPERATURE 59 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 intelligently be considered as due to absorption of Mr, Pi Diag-nosis Excision Of Cartilage of Knee- B °K;j«?^„>sf ^1 J? 34 ?* , aj i * ^"7 « T K ^ 10 >> >i (3 '!■ /i ,1.-, »8J1 Zo o;sEAsF. 1 a. 3 -^ -f t 7 ? 7 10 12 13 ly- »5 /t '7 /s ' Tl ^F 5? rj STE 11 il «T it a i <:a 4 a. li it 3 .^ A \^ <^ ^ 2 V- v? ^ ^ kn L-, ,»' bi Aj 5^ 7 ^ «k / ►♦ j \- \ ^ ^ A /^ / / i \ A V ■• M ^ \/ / / 1 V V . i 1^ c r1 * •« % •^ *-i V / ^ »J / M / »« \ • _ 1 1 _ _. ^ ^, 1 1 Fig. 26. — Excision of Cartilage of Knee. Sustained postoperative 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 6o PULSE, TEMPERATURE, AND RESPIRATION 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 M^ J.O 'C , Diapnosis Appendicitis, ".'J^!^ ;14 n-i J* J5 >k Al n 29 3e 31 / 3 3 4^ .<• 7 -7 O/SEflSE. / i J 9- ^ & 7 H 1 /o II /^ I"! NE 5f It. ff il ir -^t (« o H ■p M 1 Q S \ i> ■^ t V *^ "S 1 Li ^ / Ln ' ' W^ ^ i/ ^ r ^ •^ \ ^ I* ^ A ^ f N r* ^ \. V »^ V A| /I J ^ % ^ j L M *^ ^ _J _J _J _ _J _J _j Fig. 27. — 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 1 10, 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. TEMPERATURE 6l 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 M, C. K. G. Jjiag-r, Mr W. E. C, S$, ,S rwtr. ¥T. ^^1. v-'i't "yi.'-'t "^I^'hU^ 71 li 11 rfi) S/ ;ii ?1 ii IS 4 ;1 n 7t 'fl 1 2 1LJ2 t3 1 < '3 'f '?' Ji^a. jJ-3^ 0)S£»5 a 1/1 2 O l- < E. V) « '- ^ . 'ii •; i « ^ t 3 +> IH TTT' o • h t ; « i O r V T f / l -^ '^1 ^ t'* ; * V* F , / V A s ^ ^ V ^ ■^ *5 * 1 ]i A. 5S — - .F«P« rr- Jb \ f» ,* f r »^ ^ J^ \ .-•J A 1^ V W1 / J ^ »4 »-* *• J ^•^ »• \ t-r V ^% •» « Li _ __ _ _. ^ u _ _. 1 1 Fig. 28. — Hekniotomy. Rising temperatare; wound inspected on the sixth day, stitch-abscess found and relieved, imme- diate drop to normal. Fig. 29. — 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 elhcient. reaction, and then a sure and progressive decline as the drainage effec- tively acts (Fig. 27). 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, 62 PULSE, TEMPERATURE, AND RESPIRATION 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. 28). One should look for sepsis, then, whenever the reactionary rise in tem- Mr 8. S. magnosis Hvsterectomv: Phg'bitis. 1 Vc^H^ II /i. /,i /^ rj\/i/7 /e /fl^j/ JiUsJV-iSiij- jdJjSo / S?sf"f / i|3 ^ r ^1 ;>l (P ^K" // « '3 ^^ ''il^/7'^S Ti tr r> < cr 1x1 Q. 5 u in -1 a i/ z o 1- < Q. UJ cr 107 ^ "^ . . o .Zfl o ■% -3. TTT^ m tt « f J ■^ 1 1 ij. . ii ^ ^ £ Il^r^ 1 I -^^ ii^/ w« tui rt :v^ L "^^t: i^^"' 2 \^>^^--^ C17 i /'o4 ^ .no 3 " tX* »- -J! 90 I 5 *^% / 5 Z J !; LI ^f^^-^ ^ vJ^\^^ 80 ^^ i- 5? 8, ^^^ ^ ^^ ,o ^^»^^^^ ^^-^'•^«^^^%«^•^M Mr. J. r-r. BiapTiosis Ppx-"i+:orv V.4 MONTH. i\ ■S ii 1 'i 0ISE«SE. 1 i- - TI ^flE 51 irj JJ IV< r 't * - -1 j _c" y = ►i > l// /■ / "q7_j Jb y *^ ^ ' /* ' / r*^ 1 — L =^ Fig. 30. — Phlebitis on the Eighth Day. Sharp reaction in temi)erature aad pulse. Fig. 31. — General Peritonitis OF Subdiaphragmatic Origin. Temperature and pulse not so significant as the practically con- tinuous rise of 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, pyle- RESPIRATION 63 phlebitis (Fig. 30), thrombosis, and embohsm. When the temperature 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 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. In peritonitis the respirations are practically always increased and may run up to 48 per minute (Fig. 31), 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. 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 shock passes off, blood-pressure increases 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. 64 INTERNAL CONCEALED HEMORRHAGE 65 (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 is relaxed and they have a tendency to retract behind the ligature, 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 Cesarean 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, ligature, especially of silk, may cut through them. The symptoms 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 the element of shock in the dynamic insult to the heart-muscle of pumping against much decreased peripheral resistance that has to be considered. It is said that a loss of from 4 to lo 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 iDlood 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 over 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 66 POSTOPERATIVE HEMORRHAGE -by this time has reached 140 and the respirations are 30. She begs constantly for water and tries to get rehef 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 internal concealed hemorrhage is always made certain 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 vaginam, 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 extremis, 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 0^ 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. TREATMENT 67 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 sufficiently 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. Treatment- — 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. 68 POSTOPERATIVE HEMORRHAGE A man of twenty-six suffered 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 itseK in the region of the right psoas muscle. Blood and intestinal contents were free in the abdominal ca\it}' . 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 clamped. If the sloughy nature of the wound makes this difi&cult or impossible, the wound maybe packed, or the old-fashioned methods of the actual cautery, acupressure, or t}'ing 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 afterward; 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 dangerous condition. Such hemorrhage is not readily amenable to treatment, and, on the whole, when it occurs, is one of the most trying of all complications which the surgeon has to face. If the diagnosis of any of these conditions is made before operation, and the operation cannot be postponed, the patient should be given the benefit of the administration of large doses of calcium lactate for a few days before as well as ^.fter 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 HEMORRHAGIC DIATHESES 69 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. 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 precip- itated by the phosphates of the food. Saline aperients are contra-indicated for the same reason, and to relieve the constipation which the calcium salts usually induce, other cathartics should be employed. 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 Monsell's solution, may be used in the same way. A styptic is useful only when applied while the bleeding is temporarily 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 ligation 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 digitalis administered as necessary. Vasodilators and salt solution should not be given. Hemophilia has been treated by transfusion.^ Constitutional Treatment. — The treatment of these conditions after the hemorrhage has been securely stopped is mainly that of shock, but before it is certain that there is no chance of further bleeding, 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, sub- cutaneously, or by transfusion. The use of vasodilators is clearly contra- indicated. Sometimes the patient is too low to allow of operation for the control of bleeding. The condition of collapse, with its state of * F. O. Allen, Ann. Surg., 1906, xviii, 625. 70 POSTOPERATIVE HEMORRHAGE lowered tension, favors clot formation, and during collapse hemorrhage may be stayed; thus the expectant is sometimes 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 { gr, morphin, to be followed by ^q g^. 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 adre- nalin subcutaneously, by brandy, strychnin, strophanthin, digitalis, or camphor, to a state where she can stand ether and a hurried operation. It is to be remembered that in coUapse ether inhaled 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 opera- tion. 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, he should not hesitate to leave in gauze packing or a clamp. After the operation is finished, treatment for shock should be instituted (Chapter VH, page 84). The general treatment of hemorrhage may be summarized as follows : (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 vaso- motor 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 Heeding has ceased. (7) Stimulate by means of enemas, which may be composed of black co'ffee and contain ammonium carbonate, brandy, or strophanthin. (8) Stimulate by means of subcutaneous injections of strychnin, ether, adrenalin, strophanthin. TRANSFUSION The transfusion of blood has recently come into prominence in the treatment of hemorrhage. TRANSFUSION 71 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 earhest 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 subject, and research was instituted upon animals. Lower, in 1666, wrote the first detailed account we have of the method of performing transfusion, and in the same year Jean Denys, in France, carried on similar experi- ments. He also performed the operation three times successfully upon human beings. Following his report, transfusion was carried on exten- sively, 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 imlike species would be liable to cause distressing and even fatal symptoms in the person in whom it was injected. About 1835 Bischoff experimented with de- fibrinated 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 preced- ing forty years, and found that there had been 56 successful results. All these cases were cases of indirect transfusion, and in two the source of the serum was an animal. From this time on a great deal of attention was paid to transfusion, and claims of a highly exaggerated nature were advanced 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 created a source of danger, inas- ^ See Landois, Transfusion des Blutes, Leipzig, 1875; Ore, 1876, quoted by Crile, Hemorrhage and Transfusion, 1909, 151. 2 Medico-Chirurgical Transactions, 1818, ix, 56. ^ Deut. Klinik. 72 POSTOPERATIVE HEMORRHAGE much as it contained a fibrin ferment whicli miglit cause intravascular coagulation. These limitations, together with the general introduction of intravenous injection of normal saline solution, about 1875, brought about a gradual disuse of transfusion, which lasted until some time in the 8o's, when it was taken up -with renewed enthusiasm. There were three methods of transfusion ordinarily employed — 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 Fig. 32. — Transfusion Instruments. A, A, Crile carmulae, four \news; B, B, Crile clamps; C, C, mosquito forceps; D, fine scissors; E, jeweler's for- ceps; F, Elsberg camiula; G, Elsberg hooks. experiments a practical method of end-to-end suture of \'essels was perfected. Crile^ simplified this technique by the use of a cannula adapted from that which had already been introduced by Queirolo and Payr. Modifications of the Crile cannula have recently been introduced by Elsberg and Bernheim. For a complete exposition of the subject of transfusion, both ex- perimental and clinical, the reader is referred to Crile's admirable book. From it I shall quote freely, with Dr. Crile's kind permission. ^ Hemorrhage and Transfusion, New York, 1909. TRANSFUSION 73 Technique.^ — "The following instruments (Fig. 32) 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- nulas; (9) sterilized vaselin; (10) the ordinary means of closing a wound, and dressings. Fig. 33. — Transfusion. (After Crile.) Transfusion by Crile cannula: a. Threading the vein; b, making the cuff; c, pulling artery over cuffed vein; d, artery tied in place. ''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 vgin. The handle of the cannula is then tightly seized by a pair of hemostats (the fingers are too clumsy) (Fig. 33), three mos- ^ Crile, Hemorrhage and Transfusion, 284, et seq. (Copyright, 1909, by D. Appleton and Company.) 74 POSTOPERATIVE HEMORRHAGE 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 cuff'ed 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. " 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 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 difficulty 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 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 remembered. 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, TRANSFUSION 75 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." Other forms of anastomosis, direct and by means of other forms of cannulae, have been devised, a most ingenious technique being 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. 32). 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 following 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 millimeters from the ligature. Small mosquito forceps may also be used. These are given to an assistant, who makes traction on them while the operator cuts the vessel near the ligature. The moment the artery is cut the stump is pulled back over the cannula by means of the tenacula or forceps, and is held in place without ligation by the small pin-points. There is no bleeding from the artery, even though no 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 peripherally in the usual manner. A small transversa slit is made in the vein, the cannula with the cuffed artery inserted into the vein, a ligature tied around the vein and can- nula screwed open, and the blood allowed to flow. The rapidity of ^ Jour. Am. Med. Assoc, 1909, Hi, 887. 76 POSTOPERATIVE HEMORRHAGE 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 cuffing of the artery is easily accomplished without strip- ping 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 dimin- ished." . I will quote in full Bernheim's description of his ingenious improvement:^ "The technique of the transfusion is in most respects similar to that used for the Crile cannula. The vein of the donee is care- fully isolated and, after being tied off distally and secured proximally by a bull-dog clamp, is divided, leaving about 3 cm. free for manipulation. The lumen of the vessel is thoroughly washed out with warm saline, follo\\-ed by liquid vaselin, after which all superfluous ad^•entitia is removed. The artery of the donor is prepared in a similar manner. " The vein is then, by means of a needle and thread, passed through the cannula CFig. 34), hook end first, grasped by mosquito clamps at three equidistant points along its lumen, everted over the cannula, and impaled on the three hooks. Next the artery is seized in a similar ^ A Modification of the Crile Transfusion Cannula, Ann. Surg., Oct., 1909, 1, 786. Fig. 34. — Bernheim's Modifica- tion OF Crile's Cannula. TRANSFUSION 77 manner by three mosquito clamps, and, after being gently dilated, ac- cording to the suggestion of Crile, by the end of a clamp previously dipped in sterilized oil, is gently pulled over the cannula with its everted vein and also impaled on the three hooks. A tie is now placed round the cannula for the sake of greater security, and the blood allowed to flow, the clamp on the vein being removed before that on the artery. " The advantage of this over the ordinary Crile cannula is that it is absolutely unnecessary to hold either vessel while the tie is being placed round the cannula. This difficulty, slight as it may seem, is often a most serious drawback to the successful performance of a transfusion.^ As a matter of fact, if the artery has not been too much dilated before being impaled on the hooks of our cannula, no tie at all will be neces- sary, as there will be enough pull on the artery and vein to prevent leakage. As a routine, however, we think it best to put one tie round the cannula and vessels." Of these three devices for transfusion, the cannula of Elsberg is, in my opinion, in all ways the most satisfactory. 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 phy- sical 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. ^' The '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 he 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 ^ T. N. Hepburn, Ann. Surg., 1909, xlix, 115. ^ Crile, loc. cil. 78 POSTOPERATIVE HEMORRHAGE be necessary to shut off the flow altogether, with gentle pressure of the fingers, for short intervals, giving the heart a chance gradually to 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 Fig. 35. — Transfusion. (After Crile.) Diagram to show arrangement of operating room: i 2, Operating tables for recipient and donor, respec« lively; 3, table for arms of recipient and donor; 4, 5, stools for surgeon and first assistant, respectively; 6, instru- ment table; 7, table for dressings, sutures, etc. 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 of nitro- glycerin 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 analysis. The surgeon takes the place of the internist when he gives a 'dose' of blood. "The question of dosage may be very important, especially when there is hemolysis of the recipient's red corpuscles by the donor's serum; therefore, in all but emergency cases, preliminary hemolysis tests should be made in order to handle a given transfusion more intelligently and protect the recipient more fully." ^ ^ For the technique of these tests, see Crile, loc. cit., 313. TRANSFUSION 79 " 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 operat- ing room the donor and recipient each receive morphin sulphate, gr. \, hypodermically, unless there is some special reason for its being contra- indicated. "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. "Local anesthesia is obtained by injecting cocain in -j^ of i per cent, solution with a few drops of i : 1000 adrenalin chlorid solution. Several hypodermic syringes should be ready, so that there need be no 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 round the vessels. "In making the dissection it is necessary to have good light. Mos- quito 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 approximate part, as. near to the place where it comes but of the undissected tissues as con- venient. 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 8o POSTOPERATIVE HEMORRHAGE 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 ciit 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." Dr. Crile concludes his remarkably explicit and complete work on the subject thus: "Transfusion, when properly safeguarded, may be safely done. "In pernicious anemia, toxemia, certain drug poisonings, leukemia, acute hyperthyroidism, carcinoma, and uremia it has been of no value. "In tuberculosis and chronic infections it has certain value; in pathologic hemorrhage it is of marked value. "If done in time transfusion is specific in acute hemorrhage. In suitable cases it seems to be almost specific in the prevention and treat- ment of shock. "Judiciously employed, transfusion will surely prove a valuable, often life-saving, resource; injudiciously employed, it will surely become discredited." March 23, 1908, Mrs. B., seen in consultation with Dr. C. N. Cutler, Chelsea, Massachusetts. P. H. On this patient I had operated for left extra-uterine pregnancy September 5, 1907. P. I. Two days ago collapse, pallor, gasping respiration, pulse 180, abdominal pain beginning low; great tenderness but no spasm. Diagnosis, ruptured extra-uterine pregnancy. Patient too sick for operation; yester- day patient better, pulse down to 140, but this morning at 4 o'clock another collapse with pain. Pulse 160 and temperature 101° F.; gasping respiration; distention, abdominal spasm. Operation. — Assisted by Drs. Cutler, Ehrenfried, and Osgood, and four nurses. At the moment of operation, adrenalin salt solution (i : 50,000) started under the breasts, one quart jn all taken. Median celiotomy. On right parovarium ruptured pregnancy mass found. Fetus size of a thumb- nail found at once floating free on intestines. Two quarts free clot and fresh blood. This was rapidly sponged out, the mass and right tube tied off, salt solution left in abdomen, and wound closed with one layer of through-and-through sutures. Duration of operation, sixteen minutes. TRANSFUSION 8l Patient cold, no pulse at wrist, respiration 40. Patient placed on bed with heaters; foot of bed raised. Strychnin sulphate, gr. -g-'^, subcutane- ously; transfusion from left radial artery of patient's brother into left median basilic vein of patient 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 transfusion 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 in consultation with Dr. Provandie, 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, temperature 97.2° F., res- piration 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 day, to bear this- out, there were some signs of congestion of the lungs, but recovery was uneventful. 6 CHAPTER VII SHOCK: 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.^ We may consider as the cause of shock any sudden, severe, or pro- longed irritation of the peripheral nerves, especially of the sympathetics, and of nerves not accustomed to carrying impulses of tactile sensation from the surface of the body. Thus, shock will follow severe blows upon the head, larynx, abdomen ("solar plexus"), testicle, or sper- matic cord, abdominal wounds and visceral injury, gunshot wounds of the intestine, and perforation of the bowel in typhoid or appendicitis. Hemorrhage causes collapse and not shock. Shock most frequently follows operations involving the abdominal contents and visceral peri- toneum, next the visceral pleura, third, the male generative organs. In abdominal operations the state of shock seems to bear some propor- tion to the amount of manipulation the visceral peritoneum receives, or the amount of exposure of the viscera. In abdominal surgery the ^ Seelig and Lyon (Jour. Am. Med. Assoc, 1909, lii, 45) refer to Groeningen (Ueber den Shock, Weisbaden, 1885) for history. The idea that shock was due to vasomotor exhaustion was first enunciated in 1864 by W. W. Keen, S. Weir Mitchell, and C. W. Moorehouse. (See circular No. 6, Surgeon-General's Ofl&ce, 1864.) This was later con- firmed by Fisher and restated by Crile. Leydon (Samml. klin. Vortr., 1870, No. 2) and Meltzer, S. J. (The Nature of Shock, Archiv. Int. Med., 1908, i, 571) held that shock was due to a reflex inhibition of the activity of the centers of the cord. The only other theory of importance is that recently expounded by E. Boise (Am. Jour, of Obstetrics, 1907) that cardiac exhaustion is the main underlying factor. As the problem stands to-day, there are several contradictory theories. Crile and his followers declare that vasomotor exhaustion is the primary cause of shock (Blood Pressure in Surgery, Phila., 1903; An Exp'erimental Inquiry into Surgical Shock, Phila., 1899). Boise states that cardiac exhaustion is the prime cause, whereas W. H. Howell (Amer. Med., 1904, 482) believes that both these factors, namely, cardiac and vascular, must fje reckoned with. 82 ETIOLOGY 83 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 bears a proportion to the sen- sory nerve supply of the tissues destroyed or manipulated. Pain is an important factor in causing or prolonging shock. Recently the etiology of shock has been cleared up somewhat by experimental investigations on animals.^ Our present notions may be summarized as follows: Overstimulation of the sensory nerves and the severe and unaccustomed stimulation of nerves not ordinarily carrying impulses of sensation lead to a rapid exhaustion, and finally temporary suspension of function in the corresponding centers. Ac- companying, and as a result of this, there comes the dilatation of the vessels of the part which originally suffered mechanical insult. The heart, its innervation already somew^hat disturbed by the disturbance of the other nerve-centers, works harder and faster to maintain the blood-pressure, which has been lowered by this vasodilatation. Sooner or later, unless the vasomotor center recovers its tone, or relief comes from without, the heart-muscle begins to tire and finally to give way, and the picture of extreme shock develops. The blood-pressure drops; the blood, withdrawing from active circulation, stagnates in the readily distensible veins of the splanchnic area, where it interferes with the action of the heart, and the blood fails to become properly oxygenated. As a result, the vasomotor center is insufficiently supplied with blood, which is of an improper quality. This further disturbance reacts upon the heart, which wears itself out, pumping faster and faster its inade- quate supply in the attempt to maintain the normal blood-pressure, until it exhausts itself and death ensues.^ Clinically, shock may be immediate, coming on during or imme- diately after an operation; deferred, six to twenty-four hours' after operation; and continued, coming on soon after operation, and lasting 1 p. L. Mummery and W. L. Symes (Brit. Med. Jour., 1908, ii, 786, Experimental Production and Control of the Vascular Anatomy of Surgical Shock) tell us that in fully anesthetized animals manipulations of abdominal viscera are more productive of shock than are gross injuries. Such manipulations produce shock rapidly when they implicate the parietal peritoneum and the mesenteries. Shock is more rapidly produced under chloroform than under ether. 2 Eisendrath and Strauss (Some Postoperative Complications, International Clinics, 1909, iii, 114): "Collapse differs from shock in this respect only, viz., in collapse there is a sudden overpowering impulse which inhibits the vasomotor center temporarily, while in shock this center is in a state of exhaustion from long-continued peripheral irritation. When collapse following a severe hemorrhage has persisted for a considerable time, it begins to change into a condition of shock, as the vasomotor center becomes exhausted in an effort to maintain the blood-pressure at the same level." 84 shock: causes, symptoms, treatment twenty-four to forty-eight hours or even three or four days. The tw^o latter varieties are uncommon. What is called deferred shock may sometimes be the collapse of secondary hemorrhage. Continued 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. Symptoms. — The symptoms are analogous in all forms and ex- tremely 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, and 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 pro- ceeds the pulse becomes irregular and thready, the skin cold, pallid, and covered with a cold sweat, the lips become blue, and the respira- tion shallow and irregular. The patient is put to bed in a state of dull torpor, which gradually develops into coma. The pupils are dilated and the eyes half closed and staring. There is loss or impair- ment of surface sensibility and the phlegm which collects in the throat is audibly churned with the respiration. Occasionally there is hic- cough, 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 commonly expected picture of men- tal 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 develop- ment 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. Treatm.ent. — In treatment the matter of prophylaxis has an ^ J. Henderson (Apnea and Shock, Amer. Jour, of Physiology, 1909, xxiv, 66) says that increased rapidity of breathing leads to an unusual loss of carbon dioxid and shock is the result. PROPHYLAXIS 85 important place. Before operation the bowels should be empty, although overfree 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. X2T' should be administered one-half hour before operation. This use of atropin before operation in cases where shock is feared is at least theoretically sound, for, besides "guarding" the morphin, it depresses the vagus, and by central action in small doses induces constriction of abdominal arterioles, although with, in a less degree, a compensa- tory dilatation of the peripheral vessels. There is some clinical and experimental evidence confirmatory of this beneficial action. 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. Ether is always the anesthetic 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 opera- tion 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 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. ^ Crile (Surgical Shock, Boston Med. and Surg. Jour., 1908, clviii, 961) discusses certain phases of shock in their relation to surgical practice. He dwells particularly on the psychic element in prophylaxis and warns against ovcrancsthesia. 86 shock: causes, symptoms, treatment 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 operations 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 treat- ment present themselves. These we shall consider in the following order : (i) Fall in blood-pressure due to distention of the vessels of the splanchnic area. (2) Rapid heart action due to withdrawal of blood from the active circulation, causing dynamic exhaustion of the heart from working against too low resistance. (3) Anemia of the brain, and of the vasomotor center especially, from lessened amount and poor aeration of blood-supply. (4) Cardiac exhaustion from progressive weakening of the heart- muscle. (5) Pain as an element in causing or prolonging shock. (6) General measures in the care of patients. Crile has recently demonstrated on animals that the main factor in shock is a general fall in the blood- pressure in the peripheral arteries, with a coincident rise in pressure in the vessels of the portal system. Leaving the abdomen full of sterile salt solution after a celiotomy will TREATMENT 87 temporarily, at least, create a positive pressure which will partially counteract or prevent this dilatation of the splanchnic vessels. After the operation, the application of a binder over the abdomen, as tight as can be borne, padded in the middle line with folded towels, is also use- ful in overcoming the vascular distention. Hunter Robb has lately suggested the use of weights hung across the abdomen for the same purpose, and Momberg proposes a rubber tube tightly drawn about the body just below the costal arch.^ It is here also that the usefulness of the vasoconstrictors is apparent, and of these we shall consider adrenalin, caffein, and strychnin. Digitalis also acts secondarily by constricting the splanchnics, but we shall consider this drug later. 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. Whether or not it is capable of influencing directly the splanchnic vessels is still un- determined. The ordinary 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. The administra- tion 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 swallowing are dulled, so that the irritating fluid may readily pass into the larynx. Adrenalin may conveniently and rationally be given in salt solu- tion infusion, 15 minims to the quart (1:50,000 solution). Its ac- tion is very transitory," lasting only about ten minutes, so that if the desired effect is not obtained, it must be repeated. Its effect in increas- ing 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 account of the •occurrence in animals of an arteriosclerotic condition^ if the use of adrenalin is long continued, the drug must not be given in too large •doses or over long periods. ^ Die kiinstliche Blutleere der unteren Korperhalfte, Arch. f. klin. Chir., 1909, Ixxxix, 1016. He applies it until the pulse in the femoral artery just disappears, and has held it in place for as long as two hours and twenty minutes without deleterious results. 2 D. D. Jackson (Prolonged Persistence of Adrenalin in the Blood, Amer. Jour, of Thysiology, 1909, xxiii, 226) says adrenalin does not persist in the blood after its visible •effects in the rise of blood-pressure have disappeared. In the dog adrenalin disappears in about one minute. ^N. Waterman (Arteriosclerosis after Injections of Adrenalin, Virchow's Archiv, 1908, cxci, 202) says that research shows that the arteriosclerosis induced in animals ^fter injection of adrenalin closely resembles ordinary arteriosclerosis in man. 88 shock: causes, symptoms, treatment Caffein 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 sodium benzoate (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 -YQ gr. ; this may be followed in fifteen minutes by -^ gr., and then -yq 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 w^ith 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 — one ounce by mouth or tvvo ounces by rectum. The animal investigations by Crile show also 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 propeller lifted clear of the water, and may be compared with the exhausting futility of working a pump with no water in the tube. He found that if salt solution or blood were supplied to take the place of the blood stagnant in the splanchnic reservoir, the heart at once began to work more slowly and forcibly. We shall consider four methods of supplying the needed fluids: TREATMENT 89 (i) Emptying the peripheral vessels. (2) Salt solution infusion (hypodermoclysis) . (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 appliance has not generally been adopted, but the underlying principle can be met to a degree by simple elevation of the lower portion of the body, in the Trendelenburg posture, by massaging the limbs and abdomen, and by tight bandaging of the extremities with elastic rubber or fabric bandages from toes to groin and fingers to shoulder. 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. In cases of circulatory weakness due to hemorrhage, shock, or other vasomotor, conditions the injection of salt solution is a valuable mode of treatment. When, however, the trouble is due to heart failure, the increase in the quantity of fluid means an added strain upon the heart, and, is, therefore, contra-indicated. Hypodermoclysis is, on the whole, the most satisfactory method of sup- plying fluid to the circulation; the procedure has already been described in the chapter on Thirst (Chapter III). Fully twenty minutes should be allowed for the injection of three pints, at a temperature of 110° F. Care should be taken that the "fluid does not become cooled below body temperature in transit through the tube. There is usually to be noted a rapid improvement in the circulatory condition after its ad- ministration. This improvement may, however, be only temporary, and show signs of wearing off at the end of an hour, so that one should 90 shock: causes, symptoms, treatment be prepared to repeat the infusion if indicated. It is a mistake to give too large a dose; a safe and effective rule is three 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 oj 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, and imme- diate 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 incision about an inch long. Two silk ligatures are passed under it. The lower one is tied; be- tween 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 Hgature tied once about its tip. After the bottle is 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 young woman, acrobat by profession, was seen in a state of severe shock from some intra-abdominal condition. An immediate celiotomy was per- formed and simultaneously an intravenous infusion of salt solution made. The patient recovered, but the incision for the infusion became infected and left a scar. She threatened to institute suit against the operator, on the ground that the infusion was performed without her permission, and that the scar was unsightly and thus interfered \^dth her earning capacity as an acrobat. For the transfusion of blood, see p. 68, et seq. Anemia of the vasomotor center will be combatted by the measures already detailed for the purpose of equalizing and stimulating the circulatory system. It is rather important that the patient lie in bed ^ T. Meissl (Wert, der Intra-venosen Adrenalin-Kochsalzinfusionen, Wien. klin. Woch., 1908, xxi, 835) says that the result is transient and may be repeated, thus stimulating the heart action and the vasomotor center until the organism can bring up its reserves. The prospects are best in acute anemia. TREATMENT gi without a pillow, and that the foot of the bed be raised on blocks. This position facilitates the return of the blood from the extremities and increases the quantity supplied 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 splanchnic area and the resulting lowering of blood-pressure in the general circulation having been com- batted, 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 splanchnic arteries and an accompanying dilatation of the peripheral vessels, in- cluding 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; the active, isolated parts and derivatives, of which there are many in the market (digitalinum verum, digitalin, digitoxin, digalen,' soluble digitalone, etc.), are clinically uncertain and are apt to be unstable. Insomuch as absorption by mouth is probably interfered with in ^ Jour. Am. Med. Assoc, Sept. ii, 1909, liii, 869. 92 shock: causes, symptoms, treatment 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 stimulating effect in profound cardiac exhaustion.^ It is given from a hypodermic needle into a vein of the elbow-flexure in a dose of gig- gr., to be repeated in an hour if necessary. Slapping the diaphragm and dilating the anal sphincter should be resorted 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. Amy! nitrite should be volatil- ized under the patient's nostrils. This increases the cerebral circula- tion. Rapidly acting stimulants, such as ammonium carbonate, camphor, ether, or aromatic spirits of ammonia, may be given subcutaneously. Massage of the Heart. — If the patient collapses on the table dur- ing 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 min- utes elapse before the heart responds to the massage. Artificial respira- tion should be maintained 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 increas- ing 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 England. M. V. Cacko\ic (Ueber direct Massage des Herzens als Mittel zur Wiederbelebung, Archiv f. klin. Chir., 1909, IxxxA'iii, 910) reports a case of death under chloroform in a boy nine years old, in which the heart was exposed and massaged. He found 45 cases in the Mterature and analyzes the details and results. ^Massage was practised for resuscitation in 17 cases, 9 of which completely recovered. In the rest the heart failed again after working for a longer or shorter inters'al. Iii all but 5 of the cases the syncope occurred under an anesthetic. The best results were obtained by massage applied from below the diaphragm. It failed in other cases with the transdiaphragmatic technique. 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. ^ A. K. Stone, Boston 'Sled, and Surg. Jour., 1909, clxi, 586. MASSAGE OF THE HEART 93 The prospects are more favorable for direct massage of the heart when the syncope is of circulatory rather than respiratory origin. Pike, Guthrie, and Stewart (General Conditions Affecting Resuscitation and the Resus- citation of the Blood and Heart, Jour. Exp. Med., Lancaster, 1908, x, 371) state that resuscitation of the heart may sometimes be accomplished by extrathoracic massage and artificial respiration, but only during the period that the heart continues to beat; direct massage of the heart is the most certain method at hand for resuscitation. A proper blood- pressure is necessary for its continued activity. Anesthesia and hemorrhage make resus- citation more difficult than asphyxia alone. White (Maryland Med. Jour., 1908, li, 380): Child of twelve years stopped breathing under chloroform. Artificial respiration and other means of no avail. Abdomen incised and subphrenic massage instituted at rate of 25 per minute. Heart-beat reappeared feebly at end of one minute, then regularly. Convulsions appeared and child died twenty hours after operation. Mocquot (La Reanimation du Coeur, Revue de Chir., Paris, 1909, xxix, 696; 924; 1184) reviews all cases on record and adds unpublished cases. Best mode of access is through the abdomen. Complete success in 9 cases out of 22. Two complete successes with massage through the chest -wall. 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. If there is effusion into the pericardium the chances of success are very slight. 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, with- out 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. Adrenahn is a valuable aid in stimulating the heart to contract, associated with massage. In asphyxia it is more difficult to revive the heart action than in syncope. Besides massage and insufflation, which suffice for the ordinary white syncope, intravenous injec- tions of adrenalin and transfusion are required. 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 ovj; Brandy o ij ; Tr. digitalis W^', Ammon. carb gr. xx; Tr. opii nix. — 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 a^•oided. By all means possible the circulation must be efficiently maintained until the vasomotor centers have recovered from their anemia and exhaustion. CHAPTER VIII COMA: DIABETIC; 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 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 contra-indication 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 an almost 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 etherization 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 as long as possible, and their performance should be as rapid as the surgeon's technique will allow. Carbohydrates should be administered after the operation with the hope of staving off coma. There is no question but that the postoperative administration of carbohydrates in reason- able amounts assists the healing of wounds in diabetics. When the diabetic cotna 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 94 UREMIC COMA 95 four to tAvelve 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 becomes 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 eclampsia in pregnant women, uremia in patients with chronic Bright's disease, anuria, dependent upon a tying in of the ureter by mistake, and finally uremia in cases where an only kidney has been removed or a nonfunctionating kidney left behind. Eclampsia rarely occurs primarily after an operation. Oftentimes the uterus may be emptied by operative means as a result 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 elderly persons with impaired renal functions ether should always be used with circumspection. A prolonged anes- thetization in persons presumably normal may be followed by the exhibition of casts and albumin in the urine. In these patients after an operation there may be a marked increase in the amount of albu- min, renal excretion may gradually diminish in quantity and 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 is especially 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 ure- ters, dilated renal pelvis, all containing more or less pus, and a notably. decreased secreting substance in the kidney. These cases after operation ^ 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. g6 coma: diabetic; uremic, collapse; sudden death may react poorly, their urinary secretion may diminish 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 condition was diagnosed, he performed hysterectomy. In the first nineteen hours after the operation 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 cathar- sis. At the end of seventy-four hours she was catheterized, and ij ounces of urine obtained. From this onward she improved. Hall also operated on a patient, aged sixty-three, and performed abdominal hysterectomy for cancer of the uterus. Her arteries were atheromatous. 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 albumin. The urine gradu- ally decreased in quantity, until at the end of fifty hours there was scarcely any secreted. She remained in a condition bordering 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 these cases the condition is apt to develop rapidly and death may occur within twenty-four hours. The temperature falls to subnormal, there may be profuse perspiration, but 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 ends 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 subcutaneously, 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. ^ every four hours, three to ^ Am. Jour. Obst., 1898, ii, 679. Quoted by McKay, Section Cases, N. Y., 1905, 486. SUDDEN DEATH 97 six doses. Patients with nephritis should always be anesthetized with care, using a minimum amount of ether. For postoperative nephritis, see Chapter XVIII, p. 169. 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. The pulse is somewhat rapid and weak, but the temperature is about normal and the color is fair. Ordinarily collapse and shock are classed together. Collapse may occur, however, in nervous patients particularly, on comparatively slight provocation. Under these circumstances the milder method of treatment suggested in the last chapter will be of avail in restoring the patient. SUDDEN DEATH It sometimes happens in the practice of the most experienced sur- geons that a patient who is apparently progressing favorably, 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. The recent article on the subject by John Babst Blake^ is worth quoting at length : " Emotion is very often a potent factor in originating the processes w^hich result in sudden death. " 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 exertion. We have, therefore, in the routine of modern surgery, reproduced with considerable accuracy the conditions under which a majority 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 coincidental, and would have occurred with equal certainty under any other procedure which reproduced these precise conditions? " Sudden deaths before, during, or immediately following operation ^ Ann. Surg., 1909, 1, 49. 7 98 coma: diabetic; uremic, collapse; sudden death 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 sufi&cient cause. It is notorious to those who concern themselves with anesthesia that ether and chloroform are frequently blamed for catastrophes 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 cannot 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 patho- logic conditions which predispose to it and the circumstances 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 circumci- sion. 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 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 sake of the patient's safety as well as comfort. (Dr. Crile has reported an admirable method of doing this in thyroid cases.) " (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 analyzed and the essential facts brought to the attention of the medical public." 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 cehotomies. It is especially common after operations upon the uterus and adnexa and in operations about the rectum. Although thrombophlebitis in itself is a trouble- some 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 appendectomy,^ as well as opera- tions upon the female pelvic organs,^ and after delivery.^ Thrombosis occurs usually between the tenth and twentieth day. It is most apt to occur in debilitated or anemic subjects, those who have suffered from profuse and prolonged menorrhagia due to the presence of a submucous fibroid, or those who have been subjected to a pro- longed operation. Its etiology has been the subject of discussion. It is generally considered that it is the result of sepsis, and that it represents a defen- sive action on the part of the organism against infection. Sometimes a clot which forms in the ordinary course of the obliteration of a vessel behind a ligature will become infected from wound sepsis and will dis- integrate, or particles may be carried in the circulation to other points and there set up thrombosis anew, or in cases of stitch-abscesses infection ^ SarloH, Gaz. deg. Osp., 1909, 121. 2 Bland-Sutton, Lancet, 1909, i, 147. ^Hofmeier, Cent. f. Gyn., 1909, xxxiii, 21. 99 ICX) THROMBOPHLEBITIS — SUBDIAPHRAGMATIC ABSCESS may spread to the femoral and iliac vessels along branches of the super- ficial 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. 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 rarely comes on imtil 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 disin- tegrate. 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 opera- tion 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 clot becomes infected, diagnosis wiU usually make itself evident on vaginal examination by the presence of tenderness and swelling on the alTected side. In addition to this spot of tenderness in the iliac region the leg on the same side may be swollen and painful. Usually the pain will start in the calf of the leg, the pulse rise to 120, and the tem- perature to 101° or 102°, and there may be a mild initiatory chill. The whole limb may become so swollen and excessi\-ely painful that the patient will not allow it to be moved. The infected vessels will stand out like cords to 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. Prophylaxis against thrombophlebitis should always be an import- ant consideration in the after-treatment, particularly of gynecologic cases. The heart action should not be allowed to become weak. Raising the foot of the bed in the Trendelenburg position will lessen the accumu- lation of blood in the pelvic veins and will tend to stimulate the vital centers. The patient should not be allowed to lie upon her back for any long period of time without changing her position. She may be ^ A. Fraenkel, Archiv f. klin. Chir., igoS, Ixxxvi, 531. PULMONARY EMBOLISM lOI given breathing exercises every hour; the arms and hmbs should be elevated frequently, and the intestinal functions started early. Fluids by mouth, rectum, and subcutaneously will reduce the tendency to thrombosis. An excessive milk diet should not be allowed on account of the calcium which milk contains. 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: I^. Sodium citrate gr. xlviij; Oil of peppermint iTjjij; Distilled water oiv. — ^M. 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 applica- tions 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 is practically always consecutive to throm- bosis in the deep epigastric or pelvic veins and in the veins of the lower extremities or in the mesenteric veins, frequently following operation. 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-cur- rent 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. ' Lecene, Archiv. des Maladies du Coeur, March, 1909. I02 THROMBOPHLEBITIS — SUBDIAPHRAGMATIC ABSCESS 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. Embolism occurs in from 20 to 30 per cent, of all cases of post- operative thrombosis. It comes on, as a rule, any^vhere 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 ^ of i per cent, of all celiotomies, and Ranzi, in y-Q of i per cent. Frequently 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 movement to accommodate himself in bed, or it may be due to getting out of bed for the first time, sitting up in bed, and particularly straining during defecation. Death may occur within a few minutes from the first symptoms of the embolism, or several hours may elapse before the fatal termination.^ That fatali- ties 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, becomes cyanotic, and cries out from a sense of suffocation. His face takes on an anxious look, he becomes restless and complains of pain, he gradually becomes pallid, the pulse weakens and becomes inter- mittent, and the respiration gasping. Unconsciousness develops and death ensues. Recovery depends upon the size and the situation of the embolus. ^ Mauclaire, Archiv. Gen. de Chir., June 25, 1908. ^ Postoperative Embolism in the Lung, Archiv. Gen. de Chir., iqoq, 221. ^ Ranzi, Postoperative Lung CompHcations of the Nature of Embolism, Archiv f. klin. Chir., i9o8,lxxxvii, 350. * Postoperative Thrombosis-embolism, Archiv f. klin. Chir., tqoS, lxxx\-i, 531. ^ C. L. Gibson, Pulmonary Embolism following Operation, Med. Record, 190Q, Ixxv, 45. PULMONARY EMBOLISM lo O If only one branch of the 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 vi^hich is cut off from the circula- tion 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 opera- tion. " 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 ligated 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. Patients should not be rushed out of bed. After confinements, opera- tions about the rectum and operations on the uterus and adnexa, par- ticularly w^here the possibility of sepsis exists, and in other cases where predisposition might exist, the patient should not be allowed to exert herself in any way for a week or more. Her position in bed should be changed frequently, and light respiratory g3^mnastics practised in bed. 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 neglected. Stimulation should be supplied by means of hypodermic injections 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-botUes and the ^ Bartlett and Thompson, Occluding Pulmonary Embolism, Ann. Surg., 1908, xhii, 717. I04 THROMBOPHLEBITIS — SUBDIAPHRAGMATIC ABSCESS room should be kept absolutely quiet. Complete repose should be en- 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, w^hich, 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 embolism by the bold procedure of cutting down upon the artery and removing the embolus has been urged, and the operation actually performed with sufficient success as to promise some advantage in suitable cases.^ The advisability of operative interference depends upon the rapidity of the course and the accuracy of the diagnosis. As to diagnosis, the picture is characteristic. Usually there is a sudden collapse, pallor, lividity of the lips, loss of pulse, and deep and distressed respiration. In addition there may be minor indications, such as a previous opera- tion 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 generally supposed. Of 9 cases, Trendelenburg found that only 2 died suddenly 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 second rib and a vertical incision on the left side of the sternum. The part of the second rib in addition to the sternum is resected for 10 to 12 cm. A ver- tical 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 afterward drawn upon. Work must then be proceeded upon with the utmost celerity. He incises the pul- monary artery, pulls out the- embolus with a pair of forceps, and im- ^ Bidwell, Pulmonary Embolus and Thrombosis after Laparotomies, Practitioner, Feb., 1909. 2 Central, f. Chir., 1908, No. 35, Beilage. ^ See Ann. of Surg., 1908, xlviii, 772. HEART-CLOT 105 mediately closes the incision in the arterial ^Yall 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 survived the operation for thirty-seven hours, and then died from postoperative hemorrhage from the internal mammary artery. Sievers, following the Trendelenburg technique,^ removed an embolus in a pulseless patient, who survived the operation fifteen hours. Tren- delenburg reported a 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 tu- multuous 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. In cases which end fatally differentiation between heart-clot and pulmonary embolism cannot be made certain without autopsy. In ^ Fall von Embolic der Lungenarterie nach der Method von Trendelenburg operiert, Deut. Zeit. f. Chir., 1908, 93. ^ Operationen der Embolie der Lungenarterie, Deut. med. Woch., 1908, xxxiv, 1172. ^ Jour. Amer. Med. Assoc, 1909, 52, 1661. * Busch (Ueber plotzliche Todesfalle mit besonderer Beriicksichtigung der Indikations- 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 instantaneous. 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 symp- toms persisted ten minutes to three hours before death. Autopsy revealed embolism in 6, and conditions 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. Korte advocates, if the symptoms of embolism present themselves, morphin to tranquilize the respiration, digitalis injected into the vein (better strophanthin). Mean- while preparation should be made for the Trendelenburg operation, which should be resorted to if other measures do not work. Io6 THROMBOPHLEBITIS — SUBDIAPHRAGMATIC ABSCESS 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 operation for repair of hernia. Sac excised; found to contain most of omentum, trans- verse colon, and many coils of small gut. Omentum tied off in mass with interlocked sutures and intestines freed with much difficulty from sac. Adhe- sions hgated, peritoneum closed, and fibers of rectus muscle brought together with mattress sutures. Rectus sheath closed in the same way. Good ether recovery, there being almost no vomiting. Subsequent convalescence up to the tenth day uneventful; normal temperature and pulse throughout; 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; sub- cutaneous 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 loo; 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 appeared even to the end. He died in about forty minutes from the first onset of symptoms. 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 appendicitis operated upon at the Mt. Sinai Hospital. Munro^ reported a series of 9 cases. The condition appears to originate in the thrombosis which naturally occurs in the appendicular veins after their obliteration. There is 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 com- plicated by abscess formation. The pathology has been studied by Thompson^ in a series of 8 cases. ^ New York Med. Record, 1903, June 27. ^ Boston Med. and Surg. Jour., 1902, 81. ^Boston City Hospital Med. and Surg. Reports, 13th series. SUBDIAPHRAGMATIC ABSCESS I07 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. It is most likely to be confused with a secondary peritonitis. It should always suggest itself whenever a patient, shortly after an appendectomy, develops chills and an irregular high temperature. Other signs to be looked for are tenderness along the outer border of the right rectus muscle, enlargement of the spleen and liver, with, in some cases, jaundice and rapid and profound prostra- tion. 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, operation offers little hope for relief. Nevertheless, exploratory operation should always be performed and abscesses evacuated and drained. 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. 1 See A. Lawrence Mason, Subphrenic Abscess, Boston Med. and Surg. Jour., 1893, cxxix, p. 217, for history. See alsc^ Catz and Kendirdjy, Les Abces Sous-phrenicjues, Rev. de Gynec. et de Chir. Abdom., 1908, xii, 469. Io8 THROMBOPHLEBITIS — SUBDIAPHRAGMATIC ABSCESS 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 quantity, shifting dul- ness 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 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 difficulty in diagnosis, where the history of the case does not give any assistance, is compHcated 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 \ascera. 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 axillar}- 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 tubino; is usuallv more efficient than crauze. CHAPTER X ARTIFIQAL RESPIRATION; OXYGEN; ELECTRICITY 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 exciting rhythmic pressure on the sternum two or three times will usually suffice to start up respiration. If chloro- form is being used, the outlook is more serious, as with this agent, in contradistinction to ether, the cardiac action may cease simultaneously 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 unable to carry on the circulation. Practically, then, if the heart is beating 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 inhaled and the heart has been weakened thereby, and has ceased to beat or is feebly fluttering, the prognosis is not good. In recovery from the anesthetic the proposition is somewhat different. Here the failure in respiration arises from some mechanical interference. Fatal accidents have resulted from such foreign objects as plates of false teeth, plugs of gum, or tobacco falling into the air-passages. The common causes of postanesthetic asphyxia are the aspiration 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 artificial respiration: the supine and the prone. The 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 — attempts to imitate natural inspiration by increasing the capacity of the chest. This is 109 no ARTIFICIAL respiration; OXYGEN; ELECTRICITY efifected by drawing the arms upward toward the head (Fig. 37). Ex- piration occurs as the arms are gradually lowered (Fig. 38) again to the sides, and is completed by exerting pressure on the thorax (Fig. 39). Fig. 36. — Artificial Respiration on the Table. One man at head holds jaw forward and exerts rhythmic traction on tongue; one man at each side manipulates an arm. This maneuver requires three persons — one standing on either side to manipulate an arm and one forcibly to hold forv\^ard the tongue by Fig. 37. — Artifk lAL Respiration. Supine Method. Arms extended. Inspiration. means of a 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 III 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 Fig. 38. — Artificial Respiration. Supine Method. Beginning expiration. one side, and arms at right angles to the body. The operator kneels at his side and places his hands over the lowest ribs of the patient, one on either side. Then, swinging slowly forward and backward, by r-.-5.fi||f Fig. 39. — Artificial Respiration. Supine Method. Completed expiration. Arms flexed, compression of chest by pressure on elbows. 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 ^ Jour. Amer. Med. Assoc, 190S, li, Soi. 112 ARTIFICIAL RESPIRATION; OXYGEN; ELECTRICITY elasticity 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 be held; mucus, vomitus, or blood drain readily from the mouth.^ Rough artificial respiration may be the finishing touch. The first move should always be expiratory, not inspiratory. Rapid and violent efforts may lead to dilatation of the heart. Laborde- introduced the method of reflex stimulation of respiration by means of rhythmic traction on the tongue. The tip of the tongue is seized in tongue-forceps, and it is pulled out its entire length rhythmically, 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 pro- cedure 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 synchron- ous with inspiration; othenvise, before artificial respiration is com- menced, a free airway should be insured by some means of holding for- ward the tongue, such as tying a silk thread through its tip and about the subject's ear. A recent method of resuscitation consists in passing a stream of oxygen through a laryngotomy or O'Dwyer intralaryngeal tube.^ 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 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 also A. Keith, Mechanism Underhdng the Various Methods of Artificial Respira- tion, Lancet, 1909, i. ^ Les Tractions Rhythmees de la Langue, Paris, 1S95. ^ See F. Kuhn, Resuscitation in Apparent Death by Means of Oxygen and Intubation, Therap. Monats., Nov., 1908, xxii. ^ 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 RESUSCITATION II3 artery. Normal saline, Ringer's or Locke's solution, 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 pierced 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 with the injection of the adrenalin, the rhythmic pressure on the thorax is brought to a maximum. The resulting arterial circula-. tion distributes the adrenalin and spreads its stimulating contact with the artery, bringing a wave of powerful contractions and producing a rising arterial pressure. When the cor- onary 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. Ringer's solution has the following composition (Jour, of Phys., Lond., 1885, vi, 361): I^. 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., Lond., 1895, xviii, 332): ]^. CaCl2 0.024 per cent, (crystals) KCl 0.042 per cent. NaHCOj 0.03 per cent. NaCl 0.9 per cent. Dextrose o. i per cent. 8 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 mxilk, 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 t^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 alimentary 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,, 114 DIET AFTER OPERATION II5 are extremely likely, under the conditions of intestinal stasis which exist after a celiotomy, to be improperly digested and give rise to fer- mentation. Thus milk, even when peptonized, is not to be considered a proper food for mouth-feeding after abdominal operations. It is not digested by the stomach, and as curd it may pass a long way down the intestines and cause flatulence. Peptonized milk has not these drawbacks, but patients rarely like 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. 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, 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, slightly warmed, with a pinch of salt. The proprietary beef-extracts are hardly worth considering. 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 by patients to whom whole milk is obnoxious. Its food value is about that of skimmed milk, and it consists, besides water, chiefly of albumin, 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 inocu- ^ Folia Therapeutica, Jan., 1909. Il6 DIET AFTER OPERATION lating 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 remove 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 coimt 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 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." ^ "It is difficult to understand why putrefactive bacteria should not be present in the milk when tablets are used, but should be present in the same milk when the tablets are not used. 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 unnecessary. 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 wdth 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.' Those who have confidence in the merits of the Bulgarian bacillus of Metchnikoff can procure one of the preparations containing this bacillus and then proceed in the same manner as mth the butter starter." (Jour. Amer. Med. Assoc, editorial article, Jan. 30, 1909, lii, 397, quoting the results of Heinemann; Lactic Acid as an Agent to Reduce Intestinal Fer- mentation, Jour. Amer. Med. Assoc, 1909, lii, 372 ). ^ On Disorders of Assimilation, Digestion, etc., London, 1901, 108. DIET AFTER OPERATION II7 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 injured, 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, 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. no DIET AFTER OPERATION 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 profession. I believe it to be unwarrantable during convalescence for the doctor to undertake to prescribe with minute exactitude, irrespective of the pa- tient'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 individual is, in a sense, a specialist on his own digestion. He has information 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 ex- hibited. It is better, therefore, in 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, or to the selection of articles of diet not to the patient's taste. It is the function of the nurse to study the likes and dislikes of her charge, and to yield to them so far as her instructions will allow. If her orders are vague or insufficient 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 discre- tion. Meals should be served at regularly appointed intervals, for a patient 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 appearance 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- THE SERVING OF FOOD II9 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 limit 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 remnants 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 also Chapter XXX, p. 273) in the course of a few days after receiving a severe injury or undergoing an operation, even though he has indulged in no stimulation for some weeks previously. When the delirium is marked and comes on without warning, the prognosis is generally regarded as poor, and no means should be omitted which can be of aid. Usually, however, it takes some days to develop, and the patient becomes nervous and has ^ well-defined premonition of his condition. In cases of emergency alcohol should always be used, and 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. In an acute case it is well to begin by emptying the stomach and bowel by purgation and inducing vomiting. Large quantities of water should be given for its diuretic action. Carbonated waters and ginger ale act to relieve the craving for stronger drink. Next to rest, the most important object is to maintain the patient by sufficient nourishment; this is usually administered with some difficulty, as the appetite for food is usually entirely wanting. If the patient is comatose, it will often be necessary to resort to the stomach- tube or rectal enemas. The stimulating effect of the alcohol on the gastric mucosa may be simulated by the ad- dition of strong spices, ginger, or capsicum to the diet. The diet should be liquid or semifluid and given frequently in small quantities. The nervous system is always strengthened and soothed by abundant nour- ishment. Special diets are prescribed where indicated under special opera- tions in Part II. In the Appendix are given a number of food recip-ss 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 equilibrium 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 little 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- lows : 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; in this way gravity is brought to aid in the retention of the enema. A long, soft rectal tube, about 32 French in diameter, with open end and two lateral eyes, 120 THE TECHNIQUE OF ADMINISTERING A NUTRIENT ENEMA 121 is employed; in children an ordinary soft-rubber catheter may be used. The tube should be so soft that it will not do damage to 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 intestinal 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. 148.) The veins 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 valves 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 Enema, Jour. Amer. Med. Assoc, 1909, liii, 426) concludes that only in rare cases of abnormal development of the sigmoid 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 a.-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; (2) when retention of fluid is desired, as in administering saline solution, oil, nutrient material, etc. The attempt to pass the tube higher into the bowels is not only unnecessary, but because of the coiling that ine\itably occurs such a manipulation tends to produce irritabihty of the bowel. This, of course, will very probably cause expulsion of the fluid. 122 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 morning, 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 twice 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 frequently 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 efficiently 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 1 23 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 with 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, I will attempt to summarize them: 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 124 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 nutritive value 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. Whisky, 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 slightly 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. FORMULAS FOR NUTRIENT ENEMAS 12$ 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. In many patients the institution of rectal feeding is marked by satisfaction of hunger and thirst, mental relief, and apparent mainten- ance of general condition or even increase in weight. Nevertheless, 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 starva- tion, for it is now generally agreed that the limit of absorption per rectum is about one-fourth the nourishment required to maintain meta- bolic 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 protracted vomit- ing. Some of the beneficial effects of nutrient enemas may be assigned to the psychic influence of the procedure. 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 two 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 or 3 pinches (2 gm.). Sugar and milk: Grape-sugar ' 2 oz. (60 gm.); Peptonized milk. 8 oz. (250 cc). Leube: Milk 3 oz. (250 cc); Peptone 2 oz. (60 gm.). 125 RECTAL FEEDING Riegel: Milk ..3 oz. (250 cc); Egg 2 or 3; Salt 2 or 3 pinches; Red wine i tablespoonful. Boas: Milk \ 8 oz. (250 cc); Yolk of 2 eggs Pinch of salt Red wine . , . . . i tablespoonful; Starch or flour i tablespoonful. Boyd: Yolks of 2 eggs Pure dextrose i oz. (30 gm.) ; Salt 7 gr- (5 gm.); Peptonized milk to 10 oz. (300 cc). Baumgarten: Dry peptone Sugar of milk (of each) i oz.; Alcohol I oz.; Tincture of opium 10 drops; Water to make 9 oz. The following formula has been recommended by Dr. Ehrenfried: 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 wine. 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. CHAPTER XIII GAVAGE AND OTHER FORMS OF ARTIFICIAL FEEDING Gavage is the name given to the method of feeding a patient by pouring liquids through a tube into the stomach. It is not commonly used in postoperative treatment, but it may be indicated: 1. In infants or young children who persistently refuse food, or are too weak to take nourishment in sufficient quantity. 2. As an alternative for rectal feeding in persistent vomiting after an anesthetic, provided there is no stomach lesion. Fig. 40. — Lavage, First Step. Introduction of tube. Fig. 41. — Lavage, Second Step. Tube in stomach. Wash-water being poured into funnel. 3. As a method of forced feeding in acute infections, coma, delirium, insanity. 4. Where swallowing is interfered with, as after operations on the head and neck, in diseases of the mouth, lockjaw, or postdiphtheritic paralysis. The technique and apparatus are the same as for gastric lavage. A highly polished soft-rubber tube, about 30 to 32 French, should be 1'27 128 GAVAGE AND OTHER FORMS OF ARTIFICIAL FEEDING selected, of medium flexibility, with a conic end— having two open- ings, one at the end and another on the side, about f 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 piece 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 r-^m^ — w, in a sheet and held seated on the W^^ nurse's lap, with its head sup- ^^ Hm ported on her shoulder, or laid flat on its back on a table. The tube should be held some inches from the tip, and with one motion it should be passed rapidly over 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 several k ' ■ ' rapid swallowing movements and g.,. ' can resist the impulse to seize the r^. tube and pull it out, all will be well. If the tube is held too near the tip, the tip will be in 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 advisable 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 nervous patients will experience respiratory embarrassment the first time the tube is ernployed. 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 persons with cardiac disease. Fig. 42. — Lavage, Third Step. Suction and siphonage. NASAL FEEDING 1 29 The tube is passed to the point where hquid 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 tightly 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 two 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 burn 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 gently into one nostril, and held in place while the fluid is poured in. Just sufficient 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 of setting up irritation or inflammation of the middle ear by way of the Eustachian canal. 9 130 GAVAGE AND OTHER FORMS OF ARTIFICIAL FEEDING 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 hne, there wiU 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 lar}Tix. This is the only method now used and advised by Dr. John H. McCol- lom at the Boston City Hospital, South (Infectious Diseases) Depart- ment. 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 dis- tilled water fulfils these conditions well and may be given freely. Olive oil has been recommended in doses of 100 cc. injected in divided por- tions 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 s}Tingej 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. AFTER LARYNGEAL OPERATIONS I3I 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. 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 tube is well borne, as a rule, and interferes in no way with deglutition after the patient has become accustomed to its pres- ence, provided it be of the right size and well adjusted. I know, for instance, of one patient, a well-nourished negro, who has worn a tube for complete obstruction for twelve years. At lirst, apprehension 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 the feeder, to the spout of which a rubber tube may be attached, the difficulty is usually readily overcome. Until the patient can begin to take semisolids, fluids should be given in small quantities at frequent intervals. 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. 132 GAVAGE AND OTHER FORMS OF ARTIFICIAL FEEDING 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. \^ery 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 hkely 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. Oftentimes the position 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. 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 the catheter is being used as a routine, once every eight hours is fre- quent enough. This routine, once established, 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 w^ay, or if adhesions between the bladder and other organs have been separated, distention should be avoided. Accord- ingly, the catheter should be passed six hours after operation and every 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 bladder, with skill and 133 134 catheterization; cystitis; catheter tever 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 never 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 be 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- arius should be sponged with weak corrosive. Then, with the fingers Fig. 43. — Catheterization or the Female. Cleansing the parts. of the left hand 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. For the male urethra, the best catheter for routine use and in in- experienced hands is that of soft rubber. This ordinarily can readily 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 experienced at all, it is at the neck CATHETERIZATION I35 of the bladder, where spasm of the sphincter prevents the catheter from entering. If continuous hght pressure is exerted on the catheter, the spasm will gradually yield and allow the catheter to proceed. Catheters of metal are sometimes advantageous and even necessary, as, for instance, in prostatic cases. They are readily and completely sterilizable. A polished silver catheter is probably, in skilled hands, the most agreeable of all catheters to the patient. On account of the possibility of tearing the urethra, however, its use should never be allowed except by trained and competent persons. Ordinarily, the gum- 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 Fig. 44. — Catheterization of the Female. Passing the catheter. 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. The only 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 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 solu- tion, that the urethra may not be irritated by the formalin. 136 catheterization; cystitis; catheter fever 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 difl&cult to clean off. The excess of the lubricant should be wiped ofif on the meatus, so as to insure that none be carried into the bladder. 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 not appear ordinarily until a week or more has passed from the time the use of the catheter was begun. 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 usually found associated with one of .those already mentioned. The catheter may be clean and yet carry infection into the bladder, for the healthy urethra is the normal habitat of several species of bacteria which are capable of producing cystitis. A frequent source of cystitis is by contagion from contiguous organs. In the female particularly, as catheterization is commonly practised, it is extremely likely for the catheter or the fingers of the nurse to be con- taminated by organisms from the rectum or vagina. Cystitis is especi- ally likely to occur where retention of urine exists. In the female susceptibility seems to be increased during menstruation or the puer- perium. The earliest symptoms of acute cystitis are increased frequency and urgency of micturition, and pain. The patient feels compelled to CYSTITIS 137 urinate immediately the desire arises, and the expulsion of the last few drops is accompanied by sharp, scalding pain. The irritable condi- tion 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 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 w^all 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 by rectum or subcutaneous infusion, with, if necessary, the exhibition of such drugs as potassium citrate, or acetate, or digitalis. The treatment of postoperative acute cystitis may be considered under the following heads : prophylactic, medicinal, local, and operative. Prophylactic. — 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 impossibility of asepsis and its danger of 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 advocated. 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 dimin- ishes 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 sup- pository, with extract of belladonna, of each, { gr. For intense tenesmus 138 catheterization; cystitis; catheter fever 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 7J gr. every four hours for some days. As this group of drugs, whose activity depends upon the generation of formaldehyd, tend 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 efiScient in doses of 10 gr. If the urine is strongly acid, alkahs, 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- 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, bottled 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- CYSTITIS 139 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 necessary gradually to work up to the stronger antiseptics. Argyrol may be used in I : 1000 solution; silver nitrate, i : 5000, gradually increasing to I : 500; potassium permanganate, i : 5000, gradually increasing to I : 1000; or carbolic acid, i : 1000. Of these, the most commonly employed is silver nitrate; when pain follows its use, it must be aban- doned. Irrigations should be practised every other day, daily, or twice a day, depending on 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 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 to 10 per cent, argyrol solution, to remain until the next urination. 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. Sometimes in the male it is necessary to afford drainage by means of a suprapubic cystotomy or a perineal urethrotomy, and in the female by dilatation of the urethra and suprapubic or vaginal cystotomy. Curettage of the bladder is rarely indicated. (For the after-treatment of these operations, see Part II, under special headings.) I40 catheterization; cystitis; catheter fever 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 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 directly or very shortly 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 ^ Paul Thorndike, Disturbances "Which May Follow Instrumentation upon the Male Urethra and Bladder, Com. Mass. Med. Soc, 1892, v, 401; see also L. J. Hammond, Catheter Fever, Ann. Surg., 1909, xlix, 90. CATHETER FEVER I4I 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 appetite, suffers from thirst, and feels wretched. Evidences of a cystitis are present. This condition may persist for weeks and yet the patient recover. On the other hand, he may die. In the fatal cases autopsy shows ad- vanced ascending disease of ureter and kidney, such as dilated ureter, contracted bladder, hydronephrosis and pyonephrosis. Two conditions are essential to bring about this condition : one is a preexisting degen- eration 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 infection 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 geni to-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 immediately after the instrumentation and before sufficient 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 142 catheterization; cystitis; catheter fever 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, 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 geni to-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, DISTENTION, 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- sufiiciency of water, should sufiice. 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, partly from lack of energy and of desire on the side of the patient, and it is not infrequent that the fecal 143 144 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 recovery. 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 responsibilit}' 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 evacuate their bowels daily, or even twdce 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, under ordinary circum- stances, allowing the intestinal residue of a person on a fairly free diet to accumulate more than forty-eight hours. CATHARTICS I45 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 aU, is to wet the inside of a wineglass, pour in a little 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, w^ill 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 little 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 advantage in the occasional use of laxatives, 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 give these drugs in larger doses or to employ purgatives. These range from ^ Berthoumeau and Daguin (Purgative Properties of Phenolphthalein, Prcsse Medicale, Paris, 1908, xvi, 378) re\'iew the literature on this comparatively new agent and rei)ort ex- tensive personal 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. (yi to 12 gr.) it purges without griping. The laxative dose is 4 or 5 gr. or less. 10 146 CARE OF THE BOWELS Epsom salt and calomel to the drastic croton 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^ to -|- 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 sodium and potassium (Rochelle salt, usually administered as pulvis effervescens compositus or Seidlitz powder) . These act, not by irritating 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 practically insolu- ble), induces increased peristalsis and the whole is evacuated. AU these must be given in solution; if, however, the solution is weak, or if ^ W. F. Boos (Magnesium Poisoning, Boston Med. and Surg. Jour., July 22, 1909, clxi, 122) has shown that magnesium poisoning is probably more frequent than is generally supposed, the true cause of the toxic condition remaining unknown in most cases. Two of the three cases which the author had the opportunity to study were brought to his notice merely through the high specific gravity of the urine. In one case the specific gravity of the specimen obtained was 1070 and in the other loSo. These two cases recovered, while the third case ended fatally. Fraser reports a case of his own, and discusses 6 others which he found in the literature. Five of these 6 cases 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 has made a careful study of the 10 cases now available, and, in addition, has carried out certain experimental work on the conditions which govern the absorption of Epsom salt solutions. He finds that in the absence of hydremia the tendency of mag- nesium sulphate to be absorbed increases with the concentration of the solution, the dry salt being completely 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 sys- tem of excessive water is rational, but perhaps not without possible danger. In the absence of edema or ascites, the object of giving magnesium sulphate can be none other than to produce efficient catharsis. To attain this object without incurring the danger of intoxication from absorption the salt is best given in solutions not exceeding 6 per cent, in concentration. 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. CATHARTICS I47 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 especially after ether is vomiting likely to occur; in either case the salt should be given cold and dilute. Croton oil may be given in doses of ^ 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 incon- venience after other drugs have failed. Elaterin is a powerful hydra- gogue cathartic which acts rapidly by irritation. It is given in the form of the officinal trituration of elaterin, in the dose of ^ gr. The disadvantage of employing the more powerful drugs is that their action is always unpleasant to the patient and the evacuations are loose. Often- times the action of the drug may be continued over an hour or more, so that the patient is annoyed and distressed and may be considerably weakened by frequent watery movements of scanty amount. 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 -| to 2 teaspoonfuls. . The more convenient mode of administration is in the form of suppositories, the officinal 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 efficacious suppository is that made by whittling out a piece of Castile soap to shape. This should be moistened before intro- duction. Digital Bvacuation of Rectum. — If it becomes evident that there is impaction in the rectum to such an extent that these measures 148 CARE OF THE BOWELS 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 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 Bnemas.— When the bowel is filled higher up with fecal matter, it will become necessary to employ larger quantities of fluid, to insert the rectal tube further into the rectum, and to employ somewhat greater care and gentleness in making the injection, so as to insure the fluid being carried into the sigmoid without distending the rectum and thus exciting a desire to defecate. Ordinarily a mild enema will suffice to induce the desired action, and of these plain water, normal salt solu- tion, and soapy water are efficacious, given warm, in quantity about one pint for an adult; or an ounce of castor oil maybe 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. More Drastic Bnemas. — 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 ^ Crandon, Catharsis in x\bdominal Surgery, Boston Med. and Surg. Jour., 1901, cxliv, 639. ENEMAS 149 much more drastic enemas may be employed in conjunction with other means of exciting peristalsis — enemas so irritative that their use should ordinarily be avoided. Such an enema is the suds and turpentine enema : 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. 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 sigmoid flexure. A valuable contribution to the question of the practicability of the high enema is that of Soper (see also Chapter XII, p. 121). 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 150 CARE OF THE BOWELS been disputed by high authorities. Soper's experiments and the ski- agrams show that in many cases, perhaps in nearly all, the tube does not pass beyond the dome of the rectum, and that it is only in except tional conditions of dilatation and hypertrophy of the colon that it can be successfully introduced beyond the sigmoid flexure. If it could go further, there is still difficulty to be overcome before the injection could be carried anywhere near the cecum, as some have claimed. The need of introducing the injection-tube beyond the rectum is prob- ably in most cases an imaginary one. Soper himself says that he has frequently demonstrated the possibility of flushing the entire colon by using a large-caliber (^-in.) short tube. It is certainly 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 in the same issue 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 without it bending or coiling on itself. With the aid of the sigmoidoscope only the middle of the sigmoid can be reached. The practice of allowing 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 pur- pose of causing fecal evacuations, using the fountain syringe or funnel and long tube in the usual way. It is possible, as I have frequently demonstrated, thoroughly to cleanse the entire colon by using a large- caliber (^ 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 evacu- ate, then lowering the funnel until the outflow has ceased, repeating 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 the stiff tube, or the line ^ Editorial, Jour. Anier. Med. Assoc, liii, Aug. 7, 1909. DISTENTION I5I of suture separated, and the enema be poured into the peritoneal cavity — ^\vhich I have knovv^n to happen with fatal result. Likewise, after any operative procedure involving a suture of. the intestine, 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, retroperistalsis may be set up, which will carry the fluid backward with considerable force along the gastro-intestinal tract. DISTENTION After any operation, but chiefly after celiotomies, we are accustomed 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, fermentation 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 some- times increased considerably by air swallowing or "cribbing." With some persons this is simply a nervous habit; after operation a patient may swallow considerable air with the saliva which he is constantly gulping down to relieve the parched feeling in his throat. The gas ac- cumulates in the intestines because the patient will not relax his sphinc- ters 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 in- cision, cannot or will not contract to assist the intestines. As the volume of gas increases the intestines become inflated and stretched, offering less and le-ss 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 152 CARE OF THE BOWELS lump of sugar. Position seems to have an important influence on the ac- cumulation of gas; allowing the patient to turn upon his left side and to draw up his knees wi^l render easier the passage of flatus. ^Slassage 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 soap-suds 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 tendency for flatus to accumulate is always increased and the bowel is less able to expel thf collected gas. Distention goes on until the bowel-wall becomes para- lyzed, and this may prove fatal in itself, or a fatal termination may result from a kinking 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 over- distention. This can be satisfactorily done, as a rule, through the swathe; if there is any question, the swathe should be removed. If the gas has not been freely passed within tvventy-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, and the hot glycerin. 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, DISTENTION 15: 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 applications, either of heat, in the form of flax-seed 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 par- ticularly easy to burn, the skin should be greased with oil 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 tablespoonful 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 trans- verse, 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 rarely if ever due to spasm, but rather to paralysis, and atropin acts but to increase this paralysis. Eserin salicylate is highly commended by some surgeons. It is ordinarily given during or after the opera- tion, in the dose of ^^ gr. I have had no experience with it.^ ^ D. C. Craig, of Boston, has used this drug exclusively and speaks highly of it (The Pre- vention of Postoperative Intestinal Paresis and Adhesions, Amer. Jour, of Obstet., etc., April, 1904; The After-treatment of Abdominal Sections with Eserin Salicylate, New York Med. Jour., March 13, 1905). If the patient is known to react readily to cathartics, he uses -^ gr.; if she is of a constipated habit, -g'-^ gr.; when atony of the intestinal muscles exists, he gives up to 2^(j. The medium dose is -^-q, 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 it is just before the operation, gr. y-g-g-, subcutaneously. The eserin is injected under the skin after the abdomen is opened, as soon as it is evident that no contra-indication 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 e\ident 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 suspect that some more or less septic material is being left behind in the peritoneal ca^^ty, until healing is well established. Moennighoff (Postoperative Gas Distention of the Abdomen with Suggestions for Prevention, Jour. Missouri State Med. Assoc, Oct., 1908) uses eserin salicylate hypoderm- ically in celiotomies as a prophylactic against distention, giving gr. ^'g immediately after the patient has returned to bed. 154 CARE OF THE BOWELS There may arise an acute postoperative dilatation of the stomach and duodenum, apart from dilatation of the intestines. It has been produced experimentally by exerting traction on the mesentery, but air- swallowing, drinking excessive quantities of water, or sepsis may be an element in its causation. Its onset is sudden, with pain and vomiting, which is usually not fecal, and distention, which gives the succussion sound if any fluid is present in the stomach. The pulse and tempera- ture 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. Vomiting should be encouraged. A stomach-tube should be passed and left in situ, and every three or four hours the stomach washed out. The passage of the tube will be followed by the forcible expulsion of gas and fluid with immediate relief. The foot of the bed should be elevated and the patient fed only by rectum. In any obstinate case of tympanites a tube should be passed into the stomach to relieve it of accumulated gas, for in a given case it is usually difl&cult to differentiate distention of the stomach and intestines. (For details of this complica- tion see Chapter XVI, p. 156.) 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. Death in cases of simple distention must be due to the absorption of toxic products elaborated in the intestinal tract, or to the peritoneal absorp- tion of the toxic products of bacteria, which have made their way through the stretched and atonic intestinal wall, without exciting inflammatory reaction in the peritoneiun. itself. On account of these possibilities any case of postoperative t}^mpanites which progresses in spite of treat- ment should be considered operative. So long as the abdominal wall remains soft, the patient being in good condition, there is hope of ob- ^ Heile (Prophylactic Treatment of Inflammatory Ileus, Central, f. Chir., vol. xxx^'i. No. 31, July 31, 1909) states that in all cases of dififuse peritonitis he stimulates peris- talsis by injecting 50 to 100 cc. of warm castor oil directly into a high loop of the small intestine before closing the abdomen. A silk draw-thread closes the small hole made by the needle used in injecting the castor oil. It works more effectively if emulsified with a little soda and water. DISTENTION 1 55 taining 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 later. 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 purpose of allowing the escape of gas, and recoveries after this procedure have been published. The method is unsurgical and the danger of setting 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 shall 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 cavity and it may waU off. CHAPTER XVI ACUTE INTESTINAL OBSTRUCTION; ACUTE GASTRIC DILATATION ACUTE INTESTINAL OBSTRUCTION Acute intestinal obstruction is one of the most discomforting of the sequelae which the abdominal surgeon has to face. Its occurrence is not infrequent and the mortality is high/ 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. Mechanical obstruction is usually caused by adhesions. It may re- sult from kinks or twusts of the intestine upon its mesentery, by intus- susception at the point of an intestinal anastomosis, by the hernia of a knuckle of gut through an opening in the mesentery, or by pressure from a drain. It occurs most frequently in cases of local or general peritonitis where there has been a formation of adhesion bands. It occurs commonly after drained appendectomies where a few firm ad- hesions have united the cecum and an adjacent loop of small intestine. The onset of symptoms is usually late — from three to nine days after operation — and sudden in appearance. There may or may not be severe colicky pains. The passage of flatus ceases and distention develops. The distention is apt to be asymmetric, with visible peris- talsis of the distended coils. Rectal enemas come back as they went in. Vomiting appears early and rapidly becomes fecal in nature. The case at first will suggest peritonitis, but this usually can be differentiated by the lateness of the onset and by the absence of notable rise in pulse or temperature. 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 dis- closes a diffuse septic peritonitis. The formation of adhesions 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 ^ Gibson, Ann. Surg., Oct., 1900, xxix, places it at 47 per cent. ^ Forbes Hawkes, The Prevention of Intestinal Obstruction Following Operation for Appendicitis, Ann. Surg., 1909, xlix, 192. ^ Ann. Surg., June, 1906, xliii. 156 ACUTE GASTRIC DILATATION 1 57 from septic intoxication, and partly to the formation 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 peritonitis. Through a grid- iron 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. 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 chiefly to the doubt that frequently arises over the diagnosis. Usually by the time that the symptoms have de- veloped sufficiently so that there is no question about the diagnosis, the chance of recovery is small. If, after a fair deliberate consideration of the symptoms, the probability of acute intestinal obstruction seems established, operation should be performed immediately. The follow- ing 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) Chills. .(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 condition of the patient. If the operation is undertaken early with the patient in fair condition, without distention, a careful search should be made to unearth and relieve the cause of trouble. On the contrary, with the patient in bad condition, a rapidly accomplished enterostomy per- formed as low down as possible, under cocain anesthesia, may be the most radical course which can be considered. ACUTE GASTRIC DILATATION An acute dilatation of the stomach (gastrectasia, gastric paresis, gastromesenteric ileus) may follow operation. The condition is anal- ogous to distention of the small intestine, which it frequently accompanies, 158 ACUTE INTESTINAL OBSTRUCTION; ACUTE GASTRIC DILATATION and in the majority of the cases probably represents a reflex paresis. Some investigators claim that it is due to occlusion of the duodenum from the pressure of the mesentery which overlies it, and that the dila- tation and ptosis of the stomach are secondary. As this condition (called duodenal ileus or gastromesenteric ileus) is usually to be definitely diagnosticated only at autopsy, it will remain difficult to determine finally in the individual case W'hether 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. The importance of this acute and serious complication 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 fre- quently than we formerly supposed, and that in itself it is very likely to cause death. The possibility of its occurrence must be borne in mind in the after-care of any case in which abdominal symptoms present themselves. Polak^ found that it was recognized in -^jy of i per cent, of 1000 celiotomies Laffer ^ has recently collected 97 cases after operation; 69 per cent, of these occurred after laparotomies. It was 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 extremi- ties. The significance 'of anesthesia in its production is still undetermined. Laffer states that in 20 cases where the anesthetic was recorded chloro- form was used t\velve times and ether eight. Lichtenstein ^ states that it may occur when no anesthetic has been used. It is said to be common in thin, weakly indi\nduals, especially those with general enteroptosis.* Abdominal trauma, errors of diet, the accumulation of gas due to fermentation of retained foods, drinking a large quantity of fluids, especially carbonated waters, and tight ab- dominal binders have all been blamed as the source of this complica- tion. Connor ^ makes the statement that obstruction of the duodenum ^ Acute Gastric Dilatation as a Postoperative Complication, New York Med. Jour., 1909, Ixxxix, 1 1 84. ^ Acute Dilatation of the Stoma'ch and Arteriomesenteric Ileus, Ann. Surg., 1908, xlvii, 533. ^ Akute Magenlahmung, Central, f. Gyn., 1908, xxxiii, 615. ^ Borchardt, Akute Magenektasie.. Berlin, klin. Woch., 1908, xlv, 1593. ^ Amer. Jour. Med. Sci., 1907, cxxx, 345. ACUTE GASTRIC DILATATION 1 59 by the overlying mesentery must be regarded as a factor in the develop- ment of one-third to one-half of all cases of acute gastrectasia, and Polak {op. cit.) states that there can be no doubt but that the Fowler posture favors constriction of the lower end of the duodenum between the root of the mesentery and the vertebral column. Peritonitis may be a factor in certain cases. The onset of the first symptom — vomiting — is usually toward the end of the first twenty-four hours after operation. It practically always occurs within thirty-six hours. I have twice known acute dilatation to occur before sewing up the abdominal wall — once in my own 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 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 — apparently much in excess of the amount of fluid taken. It is usually continuous. 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 occur early, and they depend, among other things, on the loss of body fluids, toxemia, and interference 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 frequently be elicited on rocking the patient from side to side. The distention may be so gre^t as to tear out the abdominal sutures. It is usually unac- companied 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 usually present and may be agonizing. The temperature rises little or not at all, and as the signs of collapse increase, it may become subnormal. There is a shght and gradual 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. ^ Boston Med. and Surg. Jour., Aug. 12, 1909. l6o ACUTE INTESTINAL OBSTRUCTION; ACUTE GASTRIC DILATATION 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 be- come 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 differ- entiate it from peritonitis. The diagnosis can be made absolute by the passage of the stomach-tube. Of a series of 217 cases from all causes, 63 J per cent, died (Lafifer). 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 postoperative diet. No large meals should be allowed while the patient is in bed. Water should be given in small quantities and at first only subcutane- ously 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. Hand- ling of the stomach, and particularly pulling on the pylorus, as has been shown by Kennan,^ favors shock and gastro-intestinal paralysis. 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, because 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 wip- ing 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 introduced 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. It is Avell also to remember that acute dilatation is reported as not infrequently following the application of a plaster-jacket for Pott's disease of the spine. Treatment. — Cases of acute dilatation of the stomach when ^ Gastro-enterostomy and P3-loropIasty, Ann. Surg., 1905, 690. ACUTE GASTRIC DILATATION: TREATMENT l6l 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 exaggerated 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 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. Saline solution under the skin or by rectum should be given freely. Morphin in small doses must be given when indications arise. Stro- phanthin, gr. -^, may be indicated by a failing pulse. Some authori- ties speak highly in favor of the repeated lavage of the stomach with normal salt solution or sodium bicarbonate. Ordinarily this would seem to be contra-indicated. If the stomach can once be emptied by means of posture and siphonage through the stomach-tube, and is kept emptied through the agency of an abdominal swathe and the forbiddance of anything by mouth, as well as occasional repetition of the siphonage, the patient may be expected to recover. 11 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. Instances 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. Sometimes the exercises of a patient in delirium will result in a bursting of some of the sutures 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. 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 the shock within one 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 wound may separate. This will be followed by a hernia of the bowel covered with peritoneum and fascia. Reopening of the wound from sepsis is now fortunately uncommon. The use of the muscle-splitting incision and of the right rectus incision wherever these are practicable obviates in a large degree the possibility of the bursting of the wound in ordinary cases. Wherever a long median incision, however, has to be used, especially if the edges are held approximated only by through-and-through sutures of silk-worm gut, the possibility of reopening of the wound must not be forgotten. The patient must be compelled to lie quietly, coughing and vomiting should be controlled 162 BURSTING OF THE ABDOMINAL WOUND 1 63 SO far as possible, and due care should be exercised in transferring the patient from one bed to another if this becomes necessary. The sutures should always in these cases be reinforced by stripes of zinc oxid adhe- sive 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 surgeon arrives. If the parts are sterile and the wound 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 considerable shock to the patient, but the accident in itself need not be serious. If the parts are jiot sterile, great care should be exercised in seeing that the bowel is thoroughly washed with warm saline solution 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).^ ^ Jour. Amer. Med. Assoc, 1910, liv, 148, 149. CHAPTER XVIII SEQUELS 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 opening the mouth. This is due to the holding forward of the jaw which the anesthetist has found necessary, lest otherwise the tongue would 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 forvi^ard, 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. ii, p. 30). 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 betw'een 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 164 CONJUNCTIVITIS 165 to during or after the operation. This soreness is Hkely to persist only two or three days, and some rehef 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. Burns may be the result of using hot-water bags or bottles w^ithout adequate protection of the skin or using water for washing or irrigation which is too hot. These are sometimes severe and may be serious. Burns 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.^ 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 operating table (Fig. 13, p. 31). 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 kidney performed in the lateral posture. These paralyses are usually ephem- eral, 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.^ 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 1 Van Kaathoven, Twenty-five Hundred Cases of Gas-Ether Anesthesia without Com- plication, Ann. Surg., 1908, xl\iii, 435. 2 A. E. Haisted (Anesthesia . Paralysis, Wisconsin Med. Jour., 1908, vi, 511) gives a series of cases showing various varieties of paralysis following and dependent upon the administration of a general anesthetic. 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. 1 66 SEQUELS OF THE ANESTHESIA 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 prophylactic measure, irrigate the eye thoroughly at once, if possible, with warm water, normal saline, 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 excretion 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 directly 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 POSTANESTHETIC PNEUMONIA 1 67 stimulating effect upon the glands of the bronchi so that the secretion of mucus is increased. The secretion may be so considerable as 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 containing 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 in- spired. The prolonged use of chloroform in a poorly ventilated operat- ing room lighted by gas may induce serious respiratory conditions in the surgeon and attendants as well as the patient. Of all the respiratory complications, bronchitis 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, however, 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 edemu has been reported,^ but this must be considered as dependent on cardiac weakness, associated, perhaps, with the fact that under the influence of ether the pulmonary vessels lose their tone and dilate and thus become more pervious.^ The postoperative occurrence of pleurisy has been rarely noted. The proportion of pneumonia as reported by various observers ranges from 3 in 2400 cases in general (Crouch and Corner, quoted by Mum- mery) to 143 out of 1787 laparotomies.^ The discrepancy between 8 per cent, and one-eighth of i per cent, is to be explained by stating that the English cases were general cases, were etherized by trained anes- thetists, and that all cases of dung complication not evidently due to the ether were not admitted. There seems, however, to be general concurrence on the rarity of the lobar type. Hewitt (Anesthetics) and ^ Nauwerck, Deutsch. med. Woch., 1895, xxi, 121. ^ Lindemann, Centralb. f. allg. Path., 1898, ix, 442. ■ ^ Henle, Verhandl. d. Deutsch. Gesellsch. f. Chir., 190T, xxx, 240. 1 68 SEQUELS OF THE ANESTHESIA W. H. 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. J. C. Munro^ reports that in looo laparotomies 34 patients showed signs and symptoms pointing to trouble in the respiratory organs. Of these, all but 11 could be excluded as being not postoperative pulmonary complications. Of these n, 4 proved fatal, a mortality of ^ of i per cent. This compares favorably with the reported foreign mortality of 3 to 5 per cent., and proves the advantage of careful routine methods in preparation, etherization, and after-care. Practically all these cases, excepting the femoral hernias, were set upright in bed at once, or within a few hours, after operation. The majority were out of bed in forty-eight hours and were given as liberal a diet as they could be persuaded to take. All were encouraged to move the body and ex- tremities, and they were given water liberally to keep down thirst and to prevent the dirty dry mouth that comes with the lack of moisture. The first sign of pneumonia generally appears in the form of a rise in temperature to 101° or over during the second twenty-four hours after operation. The patient generally suffers severely, and in some w^ays the condition resembles lobar pneumonia, although there is neither the profound toxemia nor the high temperatures 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 w^aiting for evidences of cardiac weakness to present themselves. To recapitulate (John Bapst Blake), all postoperative pneumonia is bronchopneumonia; the exceptions to this are so rare that lobar pneumonia after operation is to be considered as a coincidence only. The cause of postoperative pneumonia is usually multiple : (i) Imper- fect etherization, due usually to carelessness or ignorance, occasionally to unusual difficulties inherent in the case itself; (2) neglect or insuf- ficient preoperative preparation of the teeth and mouth; (3) insufficient covering of the patient on the table and during transfer after the opera- tion; this lack includes lack of proper heat in the operating room; (4) the Trendelenburg position in too extreme a degree or for too long a time; (5) too little fresh air and too little oxygen; (6) neglect of the precaution of propping the patient up in bed at the earliest possible time ^ Boston Med. and Surg. Jour., 1895, cxxxii, 304. ^ A Brief Consideration of the Pulmonary Complications of One Thousand Laparot- omies, Jour. Amer. Med. Assoc, 1909, liii, 425. POSTANESTHETIC NEPHRITIS 1 69 and turning him on his side on the afternoon of operation if possible; (7) careless exposure of the shoulders to draughts and to open windows soon after the operation. The causes are almost always preventable. The frequency of the occurrence is from 2 to 5 per cent, in all capital operations, and is, therefore, much larger than is ordinarily stated; the proportion actually due to the irritating or chilling effect of the ether vapor on the lungs alone is probably small. It is a serious complica- tion and is the actual cause of a large percentage of the fatalities in old and debilitated cases.^ Nephritis. — After anesthesia the urinary secretion is much lessened and continues abnormally low, though gradually increasing for a week or ten days. Thus, Penrose - showed that after laparotomy the average secretion in in cases during the first t^venty-four hours was 13.4 oz., or about one-quarter the normal quantity. During the second 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 Le\%* is chiefly in the water rather than in the solids, and depends largely on the lessened amount of fluids ^ Chapman, Postoperative Pneumonia, with Experiments upon its Pathogen)-, Ann. Surg., 1904, xxxix, 700. Prescott, in reviewing 40,000 etherizations at the Massachusetts General Hospital, found but 3 cases. Silk reports 13 in 5000 surgical cases, and Anders, in a review of 12,842 surgical cases, found 30. Kelley has seen 8 cases in 1800 administrations. 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 soil suitable to their growth and multiplication, but he con- cludes that ether has a distinct irritant effect upon the lungs, causing a swelling of alveoli and the congestion of the alveolar tissue, and even intra-alveolar hemorrhage, which in- crease with the length of etherization and with the amount of forcing or crowding of the ether. V. Lichtenberg and Miiller (Verhulter der Lungen und des Herzens nach abdom- inalen Eingriffen, Miinch. med. Woch., igog, Ivi, 435) show complications on the part of the lungs to be responsible for fatalities after operation upon the stomach in 29 per cent., after operation on the biliary passages in 15 per cent., after herni- otomy in 25 per cent., after operation for goiter in 44 per cent., in gynecologic opera- tions in 20 per cent. Postoperative complications on the part of the lungs are far more common than generally recognized. Many a slight increase in temperature in the first few days after aseptic operations is the result of pulmonary complications. They may disappear entirely in a few days without inconvenience, but they may pro^dde the soil upon which pneumonia develops. The method of anesthesia, he finds, has no influence upon the development of postoperative complications, which confirms the extreme rarity of pneumonia due truly to the inhaled anesthetic. An embolic process is evidently responsible for the postoperative pulmonary complications in the vast majority of cases, but the hypo- static organ must be excepted in a few isolated cases. ^ Ann. Surg., 1895, xxvi, 184. ^ Abdominal Surgery, 1896, 137. ^ Brit. Med. Jour., 1900, i, 833. 170 SEQUELS OF THE ANESTHESIA taken and retained, purgation, sweating, etc. Cases of complete sup- pression 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 observers have reported cases where ether in elderly persons with Bright's disease or arteriosclerotic kidneys has been followed by gradual suppression and death, with no cause but the preexisting nephritis demonstrable 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 a large percentage of all cases — practically in one-quarter to one-third — immediately after operation; there are abundant casts, hyaline, fine and coarse granular and epithelial, and, somewhat less frequently, al- bumin. The occurrence after chloroform anesthesia is considerably less, although chloroform undoubtedly also acts as an irritant during elimination. These abnormal elements will have usually 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 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.^ ^ M. Hirsch (Einwirkung der allgemeinen Narkose und der Spinalanalgesie auf die Nieren und ihr Sekret, Centralb. f. d. Grenzg. der Med. u. Chir., 1908, xi, 929) analyzes 207 articles. The effect of chloroform and ether on the kidneys is merely one manifestation of a general intoxication of the system from the drug. Chloroform or ether can be used with the ordinary technique if the kidneys are known to be sound, but if the kidneys are pathologic, chloroform is absolutely contra-indicated. Under all conditions the amount of the anesthetic used should be the smallest possible. Much less of an anes- thetic is used when administered drop by drop and the limit of tolerance is more rapidly reached. Loss ot blood should be combated in every possible way, as this favors the degenerative action of the anesthetic and contributes to the possibility of chloroform in- POSTANESTHETIC NEPHRITIS 171 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 eniergency do venesection, and after bleeding give salt solution intravenously. In any case promote urinary and bowel secretion. Give digitahs and potassium acetate or citrate. Com- bat nephritis in septic cases. toxication. 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 super- imposed 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 albumin. CHAPTER XIX ACETONEMIA; ACETONURIA; AQDOSIS; ACID INTOXI- CATION; FATTY DEGENERATION OF THE LIVER Soon after chloroform 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 tv^'O to five days after the anesthetic. This was called delayed chloroform poisoning. In some cases sugar and acetone were found in the urine, and in these it was supposed that the S)arLptoms were due to an unrecognized diabetes, especially as the patients frequently 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- di\iduals, 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^^ty 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. 2 E. Becker, Arch. gen. path. Anat. u. Phys., 1895, cxl, i. ^Abram, Jour. Path, and Bact., 1896, iii, 430. *Ann. Surg., 1905, xli, 161. 172 ACETONURIA 1 73 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 w^as 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 clinical 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- ^ Boston Med. and Surg. Jour., 1905, clii, 744. ^ Jour, of Biol. Chem., 1906, i, 239. ^Lancet, 1906, ii, 1341. * Some Observations on Acetonuria, Boston Med. and Surg. Jour., 1908, clix, 47. ^ Acetone, Its Occurrence in Orthopedic and Surgical Cases, Amer. Jour, of Ortho. Surg., 1909, vi, 408. ^Ladd and Osgood ("Gauze Ether," or a Modified Drop Method with its Effect Upon Acetonuria, Ann. Surg., 1907, xlvi, 460) found that after 120 cases of etherization by the cone method at the Boston City Hospital 106 showed acetone, 88J per cent. After the drop method of anesthesia they found acetone in only 26 per cent, of 222 cases. ' Fatal Acetonemia Following an Operation for Acute Appendicitis, Ann. Surg., 1902, xxxvi, 481. ^Aciduria (Acetonuria) Associated with Death after Anesthesia, Boston Med. and Surg. Jour., 1904, cli, 2. ^ Acid Intoxication Following General Anesthesia, Medical Press and Circular, 1907, Ixxxiii, 198. *** Acidosis, Intercolonial Med. Jour., Melbourne, 1907, xii, 434. ^^ Acid Intoxication and Late Poisonous Effects of Anesthetics, Jour. Amer. Med. Assoc, 1905, xlv, 691, 757. 174 ACETONEMIA — FATTY DEGENERATION OE THE LIVER 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 betT\^een this condition and acute yellow atrophy, phosphorus-poisoning, puerperal eclampsia, and diabetic coma. 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 liver.^ 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 necrosis of the liver occurs after a single chloroform anesthesia of one hour, and intense fatty changes when chloroform is ^ E. H. Goodman, Recent Advances in Our Knowledge of the Underlying Chemical Principles of Diabetic Acidosis, Arch. Int. M«d., 1908, i, 397. " Bainbridge, Pathology of Acid Intoxication, Lancet, 1908, i, 911. ^ Fatty Acid Intoxication, Brit.- Med. Jour., 190S, ii, 1158. ■* Leathes, The Functions of the Liver in Relation to the Metabolism of Fats, Lancet, 1909, i, 593. ^ Rowland and Richards, The Experimental Study of the Pathology and Metabolism of Delayed Chloroform Poisoning, Ann. Surg., 1909, xlix, 419. FATTY LIVER FROM CHLOROFORM 1 75 given for a much shorter period. K. Reicher ^ shows that the important liquids and fats are expelled by the cells under the influence of the anesthetic. H. G. Wells- divides the cases of delayed chloroform- poisoning into two classes. In one, chiefly children, the s}Tnptoms 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 clinically is marked by a profound 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 distinctiy one or the other of the two types. 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 under ten years and two-thirds under hventy. K. Schrack ^ observed that children were frequently likely to exhibit acetone in their urine, especially in febrile affections and gastro-intestinal derangements. Marpan and Edsail showed the intimate relationship of acetonuria with cyclic vomit- ing in infants. Hecker* asserts that children are especially liable to ^ Chemical and Experimental Studies of General Anesthesia, Zeitsch. f. klin. Med., 1908, Ixv, 235. ^ Wells (Necrosis of the Liver After Chloroform Anesthesia, Arch. Int. Med., 1908, i, 589) cites a case — male, nineteen, appendix operation. Prompt recovery from anesthetic, good progress until the third day, on the morning of which pulse dropped to 66, tem- perature being 99-2°. About noon noticed to be acting irrationally. Two- hours later acute mania developed, requiring the efforts of several persons to restrain him. Kept quiet under morphin until the follo-^ing afternoon, when he became passive, l)ing quietly on his back, pulse increasing and becoming weaker. Temperature rising. Urine passed in- voluntarily. Then toxic convulsions developed, followed by coma and Chejme-Stokes respiration. This became more profound until his death, which occurred five days after the operation and forty hours after the first indication of mental disturbance. At the time of his death he was markedly jaundiced. Autopsy showed a small Uver which, under microscopic examination, showed marked necrosis. Urine showed small amount of albumin, distinct odor of acetone, and a marked reaction to diacetic acid. Chloroform may cause death by its destructive action on the liver. Its toxicity is due to its action as a protoplasmic poison upon the liver-cells, and death, which is delayed for several hours or even days, results from the perverted metalx)lism of that organ. In this condition of perverted metabolism of the liver-cells the liver not only fails to detoxicate the poisonous products of metabolism that are brought to it by the blood-stream, but it under- goes a process of self-destruction or autoclysis, and It is the combined poisons of these two perversions of function which directly induce death. ^ Fortschritte der Med., 1889, vii, 746. * Periodic Acetonemia in Children, Miinch. med. Woch., 1908, Iv, 1485; 1828. 176 ACETONEMIA — FATTY DEGENERATION OF THE LIVER 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 pregnancy 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 pregnancy. L. Knapp ^ reports 10 cases of acetonuria in pregnant and parturient women, all of whom gave birth to dead children, and from this he inferred that acetonuria in a pregnant woman is a sure sign of the death of the fetus. H. Thompson ^ reports a case w^ith the symptoms of acute yellow atrophy, in which the woman sank into a stupor, gave birth to a macerated fetus, and died t^vo days later. Couvelaine ^ and Scholten ^ demon- strated a marked increase in the acetone of the urine in the large majority of, all cases (94 per cent.) inamediately 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 vomit- ing 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 is ether. Of Bevan and Favill's 30 cases ether 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 ace- tonemia has supervened on a short anesthesia. It is stated as of par- ticular 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, although it is most commonly re- ported as occurring after laparotomies. This may be partly owing to the relatively longer time ordinarily consumed in performing laparot- ^ V. Brun (Clinica Qiinirgica, 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. ^ Ibid., 1898, xxii, 1227. * De r Acetonuria Transitoire du travail de I'accouchement, Annalesde Gyn. etd'Obst., 1899, I, 353. " Ueber puerperale Acetonuria, Beitrage zur Geb. u. Gyn., 1900, iii, 439. ^ Johns Hopkins Hosp. Bull., 1906, x\ii, 71. TESTS FOR ACETONE AND DIACETIC ACID 177 omies, 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 abdominal 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- tory. At any time from the second day 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 incessant, 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 is weak and rapid; the temperature is not raised. There may be icterus in varying degree; it appears more fre- quently and in a more marked degree after chloroform than after ether. As the condition progresses the patient becomes restless, even to the point of delirium and convulsions, between the paroxysms of vomiting; then he will quiet down, and become apathetic and stuporous. Thus he w^ill alternate, until the periods of restlessness become gradually less pronounced and the stupor finally deepens into coma. Then he develops an extreme dyspnea, cyanosis and Cheyne- Stokes respiration make their appearance, the temperature rises, and death comes on. The test commonly employed for determining the presence of an excess of acetone is that of Legal: To 10 cc. of urine in a test-tube add a small crystal of sodium nitroprussid. Make strongly alkaline 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 10 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 depth of color is to a certain extent a guide as to the intensity of the acidosis. 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 12 178 ACETONEMIA — FATTY DEGENERATION OF THE LIVER 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 indicated, in the employment of sodium bicarbonate in large doses, by mouth or by rectum, subcutaneously or even intravenously, in an attempt to neutral- ize 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 symptoms in mild cases. Sodium bicarbonate should be started as soon as the diagnosis is made, and should be con- tinued 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 solution, by the drop method, through a tube carried high as possible. The solution is readily absorbed by rectum, and this route is usually the most pleasant and efficient of all. In case of emer- gency 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 pre- ventive measure before operation, appears to be rational treatment.^ I have personally observed, in confirmation of this statement, that dia- betics recover after operations with fewer complications and more rapid healing of wounds if they are put upon a moderate carbohydrate diet after operation. ^ J. B. Nichols (Acid Intoxication, Washington Med. Ann., 1908, vii, 133) recommends the free administration of alkalis. Sodium bicarbonate, 225 gr. a day, plus calcium car- bonate, 45 gr., and sodium citrate, 75 gr.. by rectum, subcutaneously, or intravenously. But even this, he says, will produce no effect in some cases. ^ Acidosis, Jour. Amer. Med. Assoc, Oct. 22, 1904, 1228. ^ 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 direcdy 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 diaphragm is synchronous with the opening of the glottis; the abnormally sudden contraction in hiccough often catches the glottis closed or half open, and the incoming column of air rushing through the narrow orifice causes the characteristic ''hie" 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 fre- quently 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. 179 i8o hiccough: causes; treatment In the neurotic it may 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 holding the breath, the administration of hot water or ice, tongue traction, or tight pressure on the costal margins, enough actually to relax the diaphragm, should first be tried. This last procedure is called "throttling the belly" — tight pressure, corset fashion, with both hands for three minutes. 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 epigastrium, turpentine stupes to abdomen, ice-bag to spine, or electricity to diaphragm. A tight adhesive swathe may be hiccough: treatment i8i applied to inclose the lower chest. 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 re- ported 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 sipping 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 service, on the theory that when the vagus nerve is busy with the mechanism of swallowing it will weaken the effect of the reflex to the diaphragm. 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 ammonia, 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 fur (coat) ; third, the degree of moisture; and fourth, the movements. Of first importance are the coat and degree of moisture. 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. 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. 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 browm; 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 overproduction or retention, may proceed to such a point as to give the tongue the appearance of being roughly plastered over. In this condition the breath is foul, and there may be ulcers or tooth-marks along the margin. Sometimes the filli- form 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 182 COATED TONGUE 183 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. 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 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 little 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 papilla are covered with white epithelium, and the intervals between the papilla 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 papilla 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. 1 Lancet, 1888, i, 558, 609, 657. 1 84 THE tongue: its significance It occurs in fevers with high temperature associated with prostration and absence of sahva. 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 papillse have disappeared and the epithelium is stripped off in patches. Changes in the condition of the tongue are frequently of local origin. Moisture of the tongue is due to 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. The movements of the tongue when it is projected have some signif- icance. The tongue may be tremulous in any conditions accompanied by prostration, etc. 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) dehydration, (2) exhaustion, (3) pyrexia, (4) local conditions about the mouth. The degree of fever, the state of the nervous system, the maintenance and abeyance of secretion, and the failure of vitality are roughly in- COATED tongue: TREATMENT 1 85 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, any at- tributable cause, local or general, may be treated. Intestinal putrefac- tion should be prevented by the reduction or removal of proteid, espe- cially meat, from the diet, by the use of carbohydrate 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 operation. CHAPTER XXII BANDAGING Bandaging as done 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, due to our more exact knowledge not only of the pathologic conditions present, but also of the means of correcting them. The almost universal 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 "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 made 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 i^ in. about the hand and head, and the 3 in. about the limbs and body. In an emer- 186 TO REMOVE A BANDAGE 1 87 gency, of course, any material available can he 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 reroll 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, 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 {i.- 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. i88 BANDAGING Fig:ure-of-8 Bandage. — After fixing, say, on the calf of the leg, allow the bandage to run diagonally upward 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 Fig. 45- — Application of Bandage. Preliminary turns have been taken to hold sheet-wadding. Figiire-of-8 has been used to cover in foot, and bandage is ascending on leg. (The ends of the gauze roll have been dipped in ink so that the turns may be clearly seen.) 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 forward, 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 h in. to one-half the width of the bandage (Figs. 45 and 46). Fig. 46. — Application of Bandage Completed. Foot and leg covered in with figure-of-8 turns, and circular used to end off with. The crossings on the anterior surface after a little practice naturally arrange themselves in perfect alignment. While applying 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 189 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 is placed on the bandage ^ 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°. The re- verse is thus completed, and the bandage is allowed gently to fall flat upon the limb; it is then carried round underneath the limb and the desired tension applied. The reverses should be in a line but not over prominent parts (i. e., anterior border of tibia), as, unlike the figure-of-8, they cause creases in the skin which may easily result in pressure sores. Fig. 47. — Spica Bandage Applied to Thigh. Fig. 48. -Spica Bandage Applied to Shoulder. The Spica bandage is really a figure-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. 47), 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 over the inguinal region into groin, around the leg, up diagonally across the inguinal region to the opposite side, and then around the pelvis; IQO BANDAGING 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. 48) 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 uncovered when bandaging the foot and leg; if it is desired to include it in the bandage, it may be done by one of the following two ways: Fig. so. — Leg Bandage Applied. Side view, showing testudo to heel. Fig. 51. — Leg Bandage Applied. Front view, showing crosses along median line and circular turn to end off with at top. (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 foot; then beneath the instep, around one side of the heel, and up over PLASTER-OF-PARIS BANDAGES I9I 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. 49). (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 bandage 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 are continued in the form of figures-of-8, with the point of crossing stationary, over the instep, and the loops alternately covering the region of the tendon of Achilles and the arch of the foot, till the heel is covered in, after which the bandage ascends the leg. This is called the testudo (Figs. 50 and 51). Pressure Bandage for Varicose Veins of the l,eg. — J. S. Davis ^ has recently described an excellent bandage for the leg, especially where varicose veins are present. Elevate the leg, sponge the skin with alcohol, dress the ulcer, and sprinkle the skin with dusting-powder. Cover the entire area to be bandaged with sheet-wadding; cover this with either 2- or 2^-in. muslin bandage, taking a loose turn around the ankle, then, with ordinary snugly fitting figure-of-8, bandaging foot and ankle from root of toes. Follow the contour of the leg upward to above the calf, making both edges of the bandage fit flat; then, after a circular turn, come down the leg with a long sweep. Repeat the above, but with shorter sweeps, always following the contour of the leg and keep- ing both edges of the bandage flat. This procedure can be repeated until the dressing is thick enough to give adequate support, terminating in one or more circular turns. Plaster-of- Paris Bandages. — Plaster of Paris, or gypsum, is used to maintain complete or partial fixation over a more or less extended 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 the most satisfactory material. Plaster bandages may be bought at the surgical supply houses put up in sealed tins. Care should be taken that the plaster does not become air-slaked by exposure to darpp air, otherwise the cast will crumble and disintegrate ^ Johns Hopkins Hosp. Bull., 1908, xix, 114. 192 BANDAGING after it is applied. For this reason bandages that have been in stock for some time should be baked in an oven before using. Fig. 52. — HoFFA Table. For application of plaster-of-Paris spica. bandage to hip. To apply, cover the leg smoothly and evenly with strips torn from a sheet of cotton wadding (Fig. 53), protecting amply all bony promi- nences. Completely immerse the plaster roller in luke-warm water for Fig. 53. — Plaster-of-Paris Bandage. Sheet-wadding applied. Foot held at right angles, slightly inverted, to overcome tendency to formation of " flat-foot." 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- ting; if it is not dissolved, it will get into the plaster and make it crumble. If allowed to remain too long in the water, the rollers set and become PLASTER-OF-PARIS BANDAGES 1 93 hard. When taking the roller out of the water, both ends should be Fig. 54. — Plaster-of-Paris Bandage. In removing rollers from water the excess is squeezed out by pressure on the ends, the fingers being closed to prevent the plaster from running out- .-, F Fig. 55. — Plaster-of-Paris Bandage Im- properly Wrung Out. The twisting action wrinkles the bandage and re- moves too much plaster. Fig. 56. — Plaster-of-Paris Bandage. Roller being applied. The foot is being correctly held by an assistant. grasped and the water gently squeezed out (Fig. 54); a tv\^isting or wringing motion (Fig. 55) will force the plaster to run out through 13 194 BANDAGING the meshes. Roll around the leg smoothly, following the natural curves with spiral or figure-of-8 turns; never use the reverse; never pull tightly; always keep in mind the danger of localized pressure. Fig. 57. — Plaster-of-Paris Bandage. The first roller is being finished. This layer will now be rubbed in, and a second and third roller similarly applied. After the plaster has been 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 plaster through until Fig. s8. — Plaster-of-Paris Bandage. Application has been completed, plaster has been allowed to set, and has been split down each side (" bivalved ") to allow for swelling and for inspection. Shows the proper method of applicatioa of web- bing straps to keep the halves together. ' the sheet-wadding is reached. This can be cut later with scissors. It is best to defer removal of the piece which has been cut till the next day to allow the plaster to harden (Fig. 58). MODIFIED BARTON 195 Recurrent Bandage — Hand or Amputated IVimb.— 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 opposite the point of starting; then place the fingers of the left hand on the bandage, double it upon itself, and bring the bandage directly back the way it came over 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. Recurrent Bandage of Head.— Fix the bandage by two circular 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 keep- ing 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 sur- geon 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 intro- duced where the recurrent turns were made to make the dressing more secure (Fig. 59). Modified Barton. — ^The bandage should be started by t\vo 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 Fig. 59. — Recurrent Bandage of Head, Some- times Called the " Melon." 196 BAXDAGIXG vertex of the skull, downward over the zygomatic arch, under the chin, then upward over the opposite zygomatic arch and over top of the head, crossing the first turn in the median line and well fonvard. The bandage is then passed obliquely backward and downward under the occipital protuberance and then out once more over the chin (Fig. 60). These figure-of-8 turns are to be continued until roller is exhausted. The original Barton's bandage omits the turn around the forehead; this, how- ever, adds greatly to its stability. The Desault Bandage. — De- sault,^ about the beginning of the nine- teenth century, devised the following apparatus for treatment of injuries to the clavicle. He placed a wedge- shaped pad in the axilla, which was held in place by circular turns around the body and over the opposite shoulder (first roller) ; the arm was then securely Fig. 6o.-barton^^^^k«d.ge beixg ap- bandaged 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 is 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 cla\icle, rims 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 fonvard and upward to shoulder as before; these turns are continued until bandage is exhausted. Velpeau Bandage.— Velpeau,^ about 1839, finding the Desault apparatus apt to cause serious pressure on the brachial vessels and nerves, adopted the following method of application for injured clavicle : The initial 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 ^ Ocuvres Chirurgicales ou Expose de la Doctrine et de la Pratique de Desault par Xav. Bichat, Troisieme edition, Paris, Megnignon, 1813. ^ \'elpeau, Nouveux Elements de Medicine Ope'ratoire, Deuxieme edition, Paris, Bailliere, 1839. MODIFIED VELPEAU 197 the clavicle, 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 completed 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- FiG. 61. — Modified Velpeau. Showiog preliminary application of sheet-wadding. The bandage has been fixed and started by two circu- lars about elbow and thorax; the second turn has been carried obliquely upward across the back, over the tip of the shoulder, under the elbow, up over the shoulder again, obliquely down across the chest. Fig. 62. — Modified Velpeax;. In process of application, from behind, show- ing sheet-wadding placed to protect axilla and shoulder-tip. 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. 61). The bandage is fixed by tAvo 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 198 BANDAGING of the arm, under the elbow, up the back of the arm, over the tip of the shoulder, across the chest to the other axilla (Fig. 61). 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. 62). These turns are repeated, leaving one-third of pre- ceding turn uncovered, up the arm and shoulder until all is covered in Fig. 63. — Modified Velpeau, Completed. Cp^Q Ao^ I^und Swathe. 1 — The swathe as described by Lund is a most efficient method of immobilizing with comfort the forearm acutely flexed at the elbow. A cotton swathe ^^^^^i^^^^^. ^ is---^^^ of the width of the shoulder, and long enough to make a figure-of-8 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 over the shoulder, diagonally downward across the back and under the opposite arm, where it is pinned to the other end, which is brought forward 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, to be pinned to the part surround- ing the flexed arm, thus making a com- plete circular turn around the body and fixing the arm to the body; the part brought over the shoulder is pinned ^ F. B. Lund, Med. and Surg. Reports of the Boston City Hospital, eighth series, 1857, p. 3. Fig. 64. — The Lund Swathe. Starting the application. BREAST BANDAGE 199 to this circular piece as it crosses the back (Figs. 65 and 66). This swathe can also be applied advantageously after the method of Sayre. Fig. 65. — Modified Lund Swathe Applied. Showing sheet-wadding under hand. Fig. 66. — Modified Lund Swathe Applied. Rear view, showing safety-pins in place. Breast Bandag-e. — The Boston Lying-in Hospital ^ bandage may be easily extemporized by fastening together in the shape of a T t^vo 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 to 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 above the breasts, and is pinned to 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, Practice of Obstetrics, 1902, p. 505. 200 BANDAGING of the breasts, carried over 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 powdered starch or some other pow^der and a large wad of absorbent cotton placed between them. The breasts are then drawn strongly inward by the hands of the patient, and the bandages pinned together on each side of the axilla, beginning at the outer edge and then working upw^ard 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 upon badly caked breasts, it should be drawn as tightly as possible without seriously embarrassing respira- tion. Its pressure there almost invariably results in the expression of all 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. 125, 126, 127, pp. 402, 403). Many-tailed Bandage. — This consists of a piece of cotton cloth of the desired length and wide enough to considerably more than sur- FiG. 67. — Many-tailed Bandage as Applied to Thigh and Lower Abdomen. round the part; into each side tears about 2 in. apart are made. It is extremely adaptable and very convenient 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 (Figs. 67 and 68). Swathes. — Swathes are used for maintaining in place abdominal and thoracic dressings, and are merely pieces of cloth the desired width and length to go around the body and are fastened by pins (see Fig. 137, P- 439)- 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. STRAPPING 20I 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 i6 in. long, to each end of which is sewed a strip of adhesive plaster about i6 in. long. The flannel part surrounds the leg; the adhesive pieces cross over the inguinal region and adhere to the flanks. (For illustration, see Fig. 138, p. 440.) Strapping Abdominal Wound.— A very neat way is to use t^\ o pieces of adhesive plaster of the requisite size; on the ends next to the wound are fixed three or four dressmakers' hooks. After the dressing Fig. 68. — Many-tailed Bandage Holding Fomentations to Hand and Forearm. The patient and bed are protected by a rubber sheet. is in place the desired tension can be obtained by lacing the two ends together. (For illustration, see Fig. 144, p. 456.) Strapping the Ankle. — Take about six pieces of adhesive plaster, i 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 ankle to the outer side of the calf; apply all the strips each over- lapping about one-half inch. To splint the external ligament reverse the direction (Fig. 69). Strapping the Ribs. — 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 202 BANDAGING plaster; 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- FiG. 69. — Strapping the Ankle. The strip of adhesive plaster is started on the outer border of the foot, carried under the arch, and across to the outer aspect of the leg. 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. : Strapping the Knee.— Take three pieces of adhesive plaster, i^ in. wide and 9 in. long, apply one strip above and one below the Fig. 7o.^Strapping Applied to Knee. One strap above patella pulling downward; one below patella pulling upward; one over patella. Each goes only from hamstring to hamstring. patella, and the third piece directly over the patella, running transversely from one hamstring to the other, overlapping the other two about i in. (Fig. 70). SLINGS 203 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 forearm, and tied or pinned at the neck. A pinned sling is much neater and less irksome than the tied one (Fig. 71). 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 Fig. 71. — Showing Method of Pinning Cor- ners OF Sling so That They Lie Flat. Fig. 72. — Double Sling Applied. Note how the hand is supported. 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. 72). 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. 204 BANDAGING The second objection is that the majority of suspensory bandages exert pressure in the region of the external abdominal ring, as the belt Fig. 73. — Hammock Suspensory (Cunningham). Webbing belt abou the waist. Under half of Can- ton flannel hammock buttoned in place. Fig. 74. — Hammock Suspensory. Anterior half buttoned up in position. 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 maintain- ing congestion. With the end in view of over- coming these objections the fol- lowing forms of suspensory band- age, 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 Canton 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 Fig. 75. — Hammock Suspensory. Hole cut in anterior half for urination. SUSPENSORY BANDAGES 205 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- sory buttoned in position (Fig. 73). The lower ends are now turned up over the scrotum and penis and also buttoned, holding the scrotum in the hammock (Fig. 74). 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, the two lower arms may be unbuttoned and the bandage dropped, or Fig. 76. — Adhesive Plaster Suspensory (Cunningham). The initial end has been made fast across the perineum. The two sections of the strap are being drawn up onto the abdomen under considerable ten- sion. Fig. 77. — Adhesive Plaster Suspensory Ap- plied. Note the efficiency with which the scrotum is sup- ported against the pubes. a hole may be cut in the suspensory through which the penis is drawn (Fig- 75)- Adhesive Plaster Suspensory. — This method of suspension may be used with advantage in all operations upon the scrotum in which the scrotal 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 supported continuously, and the bandage can- 2o6 BANDAGING not be loosened up or removed 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 elevated 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. 78. — Perineal Dressing (Cunningham). (Fig. 76). The penis is drawn forward into the apex of this slit and the two ends fastened to the abdomen (Fig. 77). The plaster is then made to fit the sides of the scrotum by sticking the two free edges to- gether. In the upright position the testicles are held elevated. 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 Dressing Bandage. — 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. 78). It is applied as follows: Patient is in the dorsal position, with the legs spread apart. The PERINEAL DRESSINGS 207 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 Fig. 79. — Perineal Dressing. The narrow flaps are crossed and pinned in the perineum; the wide flap is lying upon the table. the dressing, is placed in the center of the perineum (Fig, 79). The edges of these flaps are united by safety-pins around the scrotum, which Fig. 8(5. — Perineal Dressing. Narrow flaps pinned to belt. is held in an elevated position. These flaps are then united to the waistband by safety-pins (Fig. 80). The perineal dressing is thus held firmly in position and the testicles are elevated and held securely 208 BANDAGING 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. 8i). If a cath- FiG. Si. — Perineal Dressing. Application finished by pinning up the wide flap. eter 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: DRESSING, STITCHES, DRAINAGE, AND STITCH ABSCESS Time for Dressing. — The natural 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. Yet suppuration may take place where it is the least expected — any one of many factors, such as septic suture material, stitches tied too tightly, blood-clot in Fig. 82. — Layout for Abdominal Dressing. Probe, director, blunt scissors, hemostats, irrigating-tip, toothed and smootli forceps. the wound, etc., may enter in to mar an otherwise 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. 52). 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 14 209 2IO 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 closed 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 until 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 untouched 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 211 if the stitches are 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 crepe lisse and collodion, so that they may not be pulled apart by muscle action or by any sudden strain. If the wound 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 t^vo 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, w^hen 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 w^eek or ten days usually suffices 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 arc out, the knowledge that the dread ordeal is over, coupled with the as- surance from the surgeon that the wound 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 212 TREATMENT OE THE OPERATIVE WOUND and forceps. A pair of slender-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 special instrument used at the St. Mary's Hospital, Rochester, Minn., called the Littauer-Paynes stitch scissors (Fig. 83). Both of the blades are blunt, making it impossible to injure the tissue while removing the stitches. The stitches are lifted aw^ay from the skin by the hook at the end of the lower blade. The forceps should be the so-called "anatomic" forceps, with rather weak spring and slender points. These, w^ith the scissors, should be boiled in sodium bicarbonate water in the tray from which they are to be Fig. 83.— Scissors (Littauer-Paynes) Designed for uScd — not long CnOUgh tO injure Removal of Stitches. . , . , . the cuttmg-edge of the scissors — • the water poured off, and the tray placed upon 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 of 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^;\'0 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, w^hile 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 now remove the dressing without breaking his asepsis. So far as possible everything should be done with instruments — scissors, director, hemostatic or thumb-forceps (Fig. 82). If the dressing has "caked" and stuck to REMOVAL OF STITCHES 213 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 t^vo 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 w^alls, 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 until 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 between 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 214 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. 144, p. 456.) or to be approximated with rubber bands, and strips incorporating silk ties, to be tied over the wounds. These devices are usually unnecessary. Narrow strips of plaster of good length, if applied while proper approx- imation is being made, suffice 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 possibility 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 undisturbed 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 215 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 amount 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 doubt, ^"^ says Greig- Smith, "it is wise to drain." It is not commonly 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 tightly 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 infection 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 2l6 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 glass tube. This, in its simplest form, is a cylinder about twice 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 wound 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 off 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 217 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 conies 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 slightly. 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 efficiency 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 wound, in the flank, and through the vagina. It should be thoroughly sterile and comparatively fresh, othenvise it is liable to decompose and soften if kept in an antiseptic solution, or else become stiff and brittle 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 jnuscles 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 2l8 TREATMENT OE THE OPERATIVE WOUND will allow of the spreading of infected fluid from one focus among the intestines and between the layers of the abdominal wall. Gau^e 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. 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, between 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 hours 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 drainage, 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 the introduction of gauze into surgical practice is less of a blessing than it was first thought to have been. Instead of facilitating the removal of wound products, gauze acts as a successful stopper to the outlet of the wound and impedes the natural outflow from it. When intended 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. When 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 219 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 t\visted 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 which 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 tvv^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 wound margin and a zone about 2 in. around it in all directions thoroughly, then apply, with cotton or camel' s-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 wound 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 empt>'ing 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 220 TREATMENT OF THE OPERATIVE WOUND or in a rubber tube split or cut spirally (Fig. 84). A tube wrapped in gauze usually drains freely, both by capillary action and internal pressure. Fig. 84. — Drainage. A, Split-rubber drain; B, spiral drain; C, fenestrated rubber tube; D, cigarette wick. 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 has the advantage of being re- moved painlessly and of limiting the irritating effect of the gauze to the area about the tip. The same may be said of the gauze wrapped in a spiral cut rubber tube. Either should be removed as any gauze wick. Sometimes a surgeon will use for an appendix abscess or a localized peritonitis a rubber tube and a half dozen small gauze wicks. The small wicks have the advantage of com- ing out more easily than the large. The tube is removed on the second day, two of the wicks on the third, after this time, whatever form of drain be used, from the portions not in contact mth the drain. A loosely rolled cigarette drain, without any projection whatever of gauze from its lower end, is the less irritating, and will drain adjacent regions perfectly for twelve to eighteen hours if adhesions have not formed in them before operation, and if the fluid to be drained is not too thick, but no longer. For this reason the drain should be of ade- quate size and the patient should be kept in the proper position in bed. The position to be maintained can be easily figured out from the diagrams in the article of Dr. R. C. Coffey, Jour. Amer. Med. Assoc, March i6, 1907. Capillary action is not so important as intra-abdominal pressure. ISIore surgeons are getting away from prolonged drainings with better results. Remove the drain at the first possible moment and allow the wound to heal. Fig. Ss. — Drainage. A, Rectal plug, containing core of rubber tubing; B, inverted rubber tube designed for drainage of large cavities. STITCH ABSCESS 221 two on the fourth, and two on the fifth, and the last ones are replaced by 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 w^all 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 wicks, 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 wound 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 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 Fig. 86. — Mikulicz Tampon for Peritoneal Drain- age. 222 TREATMENT OF THE OPERATIVE WOUND 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 layers, 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, feels pain in the region of the wound, the incision should be examined. Usually there will be both pain and fever to some degree; 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, INFECTION OF THE WOUND 223 it is of extreme importance to make the diagnosis and institute treat- ment early, for with extensive suppuration there is ahvays 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 gently dissected open with the flat end of the probe, wherever there are signs of inflanmiation, 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 w'ound. 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 224 TREATMENT OF THE OPERATIVE WOUND 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 justiiies the pro- cedure, an irrigation, given very gently and under low pressure with sterile normal salt solution or weak corrosive sublimate, is efl&cient 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 wound. 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 lymphatics 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 l}Tiiphangitis, 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 drainage. 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, wfth 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 "through 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 15 « 225 226 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 (Figs. 67, 68, pp. 200, 201), 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 227 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 suffice; on the body, a bath- tub may have to be used. The solution may be of sterile water, salt, and citrate (see p. 229), 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 officinal 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 efficient means of overcoming the infection with 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 hmb 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 maybe 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. 228 TREATMENT OF SEPTIC WOUNDS Poultices. — The purpose of the poultice or fomentation is similar to that of the hot soak. It is sometimes used to substitute for the soak, and it is practically always used where moist heat is to be applied and the soak is not practicable. The poultice should be absorbent, so as to take up 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 long as possible. Many substances have been employed for this purpose, from the old-fashioned bread-and- butter and flaxseed poultice mass down to the 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, Fig. 87. — Applying a Poultice. A gauze pad is placed next the wound; over this oiled paper or silk to retain the moisture; next sheet-wad- ding to retain the heat; finally, the bandage. recent experiments have shown that the flaxseed is the better retainer of 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 been in itself rendered aseptic by heating, so that, other things being equal, when moist heat is to be applied to a discharging wound, it is usually preferable to employ fomentations of sterile gauze soaked in some antiseptic solution. When desired, however, the flaxseed poul- tice may be used if a moist sterile dressing is placed between 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 in boiling water, but with a dash of chlorinated soda, will relieve the pain and destroy the odor. In applying poultices or hot fomentations ^ J. D. Pilcher, The Rate of Cooling of Several Poultice Masses, Jour. Amer. Med. Assoc, 1909, lii, 752. poultices: weights solution 229 we must take care not to burn 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; Aquas 500.- — M. or for a recipe for home treatment write — I^. Sodii citralis 12; Sodii chloridi 48.— M. Sig. — Teaspoonful in half glass hot water to wet dressing. The dressing should not be allowed to become dry. 230 TREATMENT OF SEPTIC WOUNDS BIER HYPEREMIC TREATMENT The Bier hyperemic treatment, which at present is much in vogue, finds its chief field of usefulness before operation. However, it is de- clared that, when artificial hyperemia is employed and ample oudet for pus is provided, we are able to accomplish with a small incision what otherwise would necessitate extensive incision and too often re- sulting disfigurement 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 Martin's rubber bandage or the Esmarch tourniquet may be employed; for the suction cup, an ordinary cupping-glass or one of the larger special 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 I shall quote freely, with Professor Meyer's permission, but refer the reader to the original for completeness of detail. "The physician who- intends to make use of artificial hyperemia 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 BIER HYPEREMIC TREATMENT 23 1 first and most important principle underlying Bier's hyperemic treatmetit, namely: " The blood must continue to circulate, there must never he a stasis of the blood. This rule is of paramount importance. " Hitherto it was considered the physician's first duty to fight every kind of inflammation since inflammations were looked upon as detri- mental. "Bier teaches just the opposite; namely, to artificially increase the redness swelling, and heat, three of the four cardinal symptoms of an acute inflammation. "The practical results obtained with the hyperemic treatment have proved the absolute correctness of the theories advanced by Bier. "The fact that artificial hyperemia has already found use in such a variety of different diseases seems to speak for the correctness of Bier's prophecy made some years ago: 'This remedy, used by nature in such a profuse measure, to combat all sorts of lesions, is destined to be far more extensively employed than has hitherto been attempted.' " 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 infectious 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 promptly 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 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 indications and dosage the same as any other remedy. There is much to learn about it yet. " It must be remembered, however, that hyperemic treatment in acute diseases requires more time and attention than radical work with the 232 TREATMENT OF SEPTIC WOUNDS knife, chisel, and saw. A busy man cannot alone undertake the treat- ment of many such cases; he needs trained assistants in private as well as hospital work. "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-hyperamie ' — a term prescribing cause as well as effect." Some variety of this method has been in traditional use by the country people in Germany for an indefinite time past. "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 Blastic 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 BIER HYPEREMIC TREATMENT 233 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 white. "Bier employs a soft-rubber bandage, 2^ in. wide, which he winds around the limb about six or eight times, one layer overlapping the other by about ^ in. In this manner the pressure is evenly distributed over a comparatively 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 Fig. 88. — Passive Hyperemia. Rubber bandage in place; note distention of veins and cyanosis. bandage. With the bandage in place, the distal part of the extremity must feel' warm, not cold. Every focus of acute inflammation subjected to obstructive hyperemia will quickly show increased warmth. First, we notice a marked redness, then heat and a swelling. On seeing the swelling increase, the practitioner often becomes frightened, but there is no reason for alarm. According to Bier, this phenomenon 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. 234 TREATMENT OF SEPTIC WOUNDS "All 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 edema. 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 infected cases the rapid absorption of this inflammatory edema is often followed by some rise of temperature; this, however, is of short duration 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 t\venty- two hours per day. In chronic affections, especially those of tuberculous origin, shorter sittings, say, tv\^o 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 neck and head, a strap of garter elastic, about f in. wide, with a hook at one end and a number of eyes on the other, to allow for different degrees of compression, best answer the purpose. This band is applied around the neck below the larynx. It must never strangulate. The patient himself must be the judge. The object BIER APPARATUS 235 of the treatment is to increase the quantity of blood in the head, but hyperemia must not interfere with the patient's abihty to sleep, eat, and drink. In order to increase obstruction, a piece of soft felt may be slipped under the bandage at the site of the jugular veins. "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, pro- perly constructed and applied, have proved to be a most efficient means Fig. 89. — Suction Cups. Varieties of suction cups designed for various anatomic regions; suction pump; rubber bandage. of producing obstructive hyperemia. By applied suction hyperemia it will be seen that the skin, plus underlying tissues, 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 overdo. The skin should turn red or bluish-red, but never white "To be able to employ the method more generally, it was neces- sary to have cupping-glasses the shapes which were adapted to the 236 TREATMENT OF SEPTIC WOUNDS varying contours of the body surface (see Figs. 89-93). 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 J^ Fig. 90. — Passive Hyperemia Applied to a Localized Septic Process by Means of a Suction Cup. skin with just sufficient firmness not to drop off. To facilitate air- tight closure of the cup upon the skin it is well to spread a thick layer of vaselin over the border. Suction must never he too strong and never create pain. "The vacuum apparatus of larger size is applied Avith a suction pump, which is inserted in the end of the rubber tube in place of the Fig. 91. — Passive Hyperemia. Suction cup used over wounds discharging pus. bulb and regulates the degree of hyperemia. In all of the large-sized suction glasses and some of tlie 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. BIER HYPEREMIC TREATMENT 237 "In making use of this vacuum apparatus, we not only rely on the artificial hyperemia it produces, 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. Fig. 92. — Passive Hyperemia. Large cup applied to buttock; suction pump, with stop-cock in tube. "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 avoided by anointing with vaselin the border of the glass and also the immediate neighborhood Fig. 93. — Passive Hyperemia. Suction cup and pump; lateral enlargement of cup designed to collect exuding pus. 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. 238 TREATMENT OF SEPTIC WOUNDS Thus the entire time of treatment is three-quarters of an hour each day. "After the suction glasses of small size had been particularly tested as to their value, the manufacture of stronger bottle-shaped vessels suitable for the reception of the entire extremities was taken up." (For description and illustration of these, see Meyer and Schmieden.) " (3) 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. " The increased supply of arterial blood to any part of the body favors absorption of chronic exudates, infiltrations, adhesions, etc.; therefore, these chronic conditions, being the result of a previous acute inflamma- tion, are particularly influenced by hot-air hyperemia. This is also true of neuralgias of all varieties. "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. "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 feeHng 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." BIER HYPEREMIC TREATMENT 239 Other References B. M. Bernheim, Passive Hyperemia, Jour. Amer. Med. Assoc, 1908, 1, 840. E. H. Bradford, The Hyperemia Treatment of Congested and Inflamed Tissues, Boston Med. and Surg. Jour., 1906, cliv, 671. E. A. Codman, On the Bier Treatment of Infected and Septic Wounds of the Extrem- ities, Boston Med. and Surg. Jour., 1906, civ, 434. Frangenheim, Archiv f. klin. Chir., 1908, Ixxxvii, No. 2, reports extensive ex- periments with abscesses induced on rabbits and treated with cupping-glasses or application of a constricting band above the lesion. The results all seem to show that the hyperemia thus induced had no bactericidal action, while infectious processes in the bone-marrow and joints were unfavorably influenced. Early or immediate application of the measures to induce hyperemia never succeeded in preventing the development of the infectious process after inoculation. The formation of pus was much increased under the constricting band and with the cupping-glass, while infiltration in the vicinity of the pus focus was the rule. Suppuration, sequestrum formation, and pigmentation were much more pronounced with the induced hyperemia than without it. Klapp, Ueber die Behandlung enzuendlicher Erkrankungen mittels Saugapparaten. Munch, med. Woch., 1905, No. 16. 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-off appendix; and so long as the offend- 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 240 SINUSES AND FISTULA 241 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 1:8. 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 allowed 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 ^ Emil G. Beck (Fistulous Tracts, Tuberculous Sinuses, and Abscess Cavities, Jour. Amer. Med. Assoc, 1908, 1, 868) recommends the injection of liquefied bismuth-vaselin paste in old sinuses and fistulas for curative purposes. He states that it is applicable to all fistulae or abscess cavities except intracranial sinuses or biliary fistulse, and those com- municating with the urinary bladder. Ochsner (Beck's Injection Treatment of Fistulae and Abscesses Following Operation for Empyema, Jour. Amer. Med. Assoc, 1909, liii, 319) describes the technique as fol- lows: Formula i, one part of arsenic-free subnitrate of bismuth, and two parts sterile amber vaselrn, has a lower melting-point than formula 2, which consists of three parts of subnitrate of bismuth, six parts of amber vaselin, and one part of paraffin. Formula i is used daily, or every second day, until the sinus or abscess is free from pus, then formula 2 is used, at first every second day, and then less frequently. These mixtures are injected at 110° to 120° F. by means of an ordinary glass syringe. Only just enough force is used to fill the cavity. The outer opening is closed with a gauze plug, the cavity filling in rapidly. Symptoms of sepsis readily disappear. Another formula is — I^. Bismuth subnitrate 30 parts White wax 5 Soft paraflin 5 Yellow vaselin 60 " — M. 16 242 SINUSES AND FISTULE 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 ca\ity 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 Fig. 94. — Irrigating a Sints. infectious 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 to employ a sinus curet and scrape the walls part way through, down to a well-nourished substratum. If 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 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 SINUSES AND FISTUL^E 243 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 Fig. 9S. — Inserting a Wick. The gauze is held taut between forceps in one hand and fingers of the other hand, and is thus inserted at once to the bottom of the wound. 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 cureied, 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 244 SINUSES AND FISTULA 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 fistulce 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 give 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 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 difficult to treat. The treatment of a 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 LYMPHATIC FISTULA 245 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. Fistulee may close temporarily and then reopen, and keep 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, over the subclavian artery, to terminate in the left subclavian vein just before it joins 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 lymphatic duct.^ Symptoms. — If the thoracic duct is severed, edema appears about he 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 pro- gress. If pressure is exerted in an attempt to limit the outpouring of ^ 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 referred to 13 similar cases. The patient recovered. 2 Parsons and Sargent, On the Termination of the Thoracic Duct, Lancet, London, April 24, 1909. 246 SINUSES AND FISTULA 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 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, sufficient 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.^ 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 complica- tion of the after-treatment of celiotomies; it sometimes arises from causes which might have been, avoided. Whether or not the surgeon can ^ For further consideration rf the subject see Unterberger,Ueber Operativen-Verletzungen des Ductus Thoracicus, Beitr. zur klin Chir., xl\di, Heft 3; v. Graff, Zur Therapie der Operativen-Verletzungen des Ductus Thoracicus, Wein. klin. Woch., 1905, Nr. i; De Forrest, The Surgery of the Thoracic Duct, Ann. Surg., 1907, -^Ivi, 705. FECAL FISTULA AND ARTIFICIAL ANUS 247 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 disabling condition from which he suffers. 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. Fistulas 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 known 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 in 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, biit 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 248 SINUSES AND FISTULA 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 partially through the intestinal 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 removed and the sinus dilated occasionally, if it shows signs of closing down prematurely, or kept open by a rubber tube. The chief danger is from the backing up of feces under pressure. The fistulous tract should be kept as clean as possible by irrigating it out 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 paint- ing an area round 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 fistulas 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 intejided 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 ARTIFICIAL ANUS 249 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. 421, for details.) 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 ^vhen 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 organisms 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 communis (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 typhoid, and frequently occur in tuberculosis; in such secondary foci the corresponding organisms may at times be isolated. Secondary infection 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 formation of a thrombus, which disintegrates as a result of the suppuration and forms septic emboli, or there may be a direct extension along a vein, as in suppurative pylephlebitis. 250 PROGNOSIS 251 Virulent bacteria may be disseminated by means of infected emboli, phlebitis, or lymphangitis. In this case we speak of the condition clinically as pyemia or septicometastasis. Pyogenic organisms exercise a peptonizing and hquefying 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 the lymphatic system they cause lymphangitis and abscesses of the glands of the groin, axilla, and neck. Thrombi reaching the portal system cause the de- velopment of mesenteric and hepatic abscesses. In the systemic veins the thrombi are carried to the lungs. If they pass through the pul- monary 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 bet\veen 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 above 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 252 SEPTICOPYEMIA and drained, the result will be more propitious. The question of 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 two 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 253 254 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 restlessness 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 scarlatina there can be no question. It differs from this latter 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 255 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 mortaHty 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 sufficient, 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 camel's-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- 256 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, 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, and strychnin. I have in mind a 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. While the appearance of the efflorescence caused by each one of these drugs has certain peculiarities by which they may be sometimes 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 257 Cases of local poisoning from the use of antiseptics are uncommon, but by no means rare. Most of the ordinary agents \\\\\ 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. The question of personal idiosyncrasy 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. Ordinarily an erythematous rash appears under and about the edges of the dressing, bright red in color, and 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 absorption. 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 m.outh, under the skin, and by rectum. 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 17 258 CUTANEOUS RASHES over a rav; surface to allow absorption in sufficient amount, the patient within a few hours becomes pallid and drowsy, the respiration is labored and stertorous, and coma gradually develops, followed by collapse; 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. Although a number of cases of poisoning have been reported after topical applications, and suicidal attempts have been made by taking it internally, it is not certain that picric acid has ever been the direct cause of death. Poisoning is readily recognized by the intense yellow color which the deposit of this pigment gives to the skin and mucous membrane. The urine may be yellow, brown, or black. There are some nausea and vomiting and headache. It is differentiated 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 two 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\'ii, 138. T. S. Stone, Iodoform and Carbolic Poisoning, Amer. Jour. Obstet., 1902, xlv, 93. Gottheil, Diagnosis of Commoner Drug Eruptions, Arch, of Diagnosis, April, 190S. F. J. Shepherd, Eruptions Occurring After Abdominal Operations, Jour. Cut. Dis., 1909, xxvii, 293. CHAPTER XXVIII RARE COMPLICATIONS: TETANUS, MALIGNANT 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 sufl&cient 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 resembhng that of tetanus was ^ Krankheiten der Ovarien, Deut. Chir., 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. kHn. Woch., 1909, xlvi, 1654; and Reuben Peterson, Tetanus Developing Twelve Days After Shortening of the Round Ligaments, Jour. Amer. Med. Assoc, 1910, liv, 108. 259 26o RARE COMPLICATIONS found. It was suggested to him that in the locahty in which these cases occurred sheep ordinarily harbored tetanus bacilh 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 its Prophylaxis by Proper Dietetic and Culinary Measures.^ He reported 2 cases which occurred after the patient had eaten copiously of un- cooked 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 upon sterile tissues in which a rigorous postoperative asepsis can be maintained until healing has occurred. In those regions in which postoperative asepsis cannot be secured, for example, the extremities and the anorectal region, the liability to occurrence of tetanus cannot be completely removed. Occasionally postoperative 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 previously 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. ^ Monthly CyclopEedia and Medical Bull., 1909, ii, 705. POSTOPERATIVE TETANUS 261 of hostlers, dairymen, and others intimately associated with domestic animals show tetanus bacilh 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 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 antitoxin 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 disinfected, if possible, by the use of antiseptics. Hutchins^ states on experimental evidence 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 alrea,dy circulating in the system is rarely to be depended upon, but in spite of this it may be useful to inject 10 or 20 cc. subcutaneously in the neighborhood of the wound, 10 to 20 cc. intravenously, and if the patient's life is in imminent danger, 20 ^ Gelatin in Therapeutics, Thcrapic dcr Gegonwart, 1909, 1, 265. • ^ Festschrift liir Rindflcisch, 1907. 262 RARE COMPLICATIONS to 30 min. into the spinal cord.^ Exhaustion should be combatted 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 intraspinal injection of magnesium sulphate, as suggested by Meltzer. This inhibits the convulsive seizures and produces ascending paralysis, beginning in the lower extremities when injected into the lumbar spine. Care should be exercised in compu- ting the dose or it may be followed by death. The dose for a male adult should be i cc. of the 25 per cent, solution for every 20 pounds weight. 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 repeated every twenty-four or forty-eight hours, as indications arise. He suggests as probable that the therapeutic effect of the antitoxin is due to the car- bolic acid or tricresol which it contains as a preservative, and which in itself is strongly recommended by Baccelli.^ 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. Like the tetanus bacillus, it is found in the intestinal tract of man and animals. Infections with the gas bacillus are likely to follow ^ Rogers, Jour. Amer. Med. Assoc., 1905, xlv, 12. On the theory that the toxin is centripetal and finds its way to the central nervous system, 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. Nathan Jacobson (Trans. Amer. Surg. Assoc, 1906), after an exhaustive stud}', was led to conclude that there was practically no difference to be noted in the result, no matter how the antitoxin was administered. 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. ^ Trans. Amer. Surg. Assoc, 1909, xxvii, 279. ^ SuU'azione delle iniezione di acido fenico nelle neoralgie, nel tetano e nella tisi, Lavori di Congressi di medicina interna, Roma, 1888, i, 342. PAROTITIS 263 extensive lacerations and compound fractures, and seem to be most apt to occur when the wound has been contaminated with grease and dirt from machinery and sliafting or wagon-wheels and car-trucks. It has been known to follow operation about the rectum, and there has recently been a fatal case following amputation for diabetic gangrene at the Boston City Hospital. The first sign of gas-bacillus infection is a livid or bluish appearance about the wound, followed rapidly by the occurrence of gaseous in- filtration, which crackles and pits on pressure. A foul reddish secretion may be expressed, which contains bubbles. The process extends rapidly in the form of a moist gangrene, and may involve the entire limb within twenty-four hours. Profound prostration ensues, and the patient is likely to die of toxemia. This clinical picture accounts for the name malignant edema, which is sometimes given the condition. The treatment must necessarily be heroic. Free incision should be made wherever there is infiltration, and moist antiseptic dressings should be continually applied or the continuous bath or irrigation em- ployed. On the theory that the bacillus cannot live in the presence of oxygen, 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, amputation offers the best hope for recovery, and should be performed before the patient becomes too depressed to stand anesthesia.^ 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 it is more frequent after injuries 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 ^ Thiriar, Presse Med., Beige, 1904, Ivi, 555. ^ Abner Post, Pseudo-malignant Edema, Boston City Hosp. Med. and Surg. Reports, 1896, seventh series; Paul Thorndike, Clinical Report of Cases of Infection due to the Bacillus Aerogenes Capsulatus, Boston Med. and Surg. Jour., 1900, cxlii, 592; Joseph H. Pratt and Frank T. Fulton, Report of Cases in, which the Bacillus Aerogenes Capsulatus was Found, Boston Med. and Surg. Jour., 1900, cxlii, 599. ^ Kulka, Secondary Parotitis, Wien. klin. Woch., 1908, xxi, 691. *W. S. Fenw^ck, The Prevention of Parotitis during Rectal Feeding, Brit. Med. Jour., 1909, i, 1297. ^ Paget, Lancet, 1887, i, 314. 264 RARE COMPLICATIONS 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 operation. 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 operation. 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.^ 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 epididymi- tis and ovaritis following epidemic parotitis, which speaks for some association bet^veen this gland and the generative organs. Some authori- ties consider that toxic agents circulating in the blood are an important factor in suppurative parotitis.^ There is more evidence, however, sup- porting the theory that the germs enter the gland by way of the mouth.^ A patient who is kept upon his back and allowed only a liquid diet does not use his jaws in chewing, and, therefore, is not apt to empty his parotid ducts as he would normally. The secretion of saliva is diminished, and the germs present in the mouth take on an added viru- lence. 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 follow the pressure of the fingers of the anesthetist during an operation in holding forward the jaw. 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. Chew- ing gum or sucking a rubber nipple will oftentimes, by maintaining the salivary secretion, aid in keeping the buccal ca^•ity clean, and thus act as a prophylactic. Suppuration should always be suspected if pain is severe and pro- longed or if the temperature is maintained at 102° F. or over. \'\'hen suppuration occurs, incision should be made at once, with care that the branches of the facial nerve are not wounded.* Even if no pus is found, ^ Bumm, Miinch. med. Woch., 1887, xxxiv, 173. " Dyball, Ann. Surg., xl, 886. ^ Soubeyran and Rives, Arch. Gen. de Chir., 1908, ii, 448. * Daniel Fiske Jones, Boston Med. and Surg. Jour., 1902, c.xl%-ii, 565. STATUS LYMPHATICUS 265 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 tonsillec- tomy. The fatality has seemed to be independent of the anesthetic used, and has sometimes occurred when no anesthetic at all was em- ployed. 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. Autopsy in some of these cases of sudden death has demonstrated the presence of an enlargement of the lymphatic tissues throughout the body. There are 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 the thymus 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 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. 266 RARE COMPLICATIONS Usually death follows so suddenly upon the first appearance of symptoms that treatment is of no avail. Artificial respiration should always be instituted. 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, ^vhich may be the condition here present. References R. Park, The Status Lymphaticus and the Ductless Glands, Surg. Gyn. and Obst., 1905, i, 140. R. E. Humphn', Clinical and Post-mortem 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. See, 1908, 507. HEMOPHILIA The occurrence of postoperative hemorrhage has already been con- sidered under Chapter VI. Sometimes a patient who is subject to hemophiha is operated upon without knowledge of h^s 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 opera- tion treatment should be instituted to forestall all expected hemorrhage. Serum or the calcium salts should be administered. Treatment. — The treatment of hemophilia is frequently tedious and oftentimes barren of results. It should be followed up most as- siduously, and it sometimes resolves itself into a duel bet^;^•een death and the doctor. Internally, the patient should be stimulated by a suf- ficient diet, and iron, ergot, or thyroid extract may be administe'^ed. If the wound is accessible, it should be cleaned thoroughly down to ...e bleeding surface, and a styptic, such as Monsell's solution, tannic acid, or adrenalin in the form of powder or in solution, 5 per cent, gelatin, or 4 per cent, cocain solution; on pledgets of gauze, should be applied direct to the bleeding capillaries. These applications should be re- newed whenever the oozing of blood is sufficient to warrant it. If firm ^ Dahlgren, Hygeia, 1908, Ixx, 481. HEMOPHILIA 267 pressure can be brought to bear upon the artery which suppHes 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 the 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 little or no value. . The same may be said of gelatin by mouth or subcutaneously. Too much calcium chlorid will increase the coagulation 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 instead of calcium chlorid has recently been followed by good results, and with it more uniformity and certainty of action can be ex- pected. 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 of 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 cattle, as well as of human beings, had the power of con- trolling hemorrhagic processes by increasing the coagulability of the blood. He gave up the use of beef-serum on account of the toxic symp- toms which accompanied it. 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 might be re- peated 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 favored 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. * Rugh, Ann. Surg., 1907, xlv, 666. 2 L'Hemophille, Pathogenic et Serotherapie, Presse Med., Oct. 18, 1905; Des Injec- tions, de serum sanguin frais dans etats hemorrhagipares, Tribune Med., Jan. 12, 1907. 268 RARE COMPLICATIONS Weil's observations were confirmed by his countrymen, Elifagaray* and Carriere.^ Broca, in Germany, tried the method ^ in 3 cases of hemophiha, using diphtheria antitoxin locally with success. He de- cided that the method was very valuable as a temporary expedient, and suggested that the injections be made before operation as a prophylactic in cases where a disposition to bleeding was suspected. He suggested also that, although the method could not be considered as a cure for hereditary hemophilia, by repeating the injections 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. Lommel * reported success with the method in a boy of four years 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 hemophilia 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. Leary '' used • the procedure with success in cases of hemophilia, post- operative hemorrhage, hemorrhage of the new-born, 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 account of the danger of hemolysis or thrombosis following its injection into veins. Leary uses rabbit serum altogether. It 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 ^ These de Paris, 1907. ^ Miinch. med. Woch., 1907. ^ Med. Klin., 1907, 1445. * Ueber Blutstillung mittels Serum bei Haimophilie, Zeit. fiir innere Med., 190S, xxix, 677. ^ Der Wert der Serumbehandlung bei Hamophilie auf Grund experimenteller und klinischer Untersuchungen, Mitt, aus den Grenz. der Med. und Chir., 1909, xxi. ^ Serum as Hemostatic in Hemophiliacs, Gaz. Deg. Osp., 1909, xxx, 753. ' The Use of Fresh Animal Sera in Hemorrhagic Conditions, Comm. of the Mass. Med. Soc, 1908, xxi, 123. HEMOPHILIA 269 and ensiform. A needle. is thrust toward the middle line and slightly upward. The puncture usually penetrates the left ventricle. Blood to the amount 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 off. 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 delivered, because it has to be kept while the animals are being watched for the development of tetanus and other diseases. The same objection prob- ably holds in the use of commercially prepared sera. CHAPTER XXIX 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 between 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 victim 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 perfectly 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 terrible visionary hallucinations and violent delirium by which the nervous system reacts to its deprivation. Delirium tremens is the price that alcohol demands. To the sudden deprivation of alcohol are added ether anesthesia and enforced rest in 270 ■ , MORPHIN 271 bed, either of which in itself is sufficient often to precipitate an attack of delirium tremens. 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 calmness 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 overcome 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. 273.) 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 often ward off an incipient case. Etherization should be postponed whenever possible until the nervous system has become steadied. Mo'rphin.2 — 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 convalescence and the dose gradually reduced. Few cases are more pitiable than the suddenly restricted morphin fiend. Moreover, the diarrhea, rest- lessness, intense misery, and persistent apprehension and wakefulness * Boston Med. and Surg. Jour., 1893, cxx^dii, 253. ^ Much may perhaps be expected from the Town Treatment of these drug habits, recently indorsed by Dr. Alexander Lambert, of New York, Jour. Amer. Med. Assoc, 1909,. liii, 985. 272 HABITS AND THEIR RELATION TO SURGICAL CONDITIONS which follow the sudden withdrawal of morphin constitute a more than imaginary danger. Morphinism must be recognized as a disease. Cocain. — What has been said of morphin applies equally well to cocain. Before the patient has deteriorated to a marked degree physi- cally from the use of the drug the habit should not be a contraindication to necessary operation. Cocain users are likely 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 coflfee 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, 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 ordinarily by nothing worse than a tem- porary 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 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 convalescing patient, in part at least, to his enforced confinement. CHAPTER XXX POSTOPERATIVE PSYCHOSES: 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 of tv^^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 two 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 toa certain degree resembles that of mild shock. Then there gradually develops 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 ^^•hich he lies. The course of the disease may be divided into three stages: The first, or prodromal stage, is characterized by the condition of ner\'Ous apprehension. This usually lasts about twelve hours. The patient, as a rule, is submissive and extremely anxious to comply with all the ^ Forge and Jcanbrau, Death from Post-traumatic Delirium Tremens, Pressc Med., 1909, xvii, 19. . 18 273 274 POSTOPERATIVE PSYCHOSES 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 low 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 DELIRIUM TREMENS 275 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 ammonium, 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 in doses of i dr. repeated every four hours has been recommended. Capsicum is valuable when given for the purpose of lessening the irritation of 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 directly 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 will 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 276 POSTOPERATIVE PSYCHOSES 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. — Insanity following operation occurs relatively not often. Dewey in 5000 insane found only 3 cases of insanity following operation in persons previously of sound mind. It is uncommon also in proportion to. the total number of operations, various writers reporting from I to ^ per cent. As to the nature of the operations which seem to induce insanity operations 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 followed genital operations in 65 cases, cataract operations in 35 cases, and various operations in 96 cases. The preponderance, as regards sex, is about 4 to I in favor of women. This is clearly due to the large proportion of gynecologic operations in women as compared with opera- tions on the genital organs in men, for Sears,' 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 in those frankly insane ^ Cheever, Lectures on Surgery, Boston, 1894, 39. POSTOPERATIVE INSANITY * 277 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, predisposed, either from heredi- tary taint or from acquired nervous instability, to become unbalanced in consequence of an active disturbing factor. 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 alcohol, cocain, or morphin in those accustomed to their use. It may be traumatic, as head injuries. Besides these preoperative causes, we must consider as important 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, septi- cemia, 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 colly ri a of atropin, or the internal administration of sodium salicylate, all of which usually subside with the withdrawal of the agent — and acute confusional insanity, resembling delirium tremens, frequently due to sepsis or toxic conditions, which often lasts weeks or months, and in- cludes premature climacteric insanity in the form of melancholia fol- lowing the removal of the ovaries, and premature senile dementia, not infrequently occurring after geni to-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 alcoholism 278 POSTOPERATIVE PSYCHOSES 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 geni to-urinary tract. Especial attention should be paid if the patient is known to be " high strung," has had at- tacks 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. 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 and stimulants employed if necessary. The bowels should be kept free with mild salines. Warm baths will usually suffice 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\iii, 642. C. G. Dewey, Trans. Amer. Medico-Psycholog. Ass., 1898, v, 223. Robe, Amer. Jour. Obstetrics, 1898, xxxix, 324. Hurd, Amer. Jour. Obstetrics, 1898, xxxix, 331:. Englehardt, Deut. Zeitsch. f. Chir., 1900, Iviii, 46. Menopause. — Mild psychoses analogous to those which some- times 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 fonvard to the climacteric ^ Amer. Jour. Insan., 1893, 1, 345. ^ Com. Mass. Med. Soc, 1893, x\i, 657. POSTOPERATIVE INSANITY 279 with dread, because they have seen or heard of cases of mahgnant disease or of nervous prostration occurring in others at a similar period. Others are apprehensive 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 palpitation. Rarely the condition goes so far as to cause a nervous breakdown which requires isolation and treatment. Ordinarily, whatever nervous mani- festations 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.^ ^ Walthard, Psychoneurotic Climacteric Phenomena, Zeit. f. Gyn., 1908, xxxii, 564; D. H. Craig, The Menopause, Jour. Amer. Med. Assoc, 1908, li, 1507. CHAPTER XXXI GENERAL TREATMENT IN CONVALESCENCE Some surgeons make it a practice to administer tonic 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 effects 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 sufficient 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 x-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. • 280 GENERAL TREATMENT IN CONVALESCENCE 281 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 insomnia, loss of appetite, impoverished blood, remembering, what we have already stated, that a proper regulation of surroundings and habit and sufi&cient 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 I 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 pro- prietary 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, -gV ^° 4V S^-' ^"^'^ °^ 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 y-g-Q- 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. Ouf-of-doors and Sunlight. — Nearly all that has been said as to the value of out-of-door life and sunshine in surgical tuberculosis applies, in my opinion, to the healing of all wounds and to surgical convalescence in general. The much-vaunted air of the Engadine is, after all, only pure air, and we need not cross the ocean to find that. It is obvious that in the presence of diseases 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-of-doors atmosphere, but in general the respiration and all other vital functions are stimulated by a convalescence spent, so far as possible, out-of-doors. There is an 282 GENERAL TREATMENT IN CONVALESCENCE open-air sanitarium at every door, from which any surgeon with sufficient 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 normahty, 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 surgical convalescence, I believe that 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 likely 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 sufficient 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 rehef 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- 283 284 bed-sores: causes; prevention; treatment traneous substances should be allowed to find their way under the 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 frequently 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 will come opposite the point suffering from pressure. The same object can be accomplished by means of the rubber ring which is inflated with 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 water-bed, which distribute the pressure from the weight 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. The use of alcohol or spirits of camphor will render the skin more resistant and less hable to ulceration, and the same ts true of the saturated solution of picric acid or compound tincture of benzoin. Sometimes a generous dressing of absorbent cotton, held in place by collodion, will serve to protect a small area of pressure hyperemia, or the skin may be painted direcdy with collodion or covered with adhesive plaster. bed-sores: causes; prevention; treatment 285 When the bed-sore has formed, the part should immediately be re- lieved of all pressure by turning the patient into another position per- manently, 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 or scarlet red^ (8 per cent.) , may be relied upon. Stimulation, nourishment, and sleep are all valuable adjuvants in treatment. ^ J. S. Davis, Amer. Surg., 1910, ii, 40. 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." Neugebauer collected 109 cases of foreign bodies left in the abdomen and Schachner collected 155 cases, including in this number the cases collected by Wilson and Neugebauer. 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, I have recently seen a case where, 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. I have also removed 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 tlie 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. 286 SYMPTOMS 287 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 even 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 found 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 operation. 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 7. 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 fistulas. In 2 cases the sponges were 2S8 FOREIGN BODIES LEFT IN THE ABDOMINAL CAVITY 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. 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 fistulae 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 violently 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 hand 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 wound. 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 two. 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 OPERATION 289 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-smelhng 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 w-eak, we need not interfere for two 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. 19 29° FOREIGN BODIES LEFT IN THE ABDOMINAL CAVITY 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 under 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 j 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 McBurney 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 was left in, and 20 per cent, where the wound was 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 afccount of sepsis in the wound, poor technique, insufficient musculature, or imprudent post- operative 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. 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. An incision in which the various structures are separated along their own line of cleavage, so that they will come together more naturally, and are not divided along the same plane, so that one layer will buttress the opening in the next, is ideal from this point of 291 292 POSTOPERATIVE HERNIA: ADHESIONS view. Naturally, the median line incision, which traverses only one layer of fascia and no muscle, and in which reliance must be placed en- tirely 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 incision, 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 transverse 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 liabihty 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, homxologous structures should be brought together. This is the basis of our modern technique, the so-called tier or layer suture. Lluscle is united to muscle and fascia to fascia, and no foreign structure is alloAved 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 consequently 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 between layers. The great disad\'antage 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. POSTOPERATIVE HERNIA: SYMPTOMS 293 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 modern 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. Symptoms. — The symptoms of postoperative hernia are usually 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 omentumi get temporarily caught. Frequently the patient is altogether unconscious of the fact that he has a hernia. Habitual constipation generally accompanies large ventral herniae. 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. ^ See Barker, Causes and Operative Treatment of Umbilical and Ventral Hernia, The Practitioner, 1908, i, 149. 394 POSTOPERATIVE HERNIA: ADHESIONS 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 permanently, 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. Mere end-to-end approximation of the freshened edges of the aponeurosis which form the ring does not suffice— the fascia must be cleared back and the edges made to overlap. The flap may be transverse or longitudinal, as best suits the mechanical requirements of the situation. If there is a redundancy of skin-flap, the excess may be removed by including it in an elliptical 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 \ascera by remo\ang 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 neces- sary for separation of adhesions. The operation, in wide median line hemise, is usually so planned that the elliptical area of skin, the underlying fat, the sac, and the tied-off omentum which is adherent are removed in one mass. 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. ADHESIONS 295 This useful property has, however, another aspect. Adhesions may arise after dean 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 for relief from his adhesions. More- over, adhesions may stretch into bands, under the influence of the intestinal activity, and they are always a potential cause of acute ob- struction. 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- 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, the use of dry gauze sponges, 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 becomes adherent to an abdominal incision during the process of healing. This is salu- tory, 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 296 POSTOPERATIVE HERNIA: ADHESIONS 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 intestine 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 attenuate and gradually disappear. 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 intestine is less likely to be followed by obstruction than is the band formation, 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 inflammation. In the same way in some persons extensive adhesions will apparently 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 so compressed as to interfere seriously with its functioning. Similar re- sults may occur after operations in the female pelvis. 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 adhesions may exist and the patient suffer no impairment of health, nevertheless they are the frequent cause of digestive disturbances, ill-defined or sharply localized abdominal pain and soreness, and sometimes acute intestinal obstruction. adhesions: symptoms 297 In the insidious form the symptoms at first are sh'ght and they may appear only at intervals. The patient complains of soreness in the intestines 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 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 S3^mptom3 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 under 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 t\velve 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, more or less generalized, 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 vomiting, distention, at first to be noted just above the seat of the constriction, spasm, which is ordinarily less marked than in peri- tonitis, 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 intestine is not entirely closed off at the point of constriction. 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 298 POSTOPERATIVE HERNIA: ADHESIONS 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 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 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 artificial methods have been experimented with as means of preventing the formation of postoperative adhesions in the abdomen, between brain and dura, and about tendons. While no single agent has demonstrated its assured fitness for this purpose, the various observa- tions are worthy of record. The painting of collodion over raw surfaces was suggested by Stern;' this method is no longer used. Miiller originated the plan of leaving the abdomen full of normal saline solution; Vogel ^ declares it is ineffectual. E. Marvel ^ regards a solution ^ Bruns' Beitrage, 1889, iv. ^ Kent, Zeit. f. Chir., Ixiii, 26. ^ Jour. Med. Soc. of New York, Dec, 1905; Jour. Amer. Med. Assoc, 1907, xlix, 986. adhesions: prophylaxis 299 of adrenalin in normal saline as of value by preventing plastic exudate. The use of silk protective has been advocated by C. Lauenstein.^ Vogel {op. cit.) claims good results from a solution of gum arable (gum arabic, i part; normal saline, 2 parts; filter and sterilize). This is injected through a tube just before the wound is closed. The use of thin gold-beater's skin, made from the peritoneum of catde (sold in America under the name of Cargile membrane), has been advocated by Duschinsky^ and by Charles Cargile, of Bentonville, Arkansas. Experiments by A. B. Craig ^ and A. G. Ellis show that litde reliance can be placed on this method. The injection of salts of physostigmin have been recommended to prevent abdominal adhesions through the early institution of peristalsis,* The use of sterile olive oil over raw surfaces was first made by August Martin, of Berlin.^ Blake 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 possibly even longer; that its presence tends to prevent early and direct adhesion 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." In contradiction to these findings stand the researches of M. Busch and E. Bilergeil.^ They have experimented with clean olive oil, solid paraffin, anhydrous lanolin, liquid paraffin, gum arabic, agar, gelatin, fibrolysin, and the subcutaneous injection of physostigmin, and -conclude that it is impossible to prevent contact between abraded or injured surfaces of peritoneum and the consequent production of adhesions by means of mucilaginous or similar substances left in the abdominal 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, gelatin, and fibrolysin, are too rapidly absorbed to be of any mechanical advantage. They recommend careful operating and strict observance of the rules of peritoneal toilet. M. L. Harris ^ has had good results from the use of silver-foil after ^ Archiv f. klin. Chir., 1890, xlv, 244. ^ Inaug.-Dissert., Miinchen, 1898. ^ Ann. Surg., June, 1905, xli, 801. *D. H. Craig, Amer. Jour. Obst., 1904, xlix, 449. ^ Ellis, Proceed. Path. Soc. of Phila., 1906, ix, and J. B. Blake, Surg. Gyn. and Obst., 1908, vi, 667. ® Archiv f. klin. Chir., 1908, Ixxxvii, 99. ^ Jour. Amer. Med. Assoc, 1904, xlii, 763. 300 POSTOPERATIVE HERNIA: ADHESIONS operations on the brain, and Ellis (op. cit.) has demonstrated the value of films of celloidin wrapped about tendons to prevent adhesion to their sheaths. 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 litde residue, which might 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 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 vessels, 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.^ ^ Surg. Gyn. and Obst., 1909, v\\\, 576. ^ 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, \dii, 574. CHAPTER XXXV ABDOMINAL SWATHES: THEIR USE AND ABUSE It has until recently been considered the proper thing to recommend that a iitted 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 ail operations for hernia. The practice is rapidly becoming more and more restrrcted. 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 who 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 sho.ws under the microscope as young vascu- lar connective tissue. In the course of weeks and months this red scar tissue grad-ually contracts and loses its vascularity, becomes more ^ Kummer (Corres. f. Schweizer Acrzte, 1901, xxxix, 361) insists that an abdominal bandage be worn for three months after a celiotomy. ^ Archiv f. Gyn. u. Chir., Ivi, 656. 301 302 ABDOMINAL SWATHES fibrous in character, and changes permanently into white scar tissue. Skin and peritoneum proHferate quickly and heal rapidly by the forma- tion of new similar structures; connective tissue, fat, and muscle repair by the formation of connective tissue and repair more slowly; fascia and tendons repair very slowly by means of connective tissue. 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 hernias. 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 303 too long an incision, or unpractised technique. Incisions above the level of the umbilicus are subject to no great amount of intra-abdominal 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 detri- mental. A case has recently come to my 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 McBurney technique declare that this is usually unnecessary in their muscle-splitting incision. I so believe. However, it must be borne in mind that in a McBurney inci- sion which has been drained for any length of time, say, forty-eight hours or over, the different layers fail to fall together into close approximation, 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 appear, would not be willing or in condition to have it treated surgically. In addition to the character of the wound we must give consideration 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 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 ad- vantage during this process. Moreover, in a fat person a swathe im- parts a sense of security and satisfaction that will give confidence to undertake and continue exercise. In a man whose abdomen is ap- proximately 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 corsets 304 ABDOMINAL SWATHES and by repeated pregnancies. In a well-developed women 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. 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 m^aterially 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 sub- ject 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 \yith 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 line, such cases should wear swathes. Opera- tions for ventral and postoperative hernias should be followed by the use of swathes. The matter of the type 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, sufiiciently complicated to suit the most ingenious mind, and depending in principle on minor details usually of no great value. 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 305 swathes in accordance with the instructions of the surgeons. In special cases, at least, swathes should be specially fitted. Ordinarily, simple and inexpensive swathes of the types pictured (Figs. 96, 97, 98) may be purchased which will serve every purpose. Fig. 96. — Swathe. Showing elastic webbing straps, buckling in front, and designed to exert an upward pull on lower abdomen (Kny-Scheerer). Fig. 97. — Side View of Swathe. Similar to that iu Fig. 96, with front lacing (Kny-Scheerer). Fig. g8. — Swathe of Linen Mesh, Porous, and Containing no Elastic (J. Ellwood Lee). 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- 20 3o6 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 ARTIRQAL 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 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 important, therefore, in performing amputations to be governed by the experience of those who have to do with the making and fitting of artificial 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-joint, 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. 307 308 ARTIFICIAL LIMBS; POSTOPERATIVE FLAT-FOOT The amputation of choice, where amputation is necessary betw^een the metatarsals and the knee, is the amputation of both hones, 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 sub- jected 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. Ulceration frequently necessitates reamputation. Moreover, these stumps are usually hypersensitive. Long tibial stumps are likely to be enlarged or bulbous at the tip, w^hich interferes with the use of a socket. Tibial amputations short of 4 inches are of practically no use in throw- ing the lower leg forw^ard in walking. In addition, they are likely to be- come atrophied. The fibula, which is practically subcutaneous, as a result of friction, may be excited to periostitis, and sometimes reamputation above the knee is the only relief from the soreness or infection. Ampu- tations, therefore, in the middle 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 legs which are suitable for these amputations 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 hinged side irons. 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 con- structed 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 progressively until at last it can be removed and the ordinary socket worn. ARTIFICIAL LIMBS 309 The following letter is from a patient whose leg I amputated at the point of election. It is given entire, because it presents the subjective attitude of one artifiicial-leg wearer. The writer is a man of keen inteUigence 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 Umb I had was what they call a sUp-socket, which was made of leather. It is a very heavy, cumbersome leg, and the slip-socket I do not con- 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 circumference 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 Umb 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 feeUng which a person has, and of course, the stump being tender, there is nothing made that a per- son 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 that 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." 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 scrap'ed 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 operator as in the case of tibial amputation. Thigh stumps, like those of the tibia, are not capable of bearing w^eight 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 3IO ARTIFICIAL limbs; POSTOPERATIVE FLAT-FOOT 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 on over the oppo- site shoulder. After amputation through the hip, legs are supphed 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 permanently until the bone is properly trimmed. Nerves should always be dra^^ n 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 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, usually necessitating re- amputation. ARTIFICIAL LIMBS 31I 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. 312 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 are liable to swell. Cold spraying, massage, and flannel bandages will help to make this stage pass quickly. Many patients after a severe surgical experience, especially if the stay in bed has been long, will rise at first with their muscles and ligaments so atrophied that 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 adducted. 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 grasping effort. This is the correct standing posture (Fig. 99)- Fig. 99. II. Standing with knees "broken" or slightly bent forward, the knee- caps turned outward to simulate bow-legs, 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 as the next step is taken in this position is not thrown suddenly and POSTOPERATIVE FLAT-FOOT 3'^3 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. loo). Fig. loo. III. The legs are crossed, the feet placed parallel, 2 inches apart, the weight equally divided between the feet. This posture, maintained one Fig. loi. minute and then reversed, brings into play all the muscles of balance (Fig. 101). 314 ARTIFICIAL limbs; POSTOPERATIVE FLAT-FOOT IV. Stand on one foot placed straight forward, the other foot curled around behind the standing angle. Balance in this position without other support for a minute, first on one foot, then on the other (Fig. 102). Fig. 102. These exercises barefooted, or in correct shoes, should be taken for two or three minutes, five to twenty times a day; in other words, whenever the Fig. 103. — Weak, Out-toeing Posture, Called " Lady-like." opportunity presents for a moment, until the springy, balancing posture and gait of childhood are recovered. POSTOPERATIVE FLAT-FOOT 315 The shoe, to allow for this correct standing and walking, must have the following characteristics (Fig. 104) : 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 unstable, best by the use of soft rubber, either for the whole heel or for the outer front corner. The construction should be such that 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 foot shall not, after a short time, sink down in the middle of Fig. 104. — Good Shoeing. Oxford, thin leather, unstable heel, flexible shank, " foot-shaped" last. the 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 the 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 foot 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 around the ankle than to put a leather support on the knee. CHAPTER XXXVII FRICTION, MASSAGE, PERCUSSION, REMEDIAL MOVE- MENTS The definition and manner of doing massage ^ are not rendered any dearer by calling slow and gentle stroking in a centripetal direction effleurage, or by speaking of deep rubbing as massage a friction, or by using the term petrissage for deep manipulation ^Yithout friction, or by calling percussion tapotement, but, custom having sanctioned the use of these words, it becomes necessary to mention them. The multiform subdivisions under which the various procedures ,of massage have been described can all be grouped under four heads — ■ namely, friction, percussion, pressure, and movement. Malaxation, manipulation, deep rubbing, kneading, or massage, properly so called, is to be considered as a combination of the last t^vo. Each and all of these may be gentle, moderate, or vigorous, according to the require- ments of the case and the physical qualities of the manipulators. Some general remarks here will save repetition: (i) All the single or com- bined procedures should be begun moderately, gradually increased in force and frequency to the fullest extent desirable, and should end gradually as begun. (2) The greatest extent of surface of the fingers and hands of the operator consistent with ease and efiicacy of movement should be adapted to the surface worked upon, in order that no time be lost by working with the ends of the fingers or one portion of the hands when all the rest might be occupied. (3) If too near the patient, the manipulator will be cramped in his movements; if too far away, they will be indefinite, superficial, and lacking in energy. (4) The patient should be placed in an easy and comfortable position, with joints midway between flexion and extension, in a well-ventilated room, at a tempera- ture of 70° to 75° F. Any sensations of tickling will soon be overcome by the effects of the massage if ordinary tact be used. (5) What con- stitutes the dose of massage is to be determined by the force and fre- quency of the manipulations and the length of time during which they are employed, considered with regard to their effect upon the ^ This entire chapter is quoted from "A Treatise on Massage" by Dr. Douglass Graham, of Boston (Phila. and London, J. B. Lippincott Co., IQ02), with Dr. Graham's ven,^ kind permission and approval and through the courtesy of the pubHshers. 316 FRICTION 317 patient. A good manipulator will accomplish more in fifteen minutes than a poor one will in an hour, as an old mechanic working deliberately will accomplish more than an inexperienced one working furiously. (6) The direction of the procedures should almost invar 'ably be from the extremities to the trunk, from the insertion to the origin of the muscles, in the direction of the returning currents of circulation. FRICTION Friction, or effleurage, may be spoken of as circular and rectilinear; the latter may be vertical or parallel to the long axis of a limb, or horizontal transverse, or at right angles to the long axis. Transverse friction is a very ungraceful and awkward procedure. It has been introduced on theoretic considerations alone, and may without loss be laid aside. A slight deviation from the method ordinarily recommended in doing straight-line friction I have found to be more advantageous, for, though in almost every case the upward strokes of the friction should be the stronger, so as to aid the venous and lymph currents, yet the returning or downward movement may with benefit lightly graze the surface, im- parting a soothing influence, without being so vigorous as to retard the circulation pushed along by the upward stroke, and thus a saving of time and effort will be gained. The manner in which a carpenter uses a plane represents this forward-and-return motion very well. In giving a general massage it is immaterial whether the upper or lower extremities, be done first. Let us begin with the hands, and here a convenient extent of territory is from the ends of the fingers to the wrist, each stroke being of this length, the returning stroke being light and without removal of the hand. The rapidity of these double strokes may be from 90 to 180 a minute. The whole palmar surface of the fingers in easy extension should be employed, and in such a manner that they will fit into the depressions formed by the approximation of the phalanges and meta- carpal bones, the patient's hand meanwhile resting in the other hand of the manipulator, the right in the right and the left in the left, as if placed for shaking hands. Six to a dozen up and return strokes may be made on as much of the surface of the back and palm of the patient's hand as that of the manipulator will cover. As there will be a small portion left undone, the hand, or rather the fingers, of the manipulator will be placed on this and treated in a similar manner, while the greater portion of the surface previously worked upon will at the same time and by the same strokes be reviewed. The heel of the hand should be used for vigorous friction of the palm, done by a semicircular pushing move- 3l8 FRICTION, MASSAGE, PERCUSSION, REMEDIAL MOVEMENTS ment, and the same can be done on the sole of the foot with somewhat less of the semicircular motion. The effect of this when well done is remarkably agreeable, and for this purpose the right hand of the opera- tor should be used for the right hand and the foot of the patient and the left for the left, for in this manner they fit each other best. From the wrist to the elbow and from the elbow to the shoulder-joint are each suitable extents of surface to be worked upon, and here not only straight-line friction, extending from one joint to another, may be used,, but also circular friction. The form of the latter which appears to me most serviceable, as it includes the advantages of the other two, is that of an oval, both hands moving at the same time, the one ascending as the other descends, each stroke reaching from joint to joint, the up- ward being carefully kept within the limits of chafing the skin, while they move at a rate of from 75 to 180 each a minute, or 150 to 360 with both hands. It is well to begin these strokes on the inside of both arms and legs, so that the larger superficial and deep vessels may be first acted upon, as this influence extends at once, though indirectly, to their tributaries and ramifications. But it is not always practicable to place the hand of the patient on a support so that the operator can work with both hands on the arm. If not, as when the patient is lying down, then he can grasp the patient's right hand by its dorsum with his left while his other does oval friction on the anterior aspect of the arm. And for the back of the arm, the manipulator will grasp the patient's hand, as in the act of shaking hands, while his disengaged hand does the friction. Time, effort, and effect will be made the most of by doing friction .upon the foot with the hands at right angles to it, one hand upon the dorsal aspect, and the other upon the sole, moving alternately and in a circular manner, the one ascending as the other descends. Friction can also be very effectually done on the back of the foot by the manipu- lator sitting in front of the patient, when alternate up-strokes can be easily made with each hand at right angles to the foot from the base of the toes to the ankles. Still sitting in the same position, one hand can grasp the back of the foot just behind the toes — the left hand for the right foot the right hand for the left foot — while the other hand, mainly by its upper portion or heel, does vigorous friction on the sole from the base of the toes to the heel. Around and behind the malleoli will require a special pushing stroke with the fingers. As the lower limbs are larger than the upper, the lateral and posterior aspects from ankle to knee will form a convenient territory, while the lateral and anterior aspects will make another for thorough and efficacious friction. This FRICTION 319 will be best done with the knees semiflexed and the manipulator stand- ing facing the patient for the posterior and lateral aspects, and after having completed the friction here, without stopping the strokes, he will turn with his back to the patient and continue the stroking on the an- terior and lateral aspects, each thumb following the other with tolerably firm pressure over the anterior tibial group of muscles; but, owing to the latter position of the masseur, only upward friction can be done without the light downward stroke. While the hand on the inside of the leg is gliding from ankle to knee, the masseur can turn without losing a second of time or an inch of space. The same systematic division of surface may be made above the knee as below, with the addition of another formed by the inner and anterior aspect of the thigh, and they may be dealt with in like manner; but the operator's back to the patient will, on the whole, be the easiest and most efiScacious way of applying friction to the thighs. The number of strokes below the knees will vary from 100 to 160 with each hand; above, from 60 to 100. Back, from the base of the skull to the spine of the scapula, forms another region naturally well bounded for down- ward and outward semicircular friction, and from the spine of the scapula to the base of the sacrum and crest of the ilium forms another surface over which one hand can sweep, while the other works toward it from the insertion to the origin of the glutei at an average rate of 60 or 75 a minute with each hand for a person of medium size. It will be observed that on the back and thighs the strokes are not so rapid as on the other parts mentioned, for the reason that the skin here is thicker and coarser, in consequence of which the hand cannot glide so easily, and the larger muscles beneath can well bear stronger pressure; besides, the strokes are somewhat longer, all of which require an increased ex- penditure of time. For more thorough and special effleurage of the side of the neck, as when we are deahng with an acute rheumatism of the upper part of the trapezius, it is well to make alternate strokes from the base of the skull downward and inward toward the chest, on the theory that the circulation takes the shortest route back to the heart. And we desire more effectual friction on the hips we can make alternate strokes in a semicircular manner from the insertion to the origin of the glutei. Indeed, for this purpose one hand can make continuous friction in a circular fashion, while the other does the alternate supple- mentary semicircular stroke. The chest should be done from the insertion to the origin of the pectoral muscles, and the abdomen from the right iliac fossa in the direction of the ascending, transverse, and descending colon. But in these situations friction is seldom necessary, 320 FRICTION, MASSAGE, PERCUSSION, REMEDIAL MOVEMENTS for the procedure about to be considered accomplishes all that friction can do and a great deal more. The force used in doing friction is often much greater than is necessary, for it should only be intended to act upon the skin, as there are better ways of influencing the tissues beneath it. If redness and irritation be looked upon as a measure of the bene- ficial effects of friction upon the skin, then a coarse tov;el, a hair mitten, or a brush would answer for this purpose a great deal better than the hand alone. But for intelligent variation of pressure, agreeableness of contact, and adaptability to even and uneven surfaces, no instrument has yet been devised to supersede the human hand. In union there is strength, and the fingers should be kept close together in doing fric- tion and manipulation. But it is astonishing how persistently they are sometimes held out straight and spread far apart, reminding one of the feet of a frightened duck in a thunder-storm, and the sound of quack suggests itself as appropriate for the one as the other. This would be still more appropriate when, as often happens, the hands are made to traverse the air to an undue extent, accompanied with a snapping of the fingers, reminding us of Mrs. Boffin's horses, that stepped higher than they did longways; and if with these ungraceful flourishes perspira- tion be mistaken for inspiration, and blind enthusiasm for "magnetism," there can be no doubt of the genus to which the operator belongs. The useless flourishes of many while doing friction might impress an uninitiated spectator as evidences of expertness. They bear the same relation to massage, pure, effectual, and agreeable, that the superfluities of architecture, known as the Queen Anne style, w^herein comfort is sacrificed to beauty, bear to the classic detail of Greek architecture. MASSAGE The advantages of ordinary rubbing are not to be despised, and by many this is supposed to be all there is to massage; but it is the least essential part of it. One of the old French dictionaries says there is reason to believe that massage has upon the skin the advantage of fric- tion, that it acts, above all, upon the more deeply situated tissues, etc., thus implying that massage, properly so called, is something different from friction, and yet has the same effect upon the skin, while exerting a more extended range of influence. By this we understand massage proper to be manipulation, deep rubbing, kneading, or malaxation, which is certainly the most important, agreeable, and efficacious pro- cedure of all. It is done by adapting as much as possible of the fingers and hands to the parts to be thus treated, and, without allowing them to slip on the skin, the tissues beneath are worked upon in a circulatory MASSAGE 321 manner by a sort of kneading, rolling, squeezing, manipulatory motion, proceeding, as in friction, from the insertioii toward the origin of the muscles, from the extremities to the trunk. For this purpose the same divisions of surface as for friction will be found most convenient. Begin- ning, then, with the fingers from the roots of the nails, the thumb of the manipulator will be placed on one of the fingers of the patient and parallel to it, while on the opposite surface the second phalanx of the index-finger will be simultaneously placed at right angles to this, and bet^veen the two the finger of the patient will be compressed and malaxated at the rate of from 75 to 150 a minute. The dorsal and palmar surfaces will, of course, receive special attention, while the lateral aspects will come in for a secondary share. If the manipulator be sufficiently expert, he can work with both hands on this small surface, one in advance of the other, or he can take one of the patient's fingers in each of his own hands and proceed with the same rapidity as with one. Each finger and thumb will be taken in turn, and the manipula- tions extended over the metacarpal and carpal bones as far as the wTist- joint, and, finally, the palm of the hand will be done by stretching the tissues vigorously away from its median line. The muscles between the metacarpal bones are not very effectually reached by massage, but by pressing up with the fingers in the palm they can be tolerably worked upon by the thumb from the back of the hand. Each part included in a single grasp may receive 3 or 4 manipulations before proceeding onward to the adjacent region, and, indeed, 3 manipulations in one place and three times over the part that is being masseed makes a good general rule, here and elsewhere. The advance upon this should be such as to allow the finger and thumb to overlap one-half of what has just been worked upon. Advance and review should thus be systematically carried on, and this is of general application to all the other tissues that can be masseed. The force used here and elsewhere must be carefully gradu- ated so as to allow the patient's tissues to glide freely upon each other, for, if too great, the movement will be frustrated by the compression and perhaps bursting of the tissues; if too light, the operator's fingers will sHp; and if ghding with strong compression be used, the skin will be chafed. To avoid this last objection various greasy substances have been employed, so that ignorant, would-be masseurs may rub without injuring the skin. When the skin is cold and dry or cold and moist, and the tissues in general are insufficiently nourished, as well as in certain fevers and other morbid conditions, there can be no doubt of the value of inunction, but no special skill is required to do this, and there is no need of calling it massage, unless it be to please the fancy of 21 322 FRICTION, MASSAGE, PERCUSSION, REMEDIAL MOVEMENTS the patient. Removal of hair is entirely unnecessary. Massage can be done as effectuahy on the head as on any other part. The feet may be dealt with in much the same manner as the hands, using the ends of the fingers to work longitudinally between the meta- tarsal as between the metacarpal bones, and the tissues of the sole should be stretched vigorously away from the median line, and, lastly, the heel, accurately adapted into the palm of the hand and between the thenar eminences and fingers, will be worked upon in a squeezing, circulatory manner. Upon the arms and legs and, indeed, upon all the rest of the body, both hands can be used to better advantage than where the sur- faces are small. Each group of muscles should be systematically worked upon, and for this purpose one hand should be placed opposite the other, and where the circumference of the limb is not great, one hand may be placed in advance of the other, the fingers of one hand partly reaching on to the territory of the other, so that two groups of muscles may be manipulated at the same time with grasping, circulatory, spiral manipu- lations, one hand contracting as the other relaxes, the greatest extension of the tissues being upward and laterally, and on the trunk, forearms, and legs away from the median line. It is needlessly wearisome to both patient and manipulator if the hands are kept closely adapted to a limb its whole length in doing this vermicular squeezing; besides, it produces a dragging sensation upon the skin and interferes with the circulation. To avoid this, it is only necessary to raise the hands slightly in advanc- ing. Subcutaneous bony surfaces, as those of tibia and ulna, incident- ally get sufficient attention (unless edema be present) while manipulating their adjacent muscles, for if both be included in a vigorous grasp, un- necessary discomfort results. Care should be taken not to place the fingers and thumb of one hand too near those of the other, for by so doing their movements would be cramped. With the fingers and thumbs at proper distances from each other, not only are the tissues immediately under them acted upon, but those between them are agreeably stretched. The advance should be upon the previously unoccupied stretched region. Space and force will be indicated by the elasticity, or want of it, in the patient's tissues, the object being to obtain their normal stretch, and in this every person is a law to himself, the character of tissues varying with the amount and quality of adipose, modes of life, habits of exercise, etc. A frequent error on the part of the manipulator is in attempting to stretch the tissues in opposite directions at the same time, especially at the flexures of the joints, where the skin is delicate and sensitive, and where the temptation to such procedure is greatest because easiest, the MASSAGE 323 effect being a sensation of tearing of the skin. It is well to go over a surface gently and superficially before doing the manipulation more thoroughly and in detail. In the case of the forearm the two hands will embrace the whole circumference, one in advance of the other, the thumbs occupying the median line, on the anterior aspect, while the fingers are on the back of the arm, and, after going over this in a three- times-three manner, the forearm should then be pronated and the thumbs placed on its back, which will be similarly treated, the fingers meanwhile doing their share of the work. The supinators should receive a special malaxation with the grasp of one hand. Above the elbow, one hand will seize and squeeze the biceps, while the other alternately does the same to the triceps. The median portion of the deltoid will receive most thorough attention from the thumbs placed parallel to its fibers, while the palms and fingers are engaged with the anterior and posterior aspects of the muscles, and after this its margins and the whole muscle can be well worked by seizing the muscle with the hand at right angles to its fibers. In manipulating a leg" of considerable size three divisions of surface will be found necessary: the posterior and lateral aspects will form one; the stretching of the peroneal muscles from those of the anterior tibial region, which is done by placing one thumb in advance of the other on each side of the fibula, and alternately rolling the muscles away from each other, will make another; and for the third, the thumbs will be placed upon the tibialis anticus and a simultaneous rolling of the tissues will be made away from the crest of the tibia. In all these procedures no parts of the hands need be idle, for when not specially occupied, they can be given secondary attention to the surfaces they cover. Of course, if the limb is small, it can all be masseed at once in the grasp of the t\vo hands, but even in this case, when special massage is required, these three divisions are necessary. The cushions of the thumbs, the heel of the hand, and the thenar and hypothenar eminences fit admirably into the depressions of the joints, especially those of the ankle, knee, and elbow, while the rest of the hand is occupied with the adjacent tissues. Above the knee one hand will grasp the adductors while the other embraces the quadriceps extensor, and the alternate con- traction and relaxation of the hands will be made in such a way as to stretch these two groups of muscles away from the line of the femoral artery. The posterior femoral region may next be gone over, which will principally engage the fingers while the upper parts of the hands work upon the sides of the limbs, or the patient can turn on the chest and abdomen, when very effectual kneading with the thumbs can be 324 FRICTION, MASSAGE, PERCUSSION, REMEDIAL MOVEMENTS given to the muscles of the back of the thigh. On account of the thick- ness and tension of the fascia lata the external aspect of the thigh may receive as vigorous kneading as it is possible to give with evenly dis- tributed force, and with the thumbs in advance of each other on the rectus femoris more special and effectual manipulation can be given to the extensors, while the remaining surfaces of the hands make a review of the lateral aspects of the thigh. The hip should be masseed from the insertion to the origin of the glutei, from the back of the thigh to the sacro-iliac articulation, and, lastly, the glutei should be simultan- eously stretched away from the origin. The rate of these maneuvers varies from 75 to 150, with each hand a minute on the arms, from 60 to 90 on the legs, and from 40 to 80 on the thighs, where more force is required on account of the larger size and density of the muscles and the need of using sufficient force to extend beneath the strong, tense fascia lata. On the back the direction of these efforts will be from the base of the skull downward, stretching the tissues away from the spinal column while manipulating in graceful curves at an average rate of 60 a minute with each hand. If this be done on one side of the back, as it most frequently has to be, while the patient lies on the other side, it is one of the most difficult maneuvers for beginners to learn and some never succeed in acquiring it. While both hands are at work on separate spaces occupied by each, the one follows the other, not in an opposite, but in the same circular, m.anner alternately, the one contracting as the other relaxes. The back is most effectually masseed with the patient lying on one side, for in this position the ribs and transverse processes form a better substratum than when the patient lies on the chest and abdomen. On stout patients with firm tissues one hand should often be reenforced by placing the other upon it, and thus the massage may be done with all the strength the manipulator can put forth. The position of the shoulder-blades is important, for if the upper arm be parallel with the side, then the posterior border of the shoulder-blade will be so near the spinal column that scarcely any space will be allowed to work upon the muscles between the scapula and spine. If the upper arm be stretched forward its full length, then the superficial muscles between the spine and the scapula wnll often be so tense that those beneath cannot be effectually reached by massage. Hence, the arm should be placed midway between these two positions. With the ends of the fingers the muscles on each side of the spinal column can be rolled outward, and the supraspinous ligament can be effectually mas- seed by transverse to-and-fro movements. The ends of the fingers and MASSAGE 325 part of their palmar surface should also be placed on each side of the spinous processes, and the tissues situated between these and the trans- verse processes worked by up-and-down motions parallel to the spine, taking care to avoid the too frequent error of making pushing, jerky movements in place of smooth, uniform motions in each direction. With the patient lying face down it is sometimes well to finish off the back by adapting the hands with their w^hole surface to each side of the spinal column. On the chest and abdomen the same general direction will be observed as in using friction, but the manipulation will be more gentle than on the back and limbs, for the tissues will not tolerate being so vigorously squeezed and pinched. Here the massage will consist of moderate pressure and movement with the palms of the hands and rolling and grasping the skin and superficial fascia; and, after this, on the abdomen, firm, deep kneading in the direction of the ascending, trans- verse, and descending colon, using for this purpose the greatest force with the heel of the hand on the side of the abdomen next the operator and on the other side the strongest manipulation with the fingers, avoid- ing the frequent and disagreeable mistake of pressing at the same time on the anterior portions of the pelvis. The sides w^ill incidentally re- ceive sufficient attention while the back, chest, and abdomen are being manipulated. When constipation is obstinate, it is a good plan to com- mence manipulation of the abdomen over the left venter of the ilium and work so as to push the contents of the descending colon toward the rectum; then begin again a little farther backward on the colon and work in the same direction as before, attempting to unload the large intestine, and so on until the whole colon is traversed back to the ileo- cecal valve, and again from there to the sigmoid flexure of the colon. Except on the muscles of the back, massage by rollers is of little use in comparison with that by hand. They may be made of rubber, wood, or metal, of any size, shape, or color to suit the fancy of the so-called inventor. I have had several sorts and sizes made, and find that toler- ably fair and rapid rolling of the muscles of the back may be done by means of a rubber roller 3 in. in length and I7} in. in diameter, secured to a handle like that of a printer's ink-roller. Wooden rollers, 2 in. long and i| in. in diameter, of a somewhat oval or spindle-shaped construction, made so as to revolve, not only on their own axes, but also on the handles to which they are attached, do very well for the backs of people who are too lazy to take off their clothes. The wire of either pole of any electric battery or machine can easily be attached to a conducting roller with a non-conducting handle, but 326 FRICTION, MASSAGE, PERCUSSION, REMEDIAL MOVEMENTS the sponges or poles of any battery may be pressed and moved so as to give a kind of massage while the current is passing, and this is much more agreeable and effectual than a current from a metallic roller, or one pole may be attached to the patient, the other to the manipulator, while the latter does massage with the current passing through both of them, but the so-called "electro-massage" is hardly worthy of the name of massage. Professor Zabludowski used to scorn the idea of doing anything worthy of the name of massage with instruments or machinery, and asserted that only in the hands of physicians would it prove to be an effectual curative means. More recently, however, he sometimes uses instruments for the purpose of giving a rapid rate of percussion for affections of the heart, nerves, etc. Before leaving this part of the subject, the writer begs leave to say something more about the common errors into which manipulators fall, even some of those who pass for being skilful. Many do not know how to do the kneading or malaxation with ease and comfort to themselves and to their patients, for, in place of working from their wrists and concentrating their energy in the muscles of their hands and forearms, they vigorously fix the muscles of their upper arms and shoulders, thus not only moving their own frame with every manipulation, but also that of their patients, giving to the latter a motion and sensation as if they were at sea in stormy weather. By this display of awkward and un- necessary energy not only do they soon tire themselves out, and fancy that they have lost magnetism by imparting it to their patients, but by the too firm compression of the patient's tissues they are not allowed to glide over each other, and hence such a way of proceeding entirely fails of the object for which it is intended. Surely, cultivation is the economy of effort, and the most perfect art consists in acting so naturally that it does not appear to be any attem.pt at art at all. The following words of J. Milner Fothergill are hence applicable: "The knowledge which one man acquires by the sweat of his brow after years of patient toil and painstaking cannot be transferred in its entirety to another. Individual acquired skill cannot be passed from brain to brain any more than the juggler who can keep six balls in the air can endow an onlooker with like capacity by merely showing him how it is done. The muscles, and still more their representatives in the motor area of the brain hemis- pheres, require a long training before this manual skill can be acquired." Friction and manipulation can be used alternately, varied with rapid pinching of the skin and deeper grasping of the subcutaneous cellular tissue and muscular masses, and when necessary with percus- sion, passive, assistive, or resistive movements, finishing one conveni- » PERCUSSION 327 ent surface or limb before passing to another, and occupying, from half an hour to an hour with all or part of these procedures. Pinching is rather an agreeable way of exciting the circulation and innervation of an inert skin, and for this purpose it is best done rapidly, at the rate of 100 to 125 a minute with each hand. The grasp of a fold of skin should not be relaxed until seized by the finger and thumb of the other hand. To act upon the subcutaneous cellular tissue, a handful of skin is grasped and rolled and stretched more slowly than by the preceding method. A deeper, momentary grasping of the muscles is often ad- vantageous, and may be called a mobile intermittent compression, and this, indeed, is what the whole of massage, strictly speaking, consists of. PERCUSSION Percussion, in general applicable only over muscular masses, may be done in various ways. In the relative order of their importance they are as follow^s: (i) With the ulnar borders of the hands and fingers. (2) The same as the first, but with the fingers separated so that their adjacent sides will strike against each other like a row of ivory balls. (3) With the ends of the fingers, the tips being united on the same plane. (4) With the dorsum of the upper halves of the fingers loosely flexed. (5) With the -palms of the hands. (6) With the ulnar borders of the hands lightly shut. (7) With the palms of the hands held in a concave manner, so as to compress the air while percussing. The back of a brush or the sole of a slipper sometimes answers very well for percussion, but, still better, are india-rubber air-balls secured to steel or whalebone handles. With these one gets the spring of the handles together with the rebound of the balls, and thus rapidity of motion with easily varying intensity may be gained, if the operator knows how to let his wrists play freely, as he should do in all the different ways of percussing. The number of blows may vary from 250 to 600 with both hands. The blows should be smart, quick, and springy, not solid and hard, and they should be transversely to the course of the muscles with the ulnar border of the hand and palmar surface; except in the case of the back, which may not only be percussed with the hands at right angles to it while the patient is lying but still more effectually when the patient is standing bent forward, so as to put the dorsal muscles on the stretch. The operator's hands are then most easily parallel to the spine, and can rapidly strike the muscles on each side of it, causing, we have reason to suppose, a vibratory effect, as when the string of a bow is vibrated. Moreover, in this position the muscles, being tense, protect the trans- verse processes from the impact of the blows which is communicated 328 FRICTION, MASSAGE, PERCUSSION, REMEDIAL MOVEMENTS to the nerves as they emerge from the intervertebral foramina, and the effect is usually perceived to their distributions all over the body as a peculiar and delightful thrill. Percussion must be carefully used or it will leave the muscles lame and sore. REMEDIAL MOVEMENTS Remedial movements have been more fully than clearly described in books on "Movement Cure." A comparison of different ways of executing them demonstrates that the part of the limb or body taken hold of for leverage, and the manner of seizing the same, the direction of resistance and force opposed, are all of importance in order that the movements may be done easily, efficaciously, and harmoniously. Those who would apply them should know the anatomy and physiology of the joints of their natural limits of motion. Except in the case of relaxed joints, passive motion should be pushed until there is a feeling of slight resistance to both patient and manipulator, for by this it will be known that in healthy joints the ligaments, capsules, and attachments of the muscles and fasciae are being acted upon. Resistive movements are such as the patient can make while the operator resists, or such as the operator overcomes when the patient resists, as when a group of muscles is voluntarily contracted the operator extends them. The former have been called double concentric movements and the latter double eccentric. It seems to me that the author of these terms must have been somewhat eccentric, for even so good a writer as Estradere pardonably confounds their meaning, as can be seen by comparing his explanation of them on page 72 with that on page 80 of his book on "Massage." Brown-Sequard first pointed out the fact to me that when it is desirable to exercise a group of very much enfeebled muscles, if they first be contracted to their utmost it will require much greater force to overcome this contraction than they could overcome in passing from a state of relaxation to contraction, and I have since proved the practical value of the suggestion. Most frequently, however, it will be necessary to offer resistance against the patient's movements, and then the opposing force should be carefully and instinctively kept within the limits of the patient's strength, so that he may not recognize any weakness, and this, with all these other maneuvers, should stop short of fatigue, at least fatigue that is not soon recovered from. To alter- nately resist flexion and extension is the pons asinorum of manipulators, and in a considerable experience of teaching massage I have found but few who could learn to do it w^ell and many who could not learn to do it at all. Many a patient who has recovered from an old injury REMEDIAL MOVEMENTS 329 is still as much incapacitated as ever from the fact that his latent energies can only be discovered and made available in this manner. Midway between passive and restive movements, in the course of certain recoveries, stand assistive movements. They are but little understood and seldom used. Let it be supposed that, in the absence of adhesions and irreparable injury of the nerve-centers, the deltoid has but half the requisite strength to raise the arm. So far as any use is concerned, this is the same as if there were no power of contraction left in the muscle. But if only the other half of the impaired vigor be supplemented by the carefully grad- uated assistance of the operator, the required movement will take place; and, in some cases, if this be regularly persisted in, together with manipu- lation and percussion, more vigorous contraction will be gained, and, by and by, the patient will exert three-fourths of the necessary strength, and later the whole movement will be done without aid, and, as strength increases, resistance can be opposed to the movement. The importance of these measures can hardly be overestimated in cultivating the strength of weakened muscles while at the same time finding out how much they can be used. Still another kind of movement may be spoken of — namely, vigorous passive motion — ^with a view to breaking up adhesions in and about joints. It is the secret of success and of failure of the people who call themselves "bone-setters," the methods of whom have been well studied and explained by Dr. Wharton P. Hood, of London, in his highly entertaining book " On Bone-setting, So-called." So much for a general outline of movements. Let us speak of them more in detail. In doing a resistive movement in which the patient is the prime mover the masseur waits until he finds the movement begun, then gradually increases the resistance to the utmost within the limits of the patient's strength, and finally slacks up more slowly. This must be practised by the manipulator on well people until he can instinctively judge of the patient's strength and make elastic resistance. The re- sistance must be in hne with the patient's movements, and the grasp of the operator must not be so firm as to interfere with his own sensation or that of the patient. It will often be found that the patient uses nearly all his strength in contracting his muscles and scarcely any in overcoming the resistance, in which event it will be necessary to tell him to move more quickly and not try so hard. Here physiology steps in and gives us a reason for the faith that is in us, showing how science agrees with art. Muscular contraction presents three phases: (i) A preparatory or latent period, during which there is no visible movement when the nerve and muscle are getting ready to act. (2) A phase of shortening or contraction. (3) That of relaxation or return to its former length. 330 FRICTION, MASSAGE, PERCUSSION, REMEDIAL MOVEMENTS In harmony with these phenomena, and with the manner of doing each and all of the manipulations, and especially resistive movements, physi- ology teaches us that at the close of the latent period the muscles shorten in each fiber, at first slowly, then more rapidly, and lastly more slowly again. In accordance with these physiologic principles of muscular contraction it would be difiicult to conceive of anything that would make graduated and harmonious resistance save human power guided by human intelligence. Springs and elastic contrivances come nearest to it and do very well on starting, but the longer the pull or push, the stronger becomes the opposition, and there is no third stage of lessened resistance. The manner of taking the hand to give it passive motion of flexion and extension and to resist flexion is the same. Let the patient's fore- arm be midway between pronation and supination, and then seize the hand as if about to shake hands, the right hand for the right hand of the patient or the left for the left, so as to bring the resistance on a line with the metacarpophalangeal joints, which affords the best leverage for both patient and operator; the other hand at the same time will support and make counterresistance on the back of the arm about i in. above the wrist. To resist extension of the hand the patient's forearm should be pronated, then the operator will take the hand in such a way as to bring the resistance over the heads of the metacarpal bones, his right hand for the patient's left and the left for the right, while the other supports and steadies the arm above the wrist on the anterior surface. For passive pronation and resistive supination the manner of holding the arm is the same; the operator's right hand seizes the left wrist and lower ends of the radius and ulna of the patient so that the metacarpo- phalangeal joint of his thumb is upon and behind the styloid process of the radius, the point of resistance, care being taken not to squeeze so tightly as to prevent these bones from rotating upon each other; in the mean time the other hand of the operator gently supports the arm of the patient. For passive supination or resistive pronation the same grasp suffices, with the right hand of the manipulator for the right arm of the patient, or the left for the left, which seizes the wrist and lower ends of the radius and ulna so that the metacarpo-phalangeal joint of the thumb is anterior to the styloid process of the radius, the same care being observed not to hinder the motion by holding too tightly, while the arm of the patient rests in the other hand of the operator. For passive or resistive motion of the forearm the right wrist of the patient is gently held by the right hand of the operator, while the left hand steadies the arm just above the condyles of the humerus, and the same REMEDIAL MOVEMENTS 33'^ grasp suflSces for the passive combined motion of flexion, extension, pronation and supination, abduction and adduction, together with rota- tion of the humerus, all of these seven last movements being accomplished at one and the same time by simply making the wrist describe a circle. Circumduction of the humerus is most easily and effectually done by standing behind the patient, and, while fixing the right shoulder with the left hand or the left with the right, the other hand takes the arm just below the elbow and makes this traverse as great a circle as moderate resistance will allow, the operator remembering that the greatest re- sistance will be at the upper and outer third of the circle, owing to the natural formation of the joint. The same hold and support answer well for resisting a forward motion of the upper arm. If the patient be lying on the right side, or the operator be standing in front of the patient while the latter is sitting, tolerably good circumduction may be done by taking the left wrist in the left hand and placing the right hand upon the elbow. But this is not so effectual as the first method, owing to the great mobility of the scapula. Backward motion of the humerus can be steadily and definitely resisted by taking the right hand of the patient in the right hand of the operator, or the left with the left, while the other is placed at the back of the forearm, not to pull, but only to steady the movement. The action of the deltoid in elevating the arm can be well resisted by steadying the shoulder with one hand while the other is placed on the outside of the upper arm, and the opposition can easily be increased by moving the hand toward the elbow or dimin- ished by moving the hand toward the shoulder, the operator mean- while standing behind the patient. Standing in the same position, with the inner condyle of the humerus in the middle of the palm, the mas- seur can resist downward motion of the patient's upper arm, a most admirable procedure to tire the muscles when we have to deal with a weak deltoid. When it is desired to limit motion to one joint, it will be observed that the proximal side should be steadied while the distal side is moved, and nowhere is this more disregarded than with the fingers. For passive or resistive motion of the ankle-joint the best way of taking hold is not by seizing the heel with one hand while the other surmounts the toes, as is generally done, but with the right hand for the right foot or the left hand for the left foot, by grasping the metatarso- phalangeal joints at right angles while the other hand supports the leg above the ankle. For this purpose the operator should sit facing the patient and be careful that his active arm is in a straight line with the patient's movement. This affords the best leverage for flexion and 332 FRICTION, MASSAGE, PERCUSSION, REMEDIAL MOVEMENTS extension of the foot, as well as for a circumductory motion, by making the place of seizure describe a circle, the outer half of which will offer the greatest resistance, owing to the large internal lateral ligament and the stronger structures on the inside of the joint. The same hold answers for resisting flexion and extension of the foot. When this is done alternately, in the interval of change, here and elsewhere, the hand of the operator must alter its position slightly so as to present a proper surface for resistance. In the case of the foot and forearm, the fingers will pull and resist flexion and the heel of the hand will push against extension. On the foot the tendency is to make resistance too near the toes; opposite the heads of the metatarsal bones on the back and sole are the points that afford the best and most natural leverage. By seizing the heel and holding the ball of the foot, as just described for passive motion, a toasting motion can be given to the whole foot which acts more decidedly on the tarsal and metatarsal articulations. Flexion and extension of the leg at the knee, either passively or resistively, are seldom necessary to be done alone (except for some special reason), as they are accomplished so much better together with flexion and ex- tension of the thigh; and for this purpose the right heel of the patient is taken in the palm of the right hand of the operator, or the left in the left, while the other hand holds the calf, and a steady uniform push is made, the limb, by its own resiliency, usually returning to a state of extension. Circumduction of the thigh will be performed by simply changing the hand that holds the calf on to the top of the knee, which affords excellent and easy leverage. On each side of the forefinger of the hand that manages the heel the covering will be held by the thumb and middle finger, so that the patient may not be fanned into the next world. Op- posing flexion and extension of the leg and thigh may be done by holding the leg and foot as for passive or resistive movements of the ankle, and if the couch on which the patient lies be low, the manipulator will often require to rest on the knee next the patient on the floor, and resisting extension will throw the weight of his body in part or wholly against the extending limb, and in doing this the arm must not be extended but flexed, so as to bring the hand as near as possible to the shoulder in order that the resistance may be strong and steady by having the weight of the body added to it; or he can stand with his back to the patient and clasp his hands on the sole of the arch to resist extension. Resisting extension of leg or thigh is hard for the manipulator, easy for the patient. On the other hand, resisting flexion of the leg and thigh is easy for the masseur, hard for the patient, and both should remember that these must not degenerate into play in order to see which REMEDIAL MOVEMENTS 333 is the stronger; 6 to 12 carefully graduated pushes and pulls in each direction, either successively or alternately, may be done. Opposing abduction and adduction of the thighs scarcely needs mention, so simply are they done by alternately placing the hands on the outer and inner aspects of the semiflexed knees; and to resist the contraction of the psoas magnus and iliacus internus alone, resistance may be made to the flexing thigh on any part of its anterior aspect. Passive stretching of the arms and shoulders, of the pectoral muscles and latissimus dorsi, can be done agreeably and effectually while the patient lies squarely on the back, the head and shoulders being slightly elevated on an inclined plane. The arms of the patient are extended upward on a line with the body, and the manipulator, standing behind, holding the hands, makes a gentle, elastic, and vigorous pull; and if the feet be held, a stretch of the trunk and lower limbs can also be obtained. The manner of seizing the hands of the patient for this purpose is worthy of particular notice. They are grasped so that their palmar surfaces obliquely cross the palmar surfaces of the operator, the fingers of the manipulator surround the metacarpal region of the thumb, while the thumb of the operator passes between the thumb and index-finger of the patient, and the heel of the hand rests securely upon the meta- carpal region of the patient's little finger, so that the hands of the patient and manipulator are complementary to each other. This is a puzzle for most people to do, even after having seen it done. The same hold suffices for resisting a dowmvard pull of the arms, which brings the afore- said muscles more strongly into play, elevates the chest, and deepens inspiration. With the patient sitting slightly inclined forward, the hands clasped at the back of the head, the oblique and transverse muscles of the abdomen can be passively exercised by seizing the patient at or near the shoulder-joints and rotating the body, the manipulator, of course, standing behind the patient. The same position of the patient does well to make these muscles act more vigorously by opposing their voluntary contraction. In doing this the masseur stands behind and to one side of the patient, steadying the body of the latter with the left hand upon the left shoulder or the right hand upon the right, at the same time that the other hand holds the -humerus near the elbow, by which great leverage is obtained in resisting rotation of the trunk. At first the patient wilf naturally err in limiting the motion of the arms and chest, but he can be gradually educated to lessen this and increase the rota- tion at the waist. Upon a vigorous and healthy tone of the muscles of the abdomen depends to a large extent the welfare of the organs 334 TEICTION, MASSAGE, PERCUSSION, REMEDIAL MOVEMENTS situated beneath them, and no muscles are so much "left out in the cold" for want of exercise as these. Gentle rowing exercise for the muscles of the back can be given to invalids by standing in front of them and taking hold of the hands, but for this purpose elastic cords or straps answer well, as the weight of the body makes the pull strongest at its termination. Other movements, passive and resistive, may be devised to meet the indication of individual cases, and, of course, it will not be forgotten that active or voluntary movements may be turned to good account — ^with special modification — as remedial agents. 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, w-as 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 numlDer 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 w^e may confide in it; eftablifhing, upon indifputable facts, that the poAver of electricity is neither that admirable panacea, as it was confidered by fome fanatical and interefted perfons, nor fo ufelefs on apphcation as others have afferted; but tliat 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. 3 John Wesley, The Desideration: or Electricity made Plain and Useful by a Lovel of Mankind and of Common Sense, 1759. * Cavallo, An Essay on the Theory and Practice of Medical Electricity, London, 178a 335 336 electrotherapy; a;-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, ^^^ of light 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 of 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 constantly 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 nerve supply involved, vibration, applied to the appro- congestion; pain 337 priate nerve-center in the spine until inhibition is produced, is the first choice. This treatment should be given for ten to tw'enty 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 (galvanic) 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 or 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 338 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 10 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 two 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 gently 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. 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 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 cau'se muscular contraction by breaking the contact of the sponge with the skin. If the pain is' excessive, the positive sponge may be saturated with a 20 per cent, solution of cocain or the indirect static spark employed for five minutes. ANKYLOSIS 339 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 ?ierves should be treated as above, the treat- ment varying with the amount of the reaction of degeneration and the pain present. (c) Severed Nerves.— li 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 imder the headings: {a) Joints; (6) contractures of fingers or toes; and (c) adhesions elsewhere in the body. (a) Joints. — i\fter 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 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 10 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- 340 electrotherapy; a;-RAY therapy; radium 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 rv-ray (remembering the possibility of producing sterility), by the sodium chlorid cataphoresis described above, 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 twenty 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 with the positive side of the galvanic plate, the negative over the abdomen, lo 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 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 Arteries. — Where there is a high blood-pressure and there is no chronic interstitial nephritis, the blood-pressure may be steadily and apparently ^-RAY FOR CANCER 34 I fairly permanently reduced by autocondensation with 200 to 400 ma., flowing for twenty 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 two 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 Malignant 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 Wilhams, Be van, Coley, Rodman, Pf abler, and Johnson for both these indications. Holding 2 has analyzed 148 cases from the literature of inoperable or recurrent malignant disease treated by the Rontgen rays and found that 32 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 carcinomata, 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 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 ad\-ocates the combined use of these two agents ^ Trans. Amer. Surg. Assoc, 1903, xxi, 208. ^ Albany Med. Ann., 1903, xxiv, 94. ^ Ibid., 215. 342 electrotherapy; x-ray therapy; radium in the hope that the rays may accomphsh 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) Wave cur- rent, {h) Spark, (c) Head crown breeze. {a) Wave Current. — -Patient on insulated platform; spark balls of machine together; negative pole grounded; positive 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. (6) Spark. — Patient on insulated platform; spark balls of the machine wide apart; negative pole grounded; positive 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 Crown 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 a distance above 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. — ia) Autocondensation. (h) Low vacuum 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- GALVANIC CURRENT 343 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 t^venty minutes. Repeated every third day. (b) Loiu 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 counterirrit.ant 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 by local anesthesia, increased action of the sw^eat- 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 relieved 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 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, an interrupted galvanic, 60 to 100 interrup- tions 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. 344 electrotherapy; x-ray therapy; radium I/ight 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. Swinging 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 1 20. 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, twenty-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 region where stasis has been present. A striking example of its anesthetic properties is in orchitis, when, after fifteen minutes' exposure, examina- tion 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. VIBRATION 345 Superheated Dry Air. — The source of heat may be alcohol, gas, or gasoline, 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 t\vo main objects with vibration — either stimulation or inhibition. The latter is the result of excessive stimulation. In all vibratory 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 vertebras, 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- tifiue 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- 346 electrotherapy; o^-ray therapy; radium priate nerve centers in the spine. Treatments should be repeated daily if necessary. Similarly, stimulation or inhibition may be applied locally in th€ 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 two. Treatments should be repeated every third day and sufficient current strength used to cause agreeable muscular contractions. The Rontgfen Ray. — Since any surgeon about to purchase an x-rdy 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 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 follows: After operation for malignant disease the treat- ment by the Rontgen rays is commenced as soon as the patient can be transported to the rv-ray department (i. e., in from two 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 1 8 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 sim of RADIUM FOR CANCER 347 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 t^vo 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 rv-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 x-rays, which, where available, it has en- tirely supplanted in the treatment of small, easily accessible growths. In growths occupying a large area the x-rays alone, or in combination with radium, are indicated, and the x-rays alone in the case of malignant disease of the internal organs. The general principles for the employ- ment of the x-rays as regards indications for, reaction from, and fre- quency of exposure, apply also to radium. The method of application of radium is the following: 50 mg. (a little less than i ^r.) of pure radium bromid contained in a capsule, covered with a 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. Where the growth is very extensive, radium may be used on the worst part and then the entire surface exposed to the x-rays. The disadvantages of radium are the small surface from which the rays proceed and its enormous cost. ^ Williams, Communications of the Mass. Med. Soc, 1908, xxi, 263. 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 to me sufficient excuse for presenting my views on the subject. 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, with the assurance that every detail will bear the pragmatic test, namely, that "it 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. I have noted this so many times that I am led to believe that that part of preparation which includes preopera- tive 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 intes- tine 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 more or less starved 348 , • CATHARSIS 349 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 favorable 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 iElective Operation. — The patient is told to take a slightly increased dose of his usual cathartic morning or night, for three days, if he has the cathartic habit. If customarily he has not required cathartics, he should take from 3 to lo gr. of extract of cascara sagrada at bedtime on three successive days 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 three successive mornings instead. The night before operation a simple enema of soap-suds (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 iEmerg-ency 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. 148.) * Clin. Surg., 1902, 13. 35° PREPARATION OF THE PATIENT DIET For the Elective 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 — ^with, possibly, a litde 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 a dram of sodium bicarbonate to the pint, should be given. An attempt should be made, if time and circumstances permit, to have the teeth and month 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. I believe also that, as post- operative 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 spirochasta gracilis. In such a mouth these organisms may be found without ulceradon 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. DIET 351 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. ' ' Fig. 105. — Noma. Bacillus fusiformis and spirochasta gracilis, normal inhabitants of the mouth. The disease appears in neglected mouths after infective diseases. Examination of the urine, 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 post- operative complications. The twenty-four-hour amount of urine should be known also, if possible. 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, ofteri 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. ^ Clin. Surg., 1902, 13. 352 PREPARATION OF THE PATIENT 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 undoubtedly bad practice. As I have 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 appHcations over night in pre- paration has been used, the spread of this infectious process will be en- 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 caustici 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 * A complete list of formulas may be found in Paschkis, Cosmetik fur Aerzte, Wien, 1905, pp. 256, 257. ^ Barium sulphid mav be used equally well. DEPILATION 353 is washed off with sterile water, after which the usual preparation pro- ceeds.^ 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 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 t\N'ice. 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 ^ 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 carboHc 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 \'ulva 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 common employment." 23 354 PREPARATION OF THE PATIENT been saponified. The soap is now thoroughly washed off with con- tinued hbation 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. \A'hether 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 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 t^vice 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. . ^ 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 effective, 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, even under the nails, are sterile. PREPARATION OF SPECIAL AREAS 355 PREPARATION OF SPECIAL AREAS Scalp. — For all scalp wounds, removal of wens, and such minor matters, if surgeon and patient are willing 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 care- fully separated in the region to be treated, and the work then carried on through a hole cut in a towel or sheet. If no shaving has been done, a cocoon dressing cannot be applied, but a corrosive or carbolic pad will have to be put on after sewing. For all operations on the skull itself complete shaving of the head 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, | 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: ^- Zinciiodidi X -- ggg lodi i Glycerini q. s. ad §ij. This is applied with a brush or cotton-stick intimately around 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 opera- 356 PREPARATION OF THE PATIENT tion the whole mouth may be scrubbed out by the surgeon with boric acid, 4 per cent., or full strength liquor antisepticus, or some such cleans- ing fluid. Gargling is good as a mouth-wash, but absolutely 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 mo- ment of operation. Vagina, Cervix, and Genital Region. — Here, too, the most valuable cleansing is mechanical. On the table a douche should be 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. Fig. 106. — Vaginal Dodche. Hammock of canvas suspended on metal side-bars in bath-tub, designed to give proper elevation of pelvis. The shoulders are 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 even 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 r^ach 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. 106) , or, more simply, the douche may be taken lying on the floor with a douche pan, but under the douche ^ Boston Med. and Surg. Jour., 1908, clix, 795. PREPARATION OF SPECIAL AREAS 357 pan a pad or pillow of rubber or stork-sheeting, filled with excelsior, the whole sufficient 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. Fig. 107. — Burn Resulting from a Self-administered Douche oe Undiluted Creolin. (Case of Dr. N. R. Mason; photograph loaned by Dr. R. D. Hildreth.) 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 the tube inserted not over 6 in., thoroughly cleans rectum and sigmoid. Bladder and Urethra. — So many of the operations in this region are for obstructive conditions of the urethra, it is frequently not possible to vv^ash out either bladder or urethra. Where it is possible it should be done with warm 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 long-Tepeated soaking in hot soapy water, or, better still, soapy water with the addition of a little chlorinated soda (liquor sodai chlorinata?) . Hands or feet, soaked for half an hour every four hours the day before operation, or, in any case, two periods before, can have all the overthickened, macerated epidermis then scraped off. PART 11 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 twenty-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 t^vo 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. 225.) The general treatment of septicopyemia (see p. 252)— bed, ice-cap, wet dressings, stimulation, and, in appropriate cases, vaccine therapy— should be begun at once. Septic Wounds with Necrotic 5o/ie.— 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 358 TREPHINING AND BRAIN OPERATIONS 359 at the operative site during the first twenty-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, little 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 {h) 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. 360 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 two 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- cult)'- 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. 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 end 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 should be washed out with an alkaline antiseptic, or, if not too painful, 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. TUMORS OF THE PAROTID 36 1 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. 82.) (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. 254). If the tumor removed was sarcoma, erysipelatous infection is welcomed. (See Chapter LIII.) (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. LIII) ; in carcinoma, :v-ray therapy (see p. 341). 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. (2) Parvtid 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, 362 OPERATIONS ON THE HEAD AND FACE 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 little 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 ih 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 little more marked when a glass or gold sphere has been implanted in Tenon's capsule, but all signs usually disappear in about t\vo 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 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 OTHER PLASTIC OPERATIONS ON THE FACE 363 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. OTHER PLASTIC OPERATIONS ON THE FACE It is somewhat difi&cult 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 frequently 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 removed then in order to avoid forming stitch scars. Haemorrhage must be thoroughly stopped, since a relatively thin layer of blood-clot may prevent a plastic flap from adhering. Firm pressure, therefore, for an hour or two, even if it has to be applied 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. 572. ^Antiseptic Varnish: Iodoform or aristol (thymol iodid) -i -^ ^ j. Glycerin i Tinct. benzoin., comp 4 parts. ^ 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. 363), 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 hp itself is left so 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 apphcation 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 words 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 hp 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 little breathing space ^ Loc. cit., 410. 364 CLEFT-PALATE 365 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. CLEFT-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 gi\'en 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 two 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 these infants within the first six months, as soon as the child has a hold on life. 366 OPERATIONS ON THE MOUTH, NOSE, AND PHARYNX "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 Hps 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 widely 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. EXCISION OF THE TONGUE, PARTIAL OR COMPLETE 367 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 speUing-book and to mark the words which the pupil finds most diificult 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. Complications and Sequelae. — (i) 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 I-ondon 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 1 (Rose). ^ Jacobson and Steward, The Operations of Surgery, 1902, i, 444, 445. ^ Med. Pub. Co., Limited. * Loc. ciL, p. 467. 368 OPERATIONS ON THE MOUTH, NOSE, AND PHARYNX mouth thoroughly with some antiseptic, such as carbohc acid i : 80, boric acid, or some of the alkahne 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-gj). 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. Complications 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 of 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 betAveen 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. ALVEOLAR ABSCESS 369 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 presently 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 my experience the silk seton through both sides of the tumor gets foul from mouth contents and secretions, induces inflarmnation, 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 he 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 e^■ery 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., iqo2, p. 318. 24 37° OPERATIONS ON THE MOUTH, NOSE, AND PHARYNX the underlying bone or tissue, and paraflBn injected to restore the contour of the face. Long-standing sinuses — internal or external — usually speak 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 remove necrotic bone. PARAFFIN PROSTHESIS FOR DEFORMITY OF THE NOSE AND OTHER PARTS The danger most feared in this procedure, particularly if the paraflSn be used hot, is the irmnediate 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 Fig. io8. — Paraffin Prosthesis. Deformity resulting from abscess of septum; before Fig. 109.- -Paraffin Prosthesis After Treat- ment. 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 I 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 ^venty-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, Laryngoscope, St. Louis, 1908, xviii, NASAL POLYPI AND SPURS .371 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 heahng 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 Hemorrhag"e. — This is a frequent after-result of intra- nasal surgery. It is always advisable to define clearly the location from v/hich 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 bleeding, the nose may be packed with sterilized gauze soaked in ad- renalin, or a cigarette pack made with sterilized cotton or gauze, with ^ F. Strange Kolle, Subcutaneous Hydrocarbon Prostheses, New York, 1908. 372- OPERATIONS OX THE MOUTH, NOSE, AND PHARYNX 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 pre\'ent 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 t^\'enty-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 t^venty-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 and the antrum washed out by a glass syringe and rubber tube or catheter passed into mouth wound, the wash coming out through the nose. Dobell's 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 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 REMOVAL OF ADENOIDS 373 should be repacked and the wick changed every second day. When 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 gently 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 twenty-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 Dobell's 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 w^orn 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, parafihn 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 the growth is malignant, the patient should be sat up and an applica- tion of 1 : 1000 adrenalin solution made to the site of operation. If three or four applications of this do not stop the bleeding, a tampon of 374 OPERATIONS ON THE MOUTH, NOSE, AND PHARYNX 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. Monsell's 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 gaultheria; 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 obstruction 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 Sequelae. — (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 Dobell's solution, half strength, liquor antisepticus alkalinus, or normal salt solution. (3) Earache, due probably to infection through the Eustachian tube, either directly during operation or by unwise use of the nasal douche. ^ Jacobson and Steward, i, 372. REMOVAL OF TONSILS 375 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 powder 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 im.mediately 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 som.e 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 The same general directions for after-treatment hold as for adenoid operation; cold gargling with Dobell's solution, diluted to one-half strength, is indicated, with an occasional swab of iodin-glycerin mix- ture (iodin, 15 gr., to glycerin, i oz.) two to six times daily. If there is discomfort or pain on swallowing, orthoform powder may be blown over the cut surface or an occasional lozenge of orthoform allowed to melt in the mouth. Hemorrhage. — If persistent oozing occurs (see p. 8i), or if hemorrhage comes on several days after the removal of the tonsils, and adrenalin or Monsell's solution fail to check it, the tonsillar fossae • should be examined carefully with a strong reflected light, and the 376 OPERATIONS ON THE MOUTH, NOSE, AND PHARYNX 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 will stop the bleeding. If these measures fail, the tonsil hemostat may be used, and, as a last resort, the pillars of the Fig. 1 10. — Instruments for Tonsillar Hemorrhage. A , Mikulicz-Stoerk tonsillar clamp, with detachable handles; B and C, needles for sewing together the pillars (Yankauer). tonsil may be sutured together (see Fig. no), and if unsuccessful, the external carotid must be tied. TUHORS OF THE TONSIL If the removal has been solely through the mouth, the same care is taken as in operation on the tongue. (Seep. 367.) 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 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. RETROPHARYNGEAL ABSCESS . 377 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 linger 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- 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 suft'ocation. An ice-collar is a good prophylactic against this danger. If the incision is made through the mouth and drainage is inefficient, an. external incision along the posterior border of the sternomastoid may be made. Septicopyemia may occur and generally with fatal result. The usual general treatment applies.^ (See Chapter XXVI, p. 250.) ^ M. A. Goldstein, The Laryngoscope, St. Louis, 190S, 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 t\vo 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- 378 TRACHEOTOMY 379 mo\'ing 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 t^visting motion, A nurse should always be present and waking for at least the first t\venty-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 difficult 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. 129.) 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. " Co7iditions Which Impede the Rejnoval of 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 MacE\^en'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 I had performed 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. 380 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) Hemorrhage.— Immedisite hemxorrhage 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 beyond 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 381 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. 378.) 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 difficult 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 skiU of the operator, especially in inserting the tuVje. (5) The dangerous period during tracheotomy is the in- terval between the division of the deep cervical fascia and the efiicient 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. ' ' 382 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 two 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 supervision 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 383 elected: P^irst, 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 difficult or even impossible. Tracheotomy becomes the operation of necessity in any case w^hen, 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 dijficult 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. x\phonia 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 unless 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, w'ith 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 t}^pes 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. 384 OPERATIONS ON THE NECK Several intubation tubes of each size should be kept attached to 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 design 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 tube. 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- FiG. III. — Operating-room, Boston City Hospital, South Department. A, Tubes and introducers ready for use; B, tubes in cloth holder, with obturators; C, gags; D, blanket, folded, ready to be opened to receive patient; E, large safety-pins for pinning blanket about patient; F, stimu- lation tray (in case); G, sand-bag, to place under neck; H, gag for immediate use. tion is for one reason or another prolonged, and where the hea^7■ metal tube might eventually produce pressure necrosis. The tubes are molded in such a manner as to produce no undue pressure at 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 t\vo years, two to four, six to eight, and intubation: technique 385 ten to twelve, and several adult sizes, the latter generally of rubber. Each tube has extending the full length of its lumen a hinged piece of Fig. 112. — Instruments for Intubation. A, Mouth-gag; B, introducer; C, tubes and obturators; D, extractor; E, tracheal dilator. Tnetal termed the obturator, and from which the tube is easily disengaged when it is inserted into the larynx. This obturator, with the tube upon Fig. 113. — Intubation. 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 25 386 OPERATIONS ON THE NECK 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 above the vocal 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 1 14. — EXTUBATION. 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 ^jressed against the upper surface of intubation: after-treatment 387 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 fine 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 watched 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 ^yhen 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 SS8 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 wall 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 will fail, trache- otomy win 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 ha^^e 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 m.ay 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 expulsi\"e 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 389 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 the tube may be removed and cleaned before serious dyspnea results. Feeding. — Feeding (see also Chapter XIII, p. 129) 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 hquids. The most serious comphcation not directly connected with intubation is bronchopneumonia. The treat- ment should be carried out, eliminating drugs so far as possible. The most fa^•orable 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 wnll ordinarily not require reinsertion. Retained Tubes. — It sometimes happens that the patient re- peatedly develops signs oi stenosis whenever the tube is rem.o\'ed, in- definitely repeated reintubation has become necessary, and, finally, it is found that the tube m^ust 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 390 OPERATIONS ON THE NECK bronchopneumonia. If the patient lives, intermittent intubation must be practised for a long time, Avith 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 by mouth. If the enemas are not held and nourishment is urgently needed, the patient may be fed by stomach-tube. Complications and Sequelae. — Sepsis. — These wounds are always infected and frequently present large sloughs and vile discharge. The woimd must be thoroughly wiped out, every hour if necessary, and kept dressed, with salt and citrate solution at first, later with weak chlorinated soda or myrrh wash. PARTIAL THYROIDECTOMY 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 r.oom. 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 MVilliam S. Halsted, jNI.D., and Herbert M. Evans, S. B., Ann. Surg., Oct., 1907, xlvi, "The Parathyroid Glandules: Their Blood-supply and their Preservation in Oper- ation upon the Thyroid Gland." PARTIAL THYROIDECTOMY 391 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 t\vice ^^•ithin 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 Fig. 115. — Thyrotoxicosis. Fig. 116. — The Same Case after Operation. Bilateral enlargement and exophthalmos, before Tumor and exophthalmos gone. Pulse 100 to 120. operation. Pulse 170 to 216. 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 t^^•o or three days succeeding operation. Its employment was very imperfectly tested in three 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, unfortunately, did we succeed, with the inadequate appliances at our disposal, in doing much more than slightly cool the surface of the skin. In one case, thirty-six hours after opera- tion, the pulse, which had been steadily rising until it reached iSo, dropped 30 beats a minute Vvithin one and one-half hours of the application of the cold. In another, a good night's sleep, the first in ^ Surg. Gyn. and Obst., 1909, 602. 392 OPERATIONS ON THE NECK Mr fl ft \U •\ T \- 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 apphed 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 sufficient 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 de- cree of cold low enough almost to freeze the skin miight be necessary. Possibly to be considered as a method of treatment for desper- ately ill cases is an unclosed wound constantly irrigated with water of the desired temiperature. "I am convinced that the tox- emia 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 thy- roid gland ? It is my belief that the toxemia incident to wound healing is badly borne by the subjects of hyper- thyroidism. On several occasions, soon after thyroid lobectomy, I have seen prompt and great improve- ment follow the liberation of a dram or even a few drops of reddish serum from the wound. Moreover, the typical postoperative toxemia may, it seems, follow operations of other kinds upon patients afflicted with Graves' disease. Absorption takes place continuously during the process of repair, even in wounds which are ' dry' and healing throughout by first intention. Thus it seems to me quite reasonable to hope that something, perhaps much, may be accomplished by the adequate em- ployment of cold. The entire neck, fore and back and sides, and from YV, III, msE^sE i 3- 3 ", 5 64^ Tl ^F 5?f?"5JJJ*l< .^<^» Ih 1I 1% /f -JB 11 ^■| ij. 14 0/SfASE. 1 a ^ '^ 5- A 1 8 1 TIMF JJ ir-E ^z 'X jj 0) a> ir, 3 / \ S /* / V )i Y / w^ y _^ r L> x^ r r ^ J S • \ \ 1^ t S* ^ 111 J \f w- > »^ «v k, \ % S »" V •^ _ L L. |_ L Fig. 122. — Mastoid Abscess. Lateral sinus opened, packed with iodo- form gauze. No apparent infection of in- ternal jugular. Immediate drop of temper- ature when sinus-packing was removed. nausea, vertigo, reached. Extensive operation is imperative if this diagnosis is ^ Philip Hammond, Jour. Amer. Med. Assoc, 1906, xlvii, p, 1645. CHAPTER XLIII OPERATIONS ON THE THORAX AMPUTATION OF THE BREAST Uncomplicated, 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 Fig. 123.— Application of Swathe After Fig. 124.— Application of Swathe After Breast Amputation. Breast Amputation. The under swathe exerts even compression and The outer swathe applied bringing arm in holds on the major part of the dressing. against the chest, holding the axillary part of the dressing, supporting the forearm and wrist. (Figs. 123, 124). The affected hand is supported by a narrow sling under the second swathe, but the forearm is free and early motion of it is encouraged. 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 twenty-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 26 ^01 402 OPERATIONS ON THE THORAX operation, unless the prostration of shock or hemorrhage forbids. Stitches out on the tenth day. Complications and Sequelae. — (i) Skin-grafting. — Primary skin-grafting at the time of operation is being done constantly more and more, as surgeons observe that miost local recurrences are in the skin. For treatment of the wound which has been grafted, see p. 572. (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. 245.) (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 advisability of immediate treatment of these scars by exposure to the .x-ray should be considered. (See p. 347.) 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. Fig. 125. — Breast-bandage. A folded towel is doubled into a V of which one arm goes above the breasts and one below, meeting in the opposite axilla. The angles are pirmed to the respective ends of a folded towel behind the back. The folds are connected between the breasts; shoulder-straps are applied (Boston Lying-in Hos- pital). Fig. 126. — Breast-bandage. To exert still greater pressure an extra towel may be pinned across from axilla to axill;i. Ab- sorbent cotton is tucked in here and there to equalize the pressure. Firm pressure should be maintained- for four or five days to prevent the cavity filling with blood or serum. Stitches are taken out in eight ABSCESS OF BREAST 403 to ten days. If it has been possible to make a beveled incision, the wound can be held together by plaster straps, and there will be no stitches to remove and practically no scar to be found. Fig. 127. — Breast-bandagk. Rear view, to show application of shoulder-straps. ABSCESS OF BREAST No amount of good after-treatment will make up for an inefficient operation in this affection. 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 days, depending on the indication given by temperature or pain. The pack- ing has now made the irregular cavity into a unit. At 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. All the time a tight swathe arid 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 tin's incision. The ^ R. L. de Normandie, Boston Med. and Surg. Jour., 1909, clx, 601. 404 OPERATIONS ON THE THORAX same after-treatment is used. Large suction cups may be obtained for the application of the Klapp treatment of passive hyperemia to the breast if indications arise. The patient should sit up as soon as possible, and every 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 milk may be maintained in the other breast and nursing shortly resumed. EMPYEMA A soft-rubber bobbin or spool, a tube from ^ to i^ inches long, on each end of which is a lip or flange (Fig. 128), 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 the common Fig. 12S. — Empyema. Forms of Drainage-tubes. A, Double fenestrated soft-rubber tube; B', B^, B^, soft-rubber drainage bobbins and flanged tubes of different lengths. 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. 128). It seems best not to wash out the pleural cavity, though some surgeons do it. It is apparent that each time the washing fluid is passed 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 rapidly less. The patient should be placed in bed with the drainage EMPYEMA 405 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 difl&cult. 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 be kept in position in any case about a w^eek, and if drainage is then profuse, still longer. These patients should be carried almost immediately out-of-doors and best sitting up. If adequate protection and nursing can be provided, they should sleep out-of-doors. Lung exercises, such as deep breathing and blowing fluid from one bottle to another (Fig. 129), should be started as early as the end of the first week. In a patient who is at all intelligent, as soon as he has the strength a tube may be sealed (Fig. 130) in the Fig. 129. — Empyema. Arrangement of bottles whereby patient increases lung capacity and lessens open cavity. wound (say at the end of two weeks), and in the end of this tube the patient himself, from .time to time, perhaps five or six times a day, inserts an ordinary suction-syringe bulb and pumps (Fig. 131) from the pleural cavity both air and pus, thus partially establishing a vacuum. This procedure favors lung expansion and is a great aid to rapid con- valescence. A suction cup may be similarly used. The duration of drainage in these cases varies with the condition of the patient, the amount of pleural 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. — (i) Lack of Free Drainage. — If the characteristic fluctuations of the chart persist after operation (see Fig. 21, p. 56), an encapsulated empyema, not drained by the 4o6 OPERATIONS ON THE THORAX 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 possibiHty of Fig. 130. — Empyema. Sealing in a tube, througli which at intervals negative pressure is produced by a reversed sjTinge-bulb. empyema on the other side, although rare, must always be kept in mind. Should this arise, immediate operation might best be attempted Fig. 131. — Empyema. Suction used to encourage lung-expansion. 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. EMPYEMA 407 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 always present, and is of litde 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 w^ound in the lung sufficient to allow air to be forced into the pleural cavity with each inspiration. (4) Cardiac Dilatation. — 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. Preventive 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 over. (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 Scquelce. — Where failure to heal seems to depend upon failure of the lung to reexpand, treatment b^ valve or ^ I recently saw a case of this sort with Dr. W. W. Harvey, of Boston. The right chest had been flat to percussion, but an. hour later became tympanitic, and at the same time great reUef 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-smeUing material and symptoms as of drowning. At the same time distention of the abdomen appeared, increasing, apparently, with almost every breath. Autopsy two Tiours 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. 4o8 OPERATIONS ON THE THORAX suction apparatus is indicated (Fig. 131). This is especially of value in the more chronic cases. 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 examiaati on. "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. Sm.all 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 wrecks 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 thehi, 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." 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 obUterated, If this happens, bronchitis or bronchopneumonia follows at once. * Clin. Surg., 1902, 272. GUNSHOT AND STAB WOUNDS OF THE CHEST 409 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 woTind. 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, Experimental Surgery of Lungs, Ann. Surg., 1908; xlvii, 185; Arti- ficial Intrapulmonary Positive Pressure, Jour. Amer. Med. Assoc, 1908, li, 803; Surgical Aspects of Tuberculosis of Lungs and Pleura, Trans. VI. Internat. Cong. Tuberc, 1908, 73. Samuel Robinson and G. A. Leland, Jr., Surgery of Lungs under Positive and Nega- tive Pressure, Surg. Gyn. and Obstet., 1909, 255. These articles also contain complete bibliographies. 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 i.t 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 in 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 " la the treatment of gunshot or stab wounds of the chest it is, first, important to determine whether there is dangerous bleeding from the 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 4IO OPERATIOXS OX THE THORAX bear in mind tiie fact that the costal cartilage can be easily cut with an ordinary scalpel and that the external wound is 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 vhich 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 Avound 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 new hemorrhJage is over, but in which the blood in the pleural caxity 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 are used to diminish the respiratory excursion and to lessen the chance of secondary hemor- rhage. ^ Ochsner, Clin. Surg., 1902, pp. 277, 278. CHAPTER XLIV OPERATIONS ON THE ABDOMEN 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 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 outlet 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 com^petent 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 Sequelae. — Peritonitis is rare with a sur- geon skilled in the technique. If it develops, the wound must be opened, ^ W. J. Mayo, Five Hundred Cases of Gastro-enterostomy, Ann. Surg., 1905, xHi, 641. ^ See especially W. B. Cannon, Boston Med. and Surg. Jour., 1909, clvi, 720. 4U 412 OPERATIONS ON THE ABDOMEN the cavity washed 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 mine vomited everything until she demanded and got broiled beefsteak. If the vomiting does not stop, and bile is found in the vomitus, the surgeon must conclude that a vicious circle has been established, whereby, on account of a kink or valve fold at the enterostomy site, or obstruc- tion beyond, all the bile and pancreatic juice is flowing back through the gastro-enterostomy into the stomach. In the early days of the opera- tion 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 secondary operation to modify the first. Jejunal and Gastrojejunal Ulcer. — The possibility of such ulceration following this operation should always be in the surgeon's mind. A very thorough research on the subject has been made by Prof. Herbert J. Patersonof London.^ He reports 2 cases and has collected 61 others. 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 by 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 Avill add its quota to other devitalizing influences and assist in bringing about self-digestion." ^Ann. Surg., 1903, xxxviii, 806. " Jejunal and Gastrojejunal Ulcer Following Gastrojejunostomy, Ann. Surg., 1909, 1, 367. ^ Bolton, Trans. Royal Soc. Med., Dec, 1908, Path. Sect., p. 54. GASTROSTOMY 413 It is true that it has been asserted that the inner row of stitches in the anastomosis on animals seems to have httle influence on the heahng. 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 my 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 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-type (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 desen-'es. 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 \\dth 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 beUeve 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." 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- 414 OPERATIONS ON THE ABDOMEN 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 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 afterward 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 ^ Ochsner, Clin. Surg., 1902, pp. 179, iSo. GASTRECTOMY 415 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 gradually that the patient does not recognize it until so far advanced that it is difi&cult to dilate it again. 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 starvation. 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 between the stomach and the liver, or on the other side behind the spleen. GASTRECTOMY This unusual and rather dramatic 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 hesita- tion 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.- 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 w-as taking a full variety of food. Eight months after the operation this case was eating like any healthy person. Gradual increase in the amount leads, apparently," to a dilatation of the region near the union of esophagus and duodenum.* ^Rev. Franjaise Med. et Chir., 1905, 761. ^ A. Monprofit, La Gastrectomie, Paris, 1908, 119. ^Beit. z. klin. Chir., 1898, xix, 757. *Dr. Harvie, of New York (Ann. Surg., March, 1900, p. 344), reports a case of gastrectomy 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, practic- ally the whole of which was infiltrated and thickened. The entire stomach was removed 41 6 OPERATIONS ON THE ABDOMEN Complications and Sequelae. — (i) Constipation. — For a time, at least, there is a greatly diminished gastric digestion, and a consid- erable quantit}' 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) 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 ^ c^uotes 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. " (3) If the secretion of hydrochloric acid has been diminished or absent before operation, it remains in 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. and the cut surfaces of esophagus and duodenum united by means of sutures. The entire time consumed, from the first incision till 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.) ^ Johns Hopkins Hosp. Bull., 1902, xiii, 157. GASTROPLICATION 417 " (7) Capacity of the stomach ahvays decreases, but rarely becomes as small as normal. " (8) The pylorus recovers tone. "Points of Difference Between tJie 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 difiS- cult}^ the stomach has in reaching its normal size. " (3) Slight or negative result obtained by pyloroplasty in abstract from primary gastrectomy compared to the positiA^e results from pos- terior gastro-enterostomy." Finney now continues: " x\ccumulated 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 t^vo or three days before the operation the mouth and teeth were 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 t\venty- 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 to turn, and even allowed to be propped up in bed very soon after the operation." 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 improvement, the operation is not frequently performed. Farquhar Curtis^ says: ''If the surgeon should chance to overlook ^ Ann. Surg., igoo xxxii, 49. 27 41 8 OPERATIONS ON THE ABDOMEN 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. 411.) 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 drainage 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 dowm 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 sma.ll amounts at first, lest vomiting appear. At the end of twenty-four hours feeding by rectum should be begun. A nutrient enema (see p. 125) should be 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 fossas, 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. 235) may be used with advantage. Feeding 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 perhaps several times daily to a distressing degree. PERFORATED GASTRIC ULCER 419 Sodium bicarbonate, i dr. in one-half cup of water, will give temporary and sufficient relief to the symptom, and may be repeated many times with no bad effects. Practice as to time of beginning stomach-feeding Diagnosis Perforated Pyloric Ulcer. \ '^UW^liSiii 2 1? J5^< A!-?; 2: a* -j; ^(^ ^sjgA 3 ¥ 5 6 7 msV^E. ' A 3 3 A- <^ 7 », ? /« /) /;; li l¥is i(, ix'S "i ao Tl ^JfJJf f 5I a 2 Q. V) UJ cr ♦J -u \07_ "?"g . CO <0 ^ -!ffl . « iC V rH — ♦J +) ^ 44 — ^^ ID 1- ^ fa. ° t .il •^T i^.^E.s s. « -PA w*^ *j» — \ ia ^ =i Jo 1 S^\^**^ 50 ^ Vr'^^t''**^^ 70 fO 23-«-,» ^ .^'^'^^'^ 1 1 . _ - Fig. 132. — Perforation of Pyloric Ulcer. Operation eight hours later. Stomach-contents diffused throughout abdominal cavity. No septic reaction. after perforation varies widely. For example. Dr. Jos. A. Blake ^ remarks on a case of perforated gastric ulcer as follows: "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 mth 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 Martin, has been used with great success in several postoperative stomach cases, and is far more palatable than peptonized milk." When full diet is resumed after operation for perforated gastric ulcer, I allow the following liberal diet, the list including all things which ^ Ann. Surg., 190S, xlviii, 130. 420 OPERATIONS ON THE ABDOMEN the patient may eat. The important rule should be not what he eats so much as his method of eating. I 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 Atter Healing of Gastric Ulcer, to Avoid Recurrence. Soups : Buttermilk, Mulled wine. Purees and creams: Cream, ' Caudle, Barley, Boiled milk, 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, Lemonade, Milk: Eggnog, Grape-juice, Unskimmed, Koumiss, Mineral waters. Skimmed, Wine whey, COLOSTOMY 421 PERFORATED DUODENAL ULCER In cases operated within ten hours the peritonitis is here as in gas- tric perforation, also largely irritative and chemical rather than septic. 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- toneum — is far from being the best practice at present. The use of the Paul ^ or the Mixter (identical but devised independently) tube is much to be preferred. The glass tubes are made in two sizes. That used for the colon measures 4l inches in length by I 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. 133) is as light as is consistent with sufficient strength. It measures 3^ in. by ^ 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- , . , f 1- .1 J -n ; Fig. 133.— Paul's Tube. mg. A purse-strmg suture of -Imen 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. 422 OPERATIONS ON THE ABDOMEN the use of these tubes. One, that it is difficult to insert the tube without letting the feces escape over the wound. This is certainly true when the intestine is distended and the feces fluid. If, however, the loop to be opened is emptied into an adjacent bowel, and temporarily clamped if possible, the introduction of the tube is greatly simplified; otherwise, the operator may safely trust to drawing out the bowel as much as possible and isolating it with gauze. The other objection is that the ligature may cut its way through too quickly, " especially if the bowel is much congested. Thus the tube may be loose in two or three days; but it not infrequently remains for a week firmly adherent, partly because some of the circulation becomes reestablished behind the ligature, and partly owing to the copious exudation of lymph, which covers Fig. 134. — Colostomy. The Paul or Mixter tube has been tied in the cecum, with rubber drainage tubing previously attached, a hemostat on the end for transit from operating-table to bed. the bowel to the very end, quite conceaUng the ligature. The use of a purse- string suture to fix the tube in the bowel, and the prevention of undue tight- ness in tying in the tube, will help to lessen this trouble."^ Such a tube is fastened into the bo^^-el by a purse-string suture of catgut, and drainage leads over the bedside by means of a rubber tubing attached and running into a bottle. 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 effi- cient device be applied, such as that effected by H. B. Jackson (see Fig. 135, p. 426), 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 low, ^ Jacobson and Steward, ii, 226. COLOSTOMY 423 particularly in a more or less prominent or pendulous abdomen, a well- fitted spring truss, exerting only slight pressure, will serve well. 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. 148). By this method the gut may be efficiently cleaned throughout. Complications and Sequelae. — Where this operation has been done for obstruction due to malignant disease, death may follo^^' despite treatment /row exhaustion and toxemia — (i) due to the absorption of poi- sonous matter through the obstruction and to strain 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 v/eak 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 strangu- late between the edge of the colon and the parietes. This may happen ' Jacobson, i, loi. 424 OPERATIONS ON THE ABDOMEN at any time, near or remote, after the operation, particularly 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 remained 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 colostomy 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 w^henever 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. i\.t the first dressing it should be painted on over a generous area about the wound with a camel's-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 two, 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 t^vo 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- COLOSTOMY 425 lowing, together with extreme caution in quickly removing the discharge, will soon relieve this distressing condition: " I^. Zinci oxidi 3i Bismuthi subnit 3ij Amyli 3iv Ung. aquae rosae ^ §ij. " 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 where 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 betw^een 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 J in. from one end of each strip. Place these strips, a, b, c (see Fig. 135), radially about the wound, so that a shall be directly below ^ A better preparation is made by substituting white petroleum oil for the almond oil called for by the U. S. P. 426 OPERATIONS ON THE ABDOMEN and the hook ends of each plaster shall be about i^ 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 plaster, X, 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 plas- ters, and thereby saves considerable time to the attendant and discom- fort to the patient. If, when the main plasters are removed, they are first moistened with ether, they will come off without pulling and con- sequently 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 h and c. This will serve a triple purpose — to hold the dressing next the wound without Fig. 135. — Diagram to Show Arrangement of Adhesive Plaster Strips Used in Maintaining a Dressing in Ambulatory Colostomy Cases. a, h, c. Squares of plaster to which are sewn dressmakers' hooks, x, x, x, guard 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 INTESTINAL END-TO-END ANASTOMOSIS 427 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 digested, and a moderate degree of costiveness will give rise to less, local disturb- ance 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 attend- ant. Given these, the patient, so far as the wound itself is concerned, may be kept tolerably comfortable and may even lead a moderately 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 Connell's method- of -direct suture, Murphy's button,^ ^ E. Hahn, Deut. mcd. Woch., 1894, xx, 557. ^ Jour. Amer. Med. Assoc, 1901, xxxvii, 952. ^New York Med. Record, Dec. 10, 1892. 428 OPERATIONS ON THE ABDOMEN 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 INIurphy's button was used, there were 14 deaths, or 22 per cent., \a hile in the remaining 163 cases, in which various other methods were used, there were 44 deaths, or 27 per cent. The after-treatment varies little from that of gastro-enterostomy (p. 411). 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 tAventy-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 tAvo hours by day, are begun and rapidly increased in amount if no complications arise. While the rectal feeding is main- tained, the bo\yel should be cleansed daily (p. 122); 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 (pp. 246 and 424). (2) The Button May Not Pass. — If no symptoms arise, this need not disturb doctor or patient. The button may make difficulty in passing the external sphincter; it may cause obstruction in the gut and call for intervention. It should come away by the fourteenth day. ABSCESS OF LIVER After the abscess-caA'ity has been thoroughly opened, a large gauze wdck 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 side in bed to encourage free drainage. The outer layer of gauze is reinforced whenever it becomes necessary. The wicks are removed ^ Brit. Med. Jour., 1896, i, 451. ^ C. P. Gibson, Ann. Surg., 1900, xxxii, 4S6, 676. HYDATID CYST OF THE LIVER 429 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 Sequelae. — 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 conipleted at one sitting, the cyst is opened and 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 430 OPERATIONS ON THE ABDOMEN 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 t^vice or three times a day with 10 per cent, stearate of zinc ointment. GALL-BLADDER AND BILIARY PASSAGES Bevan's incision (Fig. 136)^ is, in my experience, by all odds the "best, the most favorable for exploration and drainage, and most efficient for after-care. This is the so-called S-incision, a main vertical arm with an extension at the upper end inward and at the lower end out\vard if necessary. Preliminary to the after-treatment of gall-bladder opera- tions, it should be noted that undoubtedly surgeons drain gall-bladders which had better be removed, and it is- here appropriate, there- fore, to insert remarks on the place of chole- cystectomy. Dr. Maurice H. Richardson^ gives the fol- lowing indications for extirpation of the gall- bladder : Fig. 136. — Sevan's Incision FOR Operations on Gall-bl.-vd- DER AND Bile-ducts (Keen's Surgery). ' ' (i) Certain lesions in themselves demand re- moval of the gall-bladder whenever possible. Such are new-growths and gangrenes. (2) Certain other lesions of the gall-bladder are better treated by cholecystectomy. These are the contracted and inflamed gall-bladders with thickened walls. All gall-bladders which do not permit easy and efficient drainage should be ex- tirpated, 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- possible — retention of the biliary reservoir to fulfil the functions of that ^ Ann. Surg., 1S99, xxx, 17. ^ Med. News, New York, 1903, Ixxxii, S17. CHOLECYSTOTOMY 43 1 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 swelling 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 ^ 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. 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. A voluminous dressing is applied, and the swathe is so pinned that the tube emerges between t^^•o safety-pins where the ends of the swathe 432 OPERATIONS ON THE ABDOMEN proximate. A hemostatic forceps is snapped on the end of the drainage- tube until the patient reaches the bed. The drainage-tube is then con- nected 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 estabhshed. 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 hernia 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. Anemia should be treated; fats and milk should be diminished or absent in the early diet. Complications and Sequelse. — (i) Hemorrhage, delayed or secondary, is not infrequent in jaundiced cases and in cancer of the gall- bladder, (2) Peritonitis may result from escape of infected bile during opera- tion, (3) A stone not found during operation may get loose from deep in CHOLECYSTEXTEROSTOMY 433 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. 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 temporary drain goes down to the site of operation, to be removed, if there is no leak, within two or three days. Complications and Sequelae. — (i) The possibility exists of infection of the ducts and the liver 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 whatever 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.^ ^ 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 cholecystotomy for jaundice, pain, etc., performed four months previously, vs^hen 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 aipposition and to he 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 ha\ang gone on well in the interval) blood was found to be oozing from the gall-bladder and the abdomiiial wound. In spite of gauze packing this continued and the patient passed into a state of collapse. On opening 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 easily seen. To remove the button it was necessary to incise both gall-bladder and bowel and unscrew the button. It being useless to reinsert the button, 28 434 OPERATIONS ON THE ABDOMEN (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." ^ 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 toward 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, wdth 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." "If 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- 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 pan- creas. ^ Moynihan, Brit. Med. Jour., 1901, i, 1136. HEPATICODOCHOTOMY 435 layers. It is important to avoid wounding or penetrating the mucosa, as any suture which gains access to the lumen of the duct may formx 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 m the cyst being sewed to the peritoneum." ^ 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 2 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. i\fter 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. HEPATICODOCHOTOMY This operation needs only to be mentioned and reference made to a single characteristic case.^ ^ Russell, Ann. Surg., 1897, xxvi, 692, quoted by Moynihan. ^Thienhaus, Ann. Surg., 1902, x.xxvi, 928. ^Elliot, Ann. Surg., 1895, xxii, 86. 436 OPERATIONS ON THE ABDOMEN "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 Uttle bile escaped. A drainage-tube and gauze were packed 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 ^ the stone is crushed in the hepatic duct by the fingers, and this procedure is usually incidental only to operation on some other portion of the biliary system. No special after-treatment, therefore, is to be noted. ^ Leonard Rogers, Brit. Med. Jour., 1903, ii, 706, quoted by Moynihan. ^ Baillet, Bull, et Mem. Soc. de Chir., xxix, 1194, quoted by Moynihan. GUNSHOT AND OTHER INJURIES OF THE ABDOMEN 437 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 war/ it is true, that many cases of abdominal gun- shot wound 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, while cases in w^hich the abdomen is traversed below the umbilicus get well without operation. He advises operation only when 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, which 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 general, though, every penetrating wound of the abdominal wall is to be explored. An attempt is made first to stop hemorrhage. Then a systematic search for injuries of the viscera is made, but with as little 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 instituted 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 nourish- ment 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 ^ Brit. Med. Jour., 1900, i, 1156. ^ Spencer, Med. Annals, 1901, quoted by Jacobson. 438 OPERATIONS ON THE ABDOMEN not continue beyond sixty hours after operation, except for injuries of stomach and duodenum. (See Gastro-enterostomy, p. 411.) If there are no signs of peritonitis or leakage from the various repaired intestinal unions, the wicks may be withdrawn in forty-eight hours. If for wicks the spiral drains (see p. 220) 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 necessary, and preferably always together with atropin. CHAPTER XLV OPERATIONS ON THE ABDOMEN (Continued) 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 bet\veen 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 sensitive in some people, show irritation, even to the extent of blistering, after Fig. 137. — Abdominal Swathe After Celiotomy. SX is made to fit snugly by taking a "gvisset" in each side with safety-pins. Folded towels are em- ployed, one about each thigh, for perineal straps, and are pinned over the anterior superior spine. ■collodion applications. The dressing is better held on, therefore, with strips of zinc-oxid plaster and a swathe applied, as in Fig. 137, 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 ■dressing may be held on by a Cunningham hernia spica. (See Figs. 138-140,) There seems to me to be not enough advantage from the application of a broad gauze spica bandage (Fig. 141), 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 piaster-of- Paris spica which some surgeons apply to maintain flexion of the thigh. AMiatever form of outside dressing is applied, care should be taken that the testicles and scrotum are well sup- 439 440 OPERATIONS ON THE ABDOMEN ported and their blood-supply not interfered with, otherwise hematoma or gangrene may result. The patient should be put to bed, with the Fig. 138. — Application of the Cunningham Hernia Spica. To one end of a strip of Shaker flannel 6 in. wide and 14 in. long is sewed a strip of zinc-oxid plaster of the same width and 24 in. long; at the other end of the flannel a piece 14 in. long. The application is started by so placing the midsection of flannel under the slighfly flexed thigh and in the crotch that the short plaster end is carried over the dressing to the loin on the operated side; the long plaster end crosses the dressing to the opposite loin. Fig. 139. — CrxxiNGHAM Hernia Spica. The two adhesive plaster strips cross over the dressing. thigh slightly flexed by means of a pillow under the knee to a\'oid un- necessary strain on the lines of sutures. The patient should be kept practically horizontal; every means should be taken to avoid cough. THE RADICAL CURE OF HERNIA 441 efforts toward sitting up, or straining at stool; the bowels should be moved by enemas only for the first ten days for this reason. Fig. 140. — Cunningham Hernia Spica. The long end being applied to the opposite loin. The single intracuticular stitch should be removed about the tenth day. The patient should not get up before the fourteenth day, and many surgeons make three weeks in bed the rule after inguinal herni- EiG. 141. — Applying the Gauze Spica Dresstxg Afti:i< HiaiNKnuMN-. otomy in men; he should avoid heavy lifting for three months if possible. In children under five or six years of age who are hard to control it is probably best to apply the plastcr-of-Paris spica bandage outside the 442 OPERATIONS ON THE ABDOMEN dressing to assist in immobilizing. These directions apply to all varie- ties of operation: the Johns Hopkins operation/ the Bassini operation,^ the autoplastic suture method of McArthur/ and femoral hernial 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. Umhilical 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 directions, and also by a snugly pinned abdominal swathe. There is probably no in- crease 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 reinforced 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 Sequelae. — Pulmonary or cardiac embolism 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. 443.) 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 months entirely unneces- sary. Our experience, based on a series of upward of 600 cases of hernia in children under fourteen years of age, has shown that t^vo to two and a half weeks is ample time for the child to remain in bed. The ^ Halsted, Johns Hopkins Hosp. Bull., 1903, xiv, 208. ^ E. Bassini, Arch. f. klin. Chir., 1890, xl, 429. ^ L. L. McArthur, Jour. Amer. Med. Assoc, 1904, xliii, 1039. * Hayward W. Gushing, Boston Med. and Surg. Jour., 1888, cxix, 546. ^ B. G. A. Moynihan, Retroperitoneal Hernia, London, 1899, reviewed in Ann. Surg., 1903, xxxvii, 120. ^ Schopf, Wien. klin. Woch., 1903, xvi, 8. ^ H. A. Lothrop, Boston Med. and Surg. Jour., 1901, cxlv, 589-611. ^ P. Berger, Re^oie de Chir., Paris, Jan., 1902. " W. J. Mayo, Ann. Surg., Aug., 1901, xxxiv. LARGE INCARCERATED HERNIA 443 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 flabby 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 truss 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 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 which 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- /^/| 4 OPERATIONS ON THE ABDOMEN 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 i^rnaud, who pubHshed 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 Mke 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 rehef. 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 little. 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 hberty. 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 deal of mercury, of the diabotanum, and the mucilages, and this I renewed every four days. We made him every morning take 10, 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, mth 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 STRANGULATED HERNIA (INGUINAL OR FEMORAL) 445 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 address'd, 'Would you escape, you must be poor and thin. To pass the hole thro' which you entered in.'" (Horace, Lib. I, Epist.) 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. io6. 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 bo^^'el 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 446 OPERATIONS ON THE ABDOMEN 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; M^ r. H R. f^P S. diagnosis Vcntr 81 hernia. 1 11 fA i? ;.v jj- a^ 21 ^Jf -?•) it Jf / A 3 ^ s ( 7 i- ^ /^ // / -2. 3 'y- .T ^ 7 ? ? 10 II /i /i 'f li- /(, '/ Tl MF 5f It E:t: ji a 2 Ul K bi (/) -i a t/i 2 O < OJ UJ cr 107' I06' (Of* 103' lOi' 101' 100' 07 97 % is-o (to 130 120 110 ICO 90 »c 70 60 so f5 fo 35 30 25- Zo 15 10. ■«-> ^- ^ « J / \ J «=s (' it2 ,^ ^ ta^ j^ su m la: ~ N »* k \ H ^ V 'v \ 's Ml r fia; . V —J « L_ Fig. 142. — Large Ventral Hernia. Marked Aseptic Reaction. 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. 439.) If the condition of the gut was such that it seemed best to drain the wound, or if, as may be the case in strangulated femoral hernia, so much of Gimbernat's ligament had to be cut that there is little chance OPERATIONS ON THE PANCREAS 447 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 Sequelae.— (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, which seem to the operator to be viable, but are not so. (2) Sepsis. — Local sepsis is fairly common in cases not operated within, a very few hours. This comphcation 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) Unobserved 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. 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 herniae. 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 swelling has disappeared perhaps completely, this has taken place 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) Obstruction 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 448 OPERATIONS ON THE ABDOMEN 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. 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 Sequelae. — (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. 68) 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 pancreatic duct from the duodenum, in the same manner that it passes up the comm_on 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 obstruction, which often so modifies the symptoms as to lead to a serious mistake in diag- nosis." ^ 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 pancreatic leakage even through a small wound. DRAINAGE OF PANCREATIC CYST These cysts are always drained, and such evidence as we have seems to show that some must be permanently drained, since, at least in those ^ Von Mikulicz, Trans. Cong. Am. Surg, and Phys., 1903. DRAINAGE OF PANCREATIC CYST 449 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 swelUng 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 transmitted impulse synchronous with the pulse, but not expansible. 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^ 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 incised. 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, o\\ing 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 * Jacobson, Trans. Med. Chir. Soc, Ixxivj 455 ^ Boston Med. and Surg. Jour., 1892, cx.xvi, 441. 29 450 OPERATIONS ON THE ABDOMEN 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." « 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 dis- ease; (5) for persistent malarial tumor; (6) for splenic anemia or leuke- mia. Of all these indications, the most favorable is that of injury. Otherwise healthy persons with spleen removed seem to live on for years in perfect health, with no physiologic changes to be observed, even in the blood. Complications and Sequelae. — (i) Secondary hemorrhageha,sheen repeatedly observed, and apparently in every case it has been due to retraction of one or more vessels from the pedicle. In such cases the pedicle has been tied when tense or each ligature 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 adherent or from adherent omentum. Should the stasis at the end of operation be in any way unsatisfactory, the cavity must be packed for twenty-four to forty-eight hours. (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 ^ " On another occasion I should divide the omentum by the transverse colon." ^ J. Pollins Warren, Ann. Surg., 1901, xxxiv, 521. APPENDICOSTOMY 451 !?: t^ f M r 3 "2 5' B •0 E 2; 3 resistance against bacteria, but it is "proper to conclude that the removal of the spleen does not alter particularly the individual susceptibility 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, I operated F. A. R., thirty-six, male, for spleen ruptured in an automobile accident. Splenectomy was done; drainage left in forty-eight hours. Convalescence was complicated by abscess 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 (Jan., 1910), with no apparent physiologic abnormality. The blood counts are shown in table. "^ >^ 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 ob- struction 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 twists 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 severed within I in. of the skin and any bleeding point secured. The .* J. C. Hubbard, Boston Med. and Surg. Jour., 1909, clx, 746. ^Brit. Med. Jour., 1894, ii, 1155. ^ New York Med. Record, Aug. 9, 1902. 452 OPERATIONS ON THE ABDOMEN 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 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. S^A^nford 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 ^vith 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 | gr. of calomel three times daily while in the hospital." ' ^ J. B. Dawson, Brit. Med. Jour., 1909, i, 78. APPENDICOSTOMY 453 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 (Joe. 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- 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. Jejuncstomy 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. Mr. Keetley ^ operated upon a child aged a year and ten months for intussusception 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 indicated." * Brit. Med. Jour., 1905, ii, 863. 454 OPERATIONS ON THE ABDOMEN APPENDICITIS AND ITS COMPLICATIONS It is to be hoped that, as time goes on, more men will train themselves to do appendectomy ^ through the McBurney ^ incision, wherein the abdominal muscles are split rather than cut, making the so-called grid- iron opening between the fibers. The advantages of this incision for all types of appendicitis, with few exceptions, have been set forth in several places ^ since McBurney's original paper. ^ It is appreciated that, etymologically, append! cectomy is the better word. ^ Ann. Surg., xx, 38. ^ 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 obhque are now seen running nearly t right angles to the external obhque. A nick between fibers, as before, is followed by tearing open of this muscle, as well as the transversaUs beneath it, and the properitoneal fat with the two fingers. "After good retraction to the full depths of the wound, the peritoneum is lifted between two forceps, nicked and sht 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 obhque. " One or, at the most, two catgut mattress sutures close the external obhque. " One or tv/o 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 before, 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 obhque. These stitches are left -ndth 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 spht in each plane in either 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 pehds it will be found that the hmit to which the split in the obhque muscles and the transversaUs ap- proaches is the right hnea semilunaris.' When, therefore, in the sphtting process this line is reached, one may then cut freely down the semilunar fine, 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, so called, goes through the skin and anterior sheath of the right rectus, the muscle-belly is retracted toward the median APPENDICITIS AND ITS COMPLICATIONS 455 I. McBurney Incision. No Drainage. — Tne intracuticular stitch of silkworm gut or horsehair is tied over a pad of gauze which rests on the wound (Fig. 143). 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. 144). A swathe may be put on for the first t^venty-four hours to keep the hand of the patient away from the region until he has fully recovered from Ijis ether. The single stitch is removed on the eighth day, and all ten- sion 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 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 be 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 ever}i;hing. " The disadvantages of the rectus incision are, in our opinion, (i) That the rectus muscle varies so much in width in different individuals, that incisions intended to be over the muscle-belly frequently come down directly on the Unea semilunaris, making the whole incision direct through the abdominal wall, with no safeguard against hernia in cases drained. (2) That there is a considerable chance of wounding the deep epigastric vessels, with trouble- some hemorrhage. (3) That, as McBurney says, the incision makes 'an overhanging sheK 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, xUi, 554) has shown that the mesenteric origin serves to shut off the right ihac 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 chance 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 beUy 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-splitting Incision. — The disadvantages of this incision are that it cannot be made so quickly, that it takes a certain amount of delicacy of dissection and care, par- ticularly if it is to be enlarged. (2) In cases of prolonged drainage miuch more care and dexterity is required in replacing the wdcks 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 noTiemia. From the moment the patient leaves the operating table every 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." 456 OPERATIONS ON THE ABDOMEN dressing of such cases, and the plaster straps are left on or renewed until at least three weeks from the day of the operation. Fig. 143.^-AppLYiNG THE Dressing After Appendectomy. The long ends of the subcuticular stitch of silkworm gut are tied together over a folded sterile gauze strip, and the ends cut short. 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 Fig. 144. — Laced Adhesive Dressing. ■ (Devised by Ernest W. Gushing, of Boston, in i8g4, but originated by D. Laurentius Heister, Venice, 1750, Vol. I., p. 109.) As used after right rectus incision. a few hours after operation. Except for purposes of drainage into the pelvis, as in the Fowler position (Fig. 151), I see no advantages from this procedure. Every patient is more or less prostrated by the ether and APPENDICITIS AND ITS COMPLICATIONS 457 its after-effects, by the psychic effect of having faced an operation, and is more or less uncomfortable on account of pain or morphin. It does -''m Fig. 145. — Removal of Perforated Sheet. Hand holding the dressing in place. not seem that anything could be better for the patient during the first day than horizontal rest. Fig. 146. — Applying Adhesive Plaster Strips, Criss-cross, over the Appendix Dressing. The morning 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, 458 OPERATIONS ON THE ABDOMEN 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 given up largely to the first high enema, the movement, and the exhaustion following it. In the afternoon of the second day and thereafter he may be up, and is to be encouraged to move about and become normal in all necessary functions as soon as possible. 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 condition showing 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 spiral drain (220), closing the wound by sutures, leaving only room enough for for the drain to emerge. Through the protruding drain there should be put transversely a sterile safety-pin, lest the drain slip into the woimd 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 temporary drain may be pulled out and a provisional suture, which was put 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. A small pad is put over this and the swathe or straps 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. 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 APPENDICITIS AND ITS COMPLICATIONS 459 10 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 forming; 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 w^hole region one clean-cut cavity without partitions and subcavities, 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, w^here 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 definite, easily accessible cavity to dress, wiping out with a dry sponge often suffices. 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 nozzle, will best serve to clean the cavity. The danger cannot be over- emphasized, however, if irrigation is used, that the fluid 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 per- formance is a signal to stop. In case much packing or several strips of gauze have been necessarily 460 OPERATIONS ON THE ABDOMEN 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 two 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 1 : 100) 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 Incision, 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. 141), call for no treatment different from a median celiotomy. The patient may sit up the day after operation. Right Rectus Incision, Drained. — ^When, unfortunately, the surgeon has to drain through this incision, care should be taken at the first removal 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. APPENDICITIS AND ITS COMPLICATIONS 461 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. Complications and Sequelae. — It is trite enough to say that no t^vo cases of appendicitis are alike, the possible postoperative com- phcations are so numerous. (i) General Peritonitis. — See pages 151, 418, 421, 458, 459, and 468. (2) Intestinal Obstruction. — If the abdomen does not distend, no effort should be made to move the bowels for the first t\venty-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; 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 in the wall of the cecum or ileum, due either to a continuation of the gan- grenous process of the original disease, or to the careless removal of an adherent drainage wick. For treatment, see pp. 246 and 421. (4) Stitch abscess (see Chap. XXIII., p. 221). (5) Abscess in the abdominal ti-all near the region of the wound may appear in places where the muscle layers have been excessively separated during operation, or where the drainage gauze has become dried and 1 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 back for operation. Total hernias through appendectomy scars 22 Through old-fashioned direct oblique incision i? Through right rectus incision 5 Through muscle-splitting incision o These figures need no comment. 462 OPERATIONS ON THE ABDOMEN 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. V. Lymphatic and Hepatic Infections. Subphrenic Abscess.^ — This complication occurs approximately in i case in 1000. The abscess may b.e within the peritoneal cavity or in the retroperitoneal tissue. If 2dL. J. _R . i<. i_ 2a j_ S. M, K. M. B 41. w . l>^agnos,s AT!t> enaicitis. J).a£,nosi5 A-Ppendicitis. "►;usk, ii. 13 ih. il i£ ^ it> J| it ^3 I'r '1 )i 3l 2J-^ li Jjs B ~ i! 21 ?» / i rr E •r ]= o/5e«sF 1 a. ^ 4 i 6 7 y f DISEASE. -i- 1 J. 3 ^ i- ^ 7 !f ? /il ///A — TI,ME 5f «t -1 31 31 1 4. 3 i u 5 <; ? OISC«sf 1 a 3 f- i i ' 7 cc U] Q. 5 1^ ui -1 a 2 107' - „ g ws' - lOf- 103" - 101' - 101' - IOC' - * .j, ■H i' * ^ * ^ • ^ ^ \ ^'.-^ \ ^ H T^ ^ ^ Z ^ 9/- %' ISC - IfC- 130 - (20- 110 - ICO - 90- 80- 70- 60. ■so - f-S- \c- 31- 30- 25- 20- '5- IC - r • h i( .^ f» , *\ J \ / w % • L Mr. A. A. 22 s, Hiapnos i s Append l c 1 1 1 s . "il^^ '7 It 'f 2i; 1/ n 2J if 7,- ^^ 71 ?,? '? 0/SE«5F. /' X J ¥■ s J ^ ?! o f i" 6 ■^ S i n i'' TIMF 3S !■« 5S 5i ii zz *ftt- •to. * 1 0. OISEASF. 1 i 2. 4^ 6 7 sr ? /o // /i /3 '^ -■ /( '7 /« '9 ^ Ti MF 5* i^ t:E w .h; Q A % n / lTychnin given subcutaneously (•^Iq 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 533 534 OPERATIONS ON THE KIDNEY, URETER, AND BLADDER 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 until 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 lining 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 little 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 two or three weeks, hexamethylamin should be given, 5 to 7^ 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 day 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. 184, 185, 186). " (2) The fact of the infection, and acute abscess of the second kidney, some nine j-ears 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,, dry, and without disa- bility, 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 bave made it seem wise to have removed it at the outset, had the patient's condition at the NEPHROTOMY 535 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 quantity (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 drainage through the loins has been uninterrupted from the time of its being instituted in both kidneys — fifteen years in all. " (5) The fact that the patient went on in perfectly good health for twelve years with- out any evidence of calculus-formation in either kidney. " (6) That he then began to have calculi from both kidneys, which continued 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 phosphatic 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 pre^dous 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 operation with 1 : 4000 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 § in. The best possible drainage has thus been maintained. " Finally hemorrhage took place from the kidney operated on first, twelve years after the operation. Nevertheless, daily irrigations went on as usual. Two weeks later he came to my office, and upon having the tube from the kidney replaced after it had been withdrawn to cleanse it, and without any trouble having occurred in the 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 sub- stance close to the inner orifice of the fistula, and after extracting a calculus from the kidney by forceps through the now much enlarged canal of the fistula, I succeeded in wholly arresting the bleeding by tamponing the wound and bleeding surface of 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- 536 OPERATIONS ON THE KIDNEY, URETER, AND BLADDER tion will probably appear. For this condition drainage must be free and efficient. Suppression or uremia may take place at once, or at any time up to two 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. 510) is, of course, the most important. Every means must be taken to produce sweating and diuresis. Persistent urinary 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 theFrench 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 of the two upright tubes of metal that are upon the upper surface of the re- ceptacle (Fig. 185). The leakage, which is so distressing a feature to the patient, and, because 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 pro\dded 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 vithin the cup of the shield and is ^vithdraw^l 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 attached to each of its wings and which buckles in front (Fig. 184). (2) 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. 184, and which also passes around the body and buckles in front. (4) Upon the lower part of the can is a metal cap, which can be detached NEPHROTOMY 537 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 escape through it. Except at the time at which the can is being thus emptied, the end of the tube is worn beneath one of the elastic belts, which retains it at whatever point is most convenient to the wearer (Fig. i86). (5) The only other feature of the apparatus which requires description is the arrangement by which the tubes connecting the shield with the receptacle are attached to the latter. This is done by passing the lower ends of the soft- r Fig. 184. — Watson's Apparatus for Permanent Drainage of the Kidney Through the Loin (Watson AND Cunningham). 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 man- ner in which the connection is made, as well as the relative positions of the shield and receptacle and othejr details of the apparatus, are shown in Figs. 184 and 185. Fig. T,86 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 538 OPERATIONS ON THE KIDNEY, URETER, AND BLADDER 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 Fig. 185. — Watson's Apparatus (Watson and Cunningham). Cup-shaped hard-rubber shield of Watson's apparatus for permanent renal drainage through the loin. short bit of another and larger tube at the point at which it passes through the shield. ■?»«?«««>. - . - ^ ~ , , — Fig. 186. — Watson's Apparatus for Permanent Drainage of the Kidney as Applied (Watson and Cunningham). The receptacle can be worn inside the trousers, and is so small and flat that it attracts no attention and causes no discomfort. NEPHRECTOMY 539 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 upon 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 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 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, a very rare operation, calls for no special consideration apart from nephrectomy in general. Complications and Sequelae. — Suppression of Urine.- — After- care of nephrectomy, as in nephrotomy, should be at first directed to- ward encouraging the other kidney to rise to its increased labor. It has been contended by some that too high an arterial pressure might be induced by forcing the ingestion of fluids, but it seems to me doubtful if suppressive congestion of the other kidney is ever due alone to pressure 540 OPERATIONS ON THE KIDNEY, URETER, AND BLADDER from 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 litde 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 Diannosis fJepTirectomy. OISE^SF. TIMF 5??5'«- '•■■i"-":=.<^ < tr Ul a 2 Ui h- u I z o < a Q. UJ £ S r / ^ ^ A A l_ / * ■^ ^ u •^ z ^ ,_ ^ V ^ \ ♦ K ^ / l^ V* ^ \ \ \ 1 Fig. i88. — Nepheorehaphy. Uneventful recovery. tion 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. SUPRAPUBIC CYSTOTOMY 543 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 operation, but in such a way that there shall be no obstruction due to the drain. If urine escapes to a notable degree from the wound, means should be taken to protect the skin (p. 514) or to collect the urine, as in a persistent nephrotomy fistula (p. 536). 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 plan successfully was Dr. L. S. Pilcher, of New York: a catheter was used until the ninth 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 ha\dng 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." ^ Jacobson, 1902, ii, 404. 544 OPERATIONS ON THE KIDNEY, URETER, AND BLADDER Complications and Sequelae. — Shock may appear immediately after operation. This is partly because patients are frequently old; because persistent hemorrhage has been usually going on for a long time before, and because during operation there may have been con- siderable 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. Fistula. — In some cases it is found advisable to allow a suprapubic opening to persist, as, for instance, in the presence of malignant disease. The patient may be up and about, so far as his general condition 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. ^ A. T. Cabot, Med. Rev., New York, Sept. 17, 1892. VAGINAL CYSTOSTOMY 545 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 x\merica. For after-treatment see Perineal Prosta- tectomy, p. 528. Complications 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. Surgical Kidney. — This condition (p. 141) may be expected after any operation on bladder or urethra. The same is true of urethritis, per- sistent fistula, calling for later operation; incontinence 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 * Trans. Amer. Surg. Assoc, v, 127. 35 546 OPERATIONS ON THE KIDNEY, URETER, AND BLADDER operation the tub-bath method of constant irrigation, as devised by G. L. Huimer,^ 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 chps. 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. 189.— 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. 189). 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 warm 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, aU 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 daily. The operation for its closure does not differ from that for any vesico- vaginal fistula (Chap. XLYI, p. 475). Neither does the after-treatment. The diet should be largely liquid. Tea, coffee, alcohol, and condi- ments 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 1 G. L. Hunner, "The Tub-bath Treatment of Cystitis," Jour. Amer. Med. Assoc, 1907, xli.x, 2066. ^ Med. Chir. Transactions, London, lii, 85. EXSTROPHY OF BLADDER 547 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. "A 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 CO. 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, wdth 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. " (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 w^as 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." ^ ^ Herczel, Centralbl. d. Harn- u. Sexorg., 1899, 563. ^ 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. 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. 85, p. 220), 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 two 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 reclining, all day if possible. These wounds, tuberculous or not, heal 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. 548 ISCHIORECTAL ABSCESS 549 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. 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. 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, I 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 rem^oved, 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, greatly advances the healing. An emollient is kept round the anus and edges of the wound. 550 OPERATIONS ON ANUS AND RECTUM The patient is out of bed as soon as he can sit on an inflated rubber rins without too much discomfort. The bowels are moved daily from the beginning. Complications and Sequelse. — Spread of Infection. — Cases in which the incisions are to any degree inefi&cient in position or size may form new pockets; the infection may spread completely over the but- tock or fonvard 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 axis 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 Avrapped in rubber dam, has been placed in the rectum, protruding from it. A T-bandage holds the dressing firmly against the parts. Before the rectal plug has been inserted at the end of the operation a suppository containing \ \.o \ 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, I 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 fiA-e 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 scA'eral days tends to produce con- HEMORRHOIDS 55 1 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- pHcations. Ungue?itum gallcB cum opio (B. P.) is an excellent ointment, applied at night and after each movement to the whole anal region, to help shrink away external redundant 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. 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-effect is practically unknown after a careful operation, but may occur where the clamp has not protected 552 OPERATIONS ON ANUS AND RECTUM 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 silver 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 perfectly 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 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.i— 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 1 Brit. Med. Jour., Feb. 26, 1S87. KRASKE S OPERATION FOR CANCER OF THE RECTUM 553 should not go more than a third of the way round the circle, lest the ^^•hole 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. Hemorrhage, which is sometimes supposed to be a comxmon 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). 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 number 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. ^ Brit. Med. Jour., Oct. 30, 1909. ^ Archiv f. klin. Chir., 1S86, xxxiii, 563. 554 OPERATIONS ON ANUS AND RECTUM 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 I 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 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 ^ Care must be exercised in introducing the rectal tube. A case has come to my notice where fatal peritonitis resulted from the nurse forcing the tube through the line of sutures into the peritoneal cavity. KRASKE S OPERATION FOR CANCER OF THE RECTUM 555 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. Complications 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- c[uently 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 Adjace^it 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 genito-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. 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 556 OPERATIONS ON ANUS AND RECTUM 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 pelvis, 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 coccyx 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 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 Sequelae. — Peritonitis, shock, secondary hemorrhage, 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. ^ Jour. Amer. Med. Assoc, 1901, xxwii, 801. VAGINAL PROCTECTOMY 557 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 Kjaske'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 Sequelae. — Sepsis may be met by drainage through the wound opening, as little 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 Emholism. — 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, slightly elevated, and all sudden movements must be especially prevented, lest embolism occur. Painful Stump. — This diagnosis must not be made too quicldy. 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, 558 AMPUTATIONS 559 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 two 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 between 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. 560 OPERATIONS ON THE EXTREMITIES of which a figure-of-8 bandage is apphed 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^eg. — 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 sphnt 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, with 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 hgation 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. LIGATION OF THE SUBCLAVIAN ARTERY 561 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 Sequelae. — 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 vision, 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 Sequelse. — 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 case and gives complete bibliography of the subject. 36 562 OPERATIONS ON THE EXTREMITIES 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 circulation 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 he 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 he injured when the needle is passed during the operation, but, except for infection, this accident is of little 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. Within the last few years the brilliant experimental work of Carrel,"-^ Guthrie, and others has aroused renewed interest in this operation. Among others, Lund ^ and Sher- man * have reported successful cases of arterial suture. The number of cases is still limited, but from the study of the available literature the following rules for after-treatment may be set forth as conservative and ^ Lambert: Medical Observations and Inquiries, London, 1762. ^ Carrel: Jour. Amer. Med. Assoc, 1905, xlv, 1645; Ann. Surg., 1906, xliii, 203; Surg., Gyn. and Obst., 1906, ii, 266; Bull. Johns Hopkins Hosp., 1907, xviii, i8. ^ Ann. Surg., 1909, xlix, 394. * California State Medical Journal, 1908, vi, 56. MATAS' OPERATION FOR ANEURYSM 563 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. 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 v/ound 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 hmb is immobilized by a posterior 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. If 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 ^ Ann. Surg., 1906, xliv, 559; 1908, xlviii, 897. ^ Matas, Trans. Amer. Surg. Assoc, 1902, xx, 396. See also F. G. Balch and F. T. Murphy, Aneurysm of the External Iliac Artery, Boston Med. and Surg. Jour., 1909, clix, 860. 564 OPERATIONS ON THE EXTREMITIES 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 t^'elve days, the bandage being reapplied daily, but the wounds left undisturbed until the twelfth 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. 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 ^ C. H. Mayo, Surg., Gyn. and Obst., 1906, ii, 3S5. SUTURE OF TENDON AND MUSCLE 565 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 treat- ment before operation, this area should be sealed over with compound tincture of benzoin until the operative w^ound is sufficiently well healed, two or three days, to prevent the entrance of infection. Complications and Sequelae. — Infection and pulmonary em- bolism occur in rare instances. 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 c{uadriceps extensor, and other muscles and tendons have been reported. If an important tendon 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 w^ound 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. O «wJ o 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 uniting 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 efficiently 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 twice a week and careful passive motion of the fingers carried 566 OPERATIONS ON THE EXTREMITIES 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 sphnt 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 woimds 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. 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, and the ulnar near the internal condyle. The skin incision is closed without drainage unless the injury was accompanied by considerable 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 complete 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 ^ E. H. Bradford and R. Soutter, Boston Med. and Surg. Jour., 1907, clvi, 655. NERVE ANASTOMOSIS 567 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, begirming with the galvanic 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. 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 ^ Arch. f. klin. Chir., 1897, liv, 271. ^ Brit. Med. Jour., 1903, i, 1009. ^ Gaz. des Hop., 1898, 71^ annee, 259. * Phil. Trans. Roy. Soc, 1900, cxciv, 127. 568 OPERATIONS ON THE EXTREMITIES 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. cit.) 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. The after-treatment of nerve anastomosis does not differ from that of simple nerve suture as regards electricit}', 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. No immobilization of the head is required. Electricity is begun at the end of ten days. 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 vrhen 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 di\iding the sound nerve, but merely taking part of it to form the anastomosis, or anastomosing the distal end of the para- lyzed nerve directly into the sound one. Even under such circumstances more or less atrophy and paralysis will result, but this will entirely cleai up within two or three months. Electricity should be applied to the muscles normally supplied by the sound as well as those by the paralyzed ^ Cent. f. Chir., 1904, xxxi, 6S4. ^ ProA-idence Med. Jour., 1900, i, i. PSOAS ABSCESS 569 nerve. Improvement in the appearance of the face during repose is the first sign of returning function in the facial nerve. This may be expected within a few weeks, but even the shghtest power of motion is not to be looked for sooner than three to five months or even longer. The maximum improvement may not be reached for over a year. 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, twice, 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, t^venty- 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 ^ E. G. Bracket! and L. R. G. Crandon, Boston Med. and Surg. Jour., 1905, cliii, 515. 570 OPERATIONS OX THE EXTREMITIES nerves with paresis of tiie quadriceps extensor and much neuralgic pain. Time and galvanism may give rehef, othenvise it will become necessary to free the nerve of pressure by operation. 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 tiventy- 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 apphcation. 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 sufficient. If the nail is removed, no incision is necessary. After removal a rubber ffiiger-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 tw^o or three days. At the end of this time all dressing is removed except a bit of balsam of Peru or scarlet red ointment imtil 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. 315.) 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. dupuytren's contraction 571 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. DUPUYTREN'S 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 mechanical appliances. The dissection can be carried out through a longitudinal incision over each contraction band (Kocher), or, better still, in case two or more fingers are affected, a U- shaped flap can be turned back onto the wrist (Keen), uncovering the entire palm. The hand can be put up in plaster-of -Paris or on a simple malleable iron splint, or on a palmar splint of wood. The importance of complete asepsis is to be emphasized. The hand should be thoroughly cleaned before the operation (Chap. XXXIX, p. 357), and it should be protected with care until entirely healed. Sepsis in the wound usually 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 miust also be corrected by splitting and hemisection. 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 palmar splint or to a malleable iron strap, which should extend from the wrist to the tips of the affected 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 a 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. 572 OPERATIONS ON THE EXTREMITIES 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.^ 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 3 Thiersch Grafts. — A convenient and efficient form of dressing is sterilized silver-foil, after the manner first ad^^sed 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 whole 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 over 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 my 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 OA^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 ^ A. H. Tubby, Trans. Amer. Orthop. Assoc, 1900, xiii, 149, and Lancet, 1901, i, 90. ^ L'Orthopedie Indispensable, 1909, 705. 3 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. SKIN-GRAFTS 573 of sterile cotton cloth in ^-inch strips containing holes here and there for the escape of serum. A dry dressing is applied outside of these strips.^ 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 a point of skin is then laid here and there all over the clean granulating area to be grafted. Silver foil or sterile fenestrated compress cloth may be used in these dressings. "Wolf 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 discourage circulation into it. ^ Brockway, Johns Hopkins Hosp. Bull., 1889, i, 36. CHAPTER LI OPERATIONS ON BONES AND JOINTS EXCISION OF ELBOW Passive motions of the fingers and wrist should begin on the second or third day. The new fiail-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 angula.r 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 efl&cient, 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 the use of fixation, or passive congestion, or vaccines, or all of these methods. When the tuberculosis has subsided and has been quiet three or four years, then excision may be practised 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- 574 EXCISION OF JOINTS 575 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. EXCISION 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 twelve 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 previously inserted pro- visional stitch tied. The limb is immobilized in a plaster reaching from the perineum to the toes. Goldthwait, Painter, and Osgood ^ ^ Diseases of the Bones and Joints, Boston, 1909, 242. ^ Op. cit., p. 243. 576 OPERATIONS ON BONES AND JOINTS recommend that the leg should be put up with 5 degrees of flexion at the knee-joint rather than in complete extension, as this will give a less awkward leg. At the end of three weeks the patient is gotten out of bed, and in two w^eeks 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 wrecks. 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 dressings 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 follows 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, OPEN (or "compound") FRACTURES 577 ■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 during the first thirty-six hours. If the pain continues more than thirty-six hours, something is wrong. Use 7io more morphin, but split the plaster and, if necessary, remove it to find the source of discomfort. Often a little adjusting of the padding is all that will be necessary. The circulation miay 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 happen in fracture of the lower end of the femur from injury to the popliteal vessels. If there are no signs of infection, the dressing in an undrained 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 .T-ray taken to show whether or not readjustment is necessary. New apparatus should nov/ be applied, after any indicated manipulation is performed, to allov/ for the removal of the wound dressing, the reduction of the post- operative swelling, and the atrophy of disuse. After this the treatment is that for closed fractures of the same type. In case drainage has been left, as is frequently the case, proAision should be made for dressing the wound after forty-eight hours. If the fracture has been put up in plaster, a window should have been cut or the plaster split before it has hardened, and the lid held in place by 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 serum, it is aseptically removed, a new dressing applied, the window-lid put in place and fixed by a plaster-of-Paris roller, and the limb is not again disturbed until the ten days or two weeks are up. ■Careless technique at this first dressing is, without doubt, frequently responsible 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 tempera- ture if seen immediately. The temperature after the operation may be expected in the first tw^enty-four hours to rise to 99.6° F. If on 578 OPERATIONS ON BONES AND JOINTS the second day it continues to rise over ioo° F. (see Chart, Fig. 20, p. 55) and is associated with pain, the presence of an infection should be assumed and the wound examined. If sepsis is apparent in a red- dening about the wound, localized superficial tenderness, or a sero- purulent 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 Mr A. W P. M, ! 55 Hiagnom ftnen frflcti jre 1 noth bones of 19r. on oFWajj ,1^ 31 ,il 11 10 31 / a. 7 V ■?r ? /C /' / - I\ 1' a. i f 6 6 7 s 9' b 'f « /t , V^ Tl MF 5? ff tt l\ \l zz ^e J£ r + H CI m I- t- f conscientiously cleaned, healed by first intention. RECURRENT DISLOCATION OF THE SHOULDER 589 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. — Sepsis. — Infection of the skin around the wound may be easily met and overcome. Any persistent temperature, tenderness, or pain should lead to immediate investiga- 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- 587)- Adhesions. — The knee after this operation is always limited in motion at first. After the twenty-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 Burrell's 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 Burrell's and Ricard's operations is identical. The capsule is sutured with catgut, the muscles brought together, and the skin \vound 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 elevated and carried inward to ^ Rules of Aseptic and Antiseptic Surgen-, New York, 1888, 8. ^ Bull, de I'acad. de med., 1894, N. S., xxxi, 330. ^ Amer. Jour. Med. Sci., 1897, N. S., cxiv, 166. 59° OPERATIONS ON BONES AND JOINTS ward the median line. The arm is not disturbed until the tenth day, when the first dressing is done and the stitches removed. The Velpeau is replaced and continued until four weeks from the date of operation, when massage and passive motion are begun, and the patient is allowed to return to work at the end of eight weeks. 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. OSTEOMYELITIS For our earliest conception of the regeneration of bone from perios- teum we are indebted to Oilier.^ His technique was carried out with suc- cessful issue in two cases of suppurative periostitis by Cheever in 1868.^ The pathology of the present method of the treatment of osteomyelitis, by early resection of the necrotic bone, allowing regeneration from the periosteum, was first outlined by E. H. Nichols in 1898,^ and his sugges- tions were carried out by Dr. Hayward W. Gushing.* For an exhaus- tive 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. ^ Traite Experimentale et Clinique de la Regeneration 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. ^ Communication Mass. Med. Soc, 1898, xvii, 875. * Ann. Surg., 1899, xxx, 468. ^ Jour. Amer. Med. Assoc, 1904, xlii, 439. OSTEOMYELITIS 591 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 w^ound 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. cit.) 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 w^ith 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 which 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. 592 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 difiiculties 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\-ity, 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 canity as nearly aseptic as possible, drying it, and filhng 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, xx^^i, 385. 2 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) 593 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 Hmb 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. 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 tw^elve weeks, depending on the age of the patient and the degree of deformity. The patient should then be fitted with a 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. The following technique of plaster application, recently described by Ehrenfried,^ is particularly adaptable to the postoperative treatment 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 child. Of ^ Boston Med. and Surg. Jour., igog, rlxi, 741. 594 OPERATIONS ON BONES AND JOINTS 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 be- come solid, one can efficiently manipulate the forefoot as a unit and apply a considerable amount of force without cramping or dislocating the toes, or caus- ing pressure sloughs, for the pressure is not concentrated, but is distributed evenly through the collar (Fig. 199). " The second roll is applied, after six or eight minutes, in the form of circular turns over the thigh and under the ball of the foot. These turns are drawn. Fig. 199. — Diagram Showing Advantage in Applying a Collar and Allowing it to Set Before At- tempting TO Maintain Position over Old Method of Attempting to Overcorrect With Plaster still Wet (Ehrenfried). 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. 200). 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 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 applied in recurrent turns (Figs. 201 and 202). CLUB-FOOT (CONGENITAL EQUINOVARUS) 595 " 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 position care should be taken not to indent the plaster with the fingers, or a slough may result. After it has dried sufficiently 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 removed more readily in case of emergency or when the proper time arrives. Fig. 200. — 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). " 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 foof, 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 aud Sequelae. — Slough circulation from pressure of the plaster. and interference with 596 OPERATIONS ON BONES AND JOINTS Fig. 201. — Plaster Applied, Side View (Ehrenfried). Fig. 202.— Plaster Applied, Front View. The extreme degree of overcorrection— the foot being directed outward and upward, and the outer border elevated — is apparent (Ehrenfried). OPERATIOX FOR SPINA BIFIDA 597 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 t^vo weeks to allow of manipulation. The patient should be kept under observation for a year or two 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. Mayo's operation, whereby the exostosis is removed and the bursa is turned in to make a new joint surface, are the two 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 walking should be attempted. The pledget of cotton should be kept between the toes for four weeks at least. Right and left stockings should be used, if obtainable, and flexible anatomic shoes should be prescribed. (See Chap. XXXVI, p. 3150 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 wouiid is closed tightly with continuous cat- gut, reinforced by a iew silkworm-gut sutures. An alcohol 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 598 OPERATIONS OX BOXES AXD JOIXTS 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 temiperature during the first day or t^vo 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 im^portance 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 T,o deaths. (i) Meningitis. — This is an extremely serious complication, and results from infection, vv'hether at the time of operation or entering the wound aften^'ard. 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 inentable. (3) Superficial Infection of the W oiind .^l^oxtit (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 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 ^ Amer. Jour. Orth. Surg., 1907-08, v, 208. ^ Inaug. Diss., Breslau, 1903; Cent. f. Chir., 1904, xxi, 341. LAMINECTOMY 599 changed at from two- 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 emiployed by means of an extension apparatus like that used for cer- vical caries. If the patient sur\"ives 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 twice 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 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. jMassage 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 600 OPERATIONS ON BONES AND JOINTS 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 cerebrospinal 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 10 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 VACCINE THERAPY By George P. Sanborn, M.D., Boston Sometime Assistant in the Laboratory of Professor Sir A. E. Wright, at St. Mary's Hospital, London Principles of Immunization The science and art of immunization as applied to surgery has for its purpose tlie direction of the normal human mechanism for the combating of infective processes in the attempt to overcome surgical infections. It is intended to assist, and not to supplant, the ordinary approved surgical methods, such as incision and drainage and the em- ployment of asepsis. It is intended not to emphasize the importance of any one measure, be it surgery or bacterial vaccine, but to give to each its proper place in so far as it contributes to the process of im- munization. Surgery directs itself in the treatment of localized infectious proc- esses to extirpation of the diseased focus, or to incision and free drainage of pus, and has followed up these measures to a considerable extent by attempts to destroy the causal agents — the bacteria — ^by means of antiseptics, as applications and as irrigations of wounds, cavities, and sinuses. If success has crowned the effort to complete extirpation, if drainage is effective, and infected material is thoroughly discharged, cure is to be expected. There are exceptions, however, to this rule, notably in the case of furunculosis. Here, in spite of proper drainage and attempts to maintain the condition of the skin as sterile as possible, new furuncles will commonly develop in different parts of the body. Extirpation. — The frequency with which tuberculous nodes de- velop beneath the scar, following an operation for extirpation, indicates the difiSculty of radical and complete excision of infected tissue. Where bone is the seat of tuberculous or other infectious disease, the persistence of discharging sinuses for months and even years indicates that surgery has not been sufficient. In tuberculous infections of the genito-urinary tract, where the kidney or the testicles are involved, it is extremely 601 602 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY uncommon not to have other focus or foci in other portions of this system of organs. Where the testicles are the prominent seats of infec- tion and are removed, it is commonly to be found that the bladder, prostate, spermatic cord, etc., may be singly or severally concomitant seats of the same diseased process. Though in some cases the removal of a tuberculous kidney will result in marked improvement in tuber- culous cystitis, or the removal of a testicle will be followed by apparent freedom from other active involvement, it is most common for equally serious conditions to exist or to develop elsewhere. In attempting to extirpate, therefore, we are confronted with the difficulty of complete extirpation, and where several organs are involved which cannot be extirpated, we are confronted with the impossibility of eradicating more than perhaps the most prominent focus of disease. Drainagfe. — Upon the induction and perpetuation of free drainage depends the success in the treatment of localized infections of the pyo- genic type, and a considerable percentage of the failures to produce conditions suitable for rapid healing are due to the use of methods w^hich interfere with, rather than further, proper drainage of infected material. Antiseptics. — The attempt to destroy all the bacteria in the focus by means of antiseptics is futile. That it has been a failure is attested by the fact that for the last few years the practice has gradually gravi- tated toward the use of extremely mild antiseptics for surgical dressings, soaks, and irrigation, such as weak boric acid, chlorinated soda, or normal salt solution. If the antiseptic solution is sufficiently strong to kill the bacteria, it will be equally efficient in its injury to tissue-cells. Further, excepting in unusual cases, the antiseptic application cannot be expected to come into contact with all the bacteria. Those which have escaped its action will find a good culture-medium for further growth in the cells that have been injured, and in the exudation which the irritation of the antiseptic will have produced. Gauze drains have their part in making matters worse, when they obstruct the discharge and lead to the accumulation of pus and bacteria under some slight pressure. The persistence of infectious disease in spite of surgical effort attests in such cases surgical failure. Extirpation that does not completely extirpate, drainage that does not effectually drain, and impossible methods of destroying bacteria in the infected foci, should not be ex- pected to lead to any but a considerable percentage of failure, and suggests the adA'antage of methods that will be more effectual in the accomplishment of cure than those in present use in the treatment of localized infections. PHYSIOLOGIC IMMUNIZATION 603 The fact of spontaneous recovery from infectious disease indicates that the body has the power to immunize itself against the bacteria and the bacterial products which are its cause. The so-called "expectant treatment" attests our confidence in such immunizing ability, or physio- logic immunizing mechanism, as it were, as does the present method in the treatment of pulmonary tuberculosis, of placing the patient under the best conditions of hygiene, and trusting for the cure to the inherent power of the body; again in diphtheria, when antitoxin is in- jected for the purpose of accomplishing what the patient might not successfully accomplish if left unaided. Not only the fact of recovery from infectious disease, but future, lessened susceptibility to infection of the same nature, indicates that the body not only develops the power of destroying the bacteria, but retains that power for a certain time in sufficient degree to prevent further infection. Through laboratory research much has been learned as to the manner in which the body protects itself against bacterial invasion, and rids itself of infecting bacteria when they have overcome the normal protec- tive mechanism, and have found lodgment and produced disease. When horses are treated with increasing doses of the toxin of diph- theria bacillus they become immune to excessive doses of this poison, while if such excessive dose had been given at first, the animal would have succumbed. We find reason for this immunity in the content of the horses' blood in antitoxin, which the normal horse does not possess, and which is found to neutralize the toxin of diphtheria if the toxin and the antitoxin-bearing serum are mixed in proper proportions. The serum of such an immunized animal when injected into a patient suffer- ing from diphtheria has resulted in practice in a large diminution in the mortality from this disease. Ehrlich, by inoculating ricin into laboratory animals, showed that the blood-serum of the animal inoculated contained a substance which entered into combination with the ricin and rendered it inert. When snake venom is injected into an animal, beginning with very small doses, there is developed in the blood a substance which is found to neutralize and render ineffective snake venom, if proper proportion of each are mixed. The animal inoculated may be rendered immune to extremely large doses of the snake venom: These substances, developed as a result of inoculation with specific toxins, are a content of the blood-serum and are specific; that is, they combine with and neutralize only the particular toxin at the stimulus of which they were developed. The immunity thus developed in response to the stimulus of these poisons is termed active. The serum of these animals, in that it com- 604 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY bines with and renders inert the corresponding toxin, is termed an antitoxic serum. Such a serum injected into an animal in proper amount will produce a temporary immunity to the corresponding toxin, and to a certain degree immunity to the infection that produces it. This type of immunity, which is conferred by the injection of antitoxin, is termed passive. Diphtheria antitoxin, therefore, induces a passive immunity, in that the body cells of the treated individual have no part in the production of the antitoxin. The power of the animal body to produce substances which shall protect it against poisons, as above indicated, is not limited to the forma- tion of antitoxins against poisons or toxins. It is found also that in response to infection with living bacteria, or to the inoculation of killed pathogenic 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 new 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 bacteria and their poisons which constitute the actual stimulus to the formation of these antibacterial substances. So far it has been impossible to isolate these newly formed protec- tive antitropins, as they are termed by Wright, and they are only dif- ferentiated 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 laboratory 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, even when the serum is highly diluted, and these substances are named, according to their effect, agglutinins, bactericidins, and hacteriolysins. They are not to be demonstrated in an effective amount with serum of normal indi^iduals. In the common infectious processes, due to the staphylococcus, streptococ- cus, 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 consideration as means of pro- tection against these organisms. In the bodily reaction against typhoid, colon, cholera, and some other infections the role of these antibacterial substances appears to be an important one. There is, however, beyond these distinctly antibacterial substances, ' THE ROLE OF OPSONINS ' 605 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 those microorganisms with which they come into contact. Whereas, the first three antibacterial substances, or bacteriotropins, are produced by the body only in response to a limited 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, attributed recovery from infectious diseases, decreased susceptibility to any infectious disease from which an individual has recently recovered, and in certain cases natural immunity, to the ability of the leukocytes to ingest and kill bacteria. He did not, however, recognize 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. When, in 1895, Denys and Le Clef produced immunity to the streptococcus, by injecting rabbits wuth increasing numbers of these organisms over a considerable period, they found that such animals, when injected with living cultures of the streptococcus of erysipelas, did not develop the disease. It was their belief that this power to resist the same amount of living bacterial culture which killed rabbits which had previously not been inoculated w^as due to the increased ability, which they found the leukocytes had acquired, of ingesting bacteria. They attributed this increase of phagocytic power to the effect of some newly acquired characteristic of the serum, resulting from the inocula- tion which had the effect of stimulating the leukocytes to attack and ingest the bacteria. 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 leukocytes; 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 in much larger and more effec- tive amount in the serum of animals that are made immune to some microorganism by protective inoculation; that, in the human being, upon recovery from certain infectious diseases, increased opsonic power is demonstrable; that opsonin in normal blood is active in pre- 6o6 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY paring nearly all varieties of bacteria for phagocytosis; and that, where there is effective response to any particular infection leading toward recovery, the increase in the phagocytic powder is directed only against the infecting organism, the efficiency of phagocytosis against other organisms being approximately as found in uninfected individuals. In the systemic reaction against infection, therefore, the opsonin is an important factor, because upon it depends the ability of the body to offer effective phagocytic resistance, because it is directed against all species of pathogenic organisms, and because in conjunction with the leukocytes it constitutes the first defense of the immunizing mechanism against infection. The other means of defense which the immunizing mechanism offers, represented by the substances above referred to, the bactericidins, bacteriolysins, and agglutinins, are only called into being some time after infection has taken place as a secondary defense, and then only against a limited number of pathogenic microorganisms. In the common infections due to staphylococcus, streptococcus, pneu- mococcus, and possibly the tubercle bacillus, the opsonin not only appears to supply the means of first defense, but would also appear to exert a predominating influence in immunity from these infections, because, so far as is known, excepting for the agglutinins developed in the case of tubercle, no other antibacterial substances have been de- monstrated in effective amount. Nuttall found that the blood exerted no bactericidal action upon the staphylococcus, and this was con- firmed' by Wright. Denys found that virulent streptococci were not ingested by rabbit white corpuscles when in contact with normal rabbit serum, but when in contact with the serum of a rabbit immunized against the streptococcus, the leukocytes ingested the bacteria. The serum from the immunized rabbits had no bactericidal effect upon the streptococci. When the leukocytes were added, the bacteria were ingested and destroyed. Further evidence of the importance of op- sonin in these infections is that during acute stages of pneumococcic, streptococcic, staphylococcic, tuberculous, and other infections the phagocytic power has been found uniformly below normal, but when an immunizing response is heralded by a fall in temperature and recovery, the phagocytic power is found to rise considerably above normal. Hek- toen^ attributes to phagocytic immunity the predominating effect in the destruction of streptococcus, pneumococcus, staphylococcus, and some others, and possibly the tubercle bacillus. Opsonin and other bacteriotropins probably originate from the connective-tissue cells as a result of their stimulation by the specific * Western Medical Review, February, 1908. THE FORMATION OF OPSONINS 607 poisons, inducing them to react in the fornlation 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 the bacterial cells. In favor of local production of opsonins, that is, at the point of inoculation of killed bacteria, there is considerable evidence. Theoretic conception of the formation and the manner of action of opsonins CONNtCTlve Tissue CELLS oPsoNizeo READY roR PHAGOCYTOSIS BACTtRlOTROPINS Fig. 203. — Chart Illustrating the Probable Mode of Action of Vaccine When Injected. and other antibacterial substances, developed as a result of inoculation of killed cultures of vaccine, is well shown in Fig. 203. It will be seen that the bacterial vaccine injected locally is supposed to disintegrate in the subcutaneous tissue, setting free its specific poisons, which act upon the body cells and stimulate them to produce corresponding antisubstances or antitropins, according to the character of the micro- FOCU& (.-'^^X.-r" /CN CONNECTIVE \. TISSUE CELLS. 1—^ BACTeRlQTROP\NS- Fig. 204. — Chart Illustrating the Effect of Manipulating an Infected Focus, in Disseminating Bacteria, and the Probable Mode of Action of this Living Vaccine. organism injected. These new substances, opsonins, bactericidins, agglutinins, etc., as the case may be, are sent forth into the blood-stream, and conveyed to all parts, of the body to the foci of infection and com- bine 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 role of opsonin as a factor of 6o8 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY predominating importance in the protective mechanism of the body, but also developed the method of Leishman, so that it could be used to measure, more or less accurately, the effective opsonic power of the blood in many infectious processes. He compared the phagocytic abihty of the blood to be tested with that of the blood of uninfected individuals. In other Avords, he measured and compared the effective opsonic power of an uninfected individual and the power in the case of any individual suffering from bacterial disease, both against the infecting microorganism. The result of this comparison, that is, the ratio of the two, he termed the opsonic index. Wright's method for this determination is briefly as follows: Into a capillary pipet, as shown (Fig. 205), with a rubber teat afiflxed, are A lA. rORPUSCLES -t- EMULSION OF . NOtSMAL,^ .M i-CUCOCYTES HAVE .aO0__ 2.(oF B/fcTEHlA ' TUBERCl-E BAC1LI.1 ^ 3 E R L) n !« QtST ED ZOO BACTER\A 100 *• ^TER LEUCOCn LOKf-Uitl-C TUBERCLE BACILLI ^ SERUM ,N(i£STEQ IbO 6ACTERIA 100 1^0^1.6 MV-KUnBtR cocm A BE iFHAfi. inde;!; FKA^ INDEX , rv .- V — PAT I ENT _ l-fa — «rt OPSONIC IISDEX - NOHMAU ~ TIT " '^^ PHAGi index Fig. 205. — Essentials and Method for Detersiixation of the Tuberculo-opsokic Index. drawD equal volumes of the blood-serum of a normal individual, of blood-corpuscles which haA'e been 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^° C. A similar procedure is carried .out, using the same corpuscles 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 incubation period, the small end broken off, and the contents expressed upon a clean slide, mixed thor- THE OPSONIC INDEX 609 oughly, 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 scrutinized, it will be found that they have ingested numbers of bacteria in each of the specimens. All the bacteria contained in loo leukocytes in the case of each slide are counted, and the average number ingested by each leukocyte is calculated. This number is termed the phagocytic index. The opsonic index is determined by dividing the average number of bacteria per leukocyte which have been ingested in the experiment with the patient's serum, by the average number ingested in the experiment when the normal blood-serum is used. The resulting figure represents the ratio between the phagocytic power of the patient's and the normal serum, the normal serum being considered as unity. An opsonic index, there- fore, 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. The beginnings of vaccine therapy, as Wright has conceived and developed it, may perhaps be attributed to a suggestion of Pfeiffer, who, in conversation with Wright, stated that he had obtained in man a specific serum agglutination reaction subsequent to the injection of a heated, killed, typhoid culture.^ In experimenting along this line, Wright found that, as the result of the injection of a killed typhoid culture into human beings, the bactericidal power of the blood was in- creased by a single inoculation, sometimes a thousand-fold; that there was also to be measured a high agglutinating power, a high opsonic power, and, from clinical observation, it was suggested that a certain degree of antitoxic power was also developed, all directed specifically against the typhoid bacillus and its toxic products. The injection of killed cultures thus resulted in the elaboration of the same specific anti- baicterial or typhotropic substances to be found in the indiA'idual infected with and recovering from the disease. This suggested the employment of heated cultures to immunize against typhoid individuals exposed to the disease by artificially inducing in the body the elaboration of these protective substances. Wright put into extensive practice immunization against typhoid along these lines in the British army in South Africa. The results have ^ Wright, Antityphoid Inoculation, Constable, London, 1904. 39 6lO THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY fulfilled expectations. Mortality and incidence of the disease among those inoculated were each cut down one-half, when compared with the mortality and incidence in an uninoculated group. It was found that the blood-serum of the inoculated cases showed the characteristic presence of specific antibacterial substances against typhoid. Thus, by directing the immunizing mechanism in an appropriate manner, it was made to produce a defense of exactly the same nature that it elabor- ates as a result of actual infection. The killed cultures injected fur- nished the stimulus to the formation of protective substances in the same manner as living bacilli accomplish this result in the actual disease. It should be stated here that it is probable that the poison of typhoid bacillus, staphylococcus, streptococcus, pneumococcus, colon, and, to a certain extent, tubercle bacillus, is bound up in the cell protoplasm, and does not act effectively in its specific toxic or antigenic manner until killed and disintegrated, when its specific antigens or toxins are set free. It is obvious that the stimulation of the mechanism that produces protective substances must be chiefly a chemical one, and that intact bacteria could hardly be expected to furnish such a stimulus. We must, therefore, assume in injecting killed cultures for immunization purposes that protective substances can only result from a solution of the bacteria injected in the- tissues. It is different in a case of diphtheria and tetanus, in which the patho- genic action is due to a soluble toxin which they secrete or excrete, which is diffused into the circulation from the original focus of growth, and exerts its pathogenic action by destructive combination with certain body cells for which it has affinity. We should expect, therefore, that recovery from these diseases would depend on the ability of the body to produce an antitoxin, and this is actually the case. Antitoxic im- munity probably is not the only defense that the body offers, but that this is the predominating factor in the body defense the efficacy of anti- toxin as a curative agent in diphtheria suggests. We have considered the response of the body to infection by the formation of substances calculated to act in a destructive manner upon the infecting bacteria or to neutralize their toxins. We have seen that the same manner of protective reaction may be produced by inoculation with killed bacteria or specific bacterial toxin. To such inocula Wright has given the term "vaccines." A vaccine, according to Wright's defini- tion, is any chemical substance which, when introduced into the organ- ism, causes there an elaboration of protective substances, or induces in the organism an elaboration of bacteriotropic elements. A bacterial vaccine is a suspension of killed bacteria in sterile 0.85 NEGATIVE AND POSITIVE PHASE 6ll salt solution, with sufficient preservative added to insure constant sterility. Such a vaccine is standardized as to the number of separate bacteria which are contained in a cubic centimeter of the solution. Vaccine of the tubercle bacillus, in other words, tuberculin, comes to us in various forms from the manufacturers. It may consist of a suspen- sion of the bacteria, as the Bacillus Emulsion, which is standardized to contain 5 mg. of tubercle bacilli for every cubic centimeter. An- other form is the Tuberculin R, which consists of comminuted bodies of the bacilli with a certain amount of soluble toxin extracted. Tu- berculin R, then, is essentially the protoplasm of the bacterial cell finely comminuted and suspended in salt solution, each cubic centi- meter of which is said to contain approximately 2 mg. of solid bacil- lary substance. There are various other forms of tuberculin which contain the poisons excreted or secreted by the bacillus in its growth in liquid media. Generally speaking, then, a vaccine is composed either of the bacteria themselves unchanged, except in so far as they are affected by the heat used in killing them, or by pulverization, or is some derivative of the bacterial cell. 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 antibacterial sub- stances, particularly the agglutinins and in 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 maximum resistance to bacterial invasion and minimum sensibility to the poisonous action of the vaccine. There next comes a fall in the bacteriotropic content, resulting in a slightly lower bacterial resistance, but, compared to the period before inoculation, the blood shows an increase in its anti- tropic elements. The body at this period, however, and subsequently, seems to possess a greater power of response to the same vaccinating 6l2 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 increase in the anti- tropic substances, and after the remission of the stimulus and a slight fall in the antibacterial power, a more or less continued period of in- creased resistance. The importance of this sequence of events, which he has shown to be the case in the production of bacteriocidins, 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 cor- responding 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. By measuring the variation in the phagocytic power subsequent to staphylococcic inoculation later, Wright showed that the same sequence of negative and positive phase was to be observed. A recognition of the import of this law of negative and positive phase in the production of antibacterial substances, which a study of the blood following protective typhoid inoculation has furnished, sug- gested to him that like methods of stimulating the protective mechanism of the body in the actual presence of chronic disease, leading to the increased formation of specific antibacterial substances, might be used. In the year igco he was confronted with a case of chronic staphylococcic infection which had resisted all treatment, and he decided to make use of a corresponding staphylococcic bacterial vaccine, with the hope of inducing the formation of increased antibacterial power. In 1902^ he published the results of treatment of chronic staphylococcus infections, and stated that he found the same sequence of negative and positive phase in the diminution and increase of the phagocytic power following inoculation as he found in the bactericidins of antityphoid inoculation. The ease with which the variations in the phagocytic power could be recorded, and the fact of the predominating influence of phagocytosis in the common infections above other factors in immunity, led him to make use of it as a guide to the injection of vaccine. His aim was to inject the vaccine in such dosage, and with such frequency, that the phagocytic power of the blood should be maintained in an elevated condition over as long an interval as possible, and at the same time to ^ Lancet, March, igo2. OPSONIC INDEX IN HEALTH AND DISEASE 613 eliminate, so far as possible, the so-called negative phase or phase of diminished resistance. Thus he sought to produce in the blood an in- crease in the actual constituents which were responsible for recovery, and to obtain by frequent examination of the blood for its phagocytic power, suggestion as to the time for inoculation and the am.ount of the inoculation which could be calculated upon to produce an efficient response. The results that have been produced by means of injections of corresponding vaccines by Wright, and many others since, have confirmed their efficacy in the treatment of localized infections in certain infections which are not strictly localized. Even in some that are generalized their use has offered some considerable hope for future ■l r 80 . 76.7 ro 60 50 40 30 20 10 in. 1 - 10.7 !■ - |i .8_ L L r ■ r ■ L ■ H _ t. 7 _ _ _ Fig. 206. — Variation of the Opsonic Index in Normal Individuals. Based on 635 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, 1908, 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 0.9s 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 cornparatively small limits, 94-i per cent, being between 0.90 and i.io. success in their application. The opsonic index merely measures, more or less accurately, variations in the phagocytic power of the blood as compared with the normal individual. It is by no means to be taken as a complete measure of the immunizing response of the individual to vaccine, or as a result of infectious disease, but on account of a cor- relation with an elevated opsonic or phagocytic power with recovery, of a subnormal phagocytic power with stasis and retrogression, it may be taken as an indicator of efficient response to infection and inoculation. The study of the phagocytic power of the blood-stream in health and disease by means of the opsonic index determination has furnishec' a large amount of accurate knowledge as to the bodily resistance against infection, and this has furnished well-defined indications for the use 6l4 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY of specific measures in the way of vaccines for the control of infectious processes, and of other measures which, as adjuncts, enhance their value. The opsonic power of healthy indi\iduals conforms to a certain mean, the variation being slight in the same indhidual from day to day or in different individuals compared 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. Be- tween 600 and 700 indices were determined upon these normal indi- viduals, and it -was found that in 97-^ per cent, of the cases the extreme variation was between 0.90 and i.io, but that in only 2^ per cent, of the determinations the indices were either above 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 vras considered normal against the tubercle bacillus, showed extreme variation from 0.8 to 1.2. But three of these cases show^ed indices above i.io or below 0.90. or about 12 per cent. The remaining cases — 31 — or 877 per cent. — v:eve 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 showed a variation betveen 0.80 and i.io. Again, he found that about 87 j- 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. betAveen 0.90 and i.io.^ It appears, then, that the opsonic indices of normal individuals practically all fall within a certain definite range of variation. This holds true in other infectious processes quite as it does in tuberculosis. 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 skil- fully 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. ^ Practitioner, London, May, 1908. ^ Trans. Path. Soc. London, 1905, vol. hi, part 3 ^ Studies on Immunization, Wright, p. 145. THE NORMAL AND IMMUNE OPSONIN 615 "We ha\'e seen, therefore, that normal individuals have a practically equal ability inA-ested in their phagocytic mechanism to ingest offending bacteria; that opsonin is a normal content of the blood-serum, and that in conjunction with the leukocytes it constitutes the early and active defense against bacteria; that it is not specific, but is applied against any and all bacteria that gain entrance to the body. By means of opsonic index determination, Wright has demonstrated that after infec- tion takes place, or subsequent to inoculation of corresponding vaccine, there are certain characteristic modifications in the opsonic power of the blood. This has been confirmed by many other investigators. Whatever the direction of the variation, be it above or below normal, such variation is specific against the microorganism producing the infection, or that which has been injected as vaccine. If the same blood-serum be tested against microorganisms with which the indi- vidual is not infected, its phagocytic power will be found to be within the normal limits. This suggests that there may be a difference between the normal opsonin and that produced by inoculation or bacterial disease. As a matter of fact, the opsonin in normal individuals is not quite the same as in those infected. The action upon the bacteria is exactly the same, apparently, in its effect in preparing them for phagocytosis. The immune opsonin differs from the normal in that it is specific and acti^'e only against the invading organism.s, where the normal opsonin acts upon any and all organ- isms. A second difference is that a normal serum, heated to 60° C. for ten minutes, becomes almost totally inelficient in opsonizing bacteria, whereas immune serum heated in the same manner has a residuum of opsonic power. What the exact nature of this difference is has not been fully elucidated, but, so far as the present discussion is concerned, is comparati\'ely unimportant. In strictly localized infections, no matter what the type, it has been found that variation in the range of opsonic index is almost without exception subnormal. In the case of strictly localized tuberculosis, the findings are consistent with this general rule. Bulloch^ reports the opsonic indices in 150 cases of lupus. Com- pared with the average opsonic index 0.97, which he obtained in normal people, the average for the 150 cases was 0.75. Of these cases, 74.4 per cent, fell between 0.2 and 0.8, which latter may be taken as the lowest range of the normal individual. Wright- reports the indices of 31 cases of localized tuberculosis, the ^ Trans. Path. Soc. London, 1905, Ivl, part 3. ^ Proceedings of the Royal Society, 1906, Bd. Ixxvii. 6l6 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY average opsonic index of which was approximately 0.3, with extreme variation from 0.13 to 0.88. Lincoln ^ reports that 40 cases of localized tuberculosis had an average opsonic index of 0.68, with a range of 0.3 to 0.9. Wright reports 20 cases of staphylococcic infection, including fur- unculosis, sycosis, and acne, in which the opsonic index ranged from 0.1 to 0.88, with an average of 0.63. Wright^ states that the existence of normal phagocytic power in a case of staphylococcic infection is rare and extremely exceptional. Passing on to the condition of the opsonic power of the blood in acute infections or infections associated with systemic disturbance and temperature, we are struck at -once by the marked variations. We may take as a sample of such condition a case of pulmonary tuberculosis or other non-localized tuberculous condition. Wright^ reports opsonic indices upon the blood of a child suffering from tuberculous caries of the fibula, associated with constitutional disturbance. There were seven indices determined at from one- to nine-day intervals. The ex- trem.e 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 l^va 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 ob- served by us in connection with the stirring up, by surgical inter- ference, of tuberculous foci," A case of tuberculous caries of spine with constitutional disturbance gave five indices, determined 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. Another case, in which subsequently diag- nosis of pulmonary tuberculosis was made," showed opsonic variations of from 0.48 to 1.35, the daily variation sometimes being from 0.5 to i.i. Other observers have confirmed these wide fluctuations in the opsonic power in pulmonary tuberculosis and tuberculosis of the non-localized type- Associated with various diseases which undermine the patient's health we commonly find a condition of furunculosis. In recovery from systemic infections like typhoid it is common. In cases of diabetes patients are conspicuously subject to staphylococcic infections. A ^ Illinois Med. Jour., 190S, .\iii. ^ Studies in Immunization, p. 103. ^ Proceedings of the Royal Society, 1906, vol. x.xvii. '' Studies in Immunization, p. 153. 5 Itid., p. 385. BACTERIOTROPIC POWER OF THE BLOOD 617 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 susceptibiHty to staphjdococcic infec- tion. This study, made by Da Costa, 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. The term "strictly localized infection" is to be taken as meaning an infection which is unassociated with temperature or generalized symp- toms. Such infections are tuberculous bone disease, glands, some cases of kidney, lupus, testicle, bladder, etc., furunculosis; infections which have passed the acute stage and have become indolent, and in which the local condition and the lack of localized symptoms confirm the suspicion that the process is walled off, and no longer sends into the circulation toxic products in sufficient amount to constitute general febrile or other reaction. We have spoken of the bare facts concerning the variation in the phagocytic power of the blood-stream in health and disease. It wall now be advantageous to consider certain facts dealing with the bacterio- tropic power of the blood -stream in its relation to that existing in the localized foci of disease, in order that we may glean some indication as to wherein the immunizing mechanism fails in its effort to rid the body of infecting bacteria and suggestion as to how- failure may be averted. The circulating blood has in itself practically all the defensive forces of the body in the antibacterial elements of the serum and in the phagocytic cells which it contains. Against bacteria which chance to enter the blood-stream, the sum total of antibacterial elements is at once brought into destructive action. Against the bacteria are opposed the whole force of the leukocytes and an unlimited supply of antibacterial substances. Contrasting with the conditions of defense which the cir- culation offers with the conditions that obtain in the tissues, we see a striking difference, in that in the tissue at the moment of entrance the microorganisms will find, to antagonize them, a few phagocytes, and such protective substances as the lymph contains in the immediate vicinity; whereas the blood-stream offers against the bacteria the whole force of the leukocytes and the entire concentration of the blood-stream in pro- tective substances. It is not to be w^ondered at that septicemias are, comparatively speaking, rare occurrences; that localized infections re- main local, when extension is opposed by the citadel, as Wright terms it, of the blood-stream. Interesting and important in this connection are the experiments of Hektocn and Carlson.^ In dogs immunized to goat ^ Jour. Amer. Med. Assoc, January 8, 1910, p. 130. 6l8 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY blood they found that the lysin, agglutinin, and opsonin developed against goat corpuscles reached the highest concentration in the blood- stream; that the thoracic and neck lymph were much poorer in these substances. The same relative concentration of antibodies seems to them to obtain in normal animals. We see in the phagocytes and the opsonin factors which together form the first defense of the body against any and all bacteria. We see in the reaction of inflammation the attempt of the protective mechanism, by inducing free streaming of fresh blood in and about the infected focus, to bring into contact with the infecting microorganisms large numbers of leukocytes and a continuous supply of antibacterial sub- stances. Such is the import of inflammation. We may conceive prop- erly that infection is an every-day occurrence, while infectious disease is more or less infrequent in the individual. It is only in cases where the immunizing mechanism fails at some point that bacteria gain foothold and produce disease. The fact of infection is commonly accounted for by assuming that the organisms owe their ability to enter and grow through their extreme \irulence ; that too large numbers of them gained entrance to the body at one time for the effective defense which the body offers to prevent their growth; that they have entered at points where the blood-stream cannot be efficiently increased or properly brought into contact with them; or, finally, when the blood itself, for one reason or another, is deficient in protective substances. We know that when bacteria are brought into contact with blood- serum in vitro in sufficient numbers, the opsonin or other antibodies in the serum enters into combination with their cell protoplasm. We assume that the same is the case when a number of bacteria enter the tissues at one point, that is, the lymph at the point of inoculation will lose certain of its opsonins by absorption, on the basis of experimental evidence. Wright and Lamb^ showed that the agglutinating power of the splenic pulp in typhoid and Malta fever is invariably lower than that in the circulating blood; that the agglutinating power of the serum in typhoid spots is less than that of the circulating blood. Lamb, referred to in the same article, also showed that in spirillum fever in monkeys the splenic pulp, in which the spirilla cultivate themselves after the crisis, had much less bactericidal and lytic effect than the circulating blood of the same animals. As to the relative content in opsonin of infected foci, compared with the blood-stream, Wright- has shown, in a case of alveolar abscess, by determination of the opsonic power of fluid obtained ^ Lancet, December 23, 1898, pp. 36-44. ^ Proc. Roy. Soc, 1904, vol. Ixxiv. THEORIES RELATING TO INFECTION 619 •by centrifugalizing the pus, that the opsonic power of the patient's blood-stream was six times that of the pus. Again, in the case of a patella abscess due to streptococcus, the blood was found to have an opsonic power eleven times that of the pus fluid. In the case of localized tuberculosis, he also found that the opsonic power of the blood-stream was over three times that of the pus from the abscess. Again, in tubercu- lous peritonitis the blood-stream was found to possess six times the opsonic power that the peritoneal fluid possessed. As a control, to rule out the possibility that the lymph might normally be poor in protective substances as compared to the blood-stream, Wright compared the phagocytic power of his own serum, from an aseptic blister, and the serum from his own circulating blood. He found that they had approximately the same phagocytic ability. Blood-supply to the infected point, automatically in- creased as the first reaction of inflammation, may replace this depleted lymph with fresh, and in addition furnish sufficient numbers of phago- cytes to ingest and destroy the bacteria. Such would theoretically be the course of events in the case of an aborted infection. Such a series of events is probably taking place continuously, and represents the initial strife between the bacteria and the protective mechanism. The fact of extreme virulence may apply to certain bacteria, notably the pneumococcus and streptococcus. It has been shown by Rosenow^ that virulent pneumococci are not acted upon by the opsonin in normal serum in a manner effective enough to render them phagocytable. The same has been shown in the case of the streptococcus. This phenom- enon Rosenow fields to be due, in the pneumococcus, to a substance which they contain when \drulent, but lose after growth on culture- media. He was able to extract this substance, and found that avirulent pneumococci, when exposed to the action of this extract for twenty-four hours, became again relatively insusceptible to phagocytosis. It would seem that some virulent organisms, then, possess a substance capable of neutralizing or of resisting normal opsonin. When large numbers of bacteria enter the tissue, it may be assumed that their action is not only to absorb the effective opsonin in the locus, but, by dissemination into the blood-stream, combine with the opsonin present, with a result that the total bacteriotropic pressure of the blood- stream is at once lowered. The bacteria left in the locus may be opsoni- fied, but sufficient phagocytes are not available to destroy them. The bacteriotropic power in the locus is thus lessened, that of the blood- stream depleted, conditions that offer defective resistance to bacterial growth. The effect of such a bacterial invasion is to produce a negative ^ Illinois Med. Jour., 190S, xiii. 620 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY phase, quite like that produced by an inoculation of killed bacteria in sufficient numbers. If bacteria enter where blood-supply is deficient, the opsonin in the locus becomes rapidly absorbed, leukocytes are not brought to the scene in sufficient numbers, and growth takes place in a medium of lowered bacteriotropic power. Instance of infection due to deficient opsonin in the general blood-stream is to be found in diabetes. In this disease Da Costa has shown {loc. cit.) that the opsonic power is consistently subnormal to the staphylococcus. Hence the tendency to furuncle, carbuncle, and eczema. After localized infection has once started, the conditions favorable to its continuance are furnished by circumstances which go to prevent access to the focus of infection of the blood-serum and the phagocytic cells. Here, the body's protective mechanism, in its attempt to safe- guard the body against systemic infection, has produced conditions that are ideal in the furtherance of local chronicity of the infection. When, as we may assume, in a locus of infection, the toxins have been produced in sufficient amount to destroy tissue-cells, and the leukocytes have broken down to a considerable extent, we have pus in an abscess cavity, surrounded by a wall of tissue, infiltrated, swollen, infected, and efficient in shutting off any sufficient circulation of lymph in the infected tissue. The lymph, in contact with the bacteria, loses what antibacterial power it normally was possessed of, by combination with them,^ offering then no obstruction to further bacterial growth. In pyogenic infections we have further to deal with a ferment derived from broken-down leukocytes which is tryptic in nature (Opie), and has the effect of dissolving connective tissue, thus furthering extension of the process. If fresh leukocytes chance to enter this abscess fluid, they will find no opsonin to assist them, only bacterial toxin to destroy them. Wright has shown (loc. cit.) that the pus fluid has no power of in- ducing phagocytosis, and that leukocytes from the pus, though apparently healthy, have lost their povrer to phagocyte even in the presence of healthy serum. In cases of brawny infiltration, such as carbuncle, there is a blocking of the tissues by fibrinous exudate, pus, bacteria, and necrotic tissue. Circulation of fresh lymph is impossible; the lymph in the infected tissue has lost its opsonic power, and the bacteria are enabled to cultivate themselves, safeguarded from the circulating blood. The effect of a crust covering an ulcer is to obstruct the flow of ^ Wright, Proc. Roy. Soc, 1904, vol. Ixxiv. SIGNIFICANCE OF A FOCUS OF INFECTION 62 1 lymph. The bacteria in the lower portions of the crust absorb the opsonin in whatever lymph there may be, since circulation of lymph can only be provided for by removing the crust and allowing a discharge. Thus conditions are favorable for bacterial growth beneath the crust. The same difficulty, that of insufficient lymph circulation, is met with in chronic infected sinuses. The bacteria cultivate themselves in stagnant lymph, the antibacterial power of which has been abstracted by contact with the organisms. In the case of an effusion in a serous cavity, it is found that the fluid is very poor in opsonin, and hence has correspondingly little antibacterial action. If the phagocytes are few in such an effusion, as they commonly are, the presence of opsonin would be of little value. The opsonic power of such fluid, in the case of tubercle, has been shown to be in one case one-sixth that of the cir- culating blood. We have next to consider the conditions of the circulating blood in its content of antibacterial substances in its relation to the focus of infec- tion. There is to be found a depletion of protective substances in the circulating blood, as shown by the opsonic index, in localized infections. We have seen that, in order to respond in the elaboration of protective substances, bacterial stimulus in the way of vaccine or bacteria from the focus of infection is necessary. In the condition of local indura- tion and swelling in certain infections, of walling off of the focus in certain others by newly formed tissue, the blood-supply becomes so cut off that bacteria may not be taken up in sufficient numbers to constitute a stimulus to the formation of specific antibodies. We may further conceive that the blood-stream, coming continuously, but in a re- stricted degree, into contact with the outskirts of the focus of infection, loses gradually the opsonin of which it should normally be possessed. Hence the low opsonic power in localized infectious processes. We see, then, in the blood-stream a reservoir of antibacterial power; in the- reaction of inflammation, the endeavor to render the local bac- teriotropic pressure, as Wright terms it, as nearly equivalent as possible to that of the circulating blood. In the development of a focus of in- fection, we see both success and failure on the part of the immunizing mechanism: success in the fact of safeguarding the body from general- ized infection, failure in the fact of producing conditions locally which favor persistence and chronicity of the original infected focus. In other words, in thus safeguarding the body we may conceive that the protective mechanism has overreached itself, as it were, in that the condition of segregation of the focus of infection, which contributes to this end, also by interfering with the circulation prevents replenishment 62 2 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY of the lymph in the focus by lymph possessing the full bacteriotropic pressure of the blood. Thus, in the stagnant lymph the bacteria find a culture-medium which offers no resistance to their growth. A contributory factor to the chronicity of such a local infection its walled-off condition is responsible for, in that it does not allow the blood to take up sufficient bacteria to constitute an effective stimulus for the production of protective substances. We know that specific protective substances do not appear in the blood excepting as a result of such bacterial stimulus. If this view is correct, we should expect in local infections a more or less constant phagocytic power without any fluctuations suggestive of immunizing response, and in strictly localized infections, as we have seen, the opsonic index. would corroborate this view. And, again, the infected focus is responsible for another feature which is characteristic of such infections — the low opsonic power. It would seem reasonable to explain this on the supposition that con- tinuous contact with the outskirts of the lesion has resulted in the loss to the circulating blood of a portion of its opsonin by combination with bacteria and their poisons. When, in certain infections, such as car- buncle, erysipelas, acute accidental infections, or pulmonary tuber- culosis (certain cases) there is a temperature reaction, we must attribute it to the entrance of bacteria or their products into the circulation. If this is so, we should expect immunizing response similar to that produced by the inoculation of vaccine in the elaboration of protective substances, and it is a fact that measurement of the phagocytic power of the blood- stream furnishes evidence of a succession of negative and positive phases which could only arise through the presence of bacterial stimulus in the blood. Bearing in mind the reason for spontaneous recovery lies in the automatic response of the protective mechanism through the bacterial stimulus, it becomes evident that it must be through the agency of such automatically sent-out stimuli that the blood-stream derives its increased power of destroying bacteria. Such a stimulus would correspond in its effect to the inoculation with vaccine. It is termed a spontaneous autoinoculation. Spontaneous recovery we must look upon as having for its basis effec- tive autoinoculation. The absence of immunizing response in localized infections, as shown by the low opsonic power, indicates absence of effective autoinoculation. In the absence of stimulus to produce anti- bodies we should expect chronicity, and, as we have seen, localized cases which offer no stimulus, no spontaneous autoinoculation, are the chronic cases. Little is to be hoped for, therefore, in the Avay of spontaneous cure of many of these localized infections. AUTOINOCULATION 623 Turning to the consideration of generalized infections, we should at once have more hope for spontaneous cure, because at the outset we have certainly a sufficient condition of autoinoculation, which may be continuous if the bacteria constantly cultivate themselves in the blood, or it may vary in amount at different times, depending upon the frequency of the effective response of the body in producing sufficient antitropins to kill off most of the bacteria. The protective mechanism in such cases must be in a condition of constant activity. The strife between it and the bacteria, may be of short or long duration, depending, on the one hand, on the ability of the protective mechanism to respond, and, on the other, on that of the bacteria to immunize themselves against such opposition as the blood-stream offers. In febrile conditions, as septicemia, we expect constant fluctuation in the opsonic power, on account of constant autoinoculation. In local infections, when temperature accompanies, autoinoculation is taking place. In pulmonary tuberculosis in late febrile stages, even though the patient is in bed, opsonic index determination registers often wide variations in the phagocytic power, which can only represent response to autoinoculation. Febrile cases present, in fact, a succession of positive and negative phase, in bacteriotropic power. One of the most im- portant contributions to knowledge of the physiology of immunity came as a result of an observation made by Freeman in Wright's clinic, London, October, 1905.^ In a case of gonorrheal arthritis it was found that, following massage of an affected knee, the patient suffered con- stitutional disturbance and aggravation of joint pain during the few hours following the massage, quite the same as he had experienced after inoculation with gonococcal vaccine. The induction of symptoms following massage suggested that a negative phase had been in some way induced, and a study was made to determine this point. It was found that in every case after massage there followed a marked increase in the phagocytic power of the blood, and, in association, the joints improved rapidly; this was not confined to the joint massaged, but to all the others affected. In the rise in phagocytic power following manipu- lation was recognized an immunizing response, which could be due to nothing else than an autoinoculation, or setting free into the tissue and blood of gonococci or their products. That this improvement \a as not due to massage of each joint was proved by the fact that no matter what joint was massaged, the others partook of the clinical improvement that went hand in hand with the increase in antibacterial power. Autoinoculation. — Autoinoculation may be induced in the case of ' Lancet, November 2, 1907, p. 1226. 624 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY any focus of infection where it is possible, by some manipulation, to stir it up sufficiently to cause bacteria to be liberated into the blood or lymph eoMO- 1 .,.,._.. I "f ■*« ^ ! ^ ,'i\ 40" ■ " " i ' ^ ) 1 ' tt / \ ' ■ ['1 ^■^ \ - - ?j ' \ ' 2 5 ] 1 .,::j 1 / Sy' 1 S.S i"Wo» i;;5 / \ S«f\ ! ¥5 20 .sWo'f ^¥>' / \ 5 '\ ,'1? 1 M 20- ■ 1 i'f y^ ' }^ \\ i, -■■■-] ? f \ / ' \ * I is:_ _i .^ltt - -_j_t£it zx - t Hi it »-.' *^t Z^ ± aJ - .u.L.o*;^*-- -r.-^- rj -52. ' ^^_r_._- __ SM.Lio-*-^ -5- - r^ h ^ /' ' 1 > OS---?---- qi ~: ± _ _ - X pajjan icM 1 2 3 4 5 6 7 a 9 ic II 12 an ISI6 17 leisjolji 22 ;; 2« zs 2i 77 7« 25 y: 1 I90S ocr. Rov. Fig. 207. — Induced Autoinocexation. The effect of massage of a gonorrheal joint upon the opsonic content of the blood (Wright, Lancet, November 2, 1907, 1227). Stream in sufficient numbers to serve as an effecti\-e stimulus to the pro- duction of specific protective substances. The following manipulations or exercises may induce such auto- inoculation: Massage of a gland or joint, passive or active motion of a joint, surgical operation, increase in the active blood-supply to the affected part, by heat or other means. Bier's passive hyperemia, walking, deep breathing in pulmonary tuberculosis, shouting in laryngeal tuberculosis, Wright has shown, by means of opsonic index-determina- tion, to be followed by immunizing re- sponse registered by elevation of the opsonic power of the blood. Se'\'eral charts illustrating this important phe- nomenon are here shown (Figs. 207, 208, 209, 210, 211, 212). It will be noted that in all cases the charts indi- cate decided changes in the opsonic power following the different proce- dures, and thus register immunizing re- .sponse. The nature of autoinoculation being here indicated, the significance in its relation to the workings of the protective mechanism and its usefulness in diagnosis will be dealt with later. The only real success in securing protection against and in the OPSONIC INDEX 20 1-8 1-6 l'4 f-2 NORMAL 10 0-8 OB 04 0-2 AUG. 1906 Fig. 208. — Induced Autoinoculation. The variations in the opsonic power resulting from auscultation and percussion in pulmonary tuberculosis (Wright, Lancet, November 2, 1907, 1231). 1 PERCUSSION AND AUSCULTATION !\ 1 ' ' J y ^ 1 1 \ "*s| \ V ^t u t* • • '( •• '• TUBERCULO-OPSOm J- POWER » » 1 1 1 1 1 1 1 STAPHfLQrOPSONIC POWER • 20TM 2IST 1 INDUCED AUTOIXOCULATION 625 cure of diseases produced by microorganisxTis is now known to be based upon the artificial direction of the body's own immunizing ability, by means of remo\ing obstacles to its action, of furnishing the appropriate stimulus w^hen such is lacking, or by the addition, to the blood -stream, of specific substances which the body itself produces, but not in sufiScient 1 ! 1 : 1 1 1 ■ 1 1 1 1 1 1 1 ! i 1 ■ ' : 1 60 Mi 1 1 1 1 1 Mi! ! 50 \ - \ 40 I 1 \ 30 > ^ 1 1 1 y 20 1 \ i \ \ ' ) / \ V / \ 1 \ 00 1 i 1 1 1 1 1 1 I M i ■ \'' '■ /' ^ \ M ! /I 90 i \ ■ /: / \- / 80 \ / V A / 1 o. ' l\ / 1 1 1 1 1 -(0 1 _L_l5l 1 \l / 1 1 en ll J 1 60 1 1 i^! 1 i 1 1 MM ■ : 1 ! '• i Fig. 209.- N0V.3 4 5 « 7 8 9 10 11 12 13 14 OPERATION CURVE — T.B..SALP1NG1TIS. -AuTors'ocuLATiox AS Registered by the Opsonic Index Following Operativ; IN A Case of Tuberculous Salpingitis. Procedure •quantity to be effective in the production of a state of immunity against the infection under which it is struggling. Familiar is the example of pro- tection against small-pox by the production of a mild disease^cow-pox. It would seem here that, through the stimulus which this mild disease furnishes, the cells of the body have derived an increased power and a 16 1 " ■ (3 ~ -r -- ~ T ~ -'- I— - > - 1 ^ % S> i ^ •S /*■ \ i ^ f 1 ^ •^ ■' / ,' DOnMAU r- ^ r \i \ « •~t 7 " V \ \j \r 06 iV^ i 1 1 2 3 4 !> b 7 a 9 10 li 121131 W| 15 l6,l7'iei/9 20.21 1 1900 H ^ ■• UK t AU C 1 !U la iH 11 5til Fig. 210. — In-duced Autoixocui-ation. Tuberculous bone disease — ankle. The effect of walking (Wright, Lancet, November 2, 1907, 1229).- more or less permanent power to resist infection of small-pox. Here, then, has been made use of the body's own methods of protection against disease. Again, in protection against typhoid the use of typhoid vaccine in- duces the protective mechanism to fortify the blood with elements that 40 626 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY are calculated to destroy typhoid bacilli when they enter the body;, quite the same elements appear to be responsible for recovery from the disease. The same may be said of the antiplague inoculation of Haff- kine. A good example of success in following nature's lines of treatment in the cure of disease is that obtained in the treatment of diphtheria by JNDEX -^ ~ — '" ~ "■ -f - ~ " ~ "" " 1 1 a! * s t ^ u 4 *) /v *5 i V, '' / \ L i^ / / 'V NORMAL 10 \ S \ ^^ s, / V \ OB o \ / s \ \ f s Y 6 \ / s ^ _ 04 ■ - > 02 \ 26_27 28|23 Uii z 3 4 ^s e 7 8 9 10 ini2.i3;i4 15 le 17 r8'i9 20,21 22i23;24'2S:26:27l2ei2930 3l| 1306 JUNE JULf Fig. 211. — Induced Autoinocdlation dj Tuberculosis of the Spine. The variations in the opsonic power after sitting up indicate autoinoculation (Wright, Lancet, November 2, 1907, 1229). antitoxin. Here we furnish, at a time when the body may be lacking in ability to neutralize the toxin of diphtheria, a substance which is known to neutralize diphtheria poison and render it inert. The re- TU8ERCUL0 OPSONfC INDEX 14 12 NORMAL 10 08 0-6 Fig. 212. — Induced Autoinoculaxion. The effect of fomentations as shown by variation in the opsonic index (Wright, Lancet, November 2, 1907, 1232). markable reduction in mortality in diphtheria attests the efficacy of this measure. These examples could be multiplied, but serve their purpose, in that they clearly indicate that we can do no better than to seek to follow k ^ FOMENTATIONS \ 1* tt ^Eh t ^t \ ± 3: ^ ^^^^^ '' «•- 20 21 22 23 24 25 nature's method as a prototype for treatment 627 methods which nature takes, in our treatment of the disease produced by microorganisms; to stimulate the protective mechanism of the body, if we can, where it is in default, and offer aid when and where it faUs by the use of therapeutic measures that fullil actual requirements which nature, for one reason or another, cannot fulfil. In endeavoring to outline a reasonable method for the treatment of localized infectious diseases it is \A'ell to start with the proposition that each case presents a problem in immunization which the protective mechanism of the body has failed to solve; that it becomes our business to determine wherein the bodily offense has failed, and to make use of such measures as may be calculated to supply the deficiency, to the end Dec 8 9 10 1 1 60 ^ 1 — ' ,' 1 40 1 / / 30 \ / ' 20 / - / .10 100 90 IM „ 1- < 80 < ' 1 70 60 1 GONOCOCCUS KMEE. Fig. 213. — Induced Adtoinoculation. Here is registered by a fall in the gono-opsonic power an autoinoculation due to the tapping of a gonorrheal joint. of actually neutralizing toxic products, of stimulating the normal offensive processes so that they may be set in motion, or of making effective a satisfactory bodily response. With' the realization that present methods are to a large degree inefficient, and in some degree detrimental, in the furtherance of cure of localized infections, we should not endeavor to elaborate a system of treatment which will be an adjunct to surgical measures or to any other method that is necessary or has some degree of efficiency, but should endeavor to give each method or procedure its proper place, modifying or extending each according as it is efficient in the solution of some phase of the problem in immunization. 628 THERAPEUTIC IMMUXIZATIOX AXD VACCINE THERAPY In a collection in book form of his papers on immunity and kindred subjects we find, in Wright's dedication to ]Metchnikoff and Ehrlich, the keynote of his work: "To Eli Metchnikoff and Paul Ehrlich, this endeavor to win from the intellectual seed sown by them a harvest in medicine is dedicated, as a tribute of friendship and admiration, by the author." Wright holds a unique place in medicine, in that he has been able to interpret the many facts and theories that years of research have brought out, and ivhich, in connection ivith the results of his own in- vestigations, has developed the only thoroughly rational system of thera- peutics that has been offered to medicine. When, hoAA'ever, a complete story of mimunity shall have been written, it will doubtless be found that at the present time there was much to learn. It has been the custom in the earlv stages of localized infection to apply heat in the form of soaks, poultices, etc., inasmuch as clinical obser\-ation over a long period has indicated that the procedure is of value. Until Wright indicated that such measures were merely aiding and abetting the body in carrying out the intent which it normally makes to increase the blood-supply to the part, to "even up," as Wright terms it, the bacteriotropic pressure in the focus of infection with that of the blood-stream, it was not realized that the import of the hyperemic stage of infection Avas in connection with an attempt of the body to focus all its antibacterial forces against the invading bacteria. The applica- tion of heat, then, may be called a rational procedure, because it serves to enhance the value of the process which the body normally makes use of at this time. In the early stage of infection, where hmiphangitis is present, before there has been a solution of tissue in the focus, there has been recommended at times the application of the so-called Gamgee dressing, the intent of which was to so constrict the lymphatics leading from the infected focus that, as channels for the spread of infection, they might be efi'ectually occluded. Clinical experience, however, seems not to ha-^-e been in favor of its usefulness to achieve this end. It seem.s very probable, from considerations referred to previously, that the effect of this procedure would be to produce a passive hyperemia about the focus of disease, a stagnation of hmiph in the tissue about the focus, a loss in the antitropic power of the lymph in contact with the bacteria, and, during the period of its application, the production of conditions in the focus that were less resistant to the growth of bacteria than would be expected to be the case without it. It is much more reasonable, in the hyperemic stage of infection, to trust to the ability of the increased circulation rapidly and continuously to replace the depleted lymph in the focus, rather than to run the chance of furthering bacterial growth AUTOINOCULATION BY BIER'S METHOD 629 by such an ill-advised therapeutic measure. Further, if the focus of infection were at all extensi^'e, the forcing of lymph into the focus by passive hyperemia of the Gamgee dressing could not be expected to do other than induce an autoinoculation, in size depending upon the extent of the lesion. The danger here would derive itself, in the case of an autoinoculation large enough to JDe toxic, from the lowering of the opsonic power of the blood. During such a period of depression, the temporary diminution in the power to destroy bacteria as they enter the blood- stream might allow of the development of new foci in other parts of the body. Since the excellent results produced by Bier, his pupils, and others have been published, the use of passive hyperemia has been applied to all sorts of infections at all stages. In the treatment of acute local in- fections, Bier's passive hyperemia has been used sometimes disastrously. The same objection to its use in the early stages of an infection may be offered as against the Gamgee dressing; namely, the induction of a stasis of lymph flow in the focus of the infection at a period when the introduction and replacement of fresh lymph should he as rapidly carried out as possible. At this stage such a procedure is absolutely contrary in its effect to the measure of active hyperemia which nature endeavors to enforce. It obstructs the natural process of circulation, and should not be used except under certain conditions and in rare instances. Where the infection is extensive, and there is no outlet for local discharge, the application of Bier's passive hyperemia becomes positively dangerous, because it not only interferes with the circulation in the focus, hut also tampers with the hacteriotropic pressure of the blood-stream, in that when the bandage is removed there wdll soon be introduced into the circula- tion a flooding of bacteria-impregnated lymph, which will more than likely constitute an autoinoculation of toxic proportion, which will pro- duce an immediate lowering of the hacteriotropic power and cause a diffusion of living bacteria to parts of the body where new foci may be formed. The application of Bier's bandage can never be without its danger in the case of local infection, where there is no local exit for the discharge. It is quite another story when, in one of the extremities, we are deahng with tuberculous ulcerations, or in any lesion where it is possible to in- duce a free discharge of lymph. Thus, the forcing of lymph into the focus will drive before it as a discharge that which is normally present, and the circulation, if there be any, will be outward as a discharge, and the blood-stream will obviously not receive autoinoculation of such dimen- sion as would be derived in the case of closed foci. If any exception 630 THERAPEUTIC IMMUNIZATION AND VACCINE THERaPY is to be made in the rule against Bier's passive hyperemia in acute closed infections, it may be occasionally in slight superficial processes, in which the active circulation is e\-idently not to be expected to be efl&cient in checking the growth of the bacteria. Infected hair-follicles on the fingers would appear sometimes to clear up rapidly on the proper applica- tion of Bier's bandage. The rational technique of this application in such cases would be to induce passive hyperemia for a short period — ■ say from ten to fifteen minutes only; following this, the bandage is to be loosened, and the finger immersed in a hot soak for a half hour, then the same procedure repeated, and so on, the period being varied to suit the case. The rationale of this procedure is as follows: We force the circulation of lymph in the focus, producing swelling; the lymph thus introduced reinforces that which is present by its opsonin and phago- cytes. It is not left there long enough, however, to lose all its opsonin and become a culture-media for groNvth of the bacteria. The focus being small, the increase in circulation being moderate, when the lymph is returned to the blood-stream the autoinoculation would ordinarily not be toxic in amount, but, on the contrary, would be expected to form the stimulus for an active immunizing response without a marked im- mediate effect in reducing the bacteriotropic pressure of the blood. In following up passive hyperemia by measures to induce a more intense active hyperemia, namely, by the application of heat, we derive at once a more increased active circulation in channels that have been dilated as a result of the passive hyperemia. Such a repetition of passive and active hyperemia v/ould be more effective in a case where the cir- culation is apt to be poor, as in the superficial infection, than the nor- mally increased circulation of active hyperemia or than that which could be induced by the application of heat. If the initial attack of the body mechanism, the serum and phagocytic cells, has failed, and solution of tissues takes place, new indications for treatment arise. We have in the pus a fluid almost totally deficient in opsonic power, with leukocytes which are incapable, even in the presence of opsonin, to ingest bacteria; a fluid which, in the case of pyogenic infections, contains a tryptic ferment which, when exerted against stride of connective tissue, produces their solution and opens up channels for the extension of bacterial growth. It is impossible, on account of the swelling and ' coagulation of lymph, which produce a plugging of the capillaries and lymph-spaces, to induce an effective lymph-stream from the circulating blood. The indication, therefore, in order to limit the extension of the process, is to free the tissues of the tryptic pus, to produce an active hyperemia by artificial means about THE EVILS OF ANTISEPTICS 63 1 the outskirts of the infection, in order that the full bacteriotropic pressure of the blood may be exerted at points where the bacteria might otherwise cultivate themseh'es and produce extension. The effect of such drainage -at once is to reduce the pressure of pus in the cavity, and by ridding it -of the pus, temxporarily to limit extension of the process. At this point it has been, until recently, the custom to attempt the destruction of the bacteria which must be cultivating themselves in the walls of the abscess cavity, by means of antiseptics. As has been referred to before, the absolute failure of this attempt to accomplish its purpose is attested by the fact that in commion use, at present, only irrigations of salt solu- tion or the mildest antiseptics are used. As Ehrlich puts it, strong .antiseptics are not only parasitropic and histotropic — that is, when they are sufficiently strong to kill bacteria they also destroy tissue-cells. Not only do they do this, but, as Wright has suggested, they, by irritation, induce a flow of lymph into the focus, the antibacterial power of which is rendered ineffective by the antiseptic. The antiseptic cannot be expected to come into contact wdth all the bacteria, and the cells which have been devitalized, and the lymph rendered inert by the antiseptics, cannot be other than a more or less satisfactory medium in which the bacteria can further cultivate themselves. Whether or not this con- ception is correct, it is a fact that the use of strong antiseptics is not effective in furthering the healing process. It is perfectly obvious that advantages may be gained by hot applications leading to increase in local circulation. It is further obvious that large numbers of bacteria will be present in the walls of the cavity w^hich cannot be efficiently reached by lymph from the circulating blood. The conditions that the body has achieved, which mark success in prevention of generalized infection, register, nevertheless, at this point, failure, or partial failure, inability to produce conditions that will bring blood-serum in effective contact with the microorganisms whose de- struction is necessary for cure. At this point it has been found that Bier's suction has a place of distinct value in that, by producing negative pressure in the cavity, lymph is forcibly drawn through its walls, and lymph from the blood- ■stream is enabled to flow in and take the place of that which has lost its efficiency in contact with the bacteria. This procedure has been followed in many cases by most excellent results in the treatment of these conditions, but the indictment against it as a method is that it does not take into consideration the fact that the capillaries and lymph- spaces, most of them, are plugged with fibrin, that any forcible exuda- tion which it induces is apt to be accompanied by hemorrhage on account 632 THERAPEUTIC IMMUXIZATIOX AXD VACCIXE THERAPY of rupture of small vessels. Further, to be useful, it should be applied frequently, say, every few hours, and in practice this is commonly not feasible. Recognizing the essential factor in cure is the free bathing of the bacteria in the walls of the cavity with fresh serum from the blood, with its high antitropic power, measures should be sought that would render this continuous, without producing injury to the tissue or hemorrhage. To this end Wright has devised a solution, composed of i per cent, sodium citrate and 4 per cent, sodium chlorid, with which the ca\ity may be irrigated. As a dressing, a pad wet in the solution and kept con- tinuously wet should be applied. The effect of the sodium citrate in this solution is to produce a precipitation of calcium salts in the lymph and thus prevent coagulation. Hence its presence in the wound cavity insures a comparatively free exit for lymph discharge. The sodium chlorid content, being a so-called hypertonic solution, by osmotic ac- tion draws lymph through the walls of the ca\ity, all obstruction to the flow of which has been remo\'ed by the sodium citrate, in the fact that it forestalls any plugging of the capillaries or lymph-spaces by clotting lymph. Thus is pro\ided for a free discharge, and by the aid of hot poultices or applications over the citrate and salt dressings, in- creased blood-supply is brought to the part. Hence there should be a continuous circulation of lymph of high antibacterial power from the blood-stream through the walls of the ca\ity and outward. The proof of the efficacy of this measure is to be found in its daily use. It is pos- sible to insure a continuously free drainage from any ca\ity, the opening of which does not mechanically close itself, without the use of any wick or drain whatsoever. Such an abscess ca^^ty will ne\'er be found to crust itself over if the solution of citrate and salt be continuously used. If it be necessary to use measures to keep the exit open, rubber dam or rubber tubing is all-sufficient. The use of zi'icks, as commonly applied (without sodium citrate and salt solution), is a delusion ivhich it is hard to dispel. It is probable that after a time clinical observation will arrive at the point where it will gra\^tate away from wicks, just as it has away from the use of strong antiseptics. In most cases a wick, in a few hours, through coagulation of lymph and pus, becomes more of a plug than a drain. It was only the other day that the writer was called to treat a case of cellulitis of the neck' in which there had been two operative wounds, which wounds were found to be connected by a continuous gauze wick. The wick was dry and stiff, and upon removal several dramis of pus were evacuated. Gauze wicks most decidedly have their place, but it is not to promote drainage. SODIUM CITEATE AXD SODIUM CHLORID 633 Conclusive evidence that sodium citrate and sodium chlorid, as a dressing and an irrigation, contribute to the destruction of bacteria in the walls of the abscess cavity has been, and may be, at any time ob- tained in the laboratory. The first demonstration of this observed by the writer was in Wright's clinic in London. A patient came to the clinic for treatment of an infected wound of the thumb, the result of operation for a streptococcus infection on the previous day. When first seen, in the wound was a thick coagulated mass of pus and lymph, which obstructed all flow. The patient had a temperature, and the local condition showed swelling, tenderness, and was the cause of much pain. In order to test as to whether the phagocytic activity be- neath this crust was at all efficient, the crust was removed and smears were made from fluid expressed at the base of the wound. It was found that most of the phagocytics were disintegrated, but that some appeared to be normal. It is only in the rarest instances that the streptococci were to be demonstrated within a leukocyte, but, on the contrar}^, there were a profusion of streptococci growing in long chains outside oj the phagocytes. The patient was given a small inoculation of vaccine, and a dressing of sodium citrate and sodium chlorid was apphed to the wound. The patient was told to soak the thumb one hour out of four until the next day, and between times to apply hot poultices of the same solution to the lesion. On the following day, macroscopicaUy, there was an entirely different picture. The thumb w^as less swollen, less red, there was free discharge and an absence of crust. The temperature was normal. A smear from the lymph, expressed in the same manner, from the depths of the cavity, showed a striking difference from that seen on the pre\'ious day. No broken-down leukocytes were to he seen. In practically all the leukocjles were found many inclusions of streptococci in pairs and in short chains, while outside the leuko- cytes there were no long chains to be seen and cocci were only occasionally found. It is easy in this manner to demonstrate the efficiency of this sodium citrate and sodium chlorid solution in accomplishing what the body fails to accomplish in the provision of a circulation of effective lymph- stream in a focus of infection, and maintenance of the leukocytes in a healthy condition for phagocytosis. The abolishment of wicks and antiseptics in such localized pyogenic infections has been followed, in the observation of the writer in Wright's clinic and later in his own cases, when sodium citrate and sodium chlorid solution- have been used instead, by absolutely and consistently good results. Here, then, by furnishing aid at the point where nature fails, we enable the protective mechanism to pursue its course in the destruc- tion of bacteria in approximately the natural and unobstructed manner. When the surgeon takes up his knife to produce the evacuation of pus of pyogenic organisms in localized foci, it must be with the full realization. that the operation is not an end in itself, but is merely furnish- ing assistance in achieving the riddance of pus and in preventing exten- sion of the disease by its tryptic ferment; that he is accomplishing the first step necessary in rendering the immunizing mechanism of the body efficient where it would otherwise fail; that, by the relief of pressure, 634 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY he allows of a fresh supply of lymph with higher bacterial power than that in the focus; and with it, leukocytes that are capable of ingesting bacteria to come into contact with the organisms which are responsible for the disease. With this in mind, the extent of his incision will be much more limited than it has been the common custom to make. The so-called wide surgical incision will give way to the much despised small or medical incision, particularly where it is desirable to eliminate, so far as possible, a large scar. The small incision, in that it can be kept freely open by means of sodium citrate and sodium chlorid dressings, will be quite as effectual as a drain, and at the same time will allow quite as free a circulation of lymph as a larger incision, will heal more rapidly, and present a much smaller scar. In the case of a single abscess, where there is no tendency to the development of furunculosis, the measures described will be efficient in promoting a cure, but where there are other foci and a tendency to repetition, it will be necessary to use some effective measure, which shall meet in a rational manner the defect in the protective mechanism which is responsible for the condition. It is manifestly impossible to transfer the antibacterial elements of the blood through the obstruction produced by the swollen walls of the infected focus into the pus therein contained and insure their application against present bacteria. It is quite as impossible to accomplish the same in the case of infiltrating infection, such as carbuncle and phlegmon. The indications here are surgical measures. Their effect, leading to destruction of bacteria and the prevention of extension of the infectious process, has been discussed. It should here be noted, in connection with the cause of extension in pyogenic processes (the tryptic ferment set free from the leukocytes) , that the inflowing, lymph, after the evacua- tion of pus, plays an active part also in the prevention of spread, in that it neutralizes the tryptic ferment in the pus. We may further elaborate the rationale of the efficiency of surgical measures in cure by considering the autoinoculating effect which the operative procedure, if it be at all extensive, has induced in the case of phlegmon, carbuncle, or in extirpating operations. Surgery here has unwittingly been a contributing factor to recovery, in furnishing as an autoinoculating stimulus bacteria and, their products, which the trauma to the tissue has set free in the circulating blood and lymph-spaces. Thus we should expect to have produced an immunizing response in the increase in opsonic power of the blood. In the chart relating to auto- inoculation, produced by operation for extirpation in localized tuberculo- sis (Fig. 209), we have as evidence that this takes place the record of opsonic determinations, which are indicative that immunizing response SMALL INCISIONS FOR TUBERCULOSIS 635 has taken place, and that autoinoculation must have produced it. Such immunizing response is registered as a result of operative pro- cedures which introduce bacteria into the blood, and, so far as they go, tend to the cure of the patient by fortifying the blood-stream. Such autoinoculations, however, are only temporarily efficient. 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 ex- pected to exert, and in fact does not exert, much of a dissolving action upon the connective tissue, and hence 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 preventing 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 occurrence of secondary infection in tuberculous processes makes it desirable to evacuate the pus through as small an opening as possible. 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 ha\-e to be repeated frequently, 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 improvement 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 anti- bacterial power. It would seem that tapping should be quite as efficient in tuberculous peritonitis as a celiotomy, in that the same result in this replacement of fluid follows. The persistence of a discharging sinus depends primarily on the 636 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY presence of a focus of disease at its base. When this is removed, how- ever, so far as possible, the discharge is still apt to continue, and, infected with pyogenic organisms, as it commonly is, we must conclude that these organisms are growing in the walls of such sinus, because of their isola- tion from the active blood-stream. We see reason for this in the walling off produced by the granulation tissue, which constitutes the wall of the sinus, and the clotting of lymph and blood in its exit. 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 inefi&cient, for the reason stated previously. Frequent probing does more harm than good, in 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 situation 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. Wright gives, as a fundamental principle in the treatment of localized infections, that as full a lymph-stream as possible should be caused to flow through the infected focus, in order that the antibacterial elements and leukocytes of the blood-stream may come into effective operation in the extravascular focus of infection. Up to this time we have con- sidered the methods by which this ideal may be obtained ; that they are all directed toward the furthering of some process which the body naturally directs toward the destruction of bacteria, or to rendering assistance at some point where such process fails, by removing such obstructions as may inhibit its proper working out. We have considered definitely the place of surgery in removing such obstruction, and have seen that, in con- sideration of the conditions to be brought about by such procedures, the extent of operation may be commonly lessened if it is constantly borne in mind what the conditions are that we desire to achieve. The blood-stream is, as if were, a reservoir of antibacterial sub- stances. It is higher in its bacterial power than any other fluid in the body. It is commonly many times as high as a fluid in the infected focus. It is not necessary to enlarge upon the proposition that, if the blood-stream is low in its antibacterial content, it cannot have, in its VACCINES IN LOCALIZED INFECTIONS 637 action upon the microorganisms in the infected focus, as destructive an effect as if the content in bacterial substances were greater. We have seen that in localized infections the opsonic power of the blood is con- sistently subnormal, and in many cases not more than -^q to -^-q the normal. Bulloch^ showed that in cases of lupus, where the opsonic power of the blood was markedly subnormal, treatment with x-ray and Finsen- ray had little effect in producing a cure, but when the opsonic power was Dormal or above, these measures appeared to be much more efficient. On similar considerations, Wright bases another principle which is fundamental: that in every case where the antibacterial power of the patient's blood falls below the standard under which the body is making an effective response to infection, measures to increase the antibacterial power of the blood should be used. We have seen that it is possible, by the injection of bacterial vaccine, composed of killed organisms of exactly the variety of those which are the infecting agents, 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 bac- teriotropic power may be more or less constantly maintained. 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 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 satis- factory potency and available for flushing any bacterial nidus in the tissue, wherever it may be. The first principle referred to, the determination of lymph to the focus of infection, comes next into play, in that it requires the use of measures which shall bring into operation in the focus of infection as nearly the full bacteriotropic pressure of the blood as possible. As has previously been pointed out, in certain infections where there is no outlet for discharge, determination of lymph to the part results in possibly an overwhelming autoinoculation, the result of which is to, for a time, produce a lowering of the opsonic power of the blood- stream. Where such an event would take place, the use of measures to increase the passive congestion of such a focus may be distinctly dangerous, in that they break down for the time being the barrier which the blood-stream offers against bacterial invasion. As a result of ex- cessive autoinoculation, the resistance to spread of infection is not only diminished, but also the power of the blood to exert a favorable action ^ Trans. Path. Soc. London, 1905, Ki, part 3. 638 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY upon the bacteria in the original focus leading to their destruction will be diminished or lost. In the words of Wright, "where we have to choose between the lowering of the bacteriotropic pressure of the blood- stream, by inducing autoinoculation and leaving the bacteria in the localized focus unharmed, we ought to choose the latter; that we must safeguard the citadel of the blood against septicemic invasion and prevent the passage of living bacteria from one point to another.''^ These con- siderations outweigh all others, and must be borne in mind whenever Bier's passive hyperemia is used as a therapeutic measure. It would at once suggest itself that we should find in Bier's passive hyperemia, as applied to certain infections, as tuberculous joints, ulcera- tions, 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 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 autoinoculations consist of living bacteria, as well as their products, carried into the blood-stream; that autoinoculations 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 autoinoculation may be too small to be beneficial, and where bacterial growth is gradually lessened by immunizing response to previous autoinoculation, the size of the autoinoculations will be considerably lessened; in cases where there is actually required a gradual increase in the amount of auto- inoculation in order to produce adequate immunizing response; that autoinoculations 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 applica- tion 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. The rational application' for bacterial vaccine is unquestionably met in localized infections, in that it furnishes a stimulus to the im- munizing mechanism which is absolutely necessary for the elabora- tion of specific protective substances, and which is lacking because, through the segregated condition of the focus of infection, the blood- THE PREVENTION OF AUTOINOCULATION 639 Stream is unable to derive for itself a sufficient quantity of bacteria to constitute an effective autoinoculation; in that the vaccine stimulates the otherwise dormant protective mechanism to efficient response, it is a rational procedure, and is worthy of a place in a system for immunization which has for its dominating idea the furtherance of nature's own proc- esses in the struggle against bacterial infection. As a type of cases, which, in spite of obvious autoinoculation, show little tendency to improve, I would refer to those of persisting abdominal sinus sometimes following appendectomy, which continue to discharge profusely pus which may contain colon or streptococcus chiefly and sometimes other organisms. As evidence that autoinoculation is tak- ing place, we have an irregular temperature, symptoms of toxemia, and, if the opsonic index is determined from day to day, we find wide fluctua- tions above and below normal at different times. Here we obviously have entry into the blood at times of living bacteria and their products, even though, so far as is possible, any pockets or collections of pus in and about the sinus have been carefully evacuated. It is clear that these autoinoculations are not effective in leading toward a cure. If we may presume to anticipate a little the discussion of the actual use of vaccines, we must conclude that these autoinoculations are either excessive or too often repeated to furnish a basis for satisfactory im- munizing response. The proposition that it should be our first endeavor, by using such measures as we have at our command, to prevent, so far as possible, these toxic autoinoculating doses of living bacteria, which emanate from the focus and enter the blood-stream, needs no elaboration. If it is possible in some degree to control the autoinoculation, we have in this way reduced the condition to a semblance of localized infection, and, as such, we see in it an indication for vaccine so given, that a consistently favorable immunizing response may be obtained on the part of the organ- ism. Irregular and ill-timed autoinoculation may unquestionably take place as a result of the entrance into the body of numbers of bacteria which are not sufficiently large to produce intoxication. They may even end in recovery, as a result of a more or less efficient immunizing response. In acute fulminating infections, resulting from infected wounds, we obviously have conditions of excessive autoinoculation, and, in so far as the disease spreads and toxic symptoms develop, efficient immunizing response is not obtained. In the case of tuberculous joints which show evidence in temperature, or in local symptoms, that the disease is progressing unfavorably, we may properly assume that auto- inoculation is taking place, but that it is either excessive in amount or 640 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY ' SO ill timed that it does not induce the immunizing mechanism to re- spond successfully. In pulmonary tuberculosis of the febrile type, we must assume that toxic doses of bacteria are being taken into the blood, and, in that the disease progresses, the immunizing response is not efficient. It has been clearly shown by Urwick^ that febrile cases of pulmonary tuberculosis are subject to a succession of positive and nega- tive phases — in other words, to fluctuations of the antibacterial power — ■ which can only be due to excessive autoinoculation. These instances are given to emphasize that even when autoinoculation takes place, it is commonly not efficient in producing a cure, and that, there- fore, the first requirement is to eliminate, so far as possible, such autoin- oculation. The means that we have at hand to bring this about are several. In the acute fulminating infections where pus is forming, is under pressure, and by its tryptic ferment is extending, we have conditions which may consistently be expected to be conducive to autoinoculation, and we have in these infections the temperature to prove that this is so. The use of surgery to relieve the pressure in the pus cavity, and of other local measures cited to induce a free percolation of lymph from the blood- stream into the cavity, is the most efficient measure at this time finally to inhibit autoinoculation. In a case of phlegmon, extensive incision may be necessary to bring the same condition about; in the case of a gonococcus joint, tapping may be indicated; in the case of a tuberculous joint, fixation; in a case of caries of the spine, absolute rest and surgery. Since in a case of pulmonary tuberculosis it has been demonstrated by means of the opsonic index that, following exercise such as walking, deep breathing, calisthenics, etc., autoinoculation takes place, we must conclude that such autoinoculation is due to the increased blood- supply to the lung and the more rapid breathing which exercise induces. Hence to eliminate autoinoculation absolute rest in bed should be re- quired, and in practice such procedure is found in many cases finally and absolutely to eliminate autoinoculation of any but a favorable amount. We have then, in surgical measures and in absolute rest to the part involved in the infection, measures for eliminating autoinocula- tion. Wright further advises the additional attempt to diminish auto- inoculation by lessening the lymph-stream in the focus of disease. He advises internal administration of calcium salts to the end of rendering the blood more coagulable arid less penetrating, hoping that thus it will come into contact with and take up fewer bacteria. The part that surgery has played in the cure of infectious processes has been to safeguard the blood-stream from generalized infection or ^ Brit. Med. Jour., 1906. VACCINES IN GENERAL .NFECTIONS 64I excessive autoinoculation. It reduces what may bid fair to become a generalized infection into a localized process. The persistence of such infections after surgical operation in many cases is from failure to recognize that the localization of an infectious process may he the reason for its chronicity; that the body, through local conditions, not only has lost the power of efficient attack against the invading bacteria, but for the same reason lacks the stimulus which it requires for the elaboration •of protective substances. // should no longer he considered that the surgeoii's work is ended when he lays down the knife, or when he, hy various appliances, secures complete rest to the affected part; he must further furnish the hacterial stimulus which his measures have eliminated, which shall so act upon the immunizing mechanism that elaboration of specific protective substances shall take place. Furthermore, by the proper treatment of the focus of infection, as previously indicated, the surgeon shall make it possible for the blood-stream, with its protective substances, to come into destructive action on the bacteria in the focus. The question of using bacterial vaccine in cases of generalized in- fections ought not to be prejudged, although it would appear that the addition of toxic material in the way of vaccine might merely increase the toxemia of the patient without having any effect in producing an increase in his power to cope with disease. We must realize that in general septicemia, and in diseases such as typhoid fever and pneumonia, we have a condition of continuous autoinoculation; that is, the bacteria are either growing in the blood or being continuously sent forth into it from foci wdiich are in direct communication. We may conceive that in these cases a struggle is taking place largely in the blood-stream, and that the total efficiency of the immunizing mechanism is receiving its fullest stimulus to the formation of antibodies, and that they are being applied in an absolutely unobstructed manner against the invading bacteria. It would seem here, then, that the only indication would be to stimulate, so far as possible, the immunizing mechanism to increased production of antibodies in those cases in which there is an unsatisfactory immunizing response. There is no question in these cases but that the autoinoculating stimulus to the protective mechanism is sufficiently great, but it is possible that it is not efficiently applied. As Wright puts it, "if the supposition is correct 'that protective substances are produced by the cells at the seat of inoculation, it would seem that the conditions for successful immunization must be less favorable when vaccine is injected into the blood-stream than when it is injected subcutaneously." When injected into the circulation, vaccine comes into contact with the connective-tissue cells only after it has been diluted by the whole circu- 41 642 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY lating blood. When subcutaneously inoculated directly into the tissues, vaccine is applied in a concentrated form. He states that it would, therefore, not be irrational to assume a possible advantage in these cases from inoculation of vaccine. To the objection that vaccine inoculation might aggravate intoxication, Wright suggests that there is reason to believe that the vaccine injected is probably for a certain length of time held back in the tissues and not taken into the blood-stream. In favor of this is the local toxic reaction at the point of inoculation, which may be characterized by redness, swelling, and tenderness, and which makes its appearance within a few hours after the injection of vaccine; and also the belief that there is a local elaboration of bacterio- tropic substances at the point of inoculation, a belief which has for its basis considerable suggestive evidence. Wright reasons further that, if it is a fact that the vaccine is held back in the tissues, the injection of the same amount of vaccine in the tissues will produce less intoxication than the same amount injected into the blood-stream. To whatever conclusions theoretic considerations may lead one, the fact remains that by means of bacterial vaccine in septicemic cases, in spite of the fact that the blood is the recipient of continual auto- inoculations, nevertheless, it is found that by judicious injection of vac- cine at proper intervals and in proper dosage it is possible to produce an immunizing response on the part of the patient as registered by opsonic index determinations.^ Additional evidence has been furnished by E. C. Rosenow,^ in a study of 14 cases of endocarditis, mostly due to the pneumococcus. He found that in the early part of the disease the opsonic index was generally maintained at a high level, and at this stage vaccine had apparently very little effect in producing a rise in the opsonic power. In the later stages of the disease, however, when the patient's condition was poor, and the index was found to be far below normal, injection of vaccine was followed by a rise in the opsonic power and also in the number of leuko- cytes. These changes were associated with a drop in temperature and definite improvement. In line with this definite laboratory evi- dence we have the clinical observations of Thompson,^ in which he reports the study of 7 cases, all treated by vaccine derived from organ- isms cultivated in each case from the patient's blood. Three cases re- covered and 4 died. In 2 of the fatal cases he states the effect of the ^ Lancet, November 2, 1907, Chart 15, Chart 14, etc. ^ Trans. Path. Soc, December i, 1908. ^ Amer. Jour, Med. Sci., August, 1908. INDICATIONS FOR VACCINES 643 vaccine was striking, but only temporarily beneficial; in 2 others the benefit was slight, but demonstrable. In the others, immediate and continued improvement followed the use of vaccine. Taken in connec- tion with Rosenow's and Wright's observations, Thompson's experiences would suggest the efficiency of vaccine in raising the opsonic power of the blood even in generalized infections. Summary of Indications for Vaccine. — The exhibition of vac- cine we have, therefore, found to be indicated, first, in localized infections; second, in infections which, by various procedures, have been tendered local in character; third, in infections subject to intermittent auto- inoculation which cannot be checked; fourth, we have considered the question of their indication in generalized infections; in other w^ords, 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 to 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. It is well known that a dose of vaccine containing 100,000,000 killed staphylococcus pyogenes aureus, when injected into a patient suffering from furunculosis, will commonly be followed by improvement in the local conditions during the next twenty-four hours. It is quite as well known that a dosage of 500,000,000 of the same organism in a similar case will commonly be 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 tuberculin of Jg- c. mm. O. T. is given subcutaneously, it is apt to be followed by a 644 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY febrile reaction in the subsequent few hours, associated with signs of increased activity in the focus of disease. The injection of this dosage of tuberculin in an uninfected individual is without 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 hy these agents is not primarily due to the amount of toxin they contain, otherwise we should have produced the same symptoms in normal individuals. Rather, it would appear to be that the exacerbations of the infected in- dividuals 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 with an organism corresponding to that used in the vaccine. It has. been suggested by some who favor the use of large doses of vaccine in generalized infections that in the vaccine injected we have only an in- finitesimal addition to the toxic material in the body, compared to that represented by the living organisms growing therein. If such inoculum could be added into the midst of the actual focus of disease, it is con- ceivable that the effect would be of very slight degree, but the sequence of events following injections of tuberculin and staphylococcic vac- cines, and, in fact, any others, indicates clearly that in correspondingly infected individuals there is an effect produced which is absolutely out of proportion to the amount of the inoculum, and that this effect represents a temporary breaking down of the patient's resistance to the infection is clearly indicated by the exacerbation, local and general, that frequently takes place. It is impossible to conclude otherwise than that in generalized infections, as in the localized or in pulmonary tuberculosis, we must apply the same rule that in the use of excessive dosage of vaccine, in spite of the fact that it is infinitesimal compared with the toxin within the body, we nevertheless will derive a lowering of the patient's resistance to the living organisms in the body. In other words, the injection of vaccine in already infected patients has a profound effect upon the physiologic mechanism of immunity which is disproportionate to the amount of vaccine injected when compared with the amount of toxin and living bacteria in the body. We have further practical reasons for seeking sufficient guidance for the giving of vaccine, particularly of tuberculin, in the unfortunate results which follov/ed the use of tuberculin when first it was offered by Koch. The effect which tuberculin might have in inducing an immunizing response on the part of the organism was not considered. The con- trolling idea in this first application of tuberculin in treatment was that the effect was exerted in the breaking down and the discharge of the ELISION OF THE NEGATIVE PHASE 645 tuberculous focus in the lung. In other words, tubercuKn, as originally used, was an excellent example of toxic therapeutics. The effect was not only to produce a disintegration in the focus of disease, but, as would be expected, the tendency to the spread of disease was quite as prominent as its effect upon the localized focus. It is perfectly clear now that excessive dosage was used at that time, that it lowered the patient's resistance, and was responsible for the serious consequences. Tuberculin was for a long time, therefore, under a ban as a therapeutic measure. By measuring the production of the agglutinins following typhoid inoculation Wright found that, according as the dosage was increased or diminished, the latent period w^hich elapsed before the appearance of agglutinins in the blood was likewise increased or diminished. That, in so far as the dose was increased and the latent period consequently prolonged, the constitutional symptoms were also more marked and more prolonged. He found that large doses might induce much toxic reaction, where smaller doses might produce no reaction. That in the case of small doses the response in the production of agglutinating power might be achieved in a periqd of a few hours. He found that by measuring the phagocytic power of the blood after inoculation, the same sequence of events took place — aggravation of symptoms before the rise of the phagocytic power, disappearance of symptoms asso- ciated with increase in the phagocytic power, and that the contmuance of the low phagocytic power, and the aggravation of symptoms as- sociated, were more marked according as the dosage was increased; that when minute doses of vaccine were injected there might follow an elision of the phase of diminished phagocytic power, an immediate rise taking place instead. In other words, he was able to show that it was possible to secure a protective response without any antecedent period of lowered resistance. He was further able to show that a condition of decided clinical improvement, following the use of appropriate doses of vaccine in staphylococcic and other infections, could be obtained with- out any antecedent period of serious aggravation and symptoms. It had pre\iously been generally accepted that immunizing response following vaccine could not be efficient unless toxic symptoms were induced. The keynote, therefore, of Wright's 'method of giving bacterial vaccine is to be found in his desire for, and achievement of, an adequate response \Aith- out an antecedent period of toxemia and the dangers which we have see to be attendant upon it. He has taken for his guide the phagocytic power of the blood, as registered by the opsonic index, and has endeavored, by the proper dosage of vaccine and proper interval between dosage, to secure 646 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY adequate immunizing response, as registered by an elevated phagocytic power, and to eliminate, by carefully selecting his dosage, the induction oj any protracted period of subnormal phagocytic power with its attendant toxic symptoms. 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 improvement 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. TUBERCUIO- OPSONIC INDEX 1-8 1-6 _i /, 1-4 / / \ 2001, ?* r,G RM. ^ IV 1-2 V i ^ 1 \ NORMAL 10 > ' / ^ A ^ \ ^ ^ ■> 0-8 _« ' A "1 / i / r* y 06 \ ) y / \ 04 OCT. 3 4 5 6 7 8 9 10 II 12 J3 14 15 1 Fig. 214. — Opsonic Curve Illustrating the Variations in the Opsonic Index of the Blood Follow- ing Inoculation (A. E. Wright, Lancet, igoy, 1218). In the exhibition of vaccines, it is the aim to induce the body to pro- duce at the proper time specific antibacterial substances by the use of such doses of killed bacteria as suffice to raise and maintain the opsonic power of the blood above normal. In order to arrive at a scheme to bring this about, it is necessary, in the first place, to study the effect of a single dose of vaccine in producing an immunizing response. Wright has taken arbitrarily the opsonic in- dex to register the variations in the content of the blood in antibacterial substances for various and good reasons. In Fig. 214 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 1 2000 mg. of THE INDEX AFTER INOCULATION 647 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 suflEcient dosage. At the start we have two opsonic indices, 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- 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 more elevated than at the start, he terms the sustained high tide of immunity. The form of the curve produced, and c'onsequently the sequence of events in the immunizing response, depends on the dosage of 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 Avhich produces a satisfactory immunizing response, as would be consistent with improvement in the condition of the patient, a sequence of events similar to Fig. 214 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 648 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 changes which will be produced in the case of the normal individual or one subject to chronic localized infectious dis- ease. The same law of the sequence of negative and positive phase holds also in generalized infections, but the use of sufficient dose to induce a persistence of negative phase is, 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; hence the dose is an extremely important factor. A repetition of the condition repeated in Fig. 214 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 * Lancet, August 24, 1907, p. 493. ^ Wright, Studies in Immunization, p. 273. VARIATIONS OF OPSONIC INDEX 649 in the activity or non-activity of the focus of disease. The correlation between the chnical 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- 650 THERAPEUTIC BIMUXIZATIOX AND VACCINE THERAPY 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 index 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 symptoms and conditions associated with a rise in opsonic power fol- lowing immunization by \'accine. Recognizing in the negative phase following inoculation a phase of lowered resistance, and in the positive phase a period of increased resistance; it is the endeavor, by means of vaccines, to secure, associated with as brief a period as possible of lowered phagocytic power, as pro- longed a period as possible of elevated phagocytic power. These facts lead us 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 be avoided, and that any therapeutic measure which may induce such a condition might be dangerous to the life of the patient in some cases or inimical to progress toward recovery. Opsonic determinations following the use of vaccine in the treat- ment of infectious diseases have shown that, associated with the negative opsonic phase, may be an aggravation of symptoms, such as might be expected to supervene if the phagocytic resistance were lowered for any length of time. We see in furunculosis, 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 increase ] tenderness, discharge, and the development of fresh furuncles. In the case of gonorrheal joints, associated with the negative phase after ^ Cleveland Med. Jour., May, 1909. CLINICAL USE OF THE INDEX 65 1 inoculation, we find commonly increased pain, tenderness, and pos- sibly swelling in the joint, and in some cases febrile reaction. In bladder infections following inoculation we may obtain increased pain, in- creased frequency of micturition, and increased cloudiness of the urine; in pulmonary tuberculosis, temperature and focal signs of acti\ity. Associated with the oncoming of the positive phase of increased phago- cytic power in all these diseases we see amelioration in signs and symp- toms. Where toxic doses of vaccine are given, we may obtain long per- iods of aggravation of symptoms, and associated with them continuously low opsonic power. In general, we may consider that the production of any period of lowered opsonic power as a period of retrogression, and as a period of progress that of elevated opsonic power. We have reason, therefore, to so grade our doses of vaccine that neg- ative phase will be of as short duration as possible consistent with a positive phase of sufi&cient degree and duration to be consistent wdth improvement. It has been Wright's method, therefore, in using bac- terial vaccines, to guide his dosage by frequent opsonic determinations, in order, first, to avoid prolonged negative phase, and, second, to deter- mine the time when the opsonic power shows evidence of falling, in order to derive indications for further dosage. If he finds that, twenty-four hours after inoculation, the index has been much reduced, he considers that a smaller dose than the one given would have been appropriate. If he finds that twenty-four hours after inoculation the index has been raised, and if after ten days the index has fallen to the point at which 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 was 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- 652 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 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-off 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 response. In fact, in this type of case the opsonic index is the only ^ See Trans. Med. Chir. Soc, vol. Ixxxix, 1906, Chart 5. THE SICKER THE PATIENT, THE SMALLER THE DOSE 653 method for determining whether the tubercuhn 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 afford 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 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 he 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 rcinoculation is soon necessary. A dosage might be arrived at which could be repeated every four hours, everyday, 654 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 aiitoinoculation 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 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 over 600 cases treated by the writer in the past two years, opsonic index determinations have not been user! 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 no instance in which intolerance 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- DANGERS OF OVERDOSAGE 655 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 e\ddence 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 blood through autoinoculation. 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 sufficient 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' 656 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 recei\ing 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 e^ddence 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 in any community. 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 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 probable 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 gi\-en approximately every four hours. It was stated that the idea in gi'ving such frequent and excessi\-e 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 effective 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 A CASE OF OVERDOSAGE 657 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. It is conceivable that, just antemortem, it would be possible to demonstrate the profusion of bacterial growth in the blood which was found at this time, which was several days before death. The writer has observed the bacterial gro\Ath obtained in a considerable number of blood cultures in the past ten years, but has never seen or seen reported any such profuse growth from the few drops of blood which could be absorbed by the small cotton swab used in taking the culture in this case. It is the belief of the writer that such profuse growth is only consistent with conditions of the blood- stream which may be present just antemortem, or which might be produced in cases where the antibacterial power of the blood has been artificially reduced, and so maintained, by inordinate doses of correspond- ing vaccine. In consideration of what has already been said, to the effect that toxic symptoms, induced by large and frequent dosage of vaccine in septicemic cases, are not so much due to the inherent toxic quality of the vaccine itself, as to its effect in the way of paralyzing the immunizing mechanism, we must not allow ourselves to be misguided by the asser- tion that, inasmuch as even large doses are infinitesimal in their actual toxic content compared with the amount of toxic material already in the body, vaccine can be given with impunity in cases of generalized infections. As has already been stated, there is no reason to think that large doses of vaccine in septicemias will not produce and main- tain the same lowering of the patient's resistance that we have seen takes place in localized infections, such as furunculosis and carbuncle. In treating septicemic cases, a scheme of dosage that will induce re- peated slight elevations of the opsonic power, without pre\aous 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. 42 658 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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. Vv^right 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 derived from pyogenic organisms and some others, using dosage of ser\iceable proportions, com- monly produces at the point of injection an inflammatory 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 in- dividuals uninfected by the corresponding organism. In infected indi- \dduals 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. 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. Exception to this rule is found in some individuals who have apparently not the power 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. LOCAL AND FOCAL REACTION 659 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 sufficient 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 rales, 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 -g-J-j,- 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., igo8, i, p. 432. 66o THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 vaccine is suggested by the commonly ac- cepted definition, which is as follows: The bacterial vaccine is a sus- pension of killed bacteria, which, when introduced into the animal body in su'jjicient 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 differ- ent 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 neces- sary to use coincidentally two or three differently constituted vaccines to properly meet a mixed infection. If investigation 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 be later noted. The water of condensation in three or four tubes of nutrient agar is inoculated from a pure culture, the surfaces thickly inseminated, and incubated for a period of from twent}-- four to forty-eight hours. The contents of a test-tube containing lo 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 ^vire (Fig. 217). 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 LABORATORY TECHNIQUE OF VACCINE PREPARATION 66l the course of the preparation an open tube is temporarily set aside, it should be slanted in the same manner and for the same purpose. The final tube containing the emulsion is then heated in the blow-pipe flame, drawn out and closed, and shaken vigorously for from Fig. 2i6. — Pouring Sterile Salt Solution into Agar Culture. Fig. 217. — Washing off Growth. Fig. 218. — Sterile Tube Containing Emulsion. five to ten minutes, in order to produce a homogeneous emulsion. The scaling of a test-tube containing fluid requires some skill, the result of practice. The tube, held at an angle of 45 degrees or less, in the left hand, the open end is cautiously heated in the yellow flame 662 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY until it is dry, both inside and out, up to two or three inches from its open end. Air is then turned on, and with the blue flame the extreme end of the tube is melted and a short piece of glass tubing is made to adhere to it, which shall serve as a handle when the tube is drawn out (Fig. 219). The tube is then rotated continuously in the flame, which impinges Fig. 219. — Tube Containing Bacterial Emulsiox, with Handle Attached as an Aid in Sealing* Fig. ;!2o. — Tube Partially Drawn with Walls Thickened. Fig. 221. — Tube Completely Drawn Out. as near the end as possible. When the wall of the tube is molten, the glass walls of the tube are allowed to run together, in order to thicken <^he wall of the portion that is to be drawn out. If this process of thickening is not accomplished, the wall of the portion drawn STANDARDIZATION OF A VACCINE 663 out may be too thin to be serviceable (Fig. 220). When' properly thickened, the tube is drawn out while still in the flame until the diameter of the molten part is two-thirds that of the cool portion. It is then removed from the flame, and immediately drawn out until the tapered portion is | in. or so in diameter and 3 or 4 in. long (Fig. 221). The tube is then allowed to cool, heated subsequently in a small flame, sealed, and allowed to stand up- right until cool (Fig. 222). Fig. 222. — Tube Sealed, Ready for Shaking. Standardization. — After thorough shaking (fifteen minutes is sufficient), the tapered end is deeply scratched with a file or glass-cutting knife, J in. from the end (Fig. 223), broken off, sterilized in the Bunsen flame, cooled, a few drops expressed into a clean watch- glass or other receptacle (Fig. 224), and the open end of the tube resealed. It will com- monly be found that the shaking has not broken up the clumps of bacteria, and that, there- fore, further manipulation is necessary, that the portion of the emulsion to be standardized may contain as few and as small clumps of bacteria as possible. For this purpose, a small Fig. 225.— Scratching Tube with Glass Cutting Knife, in Order to Break. pipet is drawn out with a capillary portion about i mm. in diameter, and cut off squarely about I in. from the stub. A rubber teat is affixed to this pipet, the emulsion is drawn in and out forcibly, the pipet being held at right angles to the table against the bottom of the watch-glass (Fig. 225). By this means, further breaking up is effected. The emul- sion should then contain bacteria singly, in pairs, or in very small groups. A capillary pipet, drawn from ^-in. glass tubing, exactly the same as the pipet used for opsonic index determination, the capillary end being about 5 in. long, cut squarely, 664 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY is marked with a glass marking-pencil f in. from the tip. A ligature is bound round the thumb of the left hand, the dorsum is pricked near the nail with a blunt glass needle (Fig. Fig. 224. — Expressing a Few Drops of Emulsion for Standardization; Heat of Hand Expands the Air IN the Tube, and Forces Out the Fluid. Fig. 225. — Breaking up a Bacterial Emulsion for Standardization, or for Opsonic Index Determina- tion BY PiPETING. Fig. 226.— Pricking Thumb with Glass Needle. 226). A rubber teat having been fitted to the pipet, three or four volumes of 0.S5 salt solution are drawn in, then one volume of blood, one of bacterial emulsion, and again LABORATORY TECHNIQUE 665 three or four volumes of salt solution (Fig. 227). The volumes of blood and emulsion must be separated from each other and from the salt solution in the pipet by air-bubbles; that is, as each volume is aspirated, it is allowed to run upward in the pipet, so that a space is left before the next volume is aspirated. The "volume" referred to is the amount of fluid between the end of the pipet and the pencil-mark. The amount of salt solution used does not alter the final results and need not be accurately measured. The contents Fig. 227. — Taking up One Volume of Bi.god into Pipet for Standardization. of the capillary are then thoroughly mixed on a glass slide by alternately pressing and releasing the rubber teat (Fig. 228), in order that in the mixture there shall be an even distribution of bacteria and red corpuscles. A small drop is then expressed on each of two or three clean glass slides (Fig. 229), and with the end of a fresh slide a smear is made (Fig. 230) and allowed to dry. These smeared slides are then immersed in a satu- rated solution of mercuric chlorid for three minutes, and stained with carbolthionin blue Fig.. 228. — Mixing Blood and Emulsion. Each one volume and several volumes of normal salt solution on slide. for about one minute cold (thionin pure, Griibler, \ per cent., carbolic acid, i per cent.). If stained properly, the red corpuscles will have a light green and the bacteria a deep purple tint. The actual standardization consists in counting the number of red corpuscles and bacteria contained in a series of fields of equal size in one of these slides, until 500 red corpuscles and the number of bacteria met with have been enumerated. In order to make counting easier, a more restricted field than that allowed by the eye-piece is of advantage, and to this end four hairs arc made to adhere to the diaj^hragm inside the cye-picce, in such 666 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY position that a small square field will be marked off and projected on the slide for a counting area. The number of cells and bacteria in each field are noted, added, and when 500 cells have been counted, the follo-^-ing proportion is worked out. Supposing that in count- ing 500 cells 600 bacteria have been encountered, the proportion is as follows: 500 (red cells) : 600 (bacteria) as 5,000,000,000 (the number of red cells in i cc. of normal blood) is to jf. X — 6,000,000,000 of bacteria to the cubic centimeter. Fig. 229. — A Small Drop of Mlxed Blood axd EiiuLSiON on Each of Two Slides, Ready for SiiEARS. The requirements for accuracy in this method of standardization are that the indi- vidual whose corpuscles are used shall have an approximately normal red count; that the bacterial emulsion shall be free from clumps; that where fields containing suggestions of hemolyzed red cells are met with, they should be excluded; fields should be counted in ■R-idelv separated portions of the slide to insure fair average. At its best, this numerical test of the vaccine is but an approximation, but it is quite accurate enough for use. Quite as important as the number of the bacteria is their virulence, which cannot be measured except Fig. 230. — Making Smear. by the method of trial and error upon the patient. To avoid error we use minute doses of the vaccine to start in the case of any vaccine that has never been tried. The actual numer- ical standardization of a vaccine, then, by these methods, has been satisfactorily arrived at. A more accurate count is possible, and much easier accomplished, if on the slide to be counted the number of red cells about equal that of the bacteria. Hence, if before Tnixing the blood and emulsion for standardization the vaccine appears to be extremely thick, sterile salt solution should be added in sufficient quantity properly to dilute; if the STERILIZATION OF A VACCINE 667 emulsion appears to be thin, as in the case of streptococcus and pneumococcus vaccine, two to six volurhes of emulsion should be used to one of the blood. Experience teaches one to judge the probable content of a bacterial emulsion per cc. from its opacity, so that the proper adjustment can be made from inspection. Sterilization. — As soon as the few drops of emulsion are expressed from the tube for standardization, the tube is sealed and at once immersed in a water-bath at 60° C, in which Fig. 231. — Water-bath for Sterilizing Vacci!*es. .4, Metal thermoregulator; B, wire basket; D, Spindle attached to bottom of basket; C, Diaphragm with set- screw, for holding tubes of vaccine beneath the surface of water. This slides on spindle D. it is allowed to remain for one hour. The shorter the exposure to heat, the less the vac- cinating quality of the vaccine should suffer. After the period of steriUzation, care ha\-ing been taken that the temperature of the bath has remained constant, and that the tube has been completely immersed, it is removed from the bath, the end broken off, and, with sterile precautions, one or two drops of emulsion is expressed upon the surface of an agar Fig. 232. — Expressing Drop op Vaccine on Surface of Agar Slant, for Test of Sterility. slant (Figs. 232, 233). This, incubated twelve hours, will show whether or not the vac- cine has been successfully sterilized. After sterilization, a label is affixed to the tube con- tainer stating the kind of vaccine, its derivation, number of bacteria per cubic centimeter, the length of time sterilized, and the date. The vaccine should not be used for inocula- tion until the test culture has been incubated at least twelve hours and is proved to be sterile. 668 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY Keeping qualities of vaccine may be insured by storing the stocks in a cool place. It is probable that there is some deterioration month by month. A toxin, such as old tuberculin, appears not to retain its vaccinating power for more than a few weeks if di- luted. Tuberculin R, and the so-called bacillen emulsion, apparently lose none of their efficiency in the various dilutions, even after several months. The writer has used a Fig. 233. — Expressing Drop of Emulsion on Sterile Platinltm Loop, for Test of Sterilitv of Vaccine. staphylococcic vaccine which he prepared in Wright's laboratory for over a year, and has noted very little diminution in its vaccinating qualities, even though it has been kept at room temperature. It is not necessary to keep vaccines upon ice if they are to be used within two or three months. Fig. 234. — Essentials for Blood Cultures. A, "Collin" syringe, sterilized with oil at 140° C, inserted into a sterile 8" by i" test-tube; the needle in cotton plug; a heavy rubber test-tube cap holds syringe in tube; B, bouillon in 8" by i" tube sealed; C, bile in 8" by i" tube sealed; D, lysol; E, alcohol lamp; F, glass-cutting knife. If one desires to prepare large amounts of vaccine, methods used by commercial houses may be employed. In dealing v.'ith a large inoculation clinic, the writer has found that the preparation of considerable quantities at one time is desirable. For this purpose mass cultures, grown on the surface of agar in Roux flasks, or large flat eight or sixteen- ounce bottles with wide necks, furnish the necessary growth. To inoculate such bottles a twelve-hour growth of the organism in bouillon is poured over the surface of the receptacle SOTTLING THE VACCINE 669 and stood upright in the incubator. The sterile salt solution used in the preparation may amount to 50 cc. or more, and it is, therefore, convenient to use as containers 8 by i inch extra heavy test-tubes, which will be the final containers for the stock vaccine. Care must be used in burning off the neck of a bottle or flask, both inside and out, before making any transfers of fluid by pouring. There is less danger of air contamination if the transfer of emulsions is made by means of pipets. The method of sealing the large tubes is sim- ilar to that where a smaller one is used. The other steps in the preparation of stock are Fig. 235. — Ready for Adding Lysol to Bottle of Sterile 8s Per Cent. Salt Solution. Cotton Plug Removed. as stated. It is well to have the bacterial contents of stocks, in case of staphylococcus, from 5,000,000,000 to 15,000,000,000 per cc. Bottling the Vaccine. — The next step is to dilute a portion of the vaccine prepared, in such strength and in such containers as will make it convenient for actual use in the treatment of patients. In the case of our staphylococcus vaccines, three strengths are desirable: one bottle containing 200,000,000 organisms per cc, another 500,000,000, and Fig. 236.— Adding Lysol, i of iPer Cent., to Vaccine Bottle Containing Sterilf. 85 PeR Cent. Salt Solution. Cotton Plug is Then Replaced. a third 1,000,000,000. A convenient-sized bottle for staphylococcic vaccine contains 50 cc, but where a small number of cases are being treated, bottles of 15 cc. capacity are more satisfactory. ' The mode of preparation of these vaccine bottles is as follows: A number of large- mouthed ^-ounce "French square" bottles arc washed with weak hydrochloric acid solu- tion, rinsed with water, and dried out thoroughly by inverting over a heater. The}- are then plugged lightly with cotton and placed in a dry sterilizer for one hour, in order to set 670 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY the cotton plugs. With a large pipet there is added to each bottle 15 cc. of 0.S5 per cent. salt solution, made up with distilled water, and the cotton plugs replaced. These bottles are then autoclaved for one-half hour at fifteen pounds pressure. To each bottle is then added 35 cmm. of pure 13'sol, and the cotton plug replaced (Fig. 236). The method of adding this lysol is as follows: By means of a standard millimeter pipet, 35 cmm. of Fig. 237. — After Sterile Rubber Cap is Aseptically Applied to " Blank" Vaccine Bottle, the Latter IS Dipped into Melted Paraffej (at 140° C; to Seal. mercury are measured out and drawn into a pipet similar to that used for standardization purposes. This pipet is marked off, so that the above quantity of lysol can be measured. The pipet is then sterilized in the flame and used for the above purpose. Each bottle will then contain 85 per cent, sterile salt solution, with |- of i per cent, (approximately) of lysol as a preservative. Fig. 238. — Applying Cap to Vaccine Bottle. These bottles are then to be covered with sterile rubber caps, such as those used in Wright's laboratory. 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 and boiled ten to fifteen minutes in a 10 per cent, lysol solution. The bottles should be taken one at a time, held at an angle of 45 degrees or less, the neck burned off in a Bunsen flame, with sterile forceps the cap removed from the lysol solution, and stretched over the neck of the bottle aseptically. As each bottle BOTTLING THE VACCINE 671 is capped, with the thumb pressed tightly against its top (Fig. 238), it is a^once shaken in order thoroughly to distribute the lysol, otherwise it is apt to be stringy and break up into small flocculi later. After all the bottles are thus capped and shaken they are inverted, and the cap dipped into melted paraffin in order thoroughly to seal (Fig. 237). These bottles m.ay be termed "blanks," and are to be used as containers for vaccine for use on the individual patient. The m.ethod of transferring the vaccine from the stock tube which we have just pre- pared is as follows: if we desire the vaccine to contain 1,000,000,000 per cc, we find that Fig. 239. — Abstracting Standardized and Sterilized Vaccine from Stock Tube. we need in our 15 cc. bottle atotalof 15,000,000,000 organisms. There being 6,000,000,000 organisms (in this case) in each cc. of our stock, simple calculation will show that it is necessary to add 2^ cc. of the stock to the solution in the bottle. Before adding the vac- cine, however, we must abstract an equal amount of fluid from the bottle. These transfers are made, using a 2 cc. syringe graduated to ro cc. A drop of pure lysol is placed upon the rubber cap of the "blank" bottle, the sterile needle is inserted through this lysol, the Fig. 240.- -Injectixg Proper Amoitnt of Vaccine into Bottle of Sterilf, Lvsolizf.d Salt Solution, for Actual Use, in Treatment. bottle inverted, and the amount withdrawn. The tube containing the stock vaccine is vigorously shaken for a minute or two, the end of the tapered portion is broken off, flamed, and the tube field in the left hand inverted. If the fluid does not enter the tapered portion far enough for the needle to reach it, the heat of the hand, plus a Httlc shaking, will often suffice to effect this. If not, the but end of the tube may be held near a Bunsen flame. The proper amount of emulsion, in this case 2* cc, is to be withdrawn and injected through the rubber cap inlcj the bottle (Fig. 240). The bolllc will now contain 15 cc, each cubic 67:2 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY centimeter which will hold 1,000,000,000 of organisms. This bottle, after being labeled properly and shaken, is ready for use. If the vaccine stock be a large one, or apt to be opened frequently, it is best to add, as a preservative before closing, J per cent, lysol. If the amount of emulsion to be added to each bottle is more than 10 per cent, of its total bulk, the stock should always previously receive i per cent, lysol, in order that the completed vaccine may still have the full J per cent, of lysol. To estimate roughly the amount of vaccine in a tube, in order to determine the proper amount of lysol to add, the tube is immersed, up to the level of the vaccine, in a graduated beaker with some water in it and the rise in the water noted. Allowance of the thickness of the vaccine container must be made and subtracted. Carbolic acid, I per cent, to ^ per cent, or more, may be used as a preservative instead of lysol. The advantage of the former is that the vaccine is less opalescent and does not Fig. 241. — Simple Apparatus for Oil Steriliza- tion, Consisting of Ring Stand. A, Thermometer; B, porcelain dish for oil; C, burner (Bimsen); D, clamp for thermometer; E, ring for dish. Fig. 242. — Oil Bath for Sterilization of Syringes Used in Inoculation, Prepara- tion OF Vaccines, and Taking Blood Cul- tures, Etc. A, Thermometer; B, bimetallic thermo-regula- tor; C, gas inlet and pipe leading through regulator; D, 2-foot "Bray" burner; E, prolongation of ojl re- ceptacle to accommodate thermometer and regula- tor. develop a flocculent precipitate, which occasionally forms when lysol is used. It appears to the writer that lysolized vaccines are more efficient than those preserved by carbolic acid. 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 sterilization than boiling affords is of great advantage. Sterilization by boil- ing is slow, inefficient, and causes the syringe to deteriorate. The method introduced by Wright for sterilizing syringes, by filling and refilling several times with cotton-seed oil, kept at a temperature of 130° to 150° C, meets every requirement. These temperatures at once kill bacteria or spores; that is, they give us an instantaneous autoclaving effect. Besides, the oil keeps the syringe always in easy working order. Syringes of the Roux- THE TUBERCULINS 673 Collin or the Ermold tvpe will stand these temperatures with rare breakage. The writer has used a single Ermcld 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 satisfactory oil bath, however, is one ha^•ing a device for regulating the temperature con- stantly at the desired point (Fig. 242). 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 necessary. 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 very easy and very little pipet- ing is required. In standardization of typhoid vaccine a blood should be used which does not agglutinate typhoid bacilli. For curative inoculation, t3'phoid 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 Q. 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- 43 674 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY culin R is commonly sold in vials containing i cc. of fluid in which there are 2 mg. of vaccinating substance (Miester, Lucius, and Bruning). Bacillary emulsion may be obtained in 5 cc. vials, each cubic centimeter containing 5 mg. of bacillary substance. It is convenient to prepare for actual use three strengths of tuberculin R and of bacillary emulsion, one to contain ^^^ mg. per cc, another i^jjet mg. per cc, and a third ^uVu mg. per cc, in order that the dosage may be accurately administered. Before making dilutions of the German product it has been found best to steriUze the original preparation for one hour at 60° C. If sterilization is to be done, it will be necessary to make two of Wright's so-called " curly pipets." For this purpose apiece of tf or |-inch tubing, 6 in. long, is heated in its middle and drawn out into a |-inch capillary, and cut off so that the tapered end of each tube will be 4 or 5 in. long. The undrawn end is then heated at a point such that will allow at least i cc. of fluid to be drawn into the tube. After the glass is thor- oughly molten at this point, it is drawn out so that there will be a constricted portion a little over an inch long, and while still pliable, the end of the tube is rotated in its long diam- eter or twisted so that the drawn-out portion is given a complete recurve (Fig. 243). This tube is sterilized in the flame. A second is prepared in the same way, and likewise steril- ized. The vial containing tuberculin is unstoppered, the mouth flamed, and the contents drawn up into the curly pipet and the end sealed; i cc. of sterile salt solution is poured into the vial to completely wash out the tuberculin which may have been adherent to the interior of the vial. This is drawn up into the second pipet, which is likewise sealed. These two pipets are then suspended for one hour in a water-bath at 60° C. We then have 2 cc. of tubercuUn R, in which there is a total of 2 mg. of solid substance. To an Fig. 243. — Wright's "Curly Pifet" Used as a Container for Tuberculin During Sterilization. 8 by I test-tube, containing exactly 48 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 have a solution of tuberculin R which contains nV mg. per cc. . The bacillary emulsion should be sterilized and prepared in the same manner. In this case, however, but i cc. of the fluid is withdrawn from the original vial under sterile precautions, the stopper replaced, and the remainder saved for future use. Certain American prepara- tions of tuberculin do not require sterilization, according to the statement of the manu- facturers. The technique of diluting these preparations may be as follows: To an 8 by i 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 i cc. of sterile salt solution and this added. We then have a solution containing -jV mg. per cc. The tube is sealed and labeled. The dilutions made in this manner are kept as stocks, and from them further dilutions arc made for actual use — 125 cmm. of lysol should be added to each 50 cc. stock solution. To prepare a solution to contain y^^ mg. per cc, we find that, using a 15 cc. bottle of lysolized salt solution, we require a total of j-gfj mg. of bacillary substance. There being ^ mg. in every cubic centimeter of the stock, we find that we require 0.37 cc. of the stock. This amount having been extracted from a blank lysol salt vaccine bottle with a sterile syringe, the same amount of the stock is injected through the rubber cap and the bottle well shaken. To prepare a bottle to contain -gi-^ mg. per cc. twice this amount of the stock must be added. To prepare a bottle to contain -ji^tj mg. per cc. we must transfer 3 cc. from the bottle con- taining j(}(jjj mg. per cc. Before these additions are made, equal quanta of the contents of the blank vaccine bottles must be abstracted. Tuberculin O is used fcr the von Pirquet tuberculocutaneous test. It is convenient THE DETERMINATION OF THE OPSONIC INDEX 675 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 di-awn out into a fine capillary, the long tube thus made is cut into 2-inch lengths, one end of each sterilized, 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 DETERMINATION OF THE OPSONIC INDEX Opsonic index estimation requires the preparation of — (i) a corpuscular mixture; (2) a bacterial emulsion; (3) the serum of several persons not infected by the organisms with which we are dealing, and (4) the serum of the patient or patients to be tested. The blood specimens are collected in small recurved capsules. (i) Corpuscular Mixture. — A piece of glass tubing 4 in. in length, about fs in. in diameter, of fairly thick walls, is heated at the middle in a small blow-pipe flame, drawn out quickly, so that two portions of equal length are secured, and the closed end of each heated and rounded (Fig. 244). These tubes, which are ap- proximately the same length, are to be washed thoroughly and rinsed with sodium citrate solution. They are then to be filled two-thirds full of sodium citrate solution, i^ per cent. A blunt glass needle is made by heating, in the pilot flame of a Bunsen burner and drawing out quickly, an odd piece of capillary tubing. After winding the ligature round the base of the thumb, the dorsum is pricked near the margin of the nail. The blood is allowed to flow as quickly as pos- sible into each of these tubes of citrate solution, so that each will contain three or four parts of citrate solution and one of blood. As the blood flows in, the tube is occasionally in- verted, the open end being closed by one finger, in order that there shall be no clotting or drying of blood on the inner sur- face of the tube. These tubes are then inverted several times in order to mix thoroughly the blood and the citrate solution, care being taken not to shake. The tubes are then centrif- ugalized long enough to settle all the corpuscular elements. The supernatant fluid is pipeted off, and the tubes are filled with sodium chlorid solution, 0.85 per cent., and again inverted so that the corpuscular elements are thoroughly mixed and washed free from serum, then centrifugalized attain, and the supernatant fluid again pipeted off. We now have a mixture of red and white corpuscles in a small amount of salt solution, washed free from the blood- serum. The tubes are then rotated between the palms of the hand, in order thoroughly to distribute the white cells in all parts of the mixture (Fig. 245). The corpuscular mixture is now ready for use, and the tubes are placed at an angle of 45 degrees in a small flat dish containing wet sand as a holder, active in this mixture for several days, but in opsonic work the age limit for use should be placed at twelve hours or less. (2) Bacterial Emulsion. — This is made from living cultures of the organism, against which the sera are to be tested. The period of growth for gram-positive cocci may be as long as twenty-four hours; for gram-negative cocci and organisms of the colon group no longer than twelve hours. In general, the younger the culture, the less subject it is to the formation of clumps. In dealing with the tubercle bacillus it is wiser to use killed organ- isms, and apparently c|uite as satisfactory in results. A small amount of the surface growth Fig. 244. — Tubes for Blood- corpuscles, i. e., tOK "Corpuscular" Mix- ture IN Opsonic Tech- nique. .1 , First stage, tubes drawn out; B, end of tubes sealed and rounded. Lcukccvtcs mav rerhain 676 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY of agar is removed on a sterile platinum loop, and is mixed with a few drops of sodium chlorid solution in a watch-glass. The tubercle bacillus and gram-negative cocci require a 15 per cent, salt solution; for others a 0.85 per cent, salt solution is used. The purpose now is thoroughly to break up all clumps in this emulsion, in order that we may have chiefly single bacteria, or, at the worst, groups of but two or three. In order to bring this Fig. 245. — Opsonic Index Technique. Rolling tube containing corpuscular mixture thoroughly to mix. about, a good method is to draw out a small capillary pipet, cut off the end squarely about I in. from the stub,, and with a rubber teat forcibly draw in and express the emulsion, holding the end of the tube at right angles to the bottom of the watch-glass (Fig. 245). The length of time required for this procedure depends entirely upon the nature of the organism with which we are dealing. In the case cf staphylococcus, colon bacillus, or Fig. 246. — Glass Recurved Capsule for Blood Specimen (Wright), with Fine Needle End FOR Pricking Finger. Fig. 247. — Glass Recurved Capsule (Wright) FOR Securing Blood Specimen. Heating, in order to make needle for pricking fmger gonococcus, five minutes may be sufficient; with tubercle bacillus, streptococcus, and pncu- mococcus, a much longer time is necessary. It is well to have the emulsion at first a great deal thicker than is necessary for the actual opsonic test, so that after this last procedure we can centrifugalize the emulsion in order to remove any remaining clumps. After cen- trifugalizing the upper portion of the fluid is pipeted off, and to this salt solution of ap- THE OPSONIC INCUBATOR 677 propriate strength is added, if necessary, to render the emulsion of proper strength for use. Determination of the proper opacity of the emulsion, so that it shall give us a convenient number of organisms in each white cell, is a matter of judgment based on experience. Ordinarily an emulsion of cocci will appear less opalescent than an emulsion of bacilli of the same strength. The preparation of the tubercle emulsion is more difhcult perhaps than any other. One should obtain some dry tubercle bacilli from any of the manufac- turers of tuberculin products, or it is quite as well to use those from a young culture steril- ized. If the dry bacilli are used, an amount which can be taken up on the end of a knife- blade is placed in a small agate mortar, and with a pestle ground dry until it has an even, smooth, powdery consistency; 1.5 per cent, salt solution is then added drop by drop, and the rubbing is continued until a paste is produced. The intent is, so far as possible, to separate the clumps of bacilli. Then more salt solution is added gradually and the re- sult, a fairly thick emulsion, is pipeted into a small test-tube, in which there may well be a number of small glass beads, more salt solution added, the tube is sealed up, thoroughly Fig. 248. — Opsonic Incubator. shaken, and sterilized for one-half hour at 60° C. The tube is then inverted and stood upright in a rack for a day cr two, until the drawn-out end of the tube becomes filled with the larger clumps of the bacteria, the upper portion cf the fluid having an opalescent appearance. The drawn-cut portion is then cut off, and the tube resealed and allowed to stand upright for two or three days. The upper opalescent layers are now to be used as the emulsion, but may require dilution, further breaking up by pipeting, or further cen- trifugalizing, in order to render it fit for use as an emulsion. Such as emulsion once pre- pared can be used indefinitely so long as it is kept sterile. (3) Serum. — The serum should be collected from the patient in the small curved capsules made of y^Tj-in. glass tubing. The dorsum of the thumb ha\'ing been sterilized in alcohol and the ligature applied, the blood is drawn, as previously explained, and al- lowed to flow into this glass capsule. The latter is then sealed in the flame, particular care being taken not to heat the blood, inasmuch as the opsonin is destroyed if heated to 60° C. or over. Serum should not be used until the clot has formed unless the red cells are centrifugalized. Serum from normal individuals is obtained in the same way, and is to be used %s a control. In the' determination of the tUbcrculo-opsonic index, sera from three or four normal individuals are separately tested for contrc;l, and in the case of ether organisms, equal volumes of three or four normal sera are pooled, and the resulting serum tested as a normal, or control. Technique. — We have then the essentials for determining the opsonic index, namely, corpuscular mixture, bai lerial emulsi< n, nc rmal sera, and the patient's serum, to be 678 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY tested. The method of procedure is as follows: A rubber teat is fitted over the large end of a capillar)^ pipet, and a mark placed upon it f in. from the capillary end. One vol- ume of corpuscles is drawn up a little beyond the end of the tube, lea^dng an air-space, followed by an equal volume of the bacterial emulsion, then an air-space, and then an equal volume of serum to be tested (Fig. 249). Thus we have equal volumes of each, Fig. 24g. — QpsoNic Index Technique. Pipeting an opsonic mixture prior to incubation. separated by air-spaces. These are expressed upon a clean glass slide, and alternately drawn in and out in order thoroughly to mix. Pipeting is a very difficult procedure at first and it requires special practice. The most important consideration is to have the end of the pipet cut off squarely. If this is done, and the pipet held at the proper angle Fig. 250. — Opsonic Index Technique. One volume of corpuscles and one volume of emulsion have already been taken into pipet. serum is being drawn in. One volume of of 45 degrees or slightly less, this procedure can be carried out without bubbling. The fluid is carefully drawn into the pipet, excluding air-bubbles, the end is sealed in the flame, and the pipet immediately put into the opsonic incubator (Fig. 248) at 37° C, and allowed to remain for fifteen minutes. This process is repeated with each of the sera to be tested. The time is noted when each pipet is placed in the incubator. In the case of the colon THE DETERMINATION OF THE OPSONIC INDEX 679 group and Gram-negative cocci, the incubation time should be eight or nine minutes; the others require fifteen minutes. At the appropriate time the pipets are withdrawn one by one, the contents of each blown out upon a clean sUde, and sucked up and reex- pressed until the mixture is thorough. Then a small drop is blown on each of two slides and a suitable smear made. On the efficient manner in which this smear is made depends, to a large degree, the excellence- of the preparation and the ease with which counting may be accomplished. It is possible, by using a properly made slide as a smearer, to produce a film in which practically all the leukocytes will be located at the end of the smear, so that in counting all that one has to do is to follow a rather thickly distributed line of leuko- cytes across the slide. Such a smear is time sa\ang and conser\dng of patience, and hence lends to the accuracy of the results. The proper smearer is made by nicking a thin glass slide at its center, and break- ing it in such a way that the resulting edge will be slightly concaved and smooth. The corners should be cut off, so that we have a slightly concave, sharp, even edge, about J in. long (Fig. 252). If this slide is held at the proper angle, which varies according to the concavity of the edge, and may be determined by experience, such a smear is pro- duced as has been described (Fig. 253). T0m Fig. 251. — Opsonic PiPET. Fig. 252. — Slide Prepared for Making Opsonic Smears. A, The smearing edge, slightly concave, with smooth, sharp edge. As the smears are made, two from the contents of each pipet, the slides are num- bered in duplicate, and are, after drying, placed in a saturated solution of mercuric chlorid for from two to five minutes. In dealing with the tubercle bacillus the slides are then stained with carbolfuchsin, hot, for two minutes, then decolorized in 2^ per cent, sulphuric acid until the counting edge, where the leukocytes are, is decolorized, no attention being paid to the condition of the other portion of the smear. If it is desired to destroy all red cells, leaving nothing but a line of leukocytes extending across the sHdc, a solution of 4 per cent, acetic acid is poured quickly over the slide and immediately rinsed off. This, however, is not necessary. The slides are then counterstained with aqueous methylene-blue for two or three minutes, washed quickly, and dried on blotting-paper at once. If washing is prolonged, the leukocytes are apt to become decolorized, so that their borders cannot be w^ell made out. In dealing with organisms other than tubercle a most satisfactory stain is carbolthionin blue. One or two minutes is ordinarily sufficient for staining. If the stain- ing is properly accomplished, the red cells will be of light green, the bacteria of deep purple, and the protoplasm of the leukocytes lightly stained. Counting.— The total number of bacteria in 100 leukocytes should be counted in 68o THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY each preparation. By counting groups of ten cells in ten different portions of the smear, a better average is obtained than would be if loo cells were counted in a more limited portion. The phagocytic index, so called, is the average number of bacteria contained in each leukocyte, and, therefore, is obtained by dividing the number of bacteria counted by the number of cells. The phagocytic index is thus calculated in the case of each serum tested. The opsonic index represents the relation between the phagocytic index of a patient and the phagocytic index of the normal serum or sera. To arrive at the opsonic index, therefore, the phagocytic index of the patient's serum is divided by that of the normal. In the case of the tubercle bacillus, the normal phagocytic index would be the average of those obtained in the three or four normal sera tested. In the case of other organisms, the phagocytic index should be that of the pooled normal sera. Supposing, then, that in the case of the normal serum loo leukocytes have ingested 200 bacteria, the phagocytic index will obviously be 2. In case of the patient's serum, supposing that 100 leu- kocytes will have ingested 60 bacteria, the phagocytic index in this case will be 0.6. The opsonic index would equal then the phagocytic index of the patient, divided by the normal phagocytic index, or 0.6 divided by 2, which would equal 0.3. The normal index being considered unity, the patient's serum would then be said to have fo of the normal opsonic power. Fig. 253. — Making an Opsonic Smear. The technique, as detailed, requires certain further refinement in order to make it possible to achieve accurate results. In regard to the corpuscular mixture, it is absolutely necessary that the red cells be not susceptible to agglutination when in contact vdth other sera. Consideration will show that if, in testing a certain serum, the red cells come in con- tact with it and become agglutinated, the physical properties of this mixture, so far as the relation of the bacteria and the leukocytes is concerned, will differ essentially from the con- dition found in an opsonic mixture in which the red cells are not agglutinated. If this should occur, either when in contact with the patient's serum or with the normal serum, - the opsonic indices are apt to show gross inaccuracies. For instance, Fleming's experi- ments have shown, citing one of his cases, that where he used corpuscles not agglutinated by either the patient's or the control serum, the opsonic index was 0.52, but using corpus- cles which the patient's serum did agglutinate, the opsonic index was 2.72.^ Constant use in the laboratory of the corpuscles of different workers -will solve the question as to whether or not they are satisfactory, so far as thpir non-agglutinating qualities are concerned. The writer's corpuscles agglutinate when in contact with some sera, and hence cannot be used for opsonic determinati; n. Every part of the corpuscular mixture should contain an equal distribution of leuko- cytes. Too much emphasis cannot be laid upon the importance of thorough mixing of ^ Fleming, Practitioner, London, May, 1907. THE DETERMINATION OF THE OPSONIC INDEX 68 1 the corpuscles, by rolling the tube between the palms of the hands frequently if the cor- puscles are to be used over a long period. The reason is that if in the smear derived from the patient's serum few leukocytes are to be found, while in the normal a satisfactory number are present, the phagocytic index, and, of course, the resulting opsonic index, will be greater than it would be if there were approximately the same numbers of leukocytes in each smear. The so-called leukocytic cream, a more or less concentrated layer of leukocjiies, sup- posed to remain on the surface of the corpuscular mixtures after centrifugalization, may perhaps be a constant feature, but as sufficient quantities of leukocj'tes may be found in any portion of the corpuscles if it be kept thoroughly mixed, the "cream" should be left out of consideration. Thorough mixing, then, eliminates this source of error, induced by taking up various numbers of leukocytes from a mixture in which they are unevenly dis- tributed. Fleming's experiments show that the possible error is from 20 to 50 per cent. Emulsion. — In the case of all organisms but the tubercle bacillus, the ideal emulsion for index determination is one of sufficient thickness, so that the average number taken up by each leukocyte shall be from three to five. In the case of the tubercle bacillus a count of I or I J per leukocyte is to be aimed at. When determining a large number of opsonic indices at one time a "trial trip" should be first put up in order to test the emulsion. If there are very many clumps of bacteria, or if the phagocytic count is so high that count- ing will be too laborious, so many bacteria being taken up by each cell, the emulsion must be in the former case centrifugalized or further broken up by the pipet, or, in the latter case, diluted with salt solution. The prime requisite for accurate work is a good emulsion. After any modification of the emulsion that may appear necessary after the first trial trip, a second test should be made to see if the emulsion has been improved. The trial trip will also tell us whether the corpuscles are good or not. If the leukocytes are found to be clumped, so as to make their outlines indefinite, and thus possibly hide organisms which should be counted, new corpuscles should be prepared. The trial trip then is essential, since it tells us whether our emulsion and corpuscular mixture are suitable for accurate work. As to the serum, it is best not to allow it to stand more than three or four hours at room-temperature before being tested. It has been found by Fleming {loc. cit.) that the opsonic power of the blood, standing at room-temperature, is subject to quite wide varia- tions between the fourth and twelfth hour, but that by the twelfth hour the original opsonic power is practically always regained as it was during the first three or four hours. Extreme care must be used not to heat the serum during the process of sealing in the capsule, other- wise great inaccuracies will ensue. A source of error, pointed out by Fleming, that should be avoided, is the aspiration of red cells from the blood specimen to be tested, when only the serum should be drawn into the opsonic pipet. The reason is that the opsonic index is invariably lowered in propor- tion as increasing amounts of red cells are taken into the pipet with the serum. This may be avoided by allowing the blood to clot firmly in the capsule, or by centrifugalization before using, and by the observance of great care to prevent the tip of the pipet entering the clot and taking in red corpuscles. If the details of the technique are carefully followed as here outlined, and the sources of error are appreciated and carefully guarded against, after a little experience there should be no greater error than is consistent with usefulness of the opsonic index as a guide for chnical work. By study of a large number of indices of normal individuals, repeatedly determined, in Wright's laboratory, it has been found that in about 75 per cent, of the determinations the index falls between 0.95 and 1.05, a variation of 10 per cent. In all but a few of the regaining 25 per cent, the indices fell between 0.90 and i.io. It was very unusual to find the index of an individual previously determined as normal to at any time fall below 0.90 or above i.io. Variations within these limits are apparently unavoidable. Apart from these possible variations, error does creep into the work frequently, but it is generally pcssil)ie for the Icchnician to recognize when any great inaccuracy has occurred 682 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY by scrutinizing the phagocytic indices of the normal sera. If these show wide variations in the average number of cells which contain phagocytes, it is obvious that the other sera will be subject to the same variations. The basis for accurate indices is a stable, constant normal. It is perfectly ob\'ious to one who studies the sources of error in opsonic technique, as pointed out by Fleming and referred to in this article, that accuracy cannot be consist- ently achieved unless they are recognized, and it would seem probable that herein hes the reason for the inaccurate results of so many laboratory workers, which have led them to discard the determination of the opsonic index as an impracticable, inaccurate, and, there- fore, unnecessary procedure. AGGLUTINATION TEST (WRIGHT'S METHOD) If one desires to determine the point at which a serum will agglutinate typhoid, colon, or other agglutinable organisms by macroscopic method, and is able to blow glass sufl&- FiG. 255. — Wright's Thbottled Pipet. Applying ring of sealing-u-:ix. ciently well to make a throttled pipet, Wright's method is ser\dceable. The procedure is as follows: the first step is to make a so-called throttled pipet (Fig. 254). A piece of |-inch tubing is heated in a biow-pipe flame, and drawn out into a capillary stem about J AGGLUTINATION TEST ( WRIGHT' S METHOD) 683 in. in diameter, and this is cut into S-inch lengths. One end of each capillary tube is heated in the pilot flame of a Bunsen burner, and drawn out to a minute capillary hair, which barely admits air (Fig. 254). Upon the proper drawing out of this capillary depends the usefulness of this pipet. This capillary hair may be from ^ to J in. long, and constitutes the throttle. A collar of sealing wax is applied^ to the capillary J in. below the throttled portion (Fig. 258); a piece of t? in. tubing is drawn out, and is broken off at a point in the taper where the lumen vnW be large enough to admit the capillary. Into this stub the throttled capillar)^ is introduced, open end foremost, drawn through until the sealing wax Fig. 256. — Wright's Throttled Pipet. Inserting capillary tube into stub. Fig. 257. — Wright's Throttled Pipet. Fixing the capillary tube in the stub by melting wax ring. Fig. 258. — Wrigect's Throttled Pipet FOR Agglutination Test. A, Capillary; B, seal- ing-wax ring; C, throt- tle; E, completed pipet. reaches the narrow portion of the stub (Fig. 256). This portion is then carefully heated and the sealing-wax allowed to set. The next step is to test the throttle as to whether it may or may not admit air. To do this collapse a rubber teat and apply to the large end of the pipet. If the teat very gradually fills, it shows that the throttling is good. If it does not fill, the throttle is not perv-ious, and a thin wire or glass tube may be inserted into the stub and a short piece cf the hair throttle cautiously broken off. If the hair throttle is too patent, that is, if the teat suddenly fills out, the throtiling is not properly done and the tube is useless, because it will be inefficient in controlling the several volumes of fluid which it is to contain. 684 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY A mark is placed f in. from the end of the tube as a measure of volume. For a Widal reaction a rather thick emulsion (about 5,000,000,000 per cc.) of living typhoid organisms is made by washing off an agar grovi^th with a 0.85 per cent, salt solution. This is placed in the watch-glass and pipeted, so that there will be no macroscopic clumps. The patient's blood is drawn in the same manner as for opsonic work, allowed to clot, and the clear serum used. A dish of 0.85 per cent, solution is at hand. Four slides are cleaned with watch- FiG. 259. — Method of Cleaning Slides with Jeweler's Emery Paper. maker's emery paper (Fig. 259), and wiped with a clean towel. With a rubber teat affixed to the long pipet, a series of seven volumes of salt solution is measured off and drawn consecutively into the pipet, separated by air-bubbles. Separate volume is expressed at either end of each of these four slides, except in the first, where one end is left vacant. Two volumes of serum are taken into the same pipet, separated by bubble, and one is expressed at the yacant end of the first slide. The second volume of serum is intimately Fig. 260. — Technique for Agglutination Test. Seven equal volumes of 0.85 per cent, salt solution drawn into- pipet, separated by air-bubbles. mixed with the volume of salt solution on the first slide, and one volume is extracted from this after mixing, and added to the first drop on the second slide again after mixing. A vol- ume is extracted from this drop and added to the next, and so on, until we reach the seventh drop, from which a volume is discarded after mixing. We then wash out the pipet in 0.85 per cent, salt solution in order to free it from any traces of serum. We then have on the four slides one volume of clear serum, six separate volumes of mixed sera and salt solution, and finally one volume of salt solution. We then take up eight separate vol- THE STERILIZATION OF VACCINES 685 umes of the bacterial emulsion with air-bubbles separating the volumes, and add one vol- ume to each dilution or drop on the slide, beginning at the eighth drop, which, as we shall remember, consists of nothing but one volume of salt solution. We then have as a control equal volumes of salt solution and bacterial emulsion. To each of the follo^\ang drops we add one volume of emulsion, thoroughly mixing each time. Then, after washing out the pipet again, to free it from all traces of serum, we draw into the pipet, beginning with the control, one volume from each dilution, seal the end of the tube, and place in the incu- bator upright for one hour at 37° C. It will be seen that the dilutions are as follows — i : 2, i : 4, i : 8, i : 16, i : 32, i : 64, I : 128, and finally the control. If agglutination is positive, it will be possible, with the naked eye, to note the clumping of the bacteria and the exact dilution at which the clump- ing has occurred. The difiiculties of this method are largely those associated with preparation of the pipet. The bacterial emulsion used should not be too thick — about 5,000,000,000 per cc, is about the right bacterial content; it should be free from macroscopic clumps. Killed, organisms may be used, but the dilution at which agglutination will take place is apt to be lower than in the case of living bacilli. Fig. 261. — Technique for .A.ggt.utination Test. Expressing volumes of salt solution on slides. ■• The method is not quite so delicate as the microscopic, in that in the latter clumping may occur at a somewhat higher dilution. Its advantage over some other macroscopic methods lies in the fact that the question of distinguishing between sedimentation and agglutination does not arise, for the amount of settling in an upright capillary tube in the one-half hour allowed in no case resembles the flocculent condition found where agglutina- tion has taken place. NOTE CONCERNING 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 Ije depended on to kill any species of bacteria which are at present used in the preparation of \-ac- cine. It is the temperature most commonly used. There is sufficient evidence that this amount of heating injures the vaccinating qualities of certain bacteria. It is, therefore, desirable to 686 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 staphylococcus aureus, however, from twenty to twenty- five minutes will commonly be required. In the case of gonococcus the addition of ^ of i per cent, lysol to the bacterial emulsion, thorough shaking, and exposure to a temperature of 37^° C. in an ordinary in- cubator for a period of tAvelve hours have been found to kill the organ- isms. 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 pneumococcus 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. 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 organisrns be inadvertently rubbed into these minute openings, or some injury impairs the blood-supply. The observations of Da Costa would indicate that the predisposition of dia- betics to furunculosis is dependent upon a habitually low opsonic power. It would seem that the tendency to skin infection, seen after exhausting fevers, is partly due to a deficiency of the blood-stream in its content of antibacterial substances. Predisposing factors, therefore, ACUTE FULMINATING INFECTIONS 687 to skin infection are certain conditions of the skin itself, and in some cases in all probability some deficiency in the antibacterial power of the blood-stream. Infections taking place through the normal openings of the skin are commonly 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 result 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 point and a lymph of lowered antibacterial power w^ould furnish a good medium on which bacteria which are not killed, will find more or less unbridled opportunity for growth. Swelling of the tissues from exuda- tion, destruction of leukocytes and tissue-cells, due to the virulence and numbers of the organisms, may be conceived to inhibit the satis- factory outcome in the reaction of inflammation in its attempt to bring large amounts of blood and leukocytes into contact with the bacteria in the focus, and lead to their destruction. Where the bacteria entering are in large numbers, some are taken into the circulation at once, and the antibacterial power of the blood may be temporarily lowered, and thus render the blood-stream itself less efficient than it normally was. 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 688 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY this tension and of the impossibihty 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 two 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. The use of antitoxin in diphtheria and tetanus, in that it comes to the assistance of the immuniz- ing mechanism at a point where it is deficient, furnishes perhaps the most striking example of a system of therapeusis which endeavors to make use of the body's own methods in the cure of disease. In other localized infections we have no such efficient treatment. 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 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 ACUTE FULMINATING INFECTIONS 689 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. 232, would appear more advantageous than an endeavor to increase hyperemia by heat. This is seen in slight infections of the fingers. Where the infected area is large, as in phlegmon, passive hyperemia may be decidedly dangerous, because the blood-stream may receive 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. By such a misapplied measure we not only inhibit the normally efficacious active hyperemia, but, by the excessive autoinoculation, we tamper with the blood-stream and lower its anti- bacterial efficiency. Bier's suction intermittently applied, if the infected area be small, may be of value in that it brings the serum into more intimate contact with the infected focus than might otherwise be the case. It still does not prevent, if it is not applied too often, frequent interchange of the serum with that from the blood, an interchange of lower for higher antibacterial efficiency. 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 favoral^le to local growth of bacteria, but also, by its tryptic ferment, leads to the spread of the infection by solution of the connective tissue. Further, as a corollary, the blood-stream itself is forced to receive more or less continuous autoinoculation, which, if excessive, lowers its antibacterial efficiency. The indication here met is to eliminate autoinoculation. At this point, surgical measures have always found their rational application, and remo\-ing 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 44 690 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY exerts its effect against the bacteria, but 'neutralizes the tryptic ferment of the pus and prevents further solution of the tissue. The indication next is to perpetuate such conditions as may produce a continuously fresh circulation of lymph through the walls of the ca\ity and out\vard as a discharge. Coagulation of lymph in the walls of the ca^ity unfortunately prevents such free discharge. The usual measures of using wicks as drains have done more harm than good in most cases, because, instead of lending toward a free discharge, they have pre^•ented discharge. One of the most important and efficient therapeutic measures that have been offered in the treatment of localized infections A^'right has given us in the sodium citrate and chlorid solution which he ad\'ises. This solution is composed of 4 per cent, sodium chlorid and i per cent, 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 pre\iously 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 ca\ity. 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. The use of sodium citrate and chlorid, therefore, has a distinct place in a system for immunization in localized infections, in that it renders efficient the immunizing mechanism of the body at a. point where it most com- monly fails. The writer has used this solution exclusively in the past three years to fulfil the indication as here stated, and has found it to be quite as efficient as theoretic considerations would indicate. Its consistent efficiency, contrasted with the almost total inefficiency and positive harm of strong antiseptics in the treatment of these condi- tions, should lead to its general adoption, or to the adoption of some CULTURE AT TIME OF OPERATION 69I Other solution which may be found equally good or better, in fulfiling that essential postoperative requirement; namely, that free and continuous circulation of lymph into the focus of infection must he, so far as possible, maintained, to the end of destroying bacteria by nature^s on'n method. In association with the sodium citrate and chlorid solution it may be advisable, in some cases, to make use of Bier's suction, where it can be applied, to produce a more searching lymph circulation. This measure has been rarely necessary in the writer's experience. Ha\ing 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 ha\-e 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 recei\-es no impulse leading to the production of specific antibodies. Hence we should furnish the stimulus by injection of corresponding vaccine. The failure of these processes 'to resolve is sufficient reason for the exhibition of vaccine without resorting to opsonic determinations. In every localized infection a culture should be obtained at the time of operation, not only for record as to the nature of the infection, 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. 692 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 dosage 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 maybe 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 t^vo 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. 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. GENERALIZED INFECTIONS 693 In that excellent therapeutic effect may be produced, ^vith 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 sterilizing 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 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 694 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 t\vo 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 froni 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- 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 SEPTICEMIA 695 of antibodies in the blood-stream, instead of being immediately absorbed by the bacteria, will be applied in the circulating blood against the bacteria in the focus and lead to its final localization. The clinical result of these methods is indicative of their advantage, and lead to the supposition that these theoretic considerations are not very much in error. Where temperature persists after these procedures, opsonic index determinations have shown that autoinoculation has not been thoroughly eliminated. The continuance of symptoms and temperature shows that the autoinoculation is not effective in the production of sufficient 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. The rationale of vaccine at this point has been considered. It should be reiterated that what evidence there is at hand is strongly in favor of the supposition that the blood-stream is merely the carrier of the antibacterial forces of the body, and that protective substances are derived largely from some other tissue. It has been shown by Wasser- mann and others, cited by Noon,^ that inoculation of vaccine into the blood-stream of rabbits temporarily lessens the normal production of opsonin, whereas if the same dose is inoculated subcutaneously, no negative phase or diminution in opsonic power is produced. The obvious explanation must be that vaccine is temporarily localized in the tissues and absorbed into the circulation gradually and in too small quantities to deprive it of much of its antibacterial substance. It would follow naturally that subcutaneous inoculation will minimize the risk of lowering the opsonic power of the blood-stream. It was found, in addition, that the rise in opsonic power following negative phase does not differ much in either of these methods of inoculation. If minute dosage of vaccine subcutaneously is not followed by negative phase, and if the same dose does produce diminished resistance, if inoculated intravenously, this suggests that the effect upon the immunizing mechanism in reducing its efficiency depends upon whether or not the quantum of vaccine is taken at once into the blood-stream. Finally, inasmuch as the larger the dose injected subcutaneously, the greater the amount of vaccine that will be immediately taken up into the blood-stream, it is ob^ious the larger the dose inoculated, the greater will be the diminution in the antibacterial power of the blood induced by it. In treating septicemias we cannot afford, even for a few hours, to ^ Brit. Med. Jour., August 28, 1909. 696 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 sufiSciently 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 provided 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 t^venty-four hours after inoculation of plague vaccine. Wright later showed the same was possible, using a typhoid vaccine. 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. Wright^ mentions one case of malignant endocarditis in which complete cure was achieved. A second case of the same type, associated with high temperature for three months before vaccine therapy was resorted to, devel- oped a normal temperature following inoculations, but death followed as a result of cardiac complications. In both these cases careful opsonic deter- minations showed a satisfactory immunizing response registered by a rise in the opsonic power. Three other cases of malignant endocarditis (strepto- coccus) in which the patients died. These cases, however, showed no satisfac- tory immunizing response to the inoculation, as judged by the rise in the opsonic ^ Lancet, August 24, 1907. ^ Ibid., August 24, 1907, p. 499. GENERALIZED INFECTIONS 697 power. He refers to those cases of Malta fever in which the course of the disease was favorably influenced, the clinical improvement associated in each case with an increased development of antibacterial substances in the blood. In the treatment of 14 cases of malignant endocarditis Rosenow^ showed that the opsonic index was generally normal or above at first, but toward the fatal termination of the disease it generally fell far below normal. He found that injections of vaccine were followed in from twenty-four to forty-eight hours by a rise in the opsonic index. He found that in the early part of the disease, when the index was high, no change for better or for worse was noted following vaccine, but later, when the condition was poor and the opsonic index below normal, associated with a rise in the index produced by vaccine, there was a drop in temperature and definite improvement. 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 effect of vaccine was strikingly but temporarily beneficial, and in 2 other cases the benefit was sHght but demonstrable. He reports i case of advanced pyemia as cured. In all cases striking effect was noted in the decline in temperature following vaccine, and there was associated cUnical 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 300,000,006, 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. * Trans. Chicago Path. Soc, December i, 1908. ^ Amer. Jour. Med. .Sci., August, 1909. ^ Surg., Gyn., and Obst., September, 1909. 698 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY The ■tt-riter 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 mahgnant 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 cf septicemia, following localized infections, some of them of joints, were treated after surgical measures had been exhausted and bad prognosis had been given, v-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 w^hich vaccine can have no control. For instance, it has been clearly shown by Rosenow and others that bacteria have the po\A'er of immunizing themselves agamst the blood fluid. Further, it has been shown by Rosenow that virulent 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 hsixe 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 vaccme may be required. When possible to obtain a discharge, diagnosis may be readily made, otherwise blood-culture will be necessary. The observation 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 DOSAGE IN GENERALIZED INFECTIONS 699 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. Dosagfe. — 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 po^ver may be continuously low, and apparently it would seem that even large doses of \'accine 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 he 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 untoward 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 sam.e. In the case of staphylococcus it is sometimes found that the organism is of low virulence, and it may be found tha.t even from 100,000,000 to 200,000,000 700 THERAPEUTIC IMMUNIZATION AND VACCINE THEBAPY 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 he measured hy 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 \irulence 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 patieM, the smaller the dose that should be given. A sudden rise in temperature and increase in toxic symptoms suggest that the dosage may ha\'e 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 development 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 suflScient 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 ad\isable. 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- INFECTIOUS ARTHRITIS 7OI matic 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 efEective. 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 well 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 m^eeting 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 w^ill take place through the process of healing. It appears, in general, that operative wounds heal less rapidly if this solution is kept constantly applied. With the exception of the definite indication for rubber dam, as referred to, the use of this solution fulfils every requirement for the maintenance of free drainage. This renders possible the efficient application of the protective substances of the blood- serum against the bacteria in the focus of infection in a more continuously free and unobstructed manner than would otherwise be possible. 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 writer'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. 702 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY It has been usually the case, where temperature has again developed 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. — These infections in their acute stage present a condition of more or less continuous 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 autoinoculation and thus the production of a strictly localized infection. Inasmuch as in the ordinary course of events 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. Hartweir 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 disabifity. Those which did not entirely clear up, so far as function is concerned, had already, when treatment was started, become ankylosed. Dosage, in Hartwell's 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° ^ Ann. Surg., November, 1909, p. 939. GONORRHEAL ARTHRITIS 703 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, with 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. 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 ambulator}'- 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 symptoms, 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 fr.^m 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 re])eated their ^ Arch. Int. Med., i, No. 4, 433. ^ Bull. Johns Hopkins Hospital, June, July, 1907, p. 223. 704 ' THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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. In 16 treatment was begun at from one month to two years after the acute attack. x\ll 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-five years old, who had several joints affected for over two years. The con- dition remained more or less active in the ankles, and there w^as 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 lim.p. 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. Diagnosis. — In the absence of definite evidence on which to base a diagnosis, one may give vaccine as a therapeutic test. It is more satisfactory, however, to arrive at a diagnosis, and this may commonly be achieved by the use of a method offered by Irons.^ He found that ^ Arch. Int. Med., 190S, i, p. 432. GONORRHEAL ARTHRITIS 705 the injection of 500,000,000 of dead gonococci into an individual not suffering from gonorrheal infection would produce no constitutional or ■* other disturbance, while in an infected individual, after such an inocula- tion and during the subsequent twenty-four hours, there vv'ould occur a negative opsonic phase, and associated with it would be increased pain and tenderness in the joints, general feeling of malaise, and fever. In a doubtful case the use of this method of diagnosis is advantageous. Its only disadvantage is the production of unpleasant symptoms. Per- manent harm, it appears, has in no case occurred. The use of opsonic index in the diagnosis of joint infections is a very accurate method if technique of opsonic index determinations is thor- oughly mastered. This applies not only in the diagnosis of gonococcus joints, but also in any problem of differential diagnosis relating to joint infections. If the question is between tuberculous and gonococcus infection, a series of indices from day to day, determined against the gonococcus and the tubercle bacillus respectively, may furnish the evi- dence sought. If the indices to the tubercle bacillus are within the normal limits, and those to gonococcus are continuously subnormal or show marked and wide variations from day to day, we may reasonably make a diagnosis of gonococcus infection. If the indices to tubercle bacillus show a subnormal condition or wide variations from day to day, and the gonococcus indices are practically within the normal limits, we must deduce that we are dealing with a tuberculous infection. Diagnosis cannot be made by means of one opsonic index determination, and it is always well to obtain two or more on different days where diagnosis is important. Diagnosis by means of opsonic index variation after induced auto- inoculation is one of the most delicate and accurate means of serum diagnosis which can be used. This depends upon the fact that if an infected focus is stirred up by manipulation, there follow the same fluctuations in the opsonic index that an injection of dead organisms of the same type would produce. The observation of Freeman, as re- ferred to by Wright,^ has been noted before. He showed that following massage of a gonococcal joint decided elevations of the opsonic index took place; that following the massage there was a temporary aggrava- tion in the joint troubles, which suggested the induction of a negative phase ; that in association with elevation of the opsonic power, not only the joints which were massaged improved, but also other affected joints; that like variations in the opsonic power may be produced by other measures than massage {loc. cit., Wright's chart 39), for instance, by ^Lancet, November 2, 1907, 1226. 45 7o6 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY passive hyperemia produced by Bier's bandage. There can be no other reasonable explanation for this phenomenon, except that of Freeman, who saw in the fluctuations of the opsonic index, following manipulations r-| — 1 — 1 --r n rn [-] n p -] r n - - - ~ ~ ~ ~ ~ ~ r ■ ^ i.j '" 1 c /' / n o => O o 1- CO O O DC >>g 3 3 < / - - - /' / S - - / ^ / "- / p. - - / / o> - - / / ■» - - / / ^ - - / / CD / / / ' / -- / / / ^ / ^' / / / / / / '- t o. J / / =, / / J CO / / ~-L 1 ' "* — -^ ■^ ~j 1 lU r~ » " ~- ^ ^ ^ \ " \ .™ _ 1 — — — — ' "" — — 1 — 1 — / ^ H no H jko — — ■^ ^ ^ . y H iia s, r~ a. C " s 1 ' / < anojh 3h ■show a low opsonic index. One index determination is not sufficient, however, but if several low indices are obtained at different times, or if the index shows wide fluctuations, we may presume that we are dealing with tuberculosis. We have here also the necessity of localization, and we do not obtain any more information actually than the von Pirquet skin reaction gives us. . Diagnosis by Induced Autoinoculation. — When a focus of infec- tion, whatever it be, is stirred up by massage or passive motion, or if the blood, by active or passive hyperemia, be forced into the lesion in increased amount, we have variations in the opsonic index which indicate that we are dealing with a protective response against the organism to 736 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY which the index varies. We must, therefore, have produced auto- inoculation by these measures. In the case of an infection in some portion of the body to which Bier's passive hyperemia can be apphed, a method of diagnosis is as follows: Bier's bandage is applied for one-half hour, for instance, in the case of a wrist- or knee-joint, blood specimens are taken before, immediately after, one-half hour after, and two hours, four hours, and eight hours subsequently, and once or twice on the follow- ing day. These specimens are collected and kept in an ice-box until the last one is taken, and then the opsonic indices against the tubercle and other organisms suspected are determined, in the case of each specimen of blood. If the indices show variation from normal to one of these organisms and not to the other, the diagnosis in favor of the former may be conclusively made. If the index is low at the start, there will ordinarily be a brief rise and then a subsequent fall, accentuated and prolonged according as the autoinoculation is large or small. If small, there may be an immediate rise. If the index is elevated above normal at the time, there will be ordinarily an immediate drop in the first few hours, followed by a subsequent rise If the technique is in the hands of an experienced worker, the information obtained is accurate, and this diagnostic test will be found to be one of the most delicate and accurate that can be applied. Where the lesion is in a joint, instead of the use of Bier's bandage, the patient may be made to stir up the focus of infection by walking or by active or passive motion. If the infection is in the soft tissues, such as glands, kneading or hot applications may produce the same autoinoculating effect. In questions of tuberculous peritonitis, the abdomen may be deeply kneaded in order to induce autoinoculation. If a focus is suspected in the lung, active exercise for half an hour im- mediately on arising may induce the required autoinoculation.^ It is realized that these methods involving the use of the opsonic index have a limited application, but this is on account of the fact that laboratory workers are few who have the time and the patience to undertake such delicate methods of serum diagnosis. To be diagnostic, the variation in the opsonic indices should be at least 0,30. The advantage of this method of diagnosis over all the others, when it can be successfully applied, is that it not only shows that there is tuberculosis somewhere in the body, but give e^'idence that the part which has been manipulated is the actual focus of disease. Its further advantage lies in its harmlessness. The difficulty of obtaining accurate opsonic index determination limits its usefulness in practice as a procedure for general use. ^ Inman, Lancet, January 25, 1908. METHODS OF GIVING TUBERCULIN 73/ 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 which 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. — Clinical 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 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. Sufficient 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 Opsonic Method. — The opsonic method of giving tuberculin has been previously discussed. The rationale of the method in giving tuberculin is based on the fact of correlation that has been found to exist between a high opsonic power and the amelioration of local and general symptoms; on the fact that recovery from infectious disease is preceded or accompanied, with rare exception, by an elevated opsonic power; that, on the other hand, associated with a negative phase, there have been found 47 738 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY generally to exist conditions of chronicity, local or general symptoms, which indicate that the resistance to the infecting bacteria is correspond- ingly low; further, on the fact that inoculation of appropriate vaccine in proper dosage artificially elevates the opsonic power, and if the dosage is repeated at proper intervals, a more or less continuously elevated opsonic power may be produced; that, in association with this increase in the ability of the phagocytic response, a condition of im- provement supervenes which, if maintained, may end in final cure. It recognizes that the import of the toxic symptoms that may follow the injection of tuberculin in doses of sufficient size, namely, that resistance to the tubercle bacillus has been temporarily lowered; in the low opsonic index correlated with this unfavorable condition it recognizes a condi- tion to be avoided. Based on these considerations, the aim of Wright's method is to arrive at a dosage which shall induce a brief period of lowered resistance, negative phase or period when subjective symptoms may develop, this to be followed by a period of increased resistance, associated with elevated opsonic power, lasting for several days if pos- sible. The indication for the subsequent dose is the fall of the opsonic power to or below normal. Maximum immunizing responses are thus obtained repeatedly. After several doses have been given of the same size, the opsonic power neither rises so high, nor remains elevated so long a time, as resulted from the first dose given. The period of negative phase also becomes shorter. When the opsonic index shows this to be the case, larger doses are gi\'en. Thus immunizing response is obtained with avoidance of subjecti\'e symptoms after dosage. The results of this method, using the opsonic index as a guide, appear to be consistently good in producing improvemient and cure, as will be shown later. 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 TUBERCULOUS LYMPHNODITIS 739 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 alv\ays 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 100 cases of 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 Immunising Response Efficient. — 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 740 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 r^ot 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 :x:-ray will often furnish e\ddence, 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, inasmuch as tuberculin, if used postoperatively, is usually efficient in preventing extensive recurrence, even if all the infected tissue is not removfed. 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, partly 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 ^^ ill be much bet- THE ROLE OF TUBERCULIN 74I 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 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 po^^■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 742 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 focus 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. 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 giving of tuberculin, with the opsonic idea in mind, is the most conservative method that can possibly be de^dsed, 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 favora.ble conditions with a scheme for the giving of tuberculin which mav 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^^ to goi^oo ^"^t^- "^"^^ increase should be very gradual, and may at the end of six months to a year reach as high as -^Q 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 j^^ mg., the same number of 12^)0' °^ 10^' °^ 7^' ^^*^ 5000' ^^^ ^*^ °^- -^^ ^^ ^^^ ^^ ^ uncommon, TUBERCULOUS SINUSES 743 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 increased. 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 -g^ 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, 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 e^^ery 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 va.ccine 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- 744 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY COCCUS vaccine. She suddenly developed an acute erysipelas, and coincident with recovery all the sinuses healed. Lvmph-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. 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 dose of -QQQQ mg. B. E., and gradually work up in the course of six months to j^ mg., 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 graduallv 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 PROGNOSIS IN TUBERCULOUS LYMPH-NODES 745 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. 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 15000 to 5^;^o ^S-' the latter always in the case of children. The maximal dose for children under five was j^^q, and for adults rarely exceeding ^q. 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 irhproved slightly, and i or 746 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 11 cases. Hartwell and Streeter^ report the treatment of 20 cases of glandular 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 y^g 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 uncompUcated 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 ^ Boston Med. and Surg. Jour., January 6, 1910, p. 5. DOSAGE OF TUBERCULIN 747 were cured. Applying the same criteria of cure in Hartwell's smaller group of cases, we should have approximately 95 per cent, of cures against 37^- 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 would 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 would 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. 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 jq^ '^S-j 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 Hartv^^ell 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-g-Q mg., is, therefore, not so widely different as the figures would make it appear It \^ould 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. 748 ■ THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 more 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 difi&cult. 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- ated, the results cannot be expected to be satisfactory unless auto- inoculation is eliminated by operation. Cases reported from Wright's clinic by Jones {loc. cit.) consist of 2 which were cured and 3 were 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 ^q^q ^§- °^ solid substance. The sixth case was one of tuberculosis of the lumbar vertebras, 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- ^ Boston Med. and Surg. Jour., January 6, 1910, p. 5. ^ Amer. Jour. Med. Sci., June, 1907, p. 18. ^ Lancet, November 23, 1907, p. 1450. TUBERCULOUS JOINTS: LUPUS 749 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 will 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 with other measures which have proved themselves clinically valuable in the conduct of these cases. Western reports 14 cases cured, 5 cases impro^•ed, 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. 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 w^as 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. Lupus Success in the treatment of any localized infection depends on either the condition of the normal blood-supply or the facility with which it is possible to induce an increased circulation in the affected part, and thus bring into application, where needed, the effective antibacterial power of the blood-stream. In lupus of the dry type the blood-supply is not only naturally more or less cut off, but also it is difficult to induce sufficient increase in the local supply to render tuberculin particularly effective as an agent for cure. On the other hand, lupus of the ulcera- ti^•e type offers a better field for tuberculin therapy, because it is possible, ^ Lancet, February 15, 1908, p. 480. 750 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY by means of furthering discharge from the ulcerating surfaces, to induce a more free circulation of blood and lymph in the focus of infection. The results of tuberculin treatment in this type of lupus are, in general, re- ported to be much more satisfactory than in the dry type, in which there is no vent for discharge, and in which, therefore, circulation of lymph in the part cannot be effected so satisfactorily. If tuberculin is to be efficient in either type of case, appropriate measures must be used to cause determination of lymph into the lesion by means of heat, cupping, the use of :v-ray or Finsen ray. It is possible that the two latter may have not only an effect in the production of increased blood-supply, but also some degree of bactericidal action. Western^ records the opsonic power of the blood in 80 cases of lupus. Twenty-two of these were below 0.75, that is, the opsonic power was f of the normal. The rest varied from this point to i J times the opsonic power of the normal. Bulloch^ shows in a series of 150 cases that the opsonic indices ranged from 0.25 to 1.4, and that about 77 per cent, of these cases ranged from -^ to -^ of the normal. Patients upon whom these blood examinations were made were treated by .v-ray or the Finsen light in Dr. Sequeira's cUnic at the London Hospital. The observations which were made by Bulloch and Sequeira, showed that, where the opsonic index was helow normal, the v-ray or Finsen ray had little power to stamp out the disease, whereas when the indices were above normal, they were impressed that the cases did well. They attribute the improvement in the latter group of cases not to any bactericidal effect of the light treatment, but state that it is not improbable that, in addition to the tissue reaction produced, the role of the Finsen hght is to produce determina- tion of blood to the part. If the plasma is deficient in opsonin, as it is in one of these groups (having low opsonic indices), the result of this determination of blood would be less effective than where a large quantity of opsonin was present, and this is consistent with the results of treatment. This suggested that injections of tuberculin to raise the opsonic power, associated with Hght treatment to cause determination of blood to the part, would be the proper plan to pursue. Western^ states that, in looking through the cHnical history of 80 cases of lupus which have been under treatment other than tuberculin, his impres- sion corresponds with that of Dr. Bulloch as quoted. He states there are certain exceptions, however, in which patients with low indices have shown definite rise in the opsonic power of the blood following such application of light treatment. He explains this by the supposition that the reaction caused ^ Lancet, November 16, 1907. ^ Trans. Path. Soc, London, 1905, vol. Ivi, pt. 3. ^ Lancet, November 16, 1907, p. 1378. PROGNOSIS WITH TUBERCULIN TREATMENT 751 by the application of Finsen light or the :r-ray is to produce local dilatation of the blood-vessels, flushing the seat of infection, at the same time producing autoinoculation, which results in an immunizing response as registered by the increase in the opsonic power. Western states that in his experience lupus with ulceration responds to tuberculin better than the dry type. He attributes this to the possibility of producing better circulation in the former than in the latter. He advises cupping and fomentations as measures to bring this about. Reports 7 cases, with improvement or cure in all but i . Finsen -ray alone has been used fairly successfully in the treatment of lupus, but the tendency to relapse is greater when the Finsen ray is used solely than when tuberculin is used in addition. Carmalt Jones, reporting the cases treated in Wright's clinic, London, gives the following statistics: Lupus, 2;} cases, ages fifteen to twent}'-five. Under fifteen cases were rare. Three cases cured, 8 much better, 9 better, i unchanged, and 2 unknown. Dosage was large, beginning in 3 with Jwiob' ^^^ reaching a maximum of 2000 to 5000- Secondary infection in one-half the cases. Duration of treat- ment, two years in successful cases. Relapses, five times. Prognosis with Tuberculin Treatment. — According to these statistics, it would appear that i case in 8 may be cured, and i in 2 much improved after prolonged treatment. This does not look encouraging; nevertheless, tuberculin would appear to be indicated in case the opsonic power of the blood is sub- normal. In all cases, if surgery is contraindicated, treatment by x- ray, or Finsen-ray in addition, seems to give the best results, for the reason that, beyond the possible stimulating effect they may have upon the tissue-cells, or the bactericidal effect upon the organisms present, which they may have, they appear to have an important action in causing a determination of blood to the affected part. Lupus is rare in some out-patient clinics. The writer has treated 3 cases, during periods ranging from three to six months, with a total lack of improvement. X-ray and Finsen light were not used as adjunct measures. If pos- sible, excision is the quickest and best treatment. The situation, extent, and considerations as to scar formation furnish indications as to the advisability of surgical measures. GENITO-URINARY TUBERCULOSIS Renal Tuberculosis. — It is decidedly unwise for any one, no matter how expert in the giving of tuberculin, to institute treatment in 752 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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. 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. cit.) refers to Fen- wick's statement that actual harm inay 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 ''focal" reaction in an ^ Practitioner, London, May, 190S, p. 723. GENITO-URINARY TUBERCULOSIS 753 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 j-| mg. once a month, gradually increased to J mg. "Almost from the first weight increased. Blood has not appeared in the urine since 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 disappeared. Reduction in the dosage of j-jVa rng, 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. 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 sufficiently 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 2n4foo ™S- ^^ bacillus emulsion to — ^ mg. Al 48 754 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 umbiHcus, deeply situated. He was referred back to the surgeon, operated, a large collection of pus, invohing pehis 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 everv four or live 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 t\\'0 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 invoh'ed 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, 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 kidnej' eight months. Worse in morning, aggra- vated by exercise. Nocturnal micturition for six months. Blood in urine. Frequency, half hourly in day, two hourly 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: VESICAL AND RENAL TUBEECULOSIS 755 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 bacilU. Micturition during the day even,- 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 with -^ -^ — mg. (bacillary substance). Temperature normal after two weeks. Dosage of scVff 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 httle 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 ver}^ 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, ^^jj mg. 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 slight, and few colon bacilli were to be found on recent examination. It still contains tubercle bacilli, as recent inoculation experiment proved. Micturition everj^ three to five hours, occasion^ ally once or twice at night. No fjain. 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. 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 two 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 li^•ing 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 e\"ery 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; 756 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 dimLnished. It has been found in every instance in which the dosage has reached 2 q'^q q 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 g q^q q to ^q-q q mg. (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 q-q q to 7-5-Vo'' ^^^ ^^^^ ^° j-Q^-Q mg. and so on, with the expectation that in the next six months a dosage of ywo" ™&- '^'eekly 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 Involve- 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 were found in other parts of the urogenital system. In 23 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, ulcerated and indurated. Such lesions are definitely known to be amen- able to tuberculin. Again quoting Walker {loc. cit.) : "In such cases the best results may be obtained from tuberculin treatment." He states that sometimes, after two or three injections, the patient •wall 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 sho\\ed ulceration left side of VESICAL TUBERCULOSIS 757 bladder. Groups of fine tubercles found. . Four months treated with drugs. Symptoms the same. Steadily lost weight. Tuberculin begun November, 1903, ^^ mg., 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. Januar}', 1906, injection reduced to ttj'ittt mg. for three weeks. Blood ap- peared in urine and was present some weeks. It disappeared and the urine gradually cleared, -u-ith 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 cKnic 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 , ^ \^ . but often --J-—- mg. After a time it 15,000 2o,000 was raised gradually to ^^ff. Serious results may follow large initial doses. Treatment of successfvd 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: 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 beHevcd it to be due to the gono- coccus, but there was no histor}' 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. 758 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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. cit.) 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 man 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 sh(#fed a cystitis without definite tubercles. During six months tuberculin was given. Dosage, -^-^^ to ■sJn ii^g- He gained weight; there was no blood in his urine since the early part of the treatment. Micturition less frequent. 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 cystitis ' with secondary testicular involvement: Beginning October 7, 1908, tuberculin R. was injected once a week, initial dosage 2o:56o "^S- (bacillary substance), the second j^^^ mg., the third —^^ mg., the latter repeated weekly until December 22, when it was increased sHghtly to ^ijVtj 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 every two or three hours). On December 22, 1908, after about three months' treatment, the patient stated that for the past GENITAL TUBERCULOSIS 759 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 jsViT mg. T. R. Urination every four or five hours and not at aU at night. August 3, tubercuhn 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 ^ mg. December 24, 1909, dosage had reached Tt?tr?r mg. B. E., and the last dose, March 4, 1910, was 5-J5 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 or 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 efficiency 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. 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 two 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 760 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 w^ere 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 Klsewhere. — 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. 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 ^^q mg. (B. E. solid substance) or less, repeated in from five to ten days for several inoculations, when it may be increased to ^qqq mg. The next gradation will be to 3o\)ob' ^-nd hereafter the increase must be more gradual, using several doses of gsiob' 20;^ ^^"^ isWo 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 TUBERCULIN TREATMENT 761 is evident. We have in the cHnical 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 evidence 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 Iddney 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 with, is much greater than the danger from such reactions which may be produced 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 762 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY 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 genito-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 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. NEW METHODS FOR PREPARATION OF VACCINES 763 It has been the unfortunate custom in medicine to base on briUiant results achieved by new methods in certain types of infection extra^'a- 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. NEW METHODS OF KILLING BACTERIA FOR VACCINES— THE USE OF LIVING VACCINES There is considerable evidence that vaccines composed of bacteria killed by heat are not so efficient, so far as their vaccinating qual- ities are concerned, as those killed by some other methods. It ap- pears 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. Unquestionably, a much higher degree of immunity can be produced against tuberculosis in laboratory animals by means of living cultures than by means of killed cultures. Trudeau, referred to by Webb and Williams/ states that in protective inocu- lation against tuberculosis it was only when he began to use living cultures as inocula that he met encouraging results, and that his experience indicates that the living germ is essential to what success has been obtained in the pro- duction of artihcial immunity against tuberculosis in animals. Neufeld, referred to by the same writers, abandoned attempts to immunize ^ Jour. Med. Research, January, 1909, p. 4. 764 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY animals with toxins and dead tubercle bacilli after thorough trial, but was able to produce immunity by living, but attenuated, tubercle bacilli of both human and bovine t}^e. He usually preceded the injection of living organ- isms by an injection of pulverized bacilli. Theobald Smith^ failed to produce any degree of immunity to tubercu- losis, using bovine cultures killed at 60° C, by injecting five to ten times the amount of living human tubercle bacilli which had conferred immunity upon cattle to the bovine bacillus. It would, therefore, appear that immunity to tuberculosis could be much better produced if it were possible to use living organisms. The work of Patterson and Inman - records the treatment of pulmonary tuberculosis by means of induced autoinoculation as a result of carefully graduated exercise. They proved that autoinoculation took place after exercise by means of variations in the opsonic power of the blood follow- ing such exercise. There was no explanation other than that these autoinoculations consisted of Hving tubercle bacilli. Results which Patterson has achieved by application of this method would appear to be very much superior to those obtained in the treatment of pulmonary tuberculosis in human beings by any other method. Having at their disposal that most remarkable and ingenious tech- nique devised by Barber, whereby he is able to isolate a single living tubercle bacillus or other micro-organism, and inject the same subcutane- ously, they (Webb, Williams, and Barber) were enabled to inoculate patients with as many or as few living bacilli as desired, with the idea of securing a better therapeutic effect than would be expected from ordinary tuberculin. They report the inoculation of five tuberculous men. In the first case one tubercle bacillus was injected subcutaneously. Sixty days later there was no trace of the inoculation site. The second case was given one bacillus, and six days later five more. After sixty days there was no evidence of infection at either site of inoculation. The third case, one of extensive pulmonary tuberculosis, had been treated by usual measures without beneficial result. Following the first inoculation of one bacillus, subsequent inoculations were given, at intervals of four to seven days, of from 5 up to 500 bacilli. After the ninth dose, one of 250 bacteria, the temperature fell to normal and re- mained there. They worked out the effect upon the opsonic index, and found that inoculations were followed by rise above normal. The process was arrested. The fourth case was acute pulmonary tuberculosis, first inocu- lation of 50 bacilli. They finally reached 500. With the sixth inoculation fever disappeared and cough improved. After seven weeks patient was able ^ Jour. Med. Research, June, 1908. ^ Lancet, January 25, 1908. VACCINE COMPOSED OF LIVING ORGANISMS 765 to do light work. After twenty-two inoculati@ns, the last being 500, the patient was discharged as cured. The last case, one of extensive pulmonary tuberculosis, had had tuberculin treatment for two years and sanatorium treatment for three years without distinct benefit. From an injection of one tubercle bacillus a dosage of 500 living bacilli was reached. The patient felt better, but general improvement was not demonstrated; no apparent harm was done, no local or general reactions, and no lesions were produced at the inoculation sites. It would appear, from the evidence cited, first, that li^'ing tubercle bacilli possess a greater power of inducing protective response than killed bacilli or tuberculin; second, that in the cases cited, li\-ing tubercle bacilli were injected into human beings without apparent harm being done — on the contrary, with clearly beneficial results. Castellani ^ found that much greater protective response resulted in rabbits and monkeys from the inoculation of a single dose of live tj'phoid vaccine than could be obtained from the same dose of killed culture. He found that a larger amount of agglutinins and immune bodies were produced in the former than in the latter method. He quotes Haffkine in regard to cholera vaccination, and Strong and Kolle in regard to plague vaccination, to the effect that the degree of immunization obtained by using virulent live cultures is far greater than that obtained by using dead cultures. In protective inoculation against typhoid, he used living cultures, modified by heating in a water-bath at 50° C, for one hour. Such a vaccine is alive, as proved by inoculating agar tubes. He inoculated 90 individuals with such a culture during a period of four years. Although living in a typhoid-infested district, none of them developed the disease. Among 106 cases inoculated according to Wright's method, using killed cultures, the most recent being 26 cases being inoculated three months before this paper was published (March, 1909), two developed typhoid fever, but no deaths occurred. In 220 cases he combined both methods, using for an initial dose killed cultures, and for a second his live vaccine. One hundred and fifty were inoculated eighteen months, 45 one year, and 25 three months before publishing, and none had developed the disease at this time. The effect of the vaccine upon the patients was more marked than that produced by killed cultures, hut in no case did typhoid develop and in none were there any untoward results. There were temperature and malaise for twenty-four hours or less, but the individuals were able to carry on their usual work in spite of it. These experiments are of great value, in that they indicate that living organisms modified by heating, or attenuated organisms intro- duced in small and accurately measured numbers, may produce no * Lancet, August 21, 1909. 766 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY harmful effect. The superior vaccinating qualities of unaltered bacterial protoplasm being generally accepted, it may be that further experience may justify the use of such vaccine in some cases. It does not appear, however, that we have reached the stage that would justify the use of anything but killed bacteria in the general practice of medicine. We must, nevertheless, bear in mind the work of Patterson in treating pulmonary tuberculosis by autoinoculation, which is really a method which makes use of living vaccines. We must further realize that, in the application of Bier's passive hyperemia in localized infec- tions, we must attribute the beneficial results to the entrance of autoinocu- lating numbers of bacteria into the blood. While there is no justification at present for our assuming the risk associated with inoculation of living even though attenuated bacteria, except perhaps in such apparently hopeless cases as have been cited, we have excellent reason for seeking methods of killing bacteria which may be calculated not to alter the vaccinating qualities of their protoplasm. We have good evidence, in the work of Weaver and Tunncliffe,^ that a streptococcic vaccine, composed of organisms killed by a solu- tion of galactose, has superior vaccinating qualities to the same killed by heat. By inoculating animals they compared the immunizing 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 pipeted off, and the residue desiccated in vacuum over calcium chlorid at room temperature and sealed. Usually the bacteria were found to have been 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 organ- isms 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 manner, and killed by thirty minutes' exposure to a temperature 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 ^ Jour. Infec. Dis., Dec. 18, 1908. GALACTOSE-KILLED VACCINE 767 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 injections 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 hving strepto- coccus 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 b}' 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 strepto- cocci, 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 intra- peritoneally. The rabbit did not become sick and was well a month later. A second rabbit, inoculated in the same manner, but with heat-killed strepto- cocci, 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 produce 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 ^ 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 results. " Positive cultures of the streptococcus may be obtained from the suspension " at the end of the exposure. He adds \ 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 obtain';d when Wright's rule was followed." 768 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY a considerable degree of immunity to living virulent streptococci, of sufficient 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 in opsonin; the animals thus treated, when injected with living cultures, later appear to have had even less resistance than normal animals. They report excellent results in the treatment of patients. First, a case of suppurative otitis media and mastoiditis, the second of chronic ery- sipelas. They conclude that, in view of the results in attempts in pro- tecting rabbits against virulent streptococci by heat-killed vaccine, it is doubtful if one gains any advantage in the therapeutic use of strep- tococci killed by heat. DOSAGE TABLE The vaccinating quaHties 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. Dosage of tubercuhn 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 ^^ ^^ Staphylococcus 25 m. looo m. 250 m. Streptococcus i m. 300 m. 10 m. Gonococcus ^ m. 10 m. i 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 lo m. 50 m- 25 m. Bacillus coli '2 m. 1000 m. 100 m. Bacillus t)^hosus 5 rn- Bacillus pyocyaneus > 2 m. 1000 m. 100 m. Bacillus of Friedlander 4 m. 8 m., 6 m. B. Typhosus Protective Inoculation^ First dose, loco m. Ten days later, 2000 m. ^ See p. 770. INJECTION OF VACCINE 769 Fig. 263. — Inoculation. Withdrawing vaccine from bottle by plunging sterile needle through rubber cap. Fig. 264. — Inoculation. Sterilizing point of injection by touching skin with a pledget of cotton wet with pure lysol. Fig. 265. — Inoculation. The arm is grasped so tightly that the skin is under tension. 49 770 THERAPEUTIC IMMUNIZATION AND VACCINE THERAPY The writer has varied the dosage given on p. 768 in his own practice: Initial Dosage (Febrile Cases) Tuberculin R. or B. E TniTTino '"^S- i^ children; g^mg. in adults. Streptococcus 1,000,000 to 5,000,000. Gonococctis 1,000,000 to 5,000,000. Piieumococcus 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)0oo,ooo. 1 Initial Dosage (Afebrile Cases) Tuherculin R. or B. E _^ to ^^ mg. Staphylococcus 100,000,000 to 250,000,000. Streptococcus 10,000,000. Piieumococcus 10,000,000. Gonococcus 10,000,000. Bacillus coli 10,000,000. Antityphoid Inoculation. — An attenuated culture is desirable as a basis for vaccine. One that-has grown in the laboratory for a long time is suitable. Three doses, 100,000,000, 200,000,000, and 400,000,000 at six- to eight-day intervals. Positive agglutination in a dilution of serum i : 128 has been repeat- edly obtained after a dosage of 106,000,000. Subjective symptoms using this dosage have been negligible in the few cases treated. CHAPTER LIII 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 wdth 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 a toxin of the Bacillus prodigiosus. These combined toxins, as made by Dr. Martha Tracy from Dr. Coley's directions, are much more powerful than the original liquid or the prep- arations 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 maybe 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, -h m.inim may be given on the following day, and 'the amount gradually increased 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 one or two instances. The gradually increasing dose will ultimately produce a reaction of moderate severity, which may present all the symptoms enumerated or emphasize one or two of them particularly; after a * Ann. Surg., 1891, xiv, 210. 771 772 COLEY SERUM FOR MALIGNANT TUMORS 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 ID 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 a 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 never 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 Case. — Within two 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, mth 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 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 ^Boston Med. Surg. Jour., 1908, clviii, 175. COLEY SERUM FOR SARCOMA 773 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. P'our- 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 observed. 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, Hkely that the treatment of inoperable sarcoma with the 4:oxins 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." ^ 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 -water. — Slice into a pitcher six juicy sour apples. Add a table- spoonful of sugar, and pour over them a 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 half a pint of boiling water, and let it simmer for five minutes. Keep stirring all the time, to pi event lumps and keep it from burning. Add half a 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.) Corn-starch or rice-flour gruel is made in the same way. 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 — or about two hours — stirring frequently. Strain, add the juice of a lemon and sweeten. For infants omit the lemon. Beef-essence. — Mince finely a pound 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. 774 SOME INVALID AND CONVALESCENT FOOD RECIPES 775 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, Peptonized.— To ^ 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 a tablespoonful of well-cooked oatmeal with two of boiling water. Add a 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. Broth," Chicken. — An old fowl vdll make a more nutritious broth than a young chicken. Skin, cut it up, and break the bones with a mallet. Cover well with cold water, and boil slowly for three or four hours. Salt to taste. A Uttle rice may be boiled with it, if desired. 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, a 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 a tablespoonful of pearl barley, a quart of cold water, and a teaspoonful of salt. Let it boil slowly for two hours. 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 a 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. 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 boiUng 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 burn; pour over them 3 pints of boihng 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 776 APPENDIX coffee, I egg, I pint of milk, and j pint of boiling water. Beat the rest of the egg and 4 teaspoonfuls of sugar together until stiff and Hght, 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 Uttle gelatin in water. Put | ounce of freshly ground coffee into a saucepan with i pint of new milk, which should be nearly boiUng before the coffee 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 coffee 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, Rice. — Parch, and grind like coffee, half a cupful of rice. Pour over it a quart of boiUng 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 | 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, Soft. — Take 2 tablespoonfuls of corn-starch to i quart of milk; mix the starch with a small quantity of the milk and flavor; beat up two eggs. Heat the remainder of the milk to near boiling; then add separately the mixed corn-starch, the eggs, 4 tablespoonfuls of sugar, a Uttle butter, and salt. Boil the custard two minutes, stirring briskly. Egg Broth. — Beat together i egg and half a teaspoonful of sugar until very Ught, and pour on a pint of boiling water, stirring well to keep it from curdhng. Add salt, and serve hot. Egg-nog, No. 1. — Beat the white of an egg stiffly, then stir into it in turn a tablespoonful of sugar, the yolk of the egg, a tablespoonful 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 boiUng water to cover them. Let them stand on the back of the stove where the water will keep hot, 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. SOME INVALID AND CONVALESCENT FOOD RECIPES 777 Gruel, 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 tablespoonful of flour with milk enough to make a smooth paste, and stir it into a quart of boihng milk. Boil for half an hour, being careful not to let it burn. 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 | 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 ^ 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 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. 778 APPENDIX 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 jelHed, 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 neutrahze acidity of the stomach. Milk and Albumen. — Put into a clean quart botde 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 glass; 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. — Cold Process. — Put a teacupful (gill) of cold water into a clean quart bottle 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. Possett, Treacle. — Bring a cupful of milk to the boiling-point 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. SOME INVALID AND CONVALESCENT FOOD RECIPES 779 and spread on thin slices of bread. Sear the bread slightly and serve as a sandwich. Soup, Rice. — Take J pint of chicken stock and 2 tablespoonfuls of rice. Let them simmer together for two hours, then strain and add half a pint of boiling cream and salt to taste. Boil up once and serve hot. Soup, White Celery. — To ^ 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 ^^ith boiling water. Allow a teaspoonful of tea to each haK 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, Corn. — 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. Toast, Milk. — Take i cupful of milk, half a tablespoonful of corn-starch, half a tablespoonful of butter, 2 sUces of drv- 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 boiUng water. Cover closely, and let it stand on ice until cold. Strain. A httle v.ine and sugar may be added if desired. Good in diarrhea. Wine, Mulled. — Into half a cup of boiling water put 2 teaspoonfuls of broken stick cinnamon and a half 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 780 APPENDIX one pitcher to another will make it light and foamy. Serve hot. The wine should not be boiled in tin. Wine Whey. — Heat ^ 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 Abel, 301 Abram, 172 AJlaben, J. E., 25 Allen, R. W., 724, 731 Allport, W. H., 499 Anderson, 543 Arnaud, G., 444 Aspell, 259 Baillet, 436 Bainbridge, 174 Baker, W. A., 480 Balch, F. G., 563 Baldwin, H., 173 Baldwin, J. F., 25 Baldy, J. M., 27, 493 Ballance, 567, 568 Barber, M. A., 765 Barker, 293 Bartlett, 103 Barton, 195 Bassini, E., 442 Baum, 268 Baumgarten, 126 Beck, E., 370 Beck, E. G., 241 Becker, E., 95, 172 Beebe, S. P., 395 Berger, P., 442 Bernheim, 72, 76 Bernlieim, B. M., 239 Berthoumeau, 145 Bevan, A. D., 173, 174, 175, 341, 430 Bichat, X., 196 Bid well, 104 Bier, A., 230, 233, 560 Bilergeil, 299 Bischoff, 71 Bisb)p, 553 Blake, J. A., 419 Blake, J. B., 31, 97, 168, 299 Bland-Sutton, 99 Blanlaret, 34 Blasius, 71 Blumj&eld, 33 Blundell, 71 Boas, 126 Boise, E., 82 Bolton, C., 412 Boos, W. F., 146 Boyd, 126 Brackett, E. G., 173, 175, 176, 569 Bradford, E. H., 239 Brewer, W. H., 173 Brieger, 612 Briggs, F. M., 397 Briggs, W. T., 545 Briscoe, J. C., 724 Broca, 268 Brockway, 573 Broughton, 728 Brown, F. T., 540 Brown-Sequard, 328 Brun, v., 176 Brunton, Sir L., 116 Bryant, J. D., 560 Buck, 560 Bull, W. T., 442 . Bulloch, 614, 615, 637 Bulloch, W., 750 Bumm, 264 Bumm, E., 493 Burrell, H. L., 560, 589 Busch, 105 Busch, M., 299 Buxton, 169 Buxton, H. T., 25 Byford, 300 Cabot, A. T., 480, 544 Cackovic, M. von, 92, 259 Calmette, A., 732 Calnt, 572 CampVjell, R., 173 Cannon, W. B., 411 Cargile, C, 299 781 782 INDEX OF AUTHORS Carlson, 617 Carrel, 72, 562 Carriere, 268 Castellani, A., 765 Catz, 107 Cavallo, 335 Champneys, 381 Chapman, 169 Chavasse, 559 Cheever, D. W., 271, 276, 590 Chevasser, M., 398 Clark, J. G., 502 Codman, E. A., 239 Coffey, R. C, 25, 220 Cole, R. I., 703 Coley, W. B., 341, 442, 771 Connell, 427 Connor, 158 Conti, 172 Cooper, 560 Corner, 167 Cotton, F. J., 572, 586 Couvelaine, 176 Couvelaire, A., 506 Craig, A. B., 299 Craig, D. C, 153 Craig, D. H., 279, 299 Crandon, L. R. G., 148, 454, 569 Crile, G. W., 72, 73, 77, 82, 85, 86, 88, 112 Croom, J. H., 38 Crouch, 167 Crouse, H., 502, 579 Cullen, T. S., 502 Cunningham, J. H., Jr., 201, 204, 205, 206, 439> 440, 441, 757 Curtis, F., 417 Gushing, Hayward W., 442, 590 Cutler, C. N., 80 Da Costa, 617, 620, 686 Daguin, 145 d'Arsonval, 342 Davis, E. P., 506 Davis, J. S., 285 Dawson, J. B., 452, 453 De Forrest, 246 De Garmo, 292 De Haen, 335 de Normandie, R. L., 403, 506 De Vilbiss, 359 Dent, 278 Denys, 605, 606 Denys, Jean, 71 Desault, 196 Dewey, C. G., 276, 278 Dickinson, W. H., 183 Doderlein, A., 493 Dorsett, 259 Douglas, 605 Doyen, E., 483 Duchenne, 336 Dudley, E. C, 484 Dupuytren, 276 Duschinsky, 299 Dyball, 264 Edgar, J. C., 509 Edsall, 175 Edwards, S., 452 Ehrenfried, A., 80, 126, 572, 593, 594, 595 Ehrlich, 612 Ehrlich, P., 415, 603, 628 Eiselsberg, A. von, 38 Eisendrath, D. N., 43, 83 Elifagaray, 268 Elliot, J. W., 435 Ellis, A. G., 299, 300 Elsberg, 72, 75, 77 Emmet, T. A., 475, 476, 484 Englehardt, 278 Estlander, 409 Estradere, 328 Evans, H. M., 390 Ewald, 125 Falconer, J. L., 173 Faraday, 336 Faure, 567 Favill, 173, 174, 175 Fenwick, H., 752 ' Fenwick, W. S., 263 Finney, J. M. T., 156, 416 Finsen, 336 Fisher, 82 Fleming, 614, 680, 681 Fleming, A, 719 Floyd, C, 724, 748 Forge, 273 Fothergill, J. M., 326 Fowler, G. R., 24, 467 Fowler, R. H., 24 Fraenkel, A., 100, 102 Frangenheim, A., 239 Franklin, Benj., 335 Fraser, 146 Freeman, 623 INDEX OF AUTHORS 783 Friedenwald, 126 Friedman, L. V., 489, 506 Fulton, F. T., 263 Furstner, 276 Galvani, 336 Gangani, 268 Gatch, W. D., 25 Gerster, 106, 589 Gersuny, 556 Gibbon, 48 Gibson, C. L., 102 Gibson, C. P., 428 Gibson, E. L., 156 Gigli, L., 493 Gilchrist, T. C, 719 GUliam, D. T., 25, 468, 493 Gocht, 560 Goldstein, M. A., 377 Goldthwait, J. E., 575 Goodman, E. H., 174 Gottheil, 258 Graham, A., 36 Graham, Douglas, 316 Green, C. M., 506, 509 Green, R. M., 697 Greig-Smith, 215 Grevan, 172 Groeningen, 82 Griineisen, 465 Gunn, 259 Guthrie, 72, 93, 562 Guthrie, L., 174, 178 Haddaeus, 259 Haffkine, W. M., 696, 765 Hahn, E., 427 Hall, R., 96 Hallowell, 562 Halstead, A. E., 165 Halsted,'W. S., 390, 442 Hamilton, 592 Hammond, P., 400 Harrington, C, 354 Harris, B., 728 Harris, M. L., 299 Harris, R. P., 492 Hartman, 372 Hartwell, H. F., 697, 702, 703, 746 Harvey, W. W., 407 Harvey, William, 71 Harvie, 415 Hawes, J. B., 748 Hawkes, F., 156, 219 Hay, 146 Hayem, 267 Hecker, 175 Heile, 154 Heineck, A. P., 489 Heinemann, 116 Hektoen, 617, 650 Henle, 167 Hepburn, T. N., 77 Herczel, 547 Herzog, 276 Hewitt, 167 Hilton, 226 Hirsch, M., 170 Hofmeier, 99 Hofmeier, N., 502 Holding, 341 Hood, W. P., 329 Horsley, 393 Howard, W., 366 Howe, W. C, 561 Howell, W. H., 82 Howland, 174 ■ Hubbard, J. C, 173, 451, 563 Humphry, R. E., 266 Hunner, G. L., 546 Hunter, W., 178 Hurd, 278 Hutchins, W. H., 261, 262 Inman, a. C, 736, 764 Irons, 659 Irons, E. E., 703, 704 Jackson, D. D., 87 Jackson, H. B., 422 Jacobson, N., 262 Jacobson, W. H. A., 359, 367, 376, 380, 381, 394, 416, 422, 449, 547 Jaeger, 507 Jeanbrau, 273 Johnson, 341 Johnson, A. B., 464 Jones, C, 745, 751, 753, 757, 760 Jones, D. F., 264 Jorgenscn, 612 Keen, W. W., 82 Keetley, 451, 453 Keith, A., 112 Kelly, H. A., 169, 476, 493, 497, 502 784 INDEX OF AUTHORS Kelly, J. A, 172 Kemp, 45 Kendirdjy, 107 Kennan, 160 Kennedy, 567 Kent, 298 Klapp, 239 Kleinertz, R., 259 Knapp, L., 176 Kccher, 571 KoUe, W., 765 Kraske, 553 Kredel, 256 Kronecker, 116 Kuhn, F., 112 Kulka, 263 Kummer, 301 Laborde, 112 Ladd, W. E., 173 Laffer, 158, 160 Lamb, 618 Lambert, 562 Lambert, A., 271 Landois, 71 Lane, W. A., 367 Lauenstein, C, 299 Leary, T. J., 268, 768 Leathes, 174 Le Clef, 605 Le Normant, 102 Lecene, 10 1 Lee, W. E., 38 Legal, 177 Lejars, 466 Leland, G. A., Jr., 409 Leopold, C. G., 493 Leube, 122, 125 Levy, 169 Lewis, B., 547 Leydon, 82 Lincoln, 616 Lindemann, 167* Littauer, 212 Locke, 113 Loeb, L., 773 Lommel, 268 Lessen, 276 Lothrop, H. A., 442 Lovett, R. W., 598 Low, H., 173, 175, 176 Lower, 71 Lund, F. B., 19S, 199, 245, 300, 499, 562 Lusk, W. C, 557 Lyon, 82 Macewen, 592 Madsen, 612 Mansell-Moullin, C. W„ 38 Marcy, H. O., 444 Marpan, 175 Martin, A., 299 Martin, W., 419 Marvel, E., 298 Mason, A. L., 107 Mason, N. R., 506 Matas, R., 260, 563 Mauclaire, 102 Maunsell, 453 Mayo, C. H., 163, 391, 564 Mayo, W. J., 411, 442, 597 Mayo-Robson, A. W., 38 McArthur, A. N., 173 McArthur, L. L., 442 McBurney, 435, 454 McCardie, W. J., 266 McCoUom, J. H., 130 McCormack, Sir W., 586 McDonald, E., 475 McGuire, S., 25 McKay, 38, 96 McKay, W. J. S., 286 Meakins, J. C., 703 Meisse, T., 90 Meltzer, 262 Meltzer, S. J., 82 Metchnikoff, 115, 116 Metchnikoff, E., 605, 628 Meyer, E, W., 586 Meyer, W., 230, 468 Mikulicz, 221, 448 Mintz, 568 Mitchell, S. Weir, 82 Mixter, S. J., 421 Mocquot, 93 Moennighoff, 153 Momberg, 87 Monks, G. H., 468 Monprofit, A., 415 Moore, F. C, 126 Moorehouse, C. W., 82 Morris, R. T., 352 Morrow, P. A., 258 Mosetig-]Moorhof, 592 Moynihan, B. G. A., 434, 435, 442 Miiller, 169, 172, 298 INDEX OF AUTHORS 785 Mummery, P. L., 83, 167 Munro, J. C, 106, 168, 464, 465, 466 Murphy, F. T., 563 Murphy, J. B., 44, 105, 427, 499 Murray, F. W., 5S4 Musser, J. H., 465 Nauwerck, 167 Neuber, 592 Neugebauer, F., 286, 287, 288 Newell, F. S., 199, 503, 506, 509 Newman, S. E., 44 Nichols, E. H., 590, 592 Nichols, J. B., 178 Nicolaysen, 586 Noble, 292 Noble, C. P., 475 Noon, L., 695 Nuttall, 606 OCHSNER, 33, 241, 349, 369, 408, 410, 414 O'Dwyer, 384 O'Leary, C, 181 Olshausen, 259 Olshausen, R., 483, 493 Oilier, 590 Opie, 620 Osgood, G., 80, 173 Osgood, R. B., 575 Packard, H., 531 Paget, 263 Painter, C. F., 575 Pare, A. 276 Park, R., 258, 266 Parkhill, 585 Parsons, 245 Paterson, H. J., 412, 413 Patterson, 766 Patterson, M. S., 764 Paul, F. T., 393, 421 Paynes, 212 Payr, 72 Pean, J., 483 Peckham, 568 Penrose, 169 Petersen, 560 Peterson, R., 259 Petters, 172 Pfahler, 341 Pfannensteil, 292 Pfeiflfer, 609 Pike, 93 50 Pilcher, J. D., 228 Pilcher, L. S., 543 Pinard, A., 489 Pliny, iSo Polak, 158, 159 Porter, C. A., 262 Post, A., 263 Pozzi, S., 484 Pratt, J. H., 263 Prescott, W. H., 168, 169 Provandie, P., 81 Pryor, W. R., 4S0, 483 queirolo, 72 Ranzi, 102 Raw, N., 749 Reed, C. B., 493 Reicher, K., 175 Remak, 336 Reynolds, E., 199, 506 Ricard, 589 Rice, A. G., 173 Richards, 174 Richardson, M. H., 430, 449 Richardson, O., 262 Richardson, W. G., 259 Rickard, 433 Riegel, 122, 126 Ringer, 113 Ritter, C., 37 Rives, 264 Robb, H., 87 . Roberts, W. H., 266 Robinson, S., 409 Robson, A. W. M., 416 Rodman, 341 Rogers, J., 262, 395 Rogers, L., 436 Rohe, 276, 278 RoUins, W., 347 Rose, E., 259 Rosenow, E. C, 619, 642, 698 Royster, 218 Rugh 267 Ruhrah, 126 Russell, 435 Sabouratjd, R., 719 Sampson, J. A., 502 Sanborn, G. P., 601 Sanger, 567 Sargent, 245 786 INDEX OF AUTHORS Sartoli, 99 Saxon, 43 Scannell, D. D., 454, S^S Schachner, 286 Schamberg, J. F., 728 Schede, 409, 592 Schlatter, 415 Schmieden, 230 Scholten, 176 Schopf, 442 Schrack, K., 175 Sears, G. G., 278 Senn, N., 587 Sequeira, J. Jl., 750 Sertoli, A., 468 Sever, J. W., 173 Shephard, 433 Shepherd, F. J., 258 Sherman, 562 Sichel, 276 Sick, 567 Sievert, 105 Sigault, J. R., 492 Silk, 163 Simpson, F. F., 493 Sims, J. M., 476 Sippel, 178 Skene, A. J. C, 495 Smith, Greig, 169 Smith, Harmon, 370 Smith, Theobald, 764 Soper, 121, 149, 150 Soubeyran, 264 Spencer, 437 Spitzka, E. A., 112 Stellig, 82 Stern, 298 Steward, 359, 367, 380, 394, 422 Steward, F. J., 547 Stone, A. K., 92 Stone, I. S., 258 Stone, J. S., 173, 175, 176 Stowe, H. M., 489 Strauss, 83 Streeter, E. C., 697, 746 Strong, A. L., 765 Stuart, 93 Sylvester, 109 Syme, 307 Symes, W. L., S3, 181 Telford, 173 Thienhaus, 435 Thiriar, 263 Thompson, 103, 126, 176, 642 Thompson, R. A., 106 Thompson, W. G., 697 Thorndike, P., 140, 263 Torbert, J. R., 159, 506 Tracy, M., 771 Tracy, S. E., 497, 502 Trendelenburg, 104, 105, 592 Treves, Sir F., 157, 363, 437 Trudeau, 763 Trudeau, E. L., 748 Tubby, A. H., 572 Tunncliffe, R., 766 Unna, 719 Unterberger, 246 Urwick, 614 Van der Bogart, 256 Van Kaathoven, 165 Velpeau, 196 Vogel, 298, 299 von Courty, 276 von Graff, 246 von Lichtenberg, 169 Walker, J. W. T., 752, 753, 754, 75^ Wallace, C. H., 163 Walthard, 279 Wandel, 261 Warren, J. C., 45° Wassermann, A., 695 Waterman, N., 87 Watkins, T. J., 475 Watson, F. S., 512, 534, 536, 544 Weaver, G. H., 72S, 766 Webb, G. B., 763 Webster, J. C, 300, 493 Wechsler, B. B., 44 Weil, 267 Weir, 451, 556 Weir, R., 597 WeUs, H. G., 175 Wertheim, E., 502 Wesley, John, 335 Western, 750 Western, G. T,, 74S, 749 White, 93 Whitfield, A., 719 Willem, 556 Williams, E. U., 724 WiUiams, F. H., 341, 346, 347 INDEX OF AUTHORS 787 Williams, J. B., 176 Williams, J. T., 506 Williams, J, W., 503, 509 Williams, W. W., 763 Wilson, 286 Wilson, H. A., 587 Witherspoon, T. C, 163 Wood, 546 Wright, A. E., 115, 605, 612, 615, 616, 618, 620, 628, 642, 648, 696, 738 Wright, Sir A. E., 229 Wynn, W. H., 728 Young, E. B., 480, 499 Zabludowski, 326 Zacharius, 259 Zander, 589 Zweifel, P., 492 INDEX A. S. B. PILL, 145 Abdomen, massage, for defecation, 144 operations on, 411 Abdominal adhesions, x-ray treatment, 340 dressing, layout, 209 hysterectomy, 499 swathes, 301 wound, bursting of, 162 strapping, 201 Abortion, 484 Abscess, alveolar, 369 cerebral, 400 ischiorectal, 549 of breast, 403 of Gartner's canal, 507 of groin, 570 of liver, 428 of neck, 397 pelvic, 478 peritonsillar, 377 prostatic, 532 psoas, 569 retropharyngeal, 377 subdiaphragmatic, 107 subphrenic, 107 vulvovaginal, 477 Acetone in children, 175 in pregnancy, 176 means death of fetus, 176 source of, 174 test for^ 177 Acetonemia, 172 jaundice in, 177 symptoms, 177 treatment, 178 Acetonuria, statistics, 173 Acne, vaccine treatment of, 718 Actinomycosis of pleura, 408 Active immunity, 603 Acute gastric dilatation, projjhylaxis of, 160 treatment, 161 Adenocystoma of ovary, 494 Adenoids, 373 Adhesions, 294 and olive oil, 299 causes, 295 exercises for, 300 materials to prevent, 299 nasal, 371 non-operative treatment, 300 prophylaxis, 297 symptoms, 296 Adrenalin, danger of, 87 infusion, 87 Aerogenes capsulatus, 262 Agglutination test, 682 technique of, 684 Agglutinins, 604 Alcohol and operation, 271 as a habit, 270 Alcoholism, 270 Alexander's operation, 506 Alveolar abscess, 369 Amputation of ankle, 307 of arm, 311, 559 of both bones, 308 of fingers, 559 of forearm, 559 of hip, 310, 559 of knee, 309 of leg, 560 of shoulder, 559 of shoulder-girdle, 559 of tarsus, 307 of thigh, 560 of toes, 560 Amputations in general, 558 Anastomosis of nerve, 567 Anesthesia, 27 danger of repeated, 171 first dressing under, 218 morphin after, 35 atropin before, 35 nephritis after, 169 paralysis after, 165 pneumonia after, 166 789 79° INDEX Anesthesia, relation of alcohol to, 271 sequelae of, 164 Anesthetic, after the, 28 conjuncti\atis, 165 in head cases, 359 recovery from, 29 restraint after, 29 Anesthetist, 27 nurse as, 27 Anesthol, 27 Aneurysm, 563 Ankle, strapping, 201 Ankylosis, electric treatment, 339 Anteflexion, 489 Anterior mre-sphnt, 582 Antiseptic varnish, 363 Antiseptics, futility of, 602 Antitetanic preparation, 261 serum, 261 Antitoxic serum, 604 Antitropins, 604 Antit}^hoid inoculation, 609 Antrum disease, vaccine treatment of, 725 of Highmore, 372 Anuria, 539 Anus, artificial, 248 fissure of, 548 fistula of, 548 imperforate, 549 operations on, 549 Aperient waters, 145 Appendicitis, 454 Appendicostom}', 451 Apple -water, 774 Arc light therapy, 344 Arrowroot, 774 Arterial suture, 562 Arteriosclerosis, autocondensation for, 340 Arteriovenous anastomosis, 563 Arthritis, gonorrheal, vaccine treatment of, 702 purulent, 590 suppurative, vaccine treatment of, 707 vaccine treatment of, 700 Artificial anus, 248 hand, 311 Hmbs, 307 respiration, 109 prone method, in supine method, 109 Asafetida for flatus, 152 Aseptic wounds, dressing, 210 Asphyxia, 109 Atresia of uterus, 506 of vagina, 506 Atrophy of muscle, treatment of, 338 Atropin for paresis of bowels, 153 Autocondensation, technique, 342 Autoinoculation, 623 dangers of, 638 in consumption, 624 in gonorrheal arthritis, 624 in tuberculous bones, 625 salpingitis, 625 spine, 626 induced, 624 Bacillus coli, 768, 770 Friedlander, 768 fusiformis, 351 pyocyaneus, 227 dosage, 768 typhosus, dosage, 768, 770 Bacteria, kilhng of, for vaccines, 763 Bacterial emulsion, 675 vaccine. See Vaccine. definition of, 610 Bactericidins, 604 Bacteriolysins, 604 Bandage, Barton, 195 Boston Lying-in Hospital, 199 Desault, 196 figure-of-8, 188 for varicose veins, 191 many-tailed, 200 modified Barton, 195 of heel, 190 of hip, 189 of shoulder, 190 perineal dressing, 206, 207, 208 plaster-of-Paris, 191 improper method, 193 recurrent, 195 of head, 195 rolling the, 187 to start a, 187 to remove a, 187 spica, 189 spiral reverse, 189 stump, 195 suspensory, 203 T-, 200 Velpeau, 197 Bandages, commercial roller, 186 Bandaging, 186 INDEX 791 Barley-water, 774 Bartholin's gland, cyst of, 478 Barton bandage, 195 Bassini operation, 442 Baths before operation, 350 Beard, preparation of, 355 Beck's paste, 241 Bed blocks, 18 making of, 19 Bed-board, iS Beds, specifications of, 17 Bedside chart, 22 Bed-sores, 282 causes, 282 prevention, 283 treatment, 285 Beebe's serum, 395 Beef-essence, 774 Beef-juice, 775 Beef -tea, peptonized, 775 with oatmeal, 775 Bellocq's cannula, 372 Bevan's incision, 430 Bier apparatus, 235 h}'peremic treatment, 230 for head, 234 for neck, 234 for testicles, 235 in immunization, 629 Bladder, exstrophy of, 546 operations on, 543 preparation of, 357 septic infection of, 141 Blue screen, therapy, 344 Bone, tuberculosis of, vaccine treatment of, 748 Bone-peg in fractures, 585 Bone-setting, so-called, 329 Bone-wax, 592 Boston L}ing-in Hospital bandage, 199, 402 Bowels, care of, 143 Bow-legs, 592 Brachial plexus, suture of, 567 Brain operations, 358 Branchial cleft sinus, 398 cyst, 398 Breast, abscess of, 403 amputation of, 401 bandage, 199, 402 tumors of, 402 Breeze, electric, 342 Briggs' cannula for abscess, 397 Bronchitis after anesthesia, 167 Bronchopneumonia after anesthesia, 167 Broth, chicken, 775 clam, 775 mutton, 775 oyster, 775 Bubo, inguinal, 570 Buck's extension, 582 Bunion, 597 Burns from hot-water bag, 165 of face from anesthetic, 165 Bursting of abdominal wound, 162 Cabot wire-splint, 579 Calomel, 146 Cancer of rectum, 553 radium treatment, 347 ^-ray treatment, 341 technique, 346 Cannula (Briggs) for abscess, 397 Carbolic acid poisoning, 257 Carbuncle of neck, 397 vaccine treatment of, 721 vaccine treatment of, 719 Cargile membrane, 299, 372 Carminatives, 151 Cartilage of knee, 588 Caruncle, excision of urethral, 477 Cascara, 145 Castor oil, 145 Castration, 518 Casts, shower of, after anesthesia, 170 Cataplasma kaoUni, 228 Catharsis before operation, 349 by foods, 144 by massage, 144 Cathartics, 145 Catheter, 134, 135 fever, 140 internal antisepsis in, 142 lubrication of, 136 method of retaining, 521 sterilization of, 135 Catheterization, 132 in female, 134 in male, 134 Cerebral abscess, 400 Cer\-ix operation, preparation for, 356 uteri operation, 483 Cesarean section, 503 Charcoal poultice, 228 Chart, bedside, 22 clinical, 22 nurse's, 21 792 INDEX Chest, gunshot wounds, 409 stab wounds, 409 soreness after anesthesia, 164 Chicken broth, 755 Chloralamid for alcoholism, 275 Chloretone for tetanus, 262 Chloroform, 27, 34 action on liver, 174 as respiratory irritant, 167 poisoning, delayed, 175 vomiting, 34 Chocolate, 775 Cholecystectomy, indications for, 430 Cholecystenterostomy, 433 Cholecystgastrostomy, 434 Cholecystotomy, 431 Choledochectomy, 435 Choledochenterostomy, 435 Choledochoduodenostomy, 435 Choledochostomy, 435 Choledochotomy, 434 Chopart's amputation, 307 Chronic infections, reasons for, 621 Cigarette drain, 219, 220 Circumcision, 514 Citrate and saline, 229, 632, 690 Clam broth, 775 Clamp and cautery operation, 550 Cleaning before bandaging, 187 Cleansing enema, 122 Cleft, branchial, 398 Cleft-palate, 365 speech after, 366 Clinical chart, 22 Club-foot, 593 Cocain habit, 272 Coffee, 775 and egg, 775 crust, 775 habit, 272 nutritious, 776 rice, 776 Coley treatment for sarcoma, 771 results of, 772 Collapse, 97 Collodion after hernia operation, 439 Colon vaccine, preparation of, 673 Colostomy, 421 Colpotomy for pelvic abscess, 478 Coma, diabetic, 94 uremic, 95 Compound fractures, 576 Conjuncti\'itis after anesthesia, 165 Convalescence, general treatment, 280 Convalescent recipes, 774 Corpuscular mixture, 675 Coxa vara, 592 Cream of tartar lemonade, 776 water, 511 Crepe Hsse for dressings, 211 Cribbing, 151 Crile cannula, 73 Crochet hook for stitch sinus, 243 Croton oil, 147 Cunningham hernia spica, 439, 440, 441 Curettage of uterus, 484 Custard, soft, 776 Cutaneous rashes, 253 Cyst, branchial, 398 hydatid, of liver, 429 of Bartholin's gland, 478 Cystitis, 136 causes of, 136 local treatment, 138 operative treatment, 139 prophylaxis of, 137 symptoms, 136 treatment, 137, 138, 139 vaccine treatment, 138 Cystocele, 474 Cystocolostomy, 547 Cystostomy, vaginal, 545 Cystotomy, lateral, 545 suprapubic, 543 Cysts, ovarian, 493 Death, sudden, 97 Decubitus, 282 Defecation, importance of habit, 143 mechanism of, 143 Delirium tremens, 119 causes of, 273 symptoms of, 273 treatment of, 274 D epilation versus shaving, 352 Depilatory paste, 352 Desault bandage, 196 Diabetes, chloroform in, 94 diet before operation, 178 Diabetic coma, 94 Diacetic acid, test for, 177 Diagnosis of tuberculosis by autoinocula- tion, 735 by opsonic index, 735 Diet after gastric ulcer, 420 after operation, 114 INDEX 793 Diet before operation, 350 in acute inflammation, 117 in chronic inflammation, 117 in severe injuries, 117 Digital evacuation of rectum, 147 Digitalis in shock, 91 Diphtheria antitoxin for hemophilia, 26S, 269 Diplococcus intracellularis meningitidis, dosage, 768 Dislocation, recurrent, of shoulder, 589 Distention, 151 paralytic, 152 puncture of intestine for, 155 Dosage of vaccine, guidance to, 643 of vaccines, table, 768, 770 Douche-hammock, 356 Drain, how to remove, 217 in case of doubt, 215 when to remove, 216 Drainage by cigarette, 220 by gauze, 218 by glass tube, 216 by rubber tube, 217 indications for, 215 methods of efficient, 225 reasons for, 214 temporary, 214 Dressing under anesthesia, 218 wounds, time for, 209 Dressing-tray, 212 Drug habits, 270 poisoning, 256 Duodenal ulcer, perforation of, 421 Duodenocholedochotomy, 435 Dupuytren's contraction, 571 Eclampsia, 95, 507 Eczema, vaccine treatment of, 729 Edema, pulmonary, after ether, 167 Effleurage, 316 Egg broth, 776 Egg-nog, hot, 776 No. I, 776 No. 2, 776 Eggs, scrambled, 776 soft-boiled, 776 Ehrenfried's club-foot plaster, 593 Elastic bandage for hyperemia, 232 Elaterin, 147 Elbow, excision of, 574 Electric breeze, 342 Electricity, faradic, 346 Electricity, galvanic, 343 static, 342 Electrotherapy, historic, 335 indications, 336 technique, 342 Empyema, thoracic, 404 vaccine treatment of, 724 subcutaneous, 407 Endometritis, 489 Enema, cleansing, 122 nutrient, composition of, 123, 124 proprietary preparation in 124 red urine in, 122 size of, 123 technique, 120 formulae, 125, 126 technique of giving, 150 drastic, 148 Enemas, mild, 148 Enterorrhaphy, 427 Enterostomy under cocaine, 157 Enucleation of eye, 362 Epididymitis, 527 Epispadias, 516 Epsom salt, 146 poisoning by, 146 Equinovarus, 593 Erysipelas, 254 vaccine treatment of, 727 Eserin salicylate as cathartic, 153 Esophagotomy, 390 Estlander's operation, 409 Ether as respiratory irritant, 166 drop method, 28 in stomach after operation, 35 pneumonia, statistics, 168 symptoms, 168 rash, 253 recovery, duration of, 31 position during, 32 vomiting after, 31 Ochsner treatment, 33 olive oil treatment, 36 Etherizing, 27 Ethyl chlorid, 27 Excision of elbow, 574 of shoulder, 574 of wrist, 575 of hip, 575 of knee, 575 of vulva, 476 Exstrophy of bladder, 546 Extra-uterine ])rcgnanc_\-, 502 794 INDEX Eye, enucleation of, 362 Eyebrow, preparation of, 355 Face, plastic operation on, 363 Facial paralysis, 361 Fallopian tubes, tuberculosis of, 498 Farabo.euf amputation, 307 Faradic current, 346 Fecal fistula, 246 causes of, 247 prophylaxis, 247 treatment, 248 Feeding after intubation, 389 rectal, 120 subcutaneous, 130 Feet, preparation of, 357 swelling of, 312 Femur, fracture of, 582 Finger contractures, electric treatment, 339 Finsen light for lupus, 750 Fissure in ano, 548 Fistula, 240 fecal, 246 in ano, 548 lymphatic, 245 of parotid, 361 perineal, 527 rectovaginal, 476 suprapubic, 544 treatment, by Beck's paste, 241 vesico-uterine, 507 vesicovaginal, 475 Flat-foot, exercises for, 312 postoperative, 312 shoe for, 315 Flatus, 151, 152 Flaxseed poultice, 228 Flexible shoes, 315 Fomentations, 228 Food recipes, 774 serving of, 118 Foods as cathartics, 144 Foreign bodies left in abdomen, 286 Formulae for nutrient enemas, 125, 126 Fowler position, 24, 469 relation to dilatation of stomach, 159 Fractures, compound, 576 open, 576 operative fixation of, 585 French heel bandage, 190 Friction, 317 of back, 319 of chest, 319 Friction of foot, 318 of hands, 317 of hip, 319 of leg, 318 of neck, 319 of thigh, 319 Fright, preanesthetic, 98 Frontal sinus, 373 Fulminating infections, vaccine treatment of, 686 Furuncle, vaccine treatment of, 712 Furunculosis, vaccine treatment of, 713 Gall-bladder operations, 430 Galvanic current, technique, 343 Gamgee dressing, 628 Ganglion, palmar, 570 Gangrene, poultice for, 228 Gant's operation, 592 Gartner's canal, abscess of, 507 Gas bacillus infection, 262 Gasserian ganglion, 360 Gastrectasia, 157 Gastrectomy, 415 Gastric dilatation, acute, 157 fistula, feeding in, 131 paresis, 157 ulcer, diet after, 420 perforation, 418 Gastro-enterostomy, 411 Gastromesenteric ileus, 157 Gastroplication, 417 Gastrotomy, 413 Gauze drainage, 218 Gavage, 127 indications for, 127 Gelatin as source of tetanus, 261 General peritonitis, 468 Genital tuberculosis, vaccine treatment of, 758 Genito-urinary surgery, 510 tuberculosis, vaccine treatment of, 758 Glass tube drainage, 216 Glycerin as a dressing, 219 enema, 147, 152 suppository, 147 Gonococcus, dosage, 76S, 770 vaccine, preparation of, 673 Gonorrheal arthritis, vaccine treatment of, 702 Grafting, 572 Granulations, treatment of excessive, 241 Gruel, cracker, 777 INDEX 795 Gruel, flour, 777 Indian-meal, 777 and flour, 777 oatmeal, 777 with milk, 777 Gum chewing for parotitis, 264 Gums, antiseptic for, 355 Gunshot wounds of abdomen, 437 of chest, 409 Gypsum for bandages, 191 Habit pain, 336 Habits, 270 Hairy areas, preparation of, 355 Hallux valgus, 597 Hammock, suspensory, 204 Hands, preparation of, 357 Hare-lip, 364 asphyxia after, 364 Harrington's solution, 354 Headcrown breeze, technique, 342 Heart, massage of, 92 Heart-clot, 105 Heat, methods of appl}'ing, 226 Heel, bandage of, 190 Hematemesis, 38 Hematoma, pehic, 500 Hemophilia, 266 animal serum for, 267 constitutional treatment, 267 treatment, 266 Hemorrhage, calcium lactate in, 68 causes of, 64 constitutional diathesis in, 68 treatment of, 69 delayed, 64 diagnosis of, 66 internal concealed, 65 local, treatment of, 6g Monsell's solution for, 375 nasal, 371 operative treatment of, 66 primary, 64 secondary, 67 summary treatment of, 70 symptoms, 65 Hemorrhoids, 550 Hepaticodocholithotripsy, 436 Hepaticodochostomy, 436 Hepaticodochotomy, 435 Hernia cerebri, 359 dressings, 439 Cunningham, 201 Hernia, epigastric, 442 femoral, 442 in children, 442 incarcerated, 443 inguinal, 439 interstitial, 442 obturator, 442 postoperative, 291 reduction en bloc, 447 retroperitoneal, 442 strangulated, 446 umbilical, 442 ventral, 442 Hiccough, causes, 179 pathology, 179 ■ prognosis, 180 treatment, iSo, 181 High blood-pressure, autocondensation for, 340 High-frequency current for sclerosis, 340 technique, 342 Highmore, antrum of, 372 Hip, excision of, 575 History before operation, 351 Hoffa table, use of, 583 Hoffman's anodyne for belching, 151 Hot-air treatment, 238 Hot-water bottles, burns from, 165 Houston, valves of, 149 Humerus, fracture of, 583 Hydrocele, injection for, 516 excision of, 517 Hydronephrosis, 532 Hymen, imperforate, 507 H}'peremia, methods of producing, 232 Hypodermic injection, technique of, 51 Hypospadias, 516 Hysterectomy, abdominal, 499 vaginal, 481 Icterus in acetonemia, 177 Iliac thrombosis, 502 Immunity, active, 603 duration of, after vaccine treatment, 715 passive, 604 Immunization, principles of, 601 Imperforate anus, 549 hymen, 507 rectum, 549 Incandescent light therapy, 344 Ingrowing nail, 570 Inguinal bulxj, 570 Innominate artery, ligations of, 560 796 INDEX Inoculation, antityphoid, 609 focal reaction, 659 local effects of, 716 reaction, 658 site for, 658 sterilizing syringe for, 672 technique of, 769 Insanity, causes, 276 forms, 277 occurrence, 276 postoperative, 276 prognosis, 277 treatment, 278 Instruments for abdonainal dressing, 209 for vaginal dressing, 472 Intestine, acute obstruction of, 156 puncture of, for distention, 155 Intubation, 382 after-care, 388 feeding in, 132, 389 indications for, 383 instruments for, 385 retained tube, 389 technique for, 383 Invalid recipes, 774 Inversion of uterus, 507 Iodoform poisoning, 257 Irish moss, 777 Irrigating a sinus, method of, 242 Irrigation, hot, 227 Ischiorectal abscess, 549 Jaitndice after chloroform, 177 in acetonemia, 177 Jaw, excision of lower, 360 soreness after anesthesia, 164 Jejunostomy, 427 Johns Hopkins operation for hernia, 442 Joint adhesion, electric treatment, 339 Joints, tuberculosis of, vaccine treatment of, 749 vaccine treatment of, 700 Junket, 777 cocoa, 777 egg, 778 Keloid, x-ray treatment, 342 Kidney drainage, permanent, 536 fatty degeneration of, after chloroform, 170 operations on, 533 surgical, 533 Klapp suction-cups, 235 Knee, excision of, 575 operations on, 588 strapping, 202 Knock-knees, 592 Kollmann dilator, 519 Kraske operation, 150, 553 LAillNECTOMY, 598 Laryngeal operations, feeding in, 131 Laryngotomy, 381 Lavage, technique, 127, 128 Layout for abdominal dressing, 209 Lemonade, flaxseed, 778 with egg, 778 Licorice powder, 145 Ligation of carotid artery, 561 of external Uiac artery, 562 of femoral arter}^, 562 of innominate artery, 560 of subcla\ian, 561 of ureter, 501 Light therapy, technique, 344 Limbs, artificial, 307 Lime-water, 778 Lithotomy, perineal, 545 Littauer-Paynes scissors, 212 Liver, abscess of, 428 acute yellow atrophy of, 176 hydatid cyst of, 429 post-anesthetic degeneration of, 174 superfatted, 174 action of chloroform on, 174 Locke's solution, 113 Lund swathe, 198 Lupus, treatment by Finsen-ray, 750 vaccine treatment, 749 Lymphatic fistula, 245 Lymph-nodes of neck, 396 Magnesitjm sulphate for tetanus, 262 Malta fever, 697 Many-tailed bandage, 200 Massage, 316 of abdomen, 325 of arm, 322 of back, 324 of chest, 325 of feet, 322 of fingers, 321 of heart, 92 of leg, 323 of thigh, 323 Mastoid operation, preparation for, 355 INDEX 797 Mastoiditis, 398 Matas' operation, 563 Mattress, 18 Maydl's operation, 547 McArthur's operation, 442 McBurney incision, 454 hernia after, 461 no drainage, 455 temporary drainage, 458 with abscess, 458 Meatotomy, 515 Medicinal rash, 256 Membrane, Cargile, 299 Menopause, psychoses in, 278 Mercury, idiosyncrasy to, 256 Micrococcus catarrhalis, 76S neoformans, dosage, 76S Mikulicz tampon, 221 Milk and albumen, 778 and molasses enema, 148 and water, hot, 778 peptonized, cold process, 778 immediate process, 778 sago, 778 milk-punch, 778 Miscarriage, 484 JMorphin habit, 271 Mosetig-Moorhof's bone-wax, 592 Mouth cleanliness before operation, 350 gag, 30 preparation of, 355 washing for thirst, 42 IMurphy's button, 427 Muscle atrophy, treatment, 338 suture of, 565 Mutton broth, 775 M3'ocarditis after fibroids, 502 Myomectomy, 507 Nail, ingrowing, 570 Nailing fractures, 585 Nasal adhesions, 371 feeding, 129 polypi, 371 spurs, 371 hemorrhage, 371 Nausea, 32 Neck, abscess of, 397 carbuncle of, 397 lymph-nodes of, 396 operations on, 378 Negative phase, 611 Nephrectomy, 539 Nephritis after anesthesia, 169 after chloroform, 170 post -operative, statistics, 169 treatment, 171 Nephrorrhaphy, 541 Nephrotomy, 533 apparatus, 536 double, 534 Nerve anastomosis, 567 cocainization to prevent shock, 86 injury, electric treatment, 33S suture, 566 Neurasthenia, postoperative, electric treat- ment, 340 Neuritis, pressure, 33S Nitrous oxid, 27 Noma, 351 Nose, preparation of, 356 Nurse's chart, 21 instruments, 21 Nutrient enema, 123 Obstruction, acute intestinal, 156 mechanical, of intestine, 156 septic, of intestine, 156 symptoms of, 157 when to operate, 157 whether to operate, 157 Obstructive h3^eremia, 232 Ochsner treatment of ether vomiting, 33 O'Dwyer cannula, 384 Oil injection of urethra, 513 sterilization, 672 Olecranon, fracture of, 588 Olive oil as laxative, 145 for adhesions, 299 Open fractures, 576 Ophthalmic reaction, 733 Opsonic incubator, 677 index and symptoms, correlation of, 648 formula of, 608 normal variations, 613 technique of, 675 theory of, 608 Opsonins, definition of, 605 origin of, 606 Osteomyelitis, 590 acute, 591 chronic, 592 subacute, 591 vaccine treatment of, 725 Osteoplastic resection of skull, 359 Ovarian cysts, 493 798 INDEX Ovariotomy, 493 Ovary, resection of, 493 Overdosage of vaccines, 654 Oyster broth, 775 Packard's suprapubic drainage, 531 Pain, 47 cicatricial, 337 congestive, 337 habit, 2,3^^ treatment by vacuum tube, 343 Painful stump, 558 Palmar ganglion, 570 Pancreas, wounds of, 448 Pancreatic cyst, 448 Pancreatitis, acute, 447 Paquelin cautery for paresis of bowels, 153 Paraffin prosthesis, 370 Paralysis, postanesthetic, 165 Paralytic distention, 152 Paresthesia, electric treatment, 340 Parkhill clamp, 585 Paronychia, 570 Parotid fistula, 361 tumors of, 361 Parotitis, 263 causes of, 264 suppuration in, 264 treatment, 264 Passive immunity, 604 motions, 329 Patella, fracture of, 587 Pelvic abscess, 478 hematoma, 500 Penis, operations on, 510 Percussion movements, 327 Perforation of uterus, 489 Pericardium, operations on, 409 Perineal drainage-tube, 528 dressing (Cunningham), 206 home -method for, 514 fistula, 527 prostatectomy, 528 Perineorrhaphy ,_ 471 complete, 473 Perionychia, 570 Peritoneum, drainage of, 215 tuberculosis of, 498 Peritonitis, castor oil into intestine for, 154 general, 46S Peritonsillar abscess, 377 Petrissage, 316 Pfannensteil's incision, 292 Phagocytic variations, 612 Phases, sequence of, 612 Phenol poisoning, 257 Phenolphthalein, 145 Phlebitis, portal, 466 Phlegmon, vaccine treatment of, 689 Physical examination before operation, 351 Picric acid poisoning^ 258 Pillows, 18 Pinching, 327 Pirogoff amputations, 307 Plaster jacket causing gastric dilatation, 160 Plaster-of-Paris bandage, 191, 192, 193, 194 Plastic operations on face, 363 Pneumococcus, 768 dosage, 770 vaccine, preparation of, 673 Pneumonia after anesthesia, 166 postoperative, causes of, 168 Poisoning, iodoform, 257 carbolic acid, 257 phenol, 257 picric acid, 258 Polypi, nasal, 371 Porro operation, 505 Portal phlebitis, 466 Position, Fowler, 24 Positive phase, 611 Possett treacle, 778 Posterior wire splint, 579 Postoperative flat-foot, 312 hernia, prophylaxis, 292 symptoms, 293 treatment, 294 Posture, dorsal, 23 Fowler, 24 Rose, 377 semiprone, 24 Poultices, 228 Pregnancy, extra-uterine, 502 Preparation of patient, 348 Pressure neuritis, 338 Proctectomy, vaginal, 557 Proctoclysis, 42 apparatus for, 43 . Prolapse of rectum, 553 Prostatectomy perineal, 528 • suprapubic, 530 Prostatic abscess, 532 Prostatotomy, 532 Prosthesis, paraffin, 370 Provisional sutures, 214, 219 INDEX 799 Psoas abscess, 569 Psychoses, postoperative, 273 Pubiotomy, 492 Puerperal sepsis, vaccine treatment of, 694 Pulmonary edema after ether, 167 embolism, 10 1 mortality of, 102 operative treatment, 104 prophylaxis, 103 symptoms, 102 treatment, 103 Pulse, 52 force of, 54 irregular, 54 irregularity of, 54 rate, 53 rhythm, 54 tension of, 56 volume of, 56 Puncture of intestine for distention, ^55 Pyemia, 250 Pylephlebitis, 106 diagnosis of, 107 pathology of, 106 prognosis of, 107 Pylorectomy, 418 Quinsy, 377 Rabbit serum for hemophilia, 268 Radium therapy, 347 Ranula, 368 Rash, ether, 253 medicinal, 256 septic, 253 Raw-meat sandwich, 778 Recipes for the sick, 774 Recovery room, 35 Rectal feeding, 120 indications, 120 technique, 120 plug, 220 suppository of foods, 125 lube for flatus, 152 Rectocele, 471 Rectovaginal fistula, 476 Rectum, cancer of, 553 digital evacuation of, 147 imperforate, 549 operations on, 550 preparation of, 357 prolapse of, 553 stricture of, 551 Rectus incision, drainage, 460 hernia after, 461 Recurrent bandage of head, 195 Red screen, therapy, 344 Reduction en bloc, 447 Relief of pain by electricity, 336 Remedial movements, 328 Removal of stitches, 210, 212, 213 Resistive motions, 330 Respiration, 63 artificial, 109 Rest and pain, 226 as treatment, 225 Restlessness, 39 Resuscitation by oxygen, 112 by electricity, 112 Retropharyngeal abscess, 377 Retroversion of uterus, 493 Reverdin grafts, 573 for bed-sores, 285 Ribs, strapping, 201 Ringer's solution, 113 Robson's bone-bobbin, 428 Rochelle salt, 146 Rogers' serum, 395 Rontgen ray. See X-ray. Rose position, 377 Rubber tube drainage, 217 fenestrated, 220 inverted, 220 Ruptured urethra, 528 Saline infusion, 45 rectal, 42 solution, 45 Salpingitis, tuberculous, 498 Salpingo-oophorectomy, 495 Salt and citrate solution (Wright), 632 Sarcoma, Coley treatment, 771 Scalp, preparation of, 355 wounds, aseptic, 358 septic, 358 with necrotic bones, 35S Scar, electric treatment, 338 Scarlatina, surgical, 255 Schedc's operation, 409 Scissors for stitches, 212 Scrotum, operations on, 516 Scrubbing, 353 Scidlitz powder, 146 Septic rash, 253 wounds, treatment, 225 8oo INDEX Septicemia, 250 vaccine dosage in, 699 treatment of, 693 Septico metastasis, 251 Septicopyemia, 250 causes, 250 diagnosis, 251 prognosis, 251 symptoms, 251 treatment, 252 Serum, Beebe's, 395 Coley's, 771 Shock, adrenalin in, 87 causes, 82 definition, 82 elastic suit of Crile, 89 experimental investigations, S3 hypodermoclysis in, 89 intravenous infusion in, 90 massage of heart in, 92 prophylaxis, 85 stimulating enema, 93 sjinptoms, 84 treatment, 84 by drugs, 88, 91 urethral, 140 Shoes, flexible, 315 Shoulder, excision 'of, 574 Sick-room, 17 furniture, 18 Sinus, frontal, 373 Sinuses, 240 tuberculous, vaccine treatment of, 743 vaccine treatment of, 726 Sipping, 116 Skin-grafting, 572 Skull operations, 358 Sling, 203 double, 203 Slipping of pedicle Ugature, 494 Smith splint, 582 Soda bicarbonate in acetonemia, 178 Sound, technique of passing, 522 Soup, rice, 779 white celery, 779 Spark, technique, 342 Spica bandage, 189 of hip, 189 of shoulder, 190 Spina bifida, 597 Spine, fracture of, 599 Spiral drain, 220 reverse bandage, 189 Spirochceta gracilis, 351 Splenectomy, 450 Split rubber drain, 220 Spurs, nasal, 371 Stab wounds of chest, 409 Standardization of a vaccine, 663 Staphylococcus, dosage, 768, 770 vaccine, preparation of, 660 Static electricity, 342 Status lymphaticus, 98, 265 Stauungs-h}'peremie, 232 Sterilization by oil, 672 Stimulation before operation, 351 Stitch abscess, 221 intracuticular, 213 scissors, 212 Stitches, removal of, 210 Stockings, right and left, 597 Stomach, acute dilatation of, 154, 157 causes, 158 f requeue}-, 158 dilatation, "relation of Fowler position to, 159 Strapping abdominal wound, 201 ankle, 201 knee, 202 ribs, 201 Streptococcus, dosage, 768, 770 vaccine, preparation of, 673 Strophanthin in shock, 92 Strj-chnin for paresis of bowels, 153 Stump bandage, 195 painful, 558 shrinkage of, 311 Stump-corset, 311 Subcutaneous feeding, 130 Subdiaphragmatic abscess, 107 Subphrenic abscess, 107, 462 after appendicitis, 464 Succussion in acute gastric dilatation, 160 Sucker-drainage, 216 Suction-cups, 235 Suction-pump, 237 Sudden death, 97 Sunlight in convalescence, 281 Superheated dry air, therapy, 345 Suppression of urine, 510 Suprapubic cystotom}-, 543 fistula, 544 prostatectomy, 530 Surgical kidney, 533, 545 scarlatina, 255 Suspensory bandages, 203 INDEX 8oi Suspensory bandages, adhesive plaster, 205 Suture, arterial, 562 of brachial plexus, 567 of muscle, 565 of nerve, 566 of tendon, 565 Suturing fractures, 585 Sycosis, vaccine treatment of, 728 Syme's amputations, 307 Symphysiotomy, 490 Synovial fringe of knee, 588 Swathes, 200 abdominal, 301 Sweating, 40 Sweetbreads, 779 Tamaeind-watee, 779 Tapotement, 316 T-bandage, 200 Tea, 779 corn, 779 habit, 272 Technique, electrotherapeutic, 342 of a dressing, 212 Temperature, 58 after hemorrhage, 59 aseptic, 58 in sepsis, 61 in shock, 59 intercurrent causes of, 62 Tendon, suture of, 565 transplantation, 566 Tenosynovitis, tuberculous, 570 Testicles, bandage to elevate, 203 Testis, gangrene of, 517 undescended, 518 Testudo bandage of heel, 191 Tetanus, 259 causes, 259 relation of rectal operations to, 260 treatment, 261 Therapy, light, 344 Thiersch grafts, 572 Thirst, 41 treatment of, 42 Thoracic duct, injury of, 245 fistula of, 245 Thoracoplasty, 409 Thorax, operations on, 401 Thrombophlebitis, 99 prophylaxis, 100 symptoms of, 100 treatment of, loi 51 Thrombosis, etiology, 99 iliac, 502 Throttled pipet, 682 Throttling the belly for hiccough, 180 Thyroidectomy, partial, 390 anesthesia in, 390 Thyroidism, 393 Thyrotoxicosis, 391 « serum treatment, 395 Time for dressing wounds, 209 Toast, milk, 779 peptonized milk, 779 Toast-water, 779 Tobacco habit, 272 Toe contractures, electric treatment, 339 Tongue, coating of, 183 forceps, 30 rhythmic traction of, 112 significance of, 182 soreness, after anesthesia, 164 Tonics, 281 Tonsils, enlarged, 375 tumors of, 376 Town treatment for alcohol, 271 Tracheal tube, removal of, 379 Trachelorrhaphy, 483 Tracheotomy, 378 technique of, 37 Transfusion, 70 arrangement of operating room, 78 general management of a, 77 history of, 71 technique, 73 the donor, 77 the recipient, 77 Trendelenburg position and pneumonia, 168 Trephining, 358 Truss after hernia operations, 442 Tubal pregnancy, 502 Tuberculin, choice of, 737 dosage, 747, 768, 770 methods of giving, 737 preparation of, 673 treatment of, 673 prognosis, 751 Tuberculosis, genital, vaccine treatment, 758 localized, vaccine treatment of, 731 renal and vesical, 754 vaccine treatment, 751 vesical, 756 Tuberculous lymph-nodes, prognosis, 744 x-ray treatment, 342 802 INDEX Tuberculous lymphnoditis, vaccine treat- ment of, 739 peritonitis, 49S salpingitis, 498 tenosyno\dtis, 570 Tubes, resection of, 493 Turpentine as carminative, 152 compound enemas of, 149 stupes for flatus, 153 Tympanitis, 153, 154 importance of diagnosis, 154 Typhoid, inoculation against, 609 vaccine, preparation of, 673 Ulcer of duodenum, perforation, 421 of stomach, perforation, 418 Uremia, 96 Uremic coma, 95 Ureter, accidental ligation of, 501 kink in, 542 operations on, 543 Urethra, preparation of, 357 rupture of, 528 Urethral caruncle, excision of, 477 shock, 140 Urethrotomy, external, 519 internal, 51S • Urinal, female, 546 male, 530 Urinalysis, importance of, 511 Urinary fever, acute, 140 chronic, 140 drainage for, 142 fistula, persistent, 536 Urine before operation, 351 suppression of, 510, 539 Uterine sepsis, vaccine treatment of, 694 Uterus, atresia of, 506 inversion of, 507 perforation of, 489 retroversion of, 493 Vaccine, bacterial, definition of, 610 bottling of, 669 definition of, 660 galactose-killed, 768 keeping quahties of, 668 laborator}' technique, 660 preparation of, 659 standardization of, 663 summary of, indication for, 643 therapy, dangers of, 650 treatment, diagram of, 607 Vaccine treatment of acne, 718 of antrum disease, 725 of carbuncle, 719 of eczema, 729 of empyema, 724 of erysipelas, 727 of fulminating infections, 686 of furuncle, 712 of furunculosis, 713 of gonorrheal arthritis, 702 of infectious arthritis, 700 of lupus, 749 of osteom3^elitis, 725 of phlegmon, 689 of puerperal sepsis, 694 of renal tuberculosis, 751 of septicemia, 693 of sinuses, 726 of suppurative arthritis, 707 of sycosis, 728 of tuberculosis of bones, 748 of tuberculous joints, 749 h-mphnoditis, 739 sinuses, 743 of uterine sepsis, 694 ^'accines, case of overdosage, 656 frequency of dosage, 653 living, 765 new methods of preparation, 764 overdosage, 654 serious results from, 656 sterilization of, 685 table of dosage, 768, 770 Vacuum tubes, technique, 343 Vagina, atresia of, 506 preparation of, 356 Vaginal h}-sterectomy, 481 cyst, 507 cystostomy, 545 douche, method of, 356 position, 472 drains, 219 proctectomy, 557 section for abscess, 478 for appendages, 480 Valve of Gerlach, 452 Varicocele, 517 Varicose eczema, vaccine treatment of, 729 ulcer, vaccine treatment of, 730 veins, 564 bandage for, 191 \'arnish, antiseptic, 363 \'eins, varicose, 564 INDEX 803 Velpeau bandage, 196 modified, 197 Ventrofixation, 493 Ventrosuspension, 493 Vesico-uterine fistula, 507 Vesicovaginal fistula, 475 Vibration therapy, 345 Vicious circle vomiting, 412 Vomiting, 32 Bier treatment, 37 champagne for, 37 drug treatment, 37 gastric lavage for, 36 heat and cold for, 37 in vicious circle, 412 of blood, 38 Von Pirquet reaction, 732, 733 Vulva, excision of, 476 Vulvovaginal abscess, 477 Water bed, 18 Water-drinking before operation, 350 Watson's nephrotomy apparatus, 536 perineal button, 520 drainage-tube, 528 Wave-current, technique, 342 Weak foot, 312 Weir's operation, 556 Whitehead's operation, 150, 552 Wick, method of inserting, 243 Wine, mulled, 779 whey, 779 Wiring fractures, 585 Wolf grafts, 573 Worsted truss, 443 Wounds, signs of sepsis, 223 time for dressing, 209 Wright's citrate and sahne, 229 Wrist, excision of, 575 X-RAY treatment of cancer, 341 of keloid, 342 of tuberculous lymph-nodes, 342 SAUNDERS' BOOKS on Skin, Genito-Urinary Diseases, Chemistry, and Eye, Ear, Nose, and Throat W. B. SAUNDERS COMPANY 925 WALNUT STREET PHILADELPHIA 9, HENRIETTA STREET. COVENT GARDEN. LONDON MECHANICAL EXCELLENCE |kTOT alone for their literary excellence have the Saunders publi- ^ cations become a standard on both sides of the Atlantic : their mechanical perfection is as universally commended as is their sci- entific superiority. The most painstaking attention is bestowed upon all the details that enter into the mechanical production of a book, and medical journals, both at home and abroad, in reviewing the Saunders publications, seldom fail to speak of this distinguishing feature. The attainment of this perfection is due to the fact that the firm has 'its own Art Department, in which photographs and drawings of a very high order of merit are produced. This department is of decided value to authors, in enabling them to procure the services of artists specially skilled in the various methods of illustrating medical publications. A Complete Catalogue of our Publications will be Sent upon Request SAUNDERS' BOOKS ON Barnhill and Wales' Modern Otolog(y A Text=Book of Modern Otology. By John F. Barnhill, M. D., Professor of Otology, Laryngology, and Rhinology, and Earnest DE W. Wales, M. D., Associate Professor of Otology, Laryngology, and Rhinology, Indiana University School of Medicine, Indianapolis, Octavo of 575 pages, with 305 original illustrations. Cloth, $5.50 net; Half Morocco, ;^7.oo net. THE PRACTITIONER'S OTOLOGY The authors, in writing this work, kept ever in mind the needs of the physician engaged in general practice. It represents the results of personal experience as practitioners and teachers, influenced by the instruction given by such authorities as Sheppard, Dundas Grant, Percy Jakins, Jansen, and Alt. Much space is devoted to prophylaxis, diagnosis, and treatment, both medical and surgical. There is a special chapter on the bacteriology of ear affections — a feature not to be found in any other work on otology. Great pains have been taken with the illustrations, in order to have them as practical and as helpful as possible, and at the same time highly artistic. A large num.ber represent the best work of Mr. H. F. Aitken. PERSONAL AND PRESS OPINIONS Frank AUport, M. D. Professor of Otology, Northwestern University, Chicago. " I regard it as one of the best books in the English language on this subject. The pictures are especially good, particularly as they are practically all original and not the old reproduced pictures so frequently seen." C. C. Stephenson, M. D. Professor of Ophthalmology aud Otology, College of Physicians and Surgeons, Little Rock Arkansas. " To my mind there is no work on modern otology that can for a moment compare with ' Barnhill and Wales.' " Journal American Medical Association " Its teaching is sound throughout' and up to date. The strongest chapters are those on suppuration of the middle ear and the mastoid cells, and the intracranial complications of ear disease." DISEASES OF THE EYE, DeSchweinitz's Diseases of the Eye Recently Issued — The New (6lh) Edition Diseases of the Eye: A Handbook of Ophthalmic Practice. By G. E. deSchweixitz, M.D., Professor of Ophthalmology in the Uni- versity of Pennsylvania, Philadelphia, etc. Handsome octavo of 945 pages, 354 text-illustrations, and 7 chromo-lithographic plates. Cloth, ;^5.00 net; Sheep or Half Morocco, ^6.50 net. WITH 354 TEXT-ILLUSTRATIONS AND 7 COLORED PLATES THE STANDARD AUTHORITY Dr. deSchweinitz's book has long been recognized as a standard authority upon eye diseases, the reputation of its author for accuracy of statement placing it far in the front of works on this subject. For this edition Dr. deSchweinitz has subjected his book to a most thorough revision. Fifteen new subjects have been added, ten of those in the former edition have been rewritten, and throughout the book reference has been made to vaccine and serum therapy, to the relation of tuberculosis to ocular disease, and to the value of tuberculin as a diagnostic and therapeutic agent. The text is fully illustrated with black and white cuts and colored plates, and in every way the book maintains its reputation as an authority upon the eye. PERSONAL AND PRESS OPINIONS Samuel Theobald, M.D., Clinical Professor of Ophthalmology, Johns Hopkins University, Baltimore. " It is a work that I have held in high esteem, and is one of the two or three books upon the eye which I have been in the habit of recommending to my students in the Johns Hopkins Medical School." University of Pennsylvania Medical Bulletin "Upon reading through the contents of this book we are impressed by the remarkable fulness with which it reflects the notable contributions recently made to ophthalmic literature. No important subject within its province has been neglected." Johns Hopkins Hospital Bulletin "No single chapter can be selected as the best. They are all the product of a finished authorship and the work of an exceptional ophthalmologist. The work is certainly one of the best on ophthalmology extant, and probably the best by an American author." SAUiYDERS' BOOKS ON Brtihl, Politzer, and Smith's Otology Atlas and Epitome of Otology. By Gustav Bruhl, M. D., of Berlin, with the collaboration of Professor Dr. A. Politzer, of Vienna. Edited, with additions, by S. MacCuen Smith, M.D., Pro- fessor of Otology in the Jefferson Medical College, Philadelphia. With 244 colored figures on 39 lithographic plates, 99 text illustra- tions, and 292 pages of text. Cloth, $3.00 net. Ifi Saimders' Hand- Atlas Series. INCLUDING ANATOMY AND PHYSIOLOGY The work is both didactic and clinical in its teaching. A special feature is the very complete exposition of the minute anatomy of the ear, a working knowl- edge of which is so essential to an intelligent conception of the science of otology. The association of Professor Politzer and the use of so many valuable specimens from his notably rich collection especially enhance the value of the treatise. The work contains everything of importance in the elementary study of otology. Clarence J. Blake, M. D., Professor of Otology in Harvard University Medical School, Boston. " The most complete work of its kind as yet published, and one commending itself to both the student and the teacher in the character and scope of its illustrations." Haab and deSchweinitz*s Operative Ophthalmology Atlas and Epitome of Operative Ophthalmology. By Dr. O. Haab, of Zurich. Edited, with additions, by G. E. de Schweinitz, M, D., Professor of Ophthalmology in the University of Pennsylvania. With 30 colored lithographic plates, 154 text-cuts, and 375 pages of text. In Saunders' Hand-Atlas Series. Cloth, $3.50 net. Dr. Haab's Atlas of Operative Ophthalmology will be found as beautiful and as practical as his two former atlases. The work represents the author's thirty years' experience in eye work. The various operative interventions are described with all the precision and clearness that such an experience brings. Recognizing the fact that mere verbal descriptions are frequently insufficient to give a clear idea of operative procedures, Dr. Haab has taken particular care to illustrate plainly the different parts of the operations. Johns Hopkins Hospital Bulletin " The descriptions of the various operations are so clear and full that the volume can well hold place with more pretentious text-books." DISEASES OF THE EYE. Haab and DeSchweinitz*s External Diseases qf the Eye Atlas and Epitome of External Diseases of the Eye. By Dr. O. Haab, of Zurich. Edited, with additions, by G. E. deSchweinitz, M. D., Professor of Ophthalmology, University of Pennsylvania. With 1 01 colored illustrations on 46 lithographic plates and 244 pages of text. Cloth, $3.00 net. In Smmdcrs' Hand-Atlas Scries. THE NEW (3d) EDITION Conditions attending diseases of the external eye, which are often so compHcated, have probably never been more clearly and comprehensively expounded than in the forelying work, in which the pictorial most happily supplements the verbal description. The price of the book is remarkably low. The Medical Record, New York " The work is excellently suited to the student of ophthalmology and to the practising physician. It cannot fail to attain a well-deserved popularity." Haab and DeSchweinitzV Ophthalmoscopy Atlas and Epitome of Ophthalmoscopy and Ophthalmoscopic Diagnosis. By Dr. O. Haab, of Zurich. Edited, with additions, by G. E. deSchweinitz, M. D., Professor of Ophthalmology, University of Pennsylvania. With 152 colored lithographic illustrations and 92 pages of text. Cloth, ;^3.oo net. In Saiindcrs' Hand-Atlas Series. THE NEW (2d) EDITION The great value of Prof. Haab's Atlas of Ophthalmoscopy and Ophthalmo- scopic Diagnosis has been fully established and entirely justified an English translation. Not only is the student made acquainted with carefully prepared ophthalmoscopic drawings done into well-executed lithographs of the most im- portant fundus changes, but, in many instances, plates of the microscopic lesions are added. The whole furnishes a manual of the greatest possible service. The Lancet. London "We recommend it as a work that should be in the ophthalmic wards or in the library of every hospital into which ophthalmic cases are received." SAUNDERS' BOOKS ON Cradle's Nose, Pharynx, and Ear Diseases of the Nose, Pharynx, and Ear. By Henry Gradle, M. D., Professor of Ophthalmology and Otology, Northwestern Uni- versity Medical School, Chicago. Handsome octavo of 547 pages, illustrated, including two full-page plates in colors. Cloth, $l.^Q net. INCLUDING TOPOGRAPHIC ANATOMY This volume presents diseases of the Nose, Pharynx, and Ear as the author has seen them during an experience of nearly twenty-five years. In it are answered in detail those questions regarding the course and outcome of diseases which cause the less experienced observer the most anxiety in an individual case. Topographic anatomy has been accorded liberal space. Pennsylvania Medical Journal "This is the most practical volume on the nose, pharynx, and ear that has appeared recently. ... It is exactly what the less experienced observer needs, as it avoids the confusion incident to a categorical statement of everybody's opinion." Kyle's Diseases of Nose and Throat Diseases of the Nose and Throat. By D. Braden Kyle, M. D., Professor of Laryngology in the Jefferson Medical College, Phila- delphia. Octavo, 797 pages; with 219 illustrations, 26 in colors. Cloth, ^4.00 net; Half Morocco, ^5.50 net. THE NEW (4th) EDITION Four large editions of this excellent work fully testify to its practical value. In this edition the author has revised the text thoroughly, bringing it absolutely down to date. With the practical purpose of the book in mind, extended con- sideration has been given to treatment, each disease being considered in full, and definite courses being laid down to meet special conditions and symptoms. Pennsylvania Medical Journal " Dr. Kyle's crisp, terse diction has enabled the inclusion of all needful nose and throat knowledge in this book. The practical man, be he special or general, will not search in vain for anything he needs." EYE, EAR, NOSE, AND THROAT. GET ^ • THE NEW THE BEST I^ lit 6 It 1 C Si 11 STANDARD American Illustrated Dictionary The New (5th) Edition The American Illustrated Medical Dictionary. A new and com- plete dictionary of the terms used in Medicine, Surgery, Dentistry, Pharmacy, Chemistry, and kindred branches; with over loo new and elaborate tables and many handsome illustrations. By W. A. Newman DoRLAND, M. D., Editor of "The American Pocket Medical Diction- ary." Large octavo, nearly 876 pages, bound in full flexible leather. Price, 1^4.50 net; with thumb index, ;^5.oo net. A KEY TO MEDICAL LITERATURE— WITH 2000 NEW TERMS In this edition the book has been subjected to a thorough revision. The author has also added upward of two thousand important new terms that have appeared in medical literature during the past few months. Howard A. Kelly, M. D., Professor of Gynecologic Surgery, Johns Hopkins University , Baltimore " Dr. Dorland's Dictionary is admirable. It is so well gotten up and of such convenient size. No errors have been found in my use of it." Theobald's Prevalent Eye Diseases Prevalent Diseases of the Eye. By Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology, Johns Hopkins University. Octavo of 550pages, with 219 text-cuts and several colored plates. Cloth, ^4.50 net ; Half Morocco, ^6.00 net. THE PRACTITIONER'S OPHTHALMOLOGY With few exceptions all the works on diseases of the eye, although written ostensibly for the general practitioner, are in reality adapted only to the specialist ; but Dr. Theobald in his book has described very clearly and in detail those condi- tions, the diagnosis and treatment of which come withm the province of the general practitioner. The therapeutic suggestions are concise, unequivocal, and specific. It is the one work on the Eye written particularly for the general practitioner. Charles A. Oliver, M.D.. Clinical Professor of Ophthalmology, Woman's Medical College of Pennsylvania. " I feel I can conscientiously recommend it, not only to the general physician and medical student, for whom it is primarily written, but also to the experienced ophthalmologist. Most surely Dr. Theobald has accomplished his purpose." 8 EYE, EAR, NOSE, AND THROAT. deSchweinitz and Holloway on Pulsating Exoph- thalmos Pulsating Exophthalmos. An analysis of sixty-nine cases not pre- viously analyzed. By George E. deSchweinitz, M. D., and Thomas B. Holloway, M. D. Octavo of 125 pages. Cloth, ^2.00 net. This monograph consists of an analysis of sixty-nine cases of this affection not previously analyzed. The therapeutic measures, surgical and otherwise, which have been employed are compared, and an endeavor has been made to determine from these analyses which procedures seem likely to prove of the greatest value. It is the most valuable contribution to ophthalmic liter- ature within recent years. British Medical Journal " The book deals very thoroughly with the whole subject and in it the most complete account oi the disease will be found." Jackson on the Eye The New (2d) Edition A Manual of the Diagnosis and Treatment of Diseases of the Eye. By Edward Jackson, A. M., M. D., Professor of Ophthalmology, University of Colorado. i2mo volume of 615 pages, with 184 beautiful illustrations. Cloth, ^2.50 net. The Medical Record, New York " It is truly an admirable work. . . . Written in a clear, concise manner, it bears evidence of the author's comprehensive grasp of the subject. The term ' multum in parvo' is an appropriate one to apply to this woi-k." Grant on Face, Mouth, and Jaws A Text-'Book of the Surgical Principles and Surgical Diseases OF the Face, Mouth, and Jaws. For Dental Students. By H. Horace Grant, A. M., M. D., Professor of Surgery and of Clinical Surgery, Hospital College of Medicine, Louisville. Octavo of 231 pages, with 68 illustrations. Cloth, ^2.50 net. Friedrich and Curtis on Nose, Larynx, and Ear RhINOLOGY, LARYNGOLOGy, AND OtOLOGY, AND ThEIR SIGNIFICANCE IN General Medicine. By Dr. E. P. Friedrich, of Leipzig. Edited by H. Holbrook Curtis, M. D., Consulting Surgeon to the New York Nose and Throat Hospital. Octavo volume of 350 pages. Cloth, ^2.50 net. GENITO-URINARY AND NOSE, THROAT, ETC. 9 Greene and Brooks* Genito-Urinary Diseases Diseases of the Qenito=Urinary Organs and the Kidney. By Robert H. Greene, M. D., Professor of Genito-Urinary Surgery at Fordham University ; and Harlow Brooks, M. D., Assistant Pro- fessor of Clinical Medicine, University and Bellevue Hospital Medical School. Octavo of 605 pages, illustrated. Cloth, ^5.00 net; Half Morocco, $6.50 net. THE NEW (2d) EDITION This new work presents both the medical and surgical sides. Designed as a work of quick reference, it has been written in a clear, condensed style, so that the information can be readily grasped and retained. Kidney diseases are very elaborately detailed. New York Medical Journal " As a whole the book is one of the most satisfactory and useful works on genito-urinary diseases now extant, and will undoubtedly be popular among practitioners and students." Gleason on Nose, Throat, and Ear A Manual of Diseases of the Nose, Throat, and Ear. By E. Baldwin Gleason, M. D., LL. D., Clinical Professor of Otology, Medico-Chirurgical College, Philadelphia. i2mo of 556 pages, pro- fusely illustrated. Flexible leather, $2.50 net. FOR PRACTITIONERS Methods of treatment have been simplified as much as possible, so that in most instances only those methods, drugs, and operations have been advised which have proved beneficial. A valuable feature consists of the collection of formulas. American Journal of the Medical Sciences " For the practitioner who wishes a reliable guide in laryngology and otology there are. few books which can be more heartily commended." American Text=Book of Genito=Urinary Diseases, Syphilis, and Diseases of the 5kin. Edited by L. Bolton Bangs, M. D., and W. A. Hardaway, M. D. Octavo, 1229 pages, 300 engravings, 20 colored plates. Cloth, ^7.00 net. SAUNDERS' BOOKS ON StelwagonV Diseases of the Skin A Treatise on Diseases of the Skin. By Henry W. Stelwagon, M. D., Ph. D., Professor of Dermatology in the Jefferson Medical College, Philadelphia. Octavo of 1180 pages, with 280 text-cuts and 32 plates. Cloth, ^6.00 net ; Half Morocco, $7.50 net. JUST READY— THE NEW (6th) EDITION The demand for five editions of this work in a period of five years indicates the practical character of the book. In this edition the articles on Frambesia, Oriental Sore, and other tropical diseases have been entirely rewritten. The new subjects include Verruga Peruana, Leukemia Cutis, Meralgia Paraesthetica, Dhobie Itch, and Uncinarial Dermatitis, George T. Elliot, M. D., Professor of Dermatology, Coj-nell University. " It is a book that I recommend to my class at Cornell, because for conservative judgment,' for accurate observation, and for a thorough appreciation of the essential position of derma- tology, I think it holds first place." Schamber^'s Diseases of the Skin and f^ruptive Pevers Diseases of the Skin and the Eruptive Fevers. By Jay F. Schamberg, M. D., Professor of Dermatology and the Infectious Eruptive Diseases, Philadel- phia Polyclinic. Octavo of 534 pages, illustrated. Cloth, 1^3.00 net. THE CUTANEOUS MANIFESTATIONS OF ALL DISEASES " The acute eruptive fevers constitute a valuable contribution, the statements made emanating from one who has studied. these diseases in a practical and thorough manner from the standpoint of cutaneous medicine. . . . The views expressed on all topics are con- servative, safe to follow, and practical, and are well abreast of the knowledge of the present time, both as to general and special pathology, etiology, and treatment." — American Journal of Medical Sciences. DISEASES OF THE SKIN. Mracek and Stelwa^on*s Diseases of the Skin Atlas and Epitome of Diseases of the Skin. By Prof. Dr. Franz Mracek, of Vienna. Edited, with additions, by Henry W. Stelwagon, M. 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Mracek and Bangs' Syphilis and Venereal Atlas and Epitome of Syphilis and the Venereal Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited, with additions, by L. Bolton Bangs, M. D., late Prof, of Genito-Urinary Surgery, Univer- sity and Bellevue Hospital Medical College, New York. With 71 colored plates and 122 pages of text. Cloth, $3.50 net. In Saunders' Hand-Adas Series. CONTAINING 71 COLORED PLATES According to the unanimous opinion of numerous authorities, to whom the original illustrations of this book were presented, they surpass in beauty anything of the kind that has been produced in this field, not only in Germany, but throughout the literature of the world. Robert L. Dickinson. M. D., Art Editor of " The American Text-Book of Obstetrics." " The book that appeals instantly to me for the strikingly successful, valuable, and graphic character of its illustrations is the ' Atlas of Syphilis and the Venereal Diseases.' I know of nothing in this country that can compare with it." 12 SAUNDERS' BOOKS ON Holland's Medical Chemistr y and To xicology A Text=Book of Medical Chemistry and Toxicology. By James W. Holland, M.D., Professor of Medical Chemistry and Toxicology, and Dean, Jefferson Medical College, Philadelphia. Octavo of 655 pages, fully illustrated. Cloth, $3.00 net. THE NEW (2d) EDITION Dr. Holland's work is an entirely new one, and is based on his forty years' practical experience in teaching chemistry and medicine. It has been subjected tO' a thorough revision, and enlarged to the extent of some sixty pages. The additions to be specially noted are those relating to the electronic theory, chemical equilib- rium, Kjeldahl's method for determining nitrogen, chemistn- of foods and their changes in the body, synthesis of proteins, and the latest improvements in urinary tests. More space is given to toxicology than in any other text-book on chemistry. American Medicine " Its statements are clear and terse ; its illustra.tions well chosen; its development logical,, systematic, and comparatively easy to follow. . . . We heartily commend the work." Grtinwald and Newcomb*s Mouth, Pharynx, and Nose Atlas and Epitome of Diseases of the Mouth, Pharynx, and Nose. By Dr. L. Grunwald, of Munich. From the Second Revised and Enlarged German Edition. Edited, with additions, by James E. Newcomb, M. D., Instructor in Laryngology, Cornell University Medical School. With 102" illustrations on 42 colored lithographic plates, 41 text-cuts, and 219 pages of text. Cloth, ;$3.oo net. In Saunders* Hand-Atlas Series. INCLUDING ANATOMY AND PHYSIOLOGY In designing this atlas the needs of both student and practitioner were kept constantly in mind, and as far as possible typical cases of the various diseases were selected. The illustrations are described in the text in exactly the same way as a practised examiner would demonstrate the objective findings to his class. The illustrations themselves are numerous and exceedingly well executed. The editor has incorporated his own valuable experience, and has also included exten- sive notes on the use of the active principle of the suprarenal bodies. American Medicine " Its conciseness without sacrifice of clearness and thoroughness, as well as the excellence of text and illustrations, are commendable." URINE AND IMPOTENCE. 13 O^den on the Urine Clinical Examination of Urine and Urinary Diagnosis. A Clinical Guide for the Use of Practitioners and Students of Medicine and Sur- gery. By J. Bergen Ogden, M. D., Medical Chemist to the Metro- politan Life Insurance Company, New York. Octavo, 418 pages, 54 text illustrations, and a number of colored plates. Cloth, ;$3.00 net. THE NEW (3d) EDITION In this edition the work has been brought absolutely down to the present day. Urinary examinations for purposes of life insurance have been incorporated, because a large number of practitioners are often called upon to make such analyses. Special attention has been paid to diagnosis by the character of the urine, the diagnosis of diseases of the kidneys and urinary passages ; an enumeration of the prominent clinical symptoms of each disease ; and the peculiarities of the urine in certain general diseases. The Lancet, London " We consider this manual to have been well compiled ; and the author's own experience, so clearly stated, renders the volume a useful one both for study and reference." Vecki*s Sexual Impotence The Pathology and Treatment of Sexual Impotence. By Victor G. Vecki, M. D. From the Second Revised and Enlarged German Edition. i2mo volume of 329 pages. Cloth, ^2.00 net. THIRD EDITION, REVISED AND ENLARGED The subject of impotence has but seldom been treated in this country in the truly scientific spirit that its pre-eminent importance deserves, and this volume will come to many as a revelation of the possibilities of therapeutics in this important field. The reading part of the English-speaking medical profession has passed judgment on this monograph. The whole subject of sexual impotence and its treatment is discussed by the author in an exhaustive and thoroughly scientific manner. In this edition the book has been thoroughly revised, and new matter has been added, especially to the portion dealing with treatment. Johns Hopkins Hospital Bulletin " A scientific treatise upon an important and much neglected subject. . . . The treatment of impotence in general and of sexual neurasthenia is discriminating and judicious." 14 SAUNDERS' BOOKS ON Wells' Chemical Pathology Chemical Pathology. Being a discussion of General Path- ology from the Standpoint of the Chemical Processes Involved. By H. Gideon Wells, Ph. D., M. D., Assistant Professor of Pathology in the University of Chicago. Octavo of 549 pages. Cloth, $1.2^ net; Half Morocco, ^4.75 net. Dr. Wells here concisely presents the latest work systematically con- sidering the subject of general pathology from the standpoint of the chemical processes involved. Special chapters are devoted to Diabetes and to Uric- acid Metabolism and Gout. Wm. H. Welch, M. D., Professor of Pathology, Johns Hopkins University. " The work fills a real need in the English literature of a very important subject, and I shall be glad to recommend it to my students." The New (2d) Edition Saxe's Urinalysis Examination of the Urine. By G. A. De Santos Saxe, M. D., Instructor in Genito-Urinary Surgery, York Post-graduate Medical School and Hospital. i2mo of 448 pages, fully illustrated. Cloth, ;^i.75 net. This work is intended as an aid in diagnosis, by interpreting the clinical significance of the chemic and microscopic urinary findings. Francii Carter Wood, M. D., Adjmtct Professor of Clinical Pathology, Columbia Uni- versity. "It seems to me to be one of the best of the smaller works on this subject ; it is„ indeed, better than a good many of the larger ones." deSchweinitz and Randall on the Eye, Ear, Nose, and Throat American Text-Book of Diseases of the Eye, Ear, Nose, and Throat. Edited by G. E. de Schweinitz, M. D., Professor of Ophthalmology in the University of Pennsylvania ; and B. Alex- ander Randall, M. D., Clinical Professor of Diseases of the Ear in the University of Pennsylvania. Imperial octavo, 125 1 pages,, with 766 illustrations, 59 of them in colors. Cloth, ;^7.oo net; Half Morocco, ^8.50 net. Grtinwald and Grayson on the Larynx Atlas and Epitome of Diseases of the Larynx. By Dr. L. Grunwald, of Munich. Edited, with additions, by Charles P. Grayson, M. D., Clinical Professor of Laryngology and Rhinology, University of Pennsylvania. With 107 colored figures on 44 plates, 25 text-cuts, and 103 pages of text. Cloth, ^2.50 net. In Saunders' Hand-Atlas Series. CHEMISTRY, SKIN, AND VENEREAL DISEASES. is American Pocket Dictionary sixth Edition The American Pocket Medical Dictionary. Edited by W. A. Newman Borland, M. D., Assistant Obstetrician to the Hospital of the University of Pennsylvania. Containing the pronunciation and definition of the principal words used in medicine and kindred sciences. 598 pages. Flexible leather, with gold edges, ;^i.oo net; with thumb index, ^1.25 net. James W. Holland. M. D.. Professor of Medical Chemistry and Toxicology, and Dean, Jefferson Medical College, Philadelphia, " I am struck at once with admiration at the compact size and attractive exterior. ] can recommend it to our students without reserve." Stelwa|(on*s Essentials of Skin 7th Edition Essentials of Diseases of the Skin. By Henry W. Stel- wagon, M. D., Ph.D., Professor of Dermatology in the Jeffer- son Medical College, Philadelphia. Post-octavo of 29 1 pages, with 72 text-illustrations and 8 plates. Cloth, ^i.oo net. In Saimders' Question- Comp end Series. The Medical News " In line with our present knowledge of diseases of the skin. . . . Continues to main- tain the liigh standard of excellence for which these question compends have been noted." Wolffs Medical Chemistry New (7th) Edition Essentials of Medical Chemistry, Organic and Inorganic. Containing also Questions on Medical Physics, Chemical Physiol- ogy, Analytical Processes, Urinalysis, and Toxicology. By Law- rence Wolff, M. D., Late Demonstrator of Chemistry, Jefferson Medical College. Revised by A. Ferree Witmer, Ph. G., M. D., Formerly Assistant Demonstrator of Physiology, University of Pennsylvania. Post-octavo of 222 pages. Cloth, ^^i.oo net. In Saunders' Question- Compend Series. Martin's Minor Surgery, Bandaging^, and the Venereal Diseases second Edition. Revised Essentials of Minor Surgery, Bandaging, and Venereal Diseases. By Edward Martin, A. M., M. D., Professor of Clin- ical Surgery, University of Pennsylvania, etc. Post-octavo, 166 pages, with 78 illustrations. Cloth, ^i.oo net. In Saunders* Question- Compend Series. i6 URINE, EYE, EAR, NOSE, AND THROAT. Wolfs Examination of Urine A Laboratory Handbook of Physiologic Chemistry and Urine-examination. By Charles G. L. Wolf, M. D., Instructor in Physiologic Chemistry, Cornell University Medical College, New- York. i2mo volume of 204 pages, fully illustrated. Cloth, ;^ 1.25 net British Medical Journal " The methods of examining the urine are very fully described, and there are at the end of the book some extensive tables drawn up to assist in urinary diagnosis." Jackson's Essentials of Eye Third Revised Edition Essentials of Refraction and of Diseases of the Eye. By Edward Jackson, A. M., M. D., Emeritus Professor of Diseases of the Eye, Philadelphia PolycHnic. Post-octavo of 261 pages, 82 illus- trations. Cloth, ^i.oo net. In Saunders' Question- Covipe'nd Series. Johns Hopkins Hospital Bulletin " The entire ground is covered, and the points that most need careful elucidation are made clear and easy." Gleason*s Nose and Throat Fourth Edition. Revised Essentials of Diseases of the Nose and Throat. By E. B. Gleason, S. B., M. D., Clinical Professor of Otology, Medico- Chirurgical College, Philadelphia, etc. Post-octavo, 241 pages, 112 illustrations. Clqth, $1.00 net. In Saunders' Question Compends, The Lancet, London "The careful description which is given of the various procedures would be sufficient to enable most people of average intelligence and of slight anatomical knowledge to make a very good attempt at laryngoscopy." Gleason*s Diseases of the Ear Third Edition, Revised Essentials of Diseases of the Ear. By E. B. Gleason, S. B., M. 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Your treatment of the emergent pencil of rays, and the part falling on the examiner's eye, is decidedly better than any previous account." COLUMBIA UNIVERSITY LIBRARIES (hsLstx) RD 68 C85 C.1 Surgical after-treatment 2002202166 RD68 085 , m 3-- r T> r\ 1 Date Due ■ ^ _ L. B. Cat. No. 1137