PAUL B.HOEBER MEDICAL BOOKS 69E. 59thSt.,N.Y.| UtUnntt Htbrarg GUIDING PRINCIPLES IN SURGICAL PRACTICE BY FREDERICK-EMIL NEEF, B.S., M.L., M. D. NEW YORK CITY SURGERY PUBWSHING COMPANY 92 WILI^IAM STREET NEW YORK 1914 Copyright, June, 1914 By SURGERY PUBLISHING COMPANY New York If 3133 PREFACE. In offering this monograph which embodies some of the guiding principles in surgical practice, I real- ize that it expresses only an individual viewpoint. To have reflected on a safe and logical working method, is a vital prerequisite in surgical training. If, in any case, this outline, which is derived chiefly from clinical study, has helped to supply a system where there was none, the tedious task of formu- lating it will have been worth while. Frederick-Emil Neef. 300 Central Park West, New York City. Digitized, by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/guidingprincipleOOneef CONTENTS. I. General Considerations 1 II. Preparation of the Patient for Operation 5 III. Sterile Wash and Wound Dressing's. . . 14 IV. Sterilization of Utensils and Instru- ments for Operation 27 V, The Surgeon's Hands 36 VI. Wound-Healing and Scar Formation. . . 45 VII. Aseptic Suture Material 59 VIII. The Anesthesia 74 IX. The Incision 87 X. The Course of the Operation 100 XL Care of the Patient After Operation .. . 110 XII. The Interpretation of Post-Operative Fever in Aseptic Cases 133 XIII. The Treatment of Unclean Wounds ... 154 XIV. Conclusion 167 CHAPTER I General Considerations Good surgical judgment, logical asepsis, dex- terous technic are three requirements that are of principal importance in the practice of surgery. But, while surgical judgment must gradually ma- Surgical ture, it can be supplied, to some extent, by the care- ful study of one's work, and, by consulting with others of greater experience. Dexterity in execut- Dexterous ing an operation can only come with frequent Technic repetition of a definite technic. It will be acquired sooner by him whom the hospital entrusts with the surgical care of its numerous poor, than by the col- league who has to rely on his private practice alone for a repetition of similar cases. Finally, the preservation of a logical asepsis throughout the ^°sica course of an operation involves the surgeon's at- tention and solicitude in many directions. Wound contamination may be traceable to faulty or defi- cient local preparation of the territory for opera- tion, or to the hands of the operator, or to one of his assistants or nurses, or to the instruments he uses, or the suture material ; it may be an operating- room basin or utensil that is not surgically clean; or gauze or wound-dressings or contact with un- sterile wash; or, most important of all, injudicious handling of a bacterial nidus existing in the living structures which come within the compass -of the operation. While acting in the interest of his patient's future physical well-being, the surgeon as- (1) 2 Guiding Principles in Surgical Practice Extrinsic and Intrinsic Infection sumes all the responsibility for the outcome of his measures, and for any violation of asepsis by those delegated to assist him. No matter therefore, how exacting he may be during the tension of his work, he is always entitled to alert and faithful coopera- tion. There would be little difference between the sur- geon and the assassin, if the wound were not in- flicted in the hope of bettering the patient's physical condition. No operation which is not urgent, should be undertaken before the safety of the sur- gical measure has been duly weighed. Most cases of post-operative death are due to infection. The sources of danger in operating are two-fold, extrin- sic and intrinsic. With the strict present day regime, in the preparation of the patient, Jtnd in the operating-room service, infection which is due to extrinsic causes has become systematically avoid- able. Most major complications and deaths which oc- cur after operation are due to infection which is in- trinsic in origin. The difficulty arises out of the fact that it is hard to deal with infected structures, with- out disseminating infection. Bacterial foci may be normally present within the body; thus in the ali- mentary canal or the genito-urinary tract. Althoug exert their solvent influence. In a measure, the time of catgut absorption is also affected by the thickness of the strand. It necessarily takgs longer to bring about solution of continuity in a thick, than it does in a fine suture. But the selection of bulky sutures is not in accord with the modern tendency towards finer technic. It is better to choose thin sutures, by which the most Guiding Principles in Surgical Practice 65 accurate apposition with the smallest amount of damage to the tissues, is obtainable. Instead of increasing the size to obtain the desired durability, the chromici.'^ation of the finer strands should be increased. It is only in order to get sufficient ten- sile strength that larger sizes may be introduced, but never to increase the resistance. If the material is handled with the gentleness which the delicate make-up of the tissues demands, sutures which are coarser than No. 1 or No. 2 will seldom be required in the course of major operations. In other words, the finer sutures are to be generally preferred, not- withstanding that they may have to be chemically modified in order to become sufficiently lasting. It is not tissue constriction and strangulation, but gentle tissue coaptation or apposition until the young scar is sufficiently formed to support the parts which it binds together, that is the end and aim of the reparative suture. The use, in many instances, of finer suture material than has been customary, will not appear an unnecessary refinement when besides the gross anatomy of the structures their histology is considered. Thus, a fine catgut filament, 000 in size, or more accurately, 31-32 Brown & Sharp standard wire gauge, may well replace coarser material, for whip- ping the mesenteriolum over the invaginated stump of the appendix, for suture in all circumcisions of both male and female subjects, for primary coapta- tion sutures in the bladder, for repair of the ovary after partial excision, for skin stitching where re- moval of the suture is to be avoided, for buried sutures or mucous membrane sutures when required in dainty plastic operations on the face or elsewhere. Originally (1907), I had this catgut prepared for Choice of Thin Sutures Chromic Filament , 66 Guiding Principles in Surgical Practice me by the manufacturers (Van Horn) for ovarian suture, because fine-bodied needles such as are best fitted for this repair would not admit the coarser strands which are commonly in use. Indeed, after- bleeding from the stroma or hilum is less likely to occur with this technic, than when coarser material is used, because there is less laceration of the friable tissue. In its most generally useful form, 000 cat- gut ought to be chromicized to "forty-day" resist- ance. Occasionally, however, as in the mucous membrane of the nose or rectum, "sixty-day" chromicization is necessary. Filaments so fine as those represented by 000, it may be argued, require too much caution in handling, but this objection must grow weaker as the conviction grows stronger that the tensile strength is quite sufficient for the purpose for which it is intended — the coaptation and not the compression or constriction of the Aseptic not (jgijcate living fabric which it mends. Cateut Chromicized, unlike iodized catgut, is so prepared that it contains no chromic acid which is not in stable chemical combination with its collagen. There is no free chromic acid or chromate in solution in the medium in which the strands are preserved. However, after a definite number of days, when the chromic catgut is converted into soluble bodies in the tissues, it is true that the chromic acid radical must again be liberated. But at this time, the more active healing processes are ended, and the traces of the foreign chemical no longer so readily disturb the chemistr)rof the young and susceptible growing cells. In a general way, it may be said that for the usual purposes of suture, catgut of "forty-day" resistance should be employed. This insures stability Guiding Principles in Surgical Practice 67 of the suture-line for a minimum period of about seven days, which is usually sufficient for wound healing. Only in certain localities, where the sutures are exposed to maceration from stagnating secre- tion, or when the structures are edematous as the perineum after childbirth, a bit of chromic catgut of "forty-day" resistance may undergo solution of continuity prematurely, that is, perhaps as early as the fifth day or even sooner after its insertion. Where this difficulty is anticipated, strands of "sixty" or even "eighty-day" resistance can be used, but this is rarely necessary. Where there exists doubt about the necessary resistance of a suture which involves the surface, it is better to choose inabsorbable ma- terial, such as silk-worm gut of the appropriate strength. When the suture involving the surface cannot be kept dry, silk-worm gut has many advan- tages over catgut. It is not only insoluble in dis- charge or secretion, but, unlike the collagen of cat- gut, offers no favorable medium for bacterial growth. Apposition can be maintained as long as even the most exceptional conditions may require, and when the union is secure, the silk-worm suture is easily extracted. When the stitch includes the skin, silk-worm gut is also preferable to silk or linen. Because of its lack of capillarity, it does not, as these do, imbibe bacterial fluids which bathe the surface, and conduct infection along the path of the stitch. There is ample scope to satisfy the various demands upon its tensile strength, from the coarser strands for a torn perineum, to the finest filament (XX Special, Van Horn), which is suitable for finer plastic surgery. It has the further advantage that it can be quickly sterilized by boiling in plain, or even in slightly alkalinized water. Indications for Absorbable and Inabsorbable Sutures 68 Guiding Principles in Surgical Practice Linen Thread for Hollow Organs Objections to Catgut for Skin Repair Silk and Linen Silk-worm Gut Skin Clamps In the surgery of hollow organs such as the heart, blood vessels, stomach, bowel, bladder, where structures have to be repaired which are under constant or varying tension, it is unquestionably safer to adhere to the use of inabsorbable sutures in place of catgut, notwithstanding the fact that such sutures cannot be extracted and must remain as foreign bodies in the tissues which they unite. Such an inabsorbable thread also finds its place in the purse-string closure of the caecum after appendi- cectomy, or of the peritoneal sac of a hernia. Linen thread has the great advantage over silk that it can be boiled in plain as well as slightly alkalinized water with relative impunity, while silk more rapidly loses its tensile strength. The cardinal objection to the employment of cat- gut suture on the surface of the body, is its great liability to become infected, and to transmit an infection along the stitch-canal to deeper planes. This will not appear startling, when it is recalled that the collagen content of the catgut suture easily becomes, in the presence of moisture, a good soil for bacterial growth. Silk or unimpregnated linen thread have the common disadvantage of capillarity, which also means imbibition of moisture, and con- duction of germ-growth. Silk-worm gut has none of these properties, and is therefore a very satis- factory suture material for the skin. Even when a surface is naturally apt to be contaminated on account of the location of the wound, or where it is bathed in discharge, there is but little tendency to the development of stitch infection. Metal clamps, such as Michel's clamps, eliminate the trouble from stitch infection, because they make possible skin closure by clamping without perforation. They are Guiding Principles in Surgical Practice 69 suitable in aseptic laparotomies; particularly in point, in the hairy zone of the pubes after the semi- lunar hypogastric incision. To avoid decubitus they should not be applied too firmly. Nevertheless, although correctly applied, they not infrequently occasion slight pain in the region of the wound. They should be removed after five days, a few strips of sterile adhesive plaster continuing to support the young scar for a few weeks. There need be no fear that the clamps will be dislodged by the patient, even if used on the abdomen to close incisions eight or more inches long. Occasionally, as for instance, in some incised wounds of the face in children, in order to escape stitching, or after abdominal sections in place of skin clamps, sterile zinc oxide adhesive strips can be used. The secret of success in employing them, lies in the thorough removal of the fatty secretion. From a cosmetic standpoint the result obtained by either the clamp or the adhesive strip method, per- haps surpasses that obtainable by any suture method. In contradistinction to most other tissues, in the repair of osseous tissue, the physical conditions are such that absorbable suture is commonly inadequate. Only a few of the smaller bones may be an ex- ception. When proper coaptation and fixation is not obtainable by reduction, traction, external splint- ing of a long bone, silver wire, Lane's plates, cortical or intramedullary splints of living bone, all may have their place. At the present time, the most satisfactory way of supplying sterilized, plain, as well as chemically modified catgut, is in sealed glass tubes. Since it is in this case necessary to rely on the efficiency of Coaptation with Adhesive Strips Methods of Uniting Bone 70 Guiding Principles in Surgical Practice Guarantee of Catgut Sterility Catgut is Dry Sterilized and Preserved in Sealed Tubes the sterilization of the catgut by the manufacturers, many methods for its extemporaneous preparation have been suggested. While this tendency must appeal to one who is solicitous about the asepsis, and desirous to have under his control or super- vision the sterilization of the catgut which he needs at his operations, it must be granted, on the other hand, that the usual complaint about catgut ster- ility is not well founded. For example, from the record of one series of 120 cases in which catgut, plain and chromic, from one of the firms in this city was used exclusively, in not a single instance was an infection traceable to this source. Most infections of the skin occur when a hairy territory is invaded, because it is so difficult to render it aseptic, and not because the catgut is at fault. If the catgut itself were responsible for the ordinary stitch infection, why is it that the skin and sub- jacent fascia, or the skin alone, and not the deeper strata of the sutured wound, are most usually involved? Why is it, that incisions in the hypo- gastrium near the pubes, or herniotomy incisions, are so prone to this complication, while when ordi- nary precaution is taken, incisions elsewhere on the abdomen, rarely show any redness or signs of local infection about the stitches? If water were not incompatible with the catgut suture, the problem of catgut sterilization would be a comparatively simple one. As it is, steriliza- tion by means of boiling water, or superheated steam is out. of the question, and the process is usually one in which disinfection and dry steriliza- tion in its various forms, are combined. A further difficulty presents itself in this that the medium in which the catgut is kept must be water- free, other- Guiding Principles in Surgical Practice 71 wise the tube containing it cannot be boiled. Cat- gut, plain and chromic, thoroughly desiccated, is therefore put up in a medium consisting of chloro- form and alcohol. The tube containing the strand of suture material is but half-filled with the liquid to allow for expansion, and can be boiled re- peatedly to sterilize the surface without impairing the catgut. With this preparation, tubes containing kangaroo tendon can also be boiled, whereas if but a trace of water were present the suture would swell promptly and be converted into a rubber-like mass, having no value whatever as a suture. The tubes are boiled, not so much in the hope of re- sterilising their contents as to render their surface aseptic for the supply table. This precaution is a vital one, because the surface of the tubes is apt to become coated with a fatty layer, and bacterial contamination is the result of handling. If they are simply immersed in antiseptic solutions, most of which in addition, as corrosive sublimate, are practically incapable of penetrating the fatty de- posit, a germicidal action upon imbedded bacteria is doubtful indeed. If, however, the glass tubes are subjected to the boiling process in slightly alkalinized water (1-1000 NaOH), together with the instruments, absolute surface sterility is secured. The question. What happens in the interior of the tube when it is boiled? is a natural one. In case the tube contains a mixture of chloroform and alcohol, which is absolutely water-free, and whatever may be the temperature to which this medium rises, when such a tube is boiled or placed in the steam sterilizer with the dressings, the only sterilizing effect which it can have on the contained The Surface of the Tubes is Sterilized by Boiling 72 Guiding Principles in Surgical Practice Effect of Boiling on the Catgut Strand Within the Tube strand of suture material, is that which results from the action of dry heat, not wet heat; any trace of moisture due to water in the tube, would be utterly incompatible with the catgut. According to the manufacturers, a thermometer suspended in this chloroform mixture, within a sealed glass tube, indicates that the temperature of the mixture reaches approximately the temperature of the sur- rounding medium in the sterilizer. If this is correct, the additional sterilizing effect of this measure would be equivalent, in the one case, to that of a dry sterilisation of from 10 to 25 minutes at about 100° C. (212° F.), and in the other, of a dry sterilization of not less than 35 minutes dura- tion at about 121° C. (250° F.). That the steriliz- ing effect of this procedure can be but secondary in importance becomes clear when the degree of heat obtained, and the time are compared with that which is necessary to insure unquestionable ster- ility by dry heat. Thus dry sterilization would require about three hours at 140° C. (284° F.), or about two hours at 180° C. (356° F.). As long as no water is admitted, subjecting such tubes to the action of boiling water (100° C), or steam under pressure (121° C), does not impair the quality of the suture. It is only when the dry heat is carried considerably beyond this point, that charring re- sults, and the material is destroyed. The only way, therefore, in which satisfactory sterilization of cat- gut can be obtained, without influencing the suture, is not by a single dry sterilization at very high temperature, but by repeated sterilisation at a lower degree of heat. It is not on the effectiveness of a single, but of repeated sterilisation that the sterility of surgical catgut really depends. Guiding Principles in Surgical Practice 73 To a great extent therefore, the guarantee for the undoubted sterility of the animal suture used at operations has to be accepted from the laboratory which supplies it. It would be desirable to apply wet heat either by boiling or by means of steam under pressure to all suture material, but until an absorbable material which cannot be destroyed by hydration is found, extemporaneous sterilization by these methods, is out of the question. Relation Between Surgeon and Anesthetist CHAPTER VIII The Anesthesia It is not my purpose to enter into the details of the technic in the administration of anesthetics, only so far as this may be helpful in bringing about a better understanding and co-operation between the surgeon and his anesthetist. If the surgeon alone is to be held responsible for the safety of his patient, he cannot be indifferent to the methods of anesthesia employed, any more than he can disregard the asepsis which is practiced at the operation by his assistants and nurses. If the sur- geon himself has had a thorough training in anes- thetics — which is not as often the case as it should be — he is in a better position to work together effectually with his anesthetist; if he lacks this training, he may allow himself to interfere where this is not indicated, and, as far as the narcosis is concerned, may unwittingly put himself in the way of the proper management of the case. It is easy to understand, that pure chloroform, on account of its greater potency, becomes a dangerous narcotic in the hands of those who have not learned to use it correctly. The solicitude of the surgeon, upon whom perhaps an anesthetist of questionable ex- perience has been thrust, is but natural. Indeed, there are legitimate reasons for attempts to dis- place chloroforjn by the less toxic ether, as a rou- tine anesthetic. Nevertheless, thus far chloroform has not been displaced, because of certain disad- vantages connected with the use of ether in every- (74) Guiding Principles in Surgical Practice 75 day practice. Its greater bulk and inflammability, the fact that its inhalation is more disagreeable to the patient, the relatively tedious induction of nar- cosis when it is used uncombined, the increased tendency to cause post-operative nausea and vomit- ing, all have militated against ether and have helped chloroform to retain its foothold, notwith- standing its toxicity. It is true that the induction can be shortened, and made more agreeable to the patient by preceding with nitrous-oxide gas, but the exigencies of every-day practice prohibit any cumbersome apparatus which cannot always be at hand. It is for such reasons that attempts have re- peatedly been made to combine the desirable prop- erties of chloroform and ether, and to neutralize the objectionable ones, in the hope of obtaining an ideal anesthetic for general routine. One of the most useful of these anesthetic solutions is anaes- thol — a molecular combination of chloroform (35.89%), ethyl chloride (17%), and ether (47.10%). Essentially, its administration differs but little from the administration of pure chloroform. It is the chloroform content of anaesthol, and not the ether, that dominates the narcosis, although the de- pressant action of the chloroform is counteracted to some degree by the stimulant influence of the ether which constitutes almost one-half of its vol- ume. The quantity of the anesthetic needed is relatively small — somewhat greater than when pure chloroform is used. The quantity required for an anethesia can be still further reduced when a quarter of a grain of morphine sulphate is given subcutaneously half an hour before the narcosis. Chloroform in Everyday Practice The Administration of Anaesthol 76 Guiding Principles in Surgical Practice The Use of Oil of Rose to Disguise the Vapor Ether Feeding Cardiac Collapse In an average case 15 to 20 cc. of anaesthol, given on a mask by the drop method, ought to suffice for the induction; not more than 40 to 60 cc. should be consumed during the entire narcosis lasting an hour or more. From the patient's standpoint the anesthesia is, at times, a matter of considerable moment. It may be the recollection of the ill-effects of a former narcosis that deters her from consenting to a nec- essary measure. Again, the odor of the anesthetic may become markedly repugnant to those who have previously been under its influence, and as- surance on this point may help to bring about a prompt decision. A few drops of a 10% emulsion of Persian oil of rose in deodorized alcohol on the mask, is an efficient way of eliminating this dis- agreeable element in the induction of anesthesia. A little ether is kept in a separate drop bottle, so that during the narcosis with anaesthol its stim- ulating effect can be added when this is indicated — ether feeding. Or, the narcosis may be contin- ued solely with ether by the drop method, imme- diately after the induction with anaesthol, should this appear advantageous. There is thus at com- mand a morphine-anaesthol sequence, or, if one wishes, a morphine-anaesthol-ether sequence which is very flexible and readily adapts itself to the in- dividual case. At the same time the technic which it entails is strikingly simple. The chief danger with chloroform or its com- binations lies in its action upon the circulation — cardiac collaps'e. From my own observations true cardiac collapse is very rare. Its frequency can be estimated to be about 2 :2000, one-tenth of one per cent, of all cases which come to operation. Since Guiding Principles in Surgical Practice 77 it is during the induction of the narcosis that this undue susceptibility usually becomes manifest, the importance of alertness and caution in inducing with chloroform or its combinations until the anes- thetist has discovered how the patient responds to the narcotic, cannot be overestimated. In this con- nection the question is pertinent about the toler- ance of the patient to former anesthetics. In im- pending collapse of the heart, there is increasing pallor and the pulse suddenly becomes diffuse and weak. If the induction has been gradual and the anesthetist attentive, these changes may be discov- ered in due time to avert disaster. *. ,. . r T . . , , . . Abolition of It is a point worth knowing, that hearing is one Hearing and of the senses which may be abolished rather late in Consciousness the induction, and that the patient under such cir- cumstances may hear all that is said about the operation which is to be done. In fact, the com- plete abolition of consciousness need not always take place when morphine has been administered, and minimal quantities of the anesthetic are used. Thus, I recall an instance (P. R. No. 4324) in which during a suprapubic plastic the patient, al- though insensitive to pain, was able to converse with me throughout the entire procedure. Others have no doubt had similar experience. This illus- trates that analgesia sufficient for the purpose of the surgeon, must not invariably be accompanied by complete unconsciousness. Abolition of During the narcosis it is better for the patient Reflexes to be in a tonic, than in an atonic state, as far as this is not entirely incompatible with the require- ment of the surgeon. A slight reaction, for ex- ample, when the initial incision is made is not always to be criticized; if the anesthetist is uncer- 78 Guiding Principles in Surgical Practice Erroneous Notion About the Induction of Shock tain, it is wiser to allow the patient to be a little too superficially, than at once too profoundly un- der the influence of the narcotic. With the deeper respirations of the patient, a few drops will suffice to annul the wakening effect of the initial incision when the anesthetist has regained his bearings. It is not to be lost sight of, that analgesia — freedom from pain — is the first aim of the narcosis, and the reflexes should be diminished or abolished only so far as they become a hindrance to the surgeon. When morphine has been administered, the reflexes may remain quite active, although the patient is in the proper state of analgesia, and in the correct surgical plane. If the surgeon is gentle in his work, as he should be, not only on account of the delicate make-up of the structures which he is handling, but also in order to avoid any unwar- ranted exaggeration of the numerous ingoing im- pulses to the cord and brain, this property of mor- phine will very rarely prove to be an objection to the use of the drug. The notion that shock will follow, because some of the reflexes are still active during the course of an operation, is surely not founded on experience. If the patient remains passive and feels no pain, the prime object of the anesthesia is usually at- tained. In abdominal and pelvic surgery, it is not always in the patient's interest to insist on flaccid abdominal muscles during operation. The muscles may be relaxed, but they must not be paralyzed by the anesthetic. The surgeon who is too violent or precipitate in the execution of his work, will con- tinually complain that the abdominal wound can- not be satisfactorily retracted, and the patient is insufflciently under the influence of the anesthetic. Guiding Principles in Surgical Practice 79 This is a dangerous failing, and may lead the nar- cotizer of limited experience to attempt to subdue the resisting patient with the narcotic, instead of anesthetizing her. Crowding the anesthetic is one of the chief sources of trouble in drop-method nar- cosis. The insufficient dilution of the anesthetic with air incident upon crowding, brings with it the inhalation of vapors which are too irritating to the glottis because of their great concentration. The increasing spasm of the larynx which results, im- pedes free respiration, and instead of anesthesia, a state of asphyxia is induced, which finally cul- minates in respiratory collapse. A change in the quality of the breathing sound indicated by the appearance of a few faint high-pitched notes, to- gether with the advent of a slight tinge of cyanosis, are the significant premonitors of this condition. It is then not more of the anesthetic, but less of it, that the struggling patient wants. A little fresh air admitted by raising the mask, dissolves the spasm of the larynx, and strange as it may seem to the inexperienced, the patient who now inhales the di- luted vapors freely, instead of awakening, relaxes the resisting muscles and relapses into a tranquil narcosis. The secret of success in an anaesthol or for that matter in a chloroform narcosis, lies in the systematic avoidance of crowding. Coughing should not necessarily convey the im- pression to the operator that the patient is about to become conscious. It is frequently due to irri- tation of the pharynx, and may occur at any time during the course of the operation, if the mask is suddenly charged with the anesthetic, instead of supplying it uniformly, drop by drop. The Chief Failing in the Use of Chloroform or its Combinations The Coughing Reflex 80 Guiding Principles in Surgical Practice Vomiting Vomiting efforts constitute a disagreeable inter- ruption, but the deep breaths which are inter- polated make it easy to regain the surgical plane. The head of the patient is quickly turned to one side without pushing the jazv forward, the mouth wiped and the anesthetic continued, while the sur- geon co-operates by desisting for the moment from traction on the mesentery, or other manipulations which may have given rise to the potent awakening impulse. y Very dark blood at the wound may indicate that Blood t^^ patient's breathing is embarrassed. The cause may be mechanical, as when the saliva accumulates in the mouth, or the tongue recedes, or a shoulder- - brace presses against the throat, or there is valve- action of the lips in the old who have been wear- ing a tooth-plate, or adenoid obstruction in children. When it is not feasible to remove the ade- • noids before operation, I know of no simpler way of coping with this difficulty, than by the use of The ^^^ breathing tube. A soft rubber catheter is Breathing passed through one, or both of the child's nostrils. Tube beyond the adenoid ring of Waldeyer into the laryngo-pharynx (Practical Points in Anesthesia, 1908). This manoeuvre is not only useful in the case of adenoids, but also in some of the other causes of mechanical obstruction, such as recession of the tongue. Occasionally, its use may be of diag- nostic value in satisfying the anesthetist that the respiratory impediment in a given case is due to laryngeal spasm — ^the usual result of insufhcient di- lution of the anesthetic with air. Pulse It is a good rule for the surgeon to make a mental note of the quality of the patient's pulse before the operation. He is then in a better position to judge Guiding Principles in Surgical Practice 81 the post-operative condition, or to appreciate any marked change in its normal characteristics. In weighing tlj^ necessity for post-operative stimula- tion, the surgeon should not allow the fact to escape him, that nausea and vomiting, occurring as the sub- ject recovers from the anesthetic, may cause a transitory irregularity in the pulse which is of no serious significance. Furthermore, in the case of some anesthetics, as anaesthol or ether, a stimulant effect of the nalrcotic upon the pulse may occasion- ally persist for a very brief period after operation. The amount of shock to which the patient, in a particular case, is subjected, does not depend so much, for example, on the actual extent to which the abdominal viscera are handled, but rather on the manner in which this is done. Thus, the entire mass of small intestines can be gently withdrawn from the abdominal cavity for systematic inspection, without of necessity producing in the patient the slightest evidences of post-operative shock, A great deal might be said about apparent and real contra-indications to the administration of anesthetics. A common, but erroneous impression is that heart murmurs corresponding to a valvular lesion, necessarily contra-indicate narcosis. As a miitter of fact, it is not so much the hearts that have murmurs, least of all the hearts that have loud mur- murs that presage a perilous narcosis, but the degree of myocardial involvement is the salient factor. Thus, the heart with a degenerated muscle, scarcely capable of producing an audible murmur, comfnands the greatest solicitude during the administration of the anesthetic. Particularly pure chloroform, is out of place in such a lesion. Estimating the Amount of Post-operative Shock Heart Disease in Anesthesia 82 Guiding Principles in Surgical Practice Epilepsy Anesthesia in Tuberculous and Diabetic Subjects The Choice Between Chloroform and Ether Epilepsy does not contra-indicate the giving of an anesthetic, nor the execution of an operation; in fact, epileptic seizures of reflex origin, occasionally disappear after a simple narcosis or operation. Great judgment must be exercised in establishing the indication for narcosis and operation in all sub- jects with tuberculous lesions of the lung; the dan- ger lies in the exaggeration of an active process, or in the enkindling of a latent one. Moreover, operation performed in a tuberculous territory, in any part of the body, it is well known, may lead to dissemination of the trouble. In diabetic pa- tients, where there is 2% or more of sugar which is not influenced readily by diet, coma is very prone to follow narcosis and operation, and seems to be directly or indirectly precipitated by these measures. It is in these two groups of cases, that both ether and chloroform or its combinations have distinct disadvantages, and while there is available no entirely satisfactory form of narcosis, nitrous oxide-oxygen correctly administered, holds a legiti- mate place. It may be that as soon as the construc- tion of the necessary apparatus can be simplified, and its weight and bulk reduced to make it really portable, the nitrous oxide-oxygen sequence will receive the wider application in practice, which it deserves. While I have repeatedly voiced the use of anaes- thol — chloroform modified to increase its safety without impairing its anesthetic usefulness — as an acceptable substitute for chloroform in every-day practice, I would not convey the impression that I am inimical to the choice of an uncombined ether narcosis, only in so far as it is not practical. In addition, it is clear that the rigid adherence to any Guiding Principles in Surgical Practice 83 routine, would be foreign to one who believes in adapting the anesthesia to the peculiarities of the case. As a routine procedure, it is true, the mor- phine-anaesthol sequence with or without the addi- tion of ether, allows considerable latitude for in- dividualization. But this will not always suffice to meet the special requirements in special cases. In operations on the brain and cranial nerves it is not difficult for the anesthetist to maintain the surgical plane, because the awakening stimuli set up during the operation are slight. But it is a distinct advantage to have the anesthetist away from the surgeon's precinct. Instead of using the ordinary mask, the anesthetic is therefore administered through a funnel, covered with gauze, and connected with one or two rubber tubes which conduct the anesthetic vapors. In this very simple form of tube narcosis, the tube passing the base of the tongue enters the laryngo-pharynx, but not the larynx itself. If chloroform or anaesthol are used, and a full dose of morphine was given half an hour before the nar- cosis, to diminish the amount of anesthetic required, it ought ordinarily to be a comparatively easy matter to keep the patient sufficiently under the in- fluence of the narcotic. If there is difficulty experi- enced in doing this, it may be that the calibre of the tube or tubes employed is too small. In a cere- bellar tumor, or a tumor of the acoustic nerve, when an occipital flap must be made, and the pa- tient's face is turned downward, the anesthetist may be seated at the foot of the patient, or,. in some cases, advantageously out of the way of the surgeon and his assistants and nurses, on a stool beneath the operating table itself. Narcosis in Operations on the Brain and Cranial Nerves 84 Guiding Principles in Surgical Practice Narcosis in Tumors of the Larynx Intratracheal Insufflation Narcosis for Intrathoracic Operations In extrinsic tumors of the larynx, after opening the throat by subhyoidean pharyngotomy, the nar- cosis by this method is not feasible. The tube in- stead of merely approaching the vicinity of the larynx, must be passed into it and the trachea. The surgeon selects a rubber tube of about the thickness of a stomach tube which has been sterilized for the purpose, and introduces, first, the end with the eye, into the trachea, ascertains that the respiratory air streams freely through it, and then, at once delivers the other end to the anesthetist, upward through the patient's mouth, where it should be fixed with ad- hesive plaster to prevent dislodgment. In this man- ner the asepsis at the field of operation is not vio- lated, as it would be, if the tube were first passed through the mouth into the surgeon's hands, before reaching the trachea. In operations in which the pleura has to be opened, or may be opened accidentally, it becomes vital to prevent collapse of the lung. In the intra- tracheal insufflation method of anesthesia developed by Meltzer and Auer, this difficulty is obviated in a strikingly simple way. Here a single rubber cathe- ter which is not too thin-walled, and about No. 22 French scale, is introduced to the vicinity of the bifurcation of the trachea, and a stream of oxygen mixed with ether vapor of a concentration not ex- ceeding 6 to 7 per cent., serves the double purpose of assisting in the inflation of the lungs, and main- taining the anesthesia. To avoid the repetition of fatalities caused- by abrupt distention of the lung, no apparatus of this description should be used on the human subject, unless it is supplied with an adequate safety valve (H. Fischer). Guiding Principles in Surgical Practice 85 Since the creation of the first separate department for intrathoracic surgery in this country, at the German Hospital of this city — the result of the untiring energy of Willy Meyer and his brother, J. Meyer — unique opportunity for the study of the comparative value of these methods is afforded. I had occasion to be incarcerated in the positive dif- ferential pressure compartment repeatedly, when the first trials of this modified Sauerbruch-Brauer chamber were made at the hospital, and it seems to me that the current impression of the great dis- comfort of the narcotizer, and the difficulties that beset him under these circumstances is not well founded. The vapors of the anesthetic do not accumulate in the chamber, the space is sufficiently large to accommodate an assistant if one should be needed, it is possible to leave the cabinet through the vestibule, without exposing the patient who is under narcosis to a sudden change in the atmos- pheric pressure. Outside of the slightly disagree- able sensation produced in the ear-drums of the occupant when the pressure within the cabinet is raised or lowered, and the disturbing vibration caused by the action of the ponderous pumps, the conditions under which the anesthetist has to work are but little dififerent from those in the ordinary operating-room. The air-tiglit rubber collar some- what encumbers the manipulation of the patient's head, but the difficulty is largely overcome when the latter is placed on a small head-rest which is sus- pended in an adjustable sling or hammock. In the administration of the anesthetic, in general, the same rules hold good as in narcosis elsewhere — the ap- paratus has to do only with the counteracting of the abnormal rise in pressure produced in the Anesthesia in the Positive Differential Pressure Cabinet 86 Guiding Principles in Surgical Practice pleural cavity by the inrush of air when the thorax is opened, and to prevent the lung from collapsing thereafter. During one of the operations executed with the aid of the apparatus, I have had occasion to observe a peculiar series of events during which the pupils Death by dilated and the patient rapidly collapsed, and which Asphyxia I have been unable to explain, except that it ap- peared likely that the fatality was not due to the action of the anesthetic or any unusual manipula- tion on the part of the anesthetist, but rather the result of some manoeuvre incident upon the opera- tion itself. Dr. J. Meltzer has, I think, offered the first scientific solution. He emphasizes that under the Brauer method, life is sustained by a small part of the normal respiration (minimum, 1/lOth of the normal). The only portion of the lung which is active in aeration under these extreme conditions is the posterior part of the lower lobe. Any manipu- lation on the part of the surgeon which interferes with the function of this portion of the lung, such as pushing it to one side during exploration, or compression of it, or expulsion of its air content by dislodging it, or lifting it out of the chest, may suffice to bring about a rapid exitus by asphyxia. At the present time, when thoracic surgery has just received a new impulse, it is impossible to pass final judgment on the relative practical value of the differential and intra-tracheal insufflation methods of anesthesia. However, the general drift seems to be towards the adoption of the intra-tracheal insufflation method for routine thoracic surgery, limiting the scope of the differential pressure method to special cases. CHAPTER IX The Incision In surgical treatment the division of healthy tissue often becomes necessary, in order to make the seat of disease or injury accessible. Since the integrity of the structures which have been deliberately divided must again be restored, it is a matter of moment how this division is done. Operations on the abdominal and pelvic organs form such a large part of the routine in major surgery, and the ab- dominal route is so frequently chosen, that a careful study of the parietal incision with the view of avoid- ing disagreeable sequelae such as neuralgia, deform- ing scars and post-operative hernia, is distinctly worth while. But the ideal incision, besides being in itself a conservative one, must allow of extension without undue mutilation of the anatomic entities which constitute the abdominal wall. Viewed in this light, very few of the stereotype methods ordi- narily practised can be considered exemplary. One of these, however, which illustrates the gen- eral principles involved in the make-up of correct parietal incisions, has been pointed out by Pfan- nenstiel, Stimson and others for operation on the pelvic organs and the lower abdomen — the semilunar hypogastric incision combined with the median separation of the recti. The incision is carried across the abdomen in a shallow curve, the con- vexity of which usually corresponds to a point one- half to three-quarters of an inch above the symphysis pubis. It begins and ends one and a half inches or (87) Conservative Incisions Semilunar Hypogastric Incision 88 Guiding Principles in Surgical Practice Division o£ the Subcutaneous Fatty Tissue less, above the midpoint of Poupart's ligament on each side. Its correct course is indicated by the furrow or sulcus of a more or less pronounced suprapubic fold, which is found in this location. Since the greater portion of the incision lies in the hairy area of the pubic region, the difficulty of rendering the skin aseptic may be cited as an objec- tion to its general use. But experience has shown, I think, that such an objection does not militate against its adoption. If the area is carefully shaved, and cleansed with soap suds when the patient is admitted, and on the evening before operation any one of the compatible iodine solutions is applied for preliminary disinfection of the points which are inaccessible to the final mechanical cleansing in the operating-room, and the skin is kept covered during the operation with sterile towels which are prevented from dislodging by means of Backhaus' towel clamps, there need be little fear that contamination of the wound will occur from a surface which is not surgically clean. In the semilunar hypogastric incision the sub- cutaneous fat, that is, the superficial layer of the superficial fascia or Camper's fascia, is split at once down to the dense structure which represents the deep layer of the superficial fascia, Scarpa's fascia. The depth of the wound at this stage varies greatly with the development of the panniculus adiposus and may be less than one-quarter inch or more than two inches. The amount of venous bleeding also varies, and is naturally greater when there is venous stasis. Most of the bleeding from the fat is due to venous oozing, and is arrested by means of dry gauze, or if this fails gauze sponges wrung in boiling water. Usually it is only four points that have to be Guiding Principles in Surgical Practice 89 secured by hemostatics — the divided ends of the superficial epigastric artery, in the right and left halves of the upper and lower flaps. The branches of the superficial external pubic on the other hand, which ascend to the zone just above the pubes, are so minute that they do not require clamping at all. The bleeding points need rarely be ligated; by the time the wound is closed, or before this, forcipres- sure alone will have sufficed to insure hemostasis. Ligating these vessels merely consumes time, hinders the re-establishment of the blood flow across the scar, while the knots of catgut, until they are dis- posed of, act as foreign bodies in the wound. By means of the gloved index finger, covered with a layer of gauze, the loosely attached fat is easily brushed from the surface of the dense fascia, exposing it to view, and widening the path of the incision. Scarpa's fascia is intimately adherent to the anterior rectus sheath, and the separation would be more or less artificial, so that in this procedure both are best treated as if they constituted but a single layer. The scalpel is carried through the structure transversely on each side of the median raphe, until the red muscle appears; a small blunt scissors is slipped into the opening, and the incision is extended to each side. While the incision through the skin follows the lines indicated by the natural crease, and is, as a rule, a shallow curve, the line of fascial division, should approach a semicircle, in order to obtain a flap which permits of better ex- posure. This point, I believe, is sometimes over- looked, and its non-observance may help to explain the difficulty which is occasionally experienced in getting sufficient working room with the semilunar hypogastric incision. The normal limits of the Scarpa's Fascia and Anterior Rectus Sheath 90 Guiding Principles in Surgical Practice Lifting the Fascial Flap and Liberating the Rectus Muscle incision are the lateral borders of the recti muscles ; in other words, it does not extend beyond the lateral confines of the rectus sheath, so that the dorsal nerves which enter it here to supply the muscle are not cut. As a rule, any separation of living tissues from each other w'hich is not imperative, is to be looked upon as harmful; but it is, in this case, essential to free the unyielding fascia from all its subjacent connections. This is easily done by lift- ing the border of the upper fascial flap, first on one, and then on the other side of the median raphe, while the index finger is passed beneath it and strips it away from the anterior surface of the rectus muscle. Sometimes a few strokes of the scalpel, may be required to free the sheath from a tendinous inscription which occurs at this low level. The median raphe is then divided by means of scissors, while it is put upon the stretch between forceps. The division of this line of attachment must be continued upward to the extent of two or three inches. In a similar manner, the inferior fascial flap is separated as far as the crest of the pubic bone. Beneath the fascia, the rectus abdominis muscle is attached by a tendon to the crest of the pubes. When the pyramidalis muscles are absent, there may be noted in their stead, in front of this tendon, near the median line, a small tendinous process which can be traced to the anterior surface of the sym- physis pubes, when the lower fascial flap is raised. At this stage, the lower flap of fascia is incised in the middle line, as far as the pubic bone — pubic extension. The incision is only one-half to three- quarters of an inch long, so that the danger of post- operative hernia at this point may be disregarded, while the advantage gained in securing a wider ex- Guiding Principles in Surgical Practice 91 posure is so decided, that it seems best to use the pubic extension as a routine. To understand fully why the recti muscles are so promptly mobilized, and can be pulled away from the median line like two yielding, elastic bands, it must be borne in mind that in this location the re- sistant rectus sheath is absent posteriorly, and the muscle is but loosely connected with a supple trans- versalis fascia and peritoneum. The replacement by a narrow strip of rigid connective tissue of one or both pyramidalis muscles, likewise affects the readi- ness with which the recti muscles can be retracted. When the pyramidalis muscles are present, the open- ing is usually effected by entering between them; sometimes it is indicated to enter to one side. In either case, some mutilation of the tapering apices can hardly be avoided. On retracting the muscle bands with McBurney retractors, the transversalis fascia and peritoneum present themselves, and are opened at a high level in the wound, by making a minute incision between forceps. With the inrush of air, the intestinal coils at once recede and the peritoneal opening is en- larged, at first upward, and then cautiously down- ward, to avoid incising the bladder. The summit of the empty bladder reaches the level of the pubic crest. By palpating the peritoneum between the thumb and finger, or by raising it so that it can be trans-illuminated before dividing it, accidental in- jury to the bladder can easily be prevented. A thick layer of properitoneal fat should not be mistaken for adherent omentum. If in doubt, it is severed cautiously in a perpendicular line, when the peri- toneum itself will soon appear and the small bowel can be seen to move freely beneath it. In the pro- Section of the Transversalis Fascia and Peritoneum 92 Guiding Principles in Surgical Practice peritoneal fat, between the transversalis fascia and the peritoneum, lie the deep epigastric arteries on each side, accompanied by their venae comites. But, approaching in their upward course, the fold of Douglas, they pierce the transversalis fascia and enter the rectus sheath. In this part of their course they lie between the posterior surface of the rectus muscle and the posterior lamella of its sheath. It is well to be heedful of this relation. I have in mind a fatality in a case in which an autopsy was not obtained, in which it seemed likely that exitus was due to internal hemorrhage from the deep epigastric artery injured in abdominal repair. At the close of the operation, the wound is re- paired layer by layer. The peritoneum is closed Suture of with a contiuous spiral suture of No. 40-day the Wound chromic catgut, while a hemostatic at the upper and lower angles of the opening, lifts it away from the bowel. To accelerate this step two stitches are taken each time before the catgut thread is tightened. To correct the recession of the peritoneum from the abdominal parietes as it approaches the top of the bladder, and to give this point additional support, one or two interrupted sutures of No. 1 or 2 40-day chromic catgut may be employed to bring the mus- cles together, and allowed to traverse the space of Retzius, including the fibrous cord, the obliterated urachus, which can be felt as a thickening beneath the peritoneum. When the repair of the muscle layer is complete, palpation of the suture line with the finger, above all, at the upper and lower angles of the incision, should reveal a uniformly firm re- sistant seam, without any yielding interstices. Ex- ceptionally, for example, in pre-existing diastasis of the recti, simple or compound, interrupted mattress Guiding Principles in Surgical Practice 93 sutures may be indicated, and the attenuated muscle planes are overlapped. In closing the fascial in- cision, it is to be observed that the anterior rectus sheath which is here, in itself, quite thick, being formed by the complete fusion of the aponeurosis of the external oblique, the internal oblique and the transversalis muscles ; is also re-enforced, by the deep layer of the superficial fascia — Scarpa's fascia — which is particularly well developed, and rich in elastic fibres. In general, the anterior rectus sheath and Scarpa's fascia are found to be quite adherent, although at the angles of the semicircular incision their individuality is easily demonstrable. After both layers have been made to coincide at the ends of the wound, the angles are clamped temporarily to aid the suture en masse. Before this step, the patient must have been returned from the Trend- elenburg to the horizontal posture, to obviate un- necessary tension. As a rule, the tension is not marked ; if notable, it is most apparent in the center of the incision, and at this point a few interrupted sutures of No. 1 or 2 40-day chromic catgut may be placed, while the remaining wound is repaired by means of a continuous glover's stitch, of the same material. When the pubic extension has been practised, both corners of the fascial flap thus formed must previously be caught with clamps and reunited. A simple mattress stitch is most efificient in bringing together the corners, and drawing them, at the same time, upward against the margin of the upper fascial flap at its midpoint. To prevent gap- ing, a continuous spiral suture of No. 000 or 40-day chromic catgut is introduced into the sub- cutaneous fat when it is abundant, that is, when the layer exceeds a quarter inch in thickness. Skin Successive Steps in Closing the Wound 94 Guiding Principles in Surgical Practice coaptation is accomplished by means of Michel's clamps, which are removed at the first dressing, on the fifth or seventh day. By this method, generally the most satisfactory closure of the skin wound is obtained in this region. In many cases there re- mains a scarcely discernable scar hidden in the recess of a natural fold. The removal of stitches or clamps can, of course, be altogether circum- vented, by using a properly chromicized catgut fila- ment. No. 000 catgut of 40-day resistance will be absorbed in due time, that is, approximately in five to twelve days. The subcuticular suture, or zinc oxide adhesive strips, are not as practicable in clos- ing this incision as they might perhaps seem to be. The subcuticular suture is difficult to apply to any semicircular flap without obtaining an uneven ap- position, while sterile zinc oxide strips are apt to adhere imperfectly, and become detached subse- quently under the influence of the sebaceous secre- tion, together with the traction exerted upon the wound when the patient awakes. The prime object of incisions, to gain satisfactory exposure, may be sacrificed unwittingly when im- portant accessories are overlooked. In a pelvic operation the surgeon may be struggling to get the intestines out of the field and the pelvic organs into better view; he may criticise the incision, the re- traction by his assistants, or his anesthetist for in- sufficient relaxation, while he is totally unconscious of the fact that the patient has not been put into Posture *^^ proper Trendelenburg posture which allows the intestines to gravitate towards the diaphragm, while the pelvic viscera prolapse into the wound. Similarly, the reverse posture may be helpful, or Correct Guiding Principles in Surgical Practice 95 an inclination of the patient's body to the right, or to the left during an operation. In the greater number of conditions which the surgeon has to deal with in the lower abdomen and pelvis, particularly in the female patient, satisfactory access is afforded by the semilunar hypogastric incision, and its increased complexity need not be in the way of its choice. However, when the time involved, is a very important factor a less intricate method of opening the lower abdomen may be legitimately employed. The simple median vertical incision, which violates nearly all of the principles that are important in reparable incisions, may be the only alternative. This technic may, however, be very much improved in a simple manner, if the opening into the fascia is made somewhat extra- median, so that the tongue and groove principle in- dicated by Frederic Kammerer in his right rectus incision, can be applied. After section of the skin and subcutaneous fatty tissue in a vertical line par- allel to the midline of the abdomen and about one inch to the left of it, the anterior lamella of the rec- tus sheath is split in the same direction. By blunt dissection the mesial border of the rectus muscle is defined. After retracting it, the posterior lamella is cut in a line corresponding to the skin incision, without injtiring the deep epigastric vessels. There is thus obtained a tongue and groove arrangement of the important fascial and muscular strata. The tongue is represented by the border of the rectus muscle, which fits into the groove formed by the mesial part of the anterior and posterior lamellae of the rectus sheath. When this incision is made over the lowest one-fourth of the rectus muscle, where the posterior lamella is deficient, the poste- Other Methods of Opening the Lower Abdomen The Mesial Rectus Incision 96 Guiding Principles in Surgical Practice rior lip of the groove which receives the rectus is represented only by the transversalis fascia and peritoneum. When a longer incision is necessary which extends beyond the level of the fold of Doug- las, the posterior lip in the upper part of the inci- sion becomes a more massive structure. There can be little doubt that the contractile muscle placed be- hind divided fascial and aponeurotic layers in this incision, is helpful in preventing postoperative her- nia. Deep In order to avoid injuring the deep epigastric Epigastric artery needlessly, by encroaching upon it while extending the division of the posterior lamella up- ward, its general course can be traced out roughly by a line drawn from the midpoint of Poupart's ligament to the umbilicus. Lineae 'pj^g development, number or absence of the lineae transversae, is also of some significance. Along the lineae transversae the anterior lamellae of the rectus sheath — but not the posterior — may be quite ad- herent, so that it may be impracticable to attempt dissecting around the border by the blunt method. In these cases the knife-blade must be used to free the muscle. Usually such an intersection is found at the level of the xiphoid process, another near the umbilicus, and one about midway between these two points. Sometimes one occurs below the umbilicus, between it and the pubic symphysis. Although the technic of the incision is somewhat encumbered by the presence of these tendinous intersections, they facilitate the secure suture of the rectus to the bottom of the groove when the wound is closed. In the lower abdomen such an incision might be substituted for the semilunar hypogastric, in case of tumors which are so large that they cannot be Guiding Principles in Surgical Practice 97 delivered through the maximum opening obtained by the former procedure. For instance, when a fibroid tumor or an ovarian cyst reaches the um- bilical level or extends beyond it. It may also be in place, when a large pus focus has to be dealt with, or in an operation for advanced cancer, or finally, when the patient's vitality is low, the case is urgent, and time becomes a more important factor. The method which I have outlined, may be ap- propriately designated, the mesial rectus incision, to distinguish from the lateral rectus incision in which the lateral, not the mesial, margin of the rectus muscle has to be retracted. In the lateral rectus incision, both retraction and extension of the in- cision are anatomically limited — the former because of the liability of injuring the dorsal nerves as they enter the lateral border of the muscle to supply it, the latter, because these nerves cross the path of the incision. The principles which are apparent in the analysis of routine incisions in the lower abdomen, are, in general, valid when the parietal route through the upper abdomen is chosen. Similarly, a routine in- cision in this region must be so outlined that it will suffice for the thorough examination of the gall- bladder and ducts, pancreas, stomach and duodenum ; it should be capable of such extension as operations on these organs may necessitate. The posture of the patient is here also none the less vital, particu- larly for the proper presentation at the wound of those organs, which lie close to the vault of the diaphragm, or, in overcoming difficulties when the incision is small, or unfavorably situated. In place of the routine incision, a number of special incisions into the abdominal wall, have been Indications for the Incision The Mesial Rectus Incision not the Lateral Routine Incisions in the Upper Abdomen 98 Guiding Principles in Surgical Practice devised by various surgeons for exceptional cases. They are indicated, when extension of the incision, or exploration is not deemed necessary. It is a good rule to make use of such an incision only, when it is unlikely that there is an error in the diagnosis. An exception may sometimes be made, when the surgeon has before him a sudden, severe, acute abdominal condition, which demands surgical in- vestigation at once, before he can decide whether the trouble is located in the upper or lower half of Special ^he abdomen. An acute appendicitis is naturally to be considered first because of its relative fre- quency, and a Kammerer right rectus incision or a small McBurney incision in the right iliac region may be made with this in view. In order to meet complications arising from errors in the diagnosis of chronic appendicitis, and to facilitate dealing with the surgical conditions which may simulate this trouble, Robert F. Weir suggested his method of extending the McBurney intermuscular incision. Again, when chronic appendicitis occurs together with a right inguinal hernia, both may be attacked through a single skin incision. Such a technic was described by Franz Torek (Annals of Surgery, May, 1906), and also, in one of my cases, which presented some complications, by A. H. Harrigan (The Combined Operation for the Radical Cure of Inguinal Hernia and Appendicitis, Medical Record, June 26, 1909). Before he approaches the operation, the surgeon should have a definite plan of procedure which is not based on ther observation of others, but on his own critical analysis of the case. The chief com- plaint of the patient, that for which relief is sought, the best route of attack; the possible error in diag- Guiding Principles in Surgical Practice 99 nosis, and the complications in the surgical technic which this may involve; all, must have been con- sidered beforehand. Whenever an exact diagnosis cannot be made, the incision assumes an exploratory character. A small incision can be widened, or Choice of readily closed, and a second incision made in a more Incision favorable situation, when the real nature of the trouble is revealed. Thus, in a patient who has had a slight rise in temperature for some time previous to her operation, if a retroperitoneal tumor con- nected with the kidney is discovered, on account of the greater safety, good surgical judgment may demand the selection of the retroperitoneal route through a lumbar, instead of a ventral incision. At the present day, when so much has been done to make surgery an exact procedure, the various modes of gaining access to the site of disease in the human body, deserve critical consideration. It is not always the simplest technic, which is at the same time the most conservative, and the best. Important details in a method, cannot conscientiously be dis- regarded in the effort to attain unwarranted speed. An operation may be quickly ended, it takes longer to complete it, still longer to finish it. CHAPTER X The Course of the Operation Division of Labor First and Second Assistants Orderly procedure calls for the definite division of labor at an operation. It helps to save time, and to conserve the surgeon's energy for the more vital phases of his work. It is not an easy matter to train assistants, and to operate at the same time. However, it lies in the nature of every-day practice, that men unacquainted with each other's peculiari- ties, occasionally have to work together. In general, there ought to be a clear understanding beforehand, about the division of labor at the operation. The surgeon who makes the plan for treatment and executes the operation, at once assumes the un- divided responsibility for the physical well-being of his patient; and whatever be the individual plan in the work assigned to those who help him, it must necessarily be subservient to his own. The surgical assistant exposes the structures so as to make them accessible, and assists the operator directly at every step. When it becomes necessary to retain exposure for a longer period, a second assistant, or in his absence, the nurse at the instru- ment table, assumes this function. Thus, the first assistant's hands are left free to work with the surgeon. In operations on the spine, or in trans- thoracic surgery, where the interfering structures are relatively inelastic and rigid, it may be practical to substitute self-retaining retractors for one of the assistants, but in most cases there is no device, which can hold or guide the retractor as well as the human hand. (100) Guiding Principles in Surgical Practice 101 Since the plan of procedure is properly formu- lated by the surgeon on whom all the responsibility for the success or failure of the undertaking de- Assistant's volves, the assistant should not consider it within Function his sphere, to suggest. Sometimes there are brief periods of relaxation during a tedious operation when the surgeon ceases, for the moment, to ex- ercise his critical judgment in the usual way. Per- haps he has been under a continued strain from previous cases, or is exhausted in body and mind from night-work and lack of sleep. At such a junc- ture, he may spontaneously give expression to his indecision, and a mature assistant may do much to aid him. Notwithstanding this, it is an impress of good training, to offer no suggestions, however tempting the situation may be, unless these are solicited, and then only with the greatest caution and reserve. Of all concerned in the operation, it is the surgeon pre-eminently, whose conception of the condition which presents itself, is apt to be the most profound, and who, while executing the work, alone is in a position to follow every phase of the situation. It is for him, therefore, and not for his assistants, to decide, what is to be done at a critical turn. Indeed, the psychology — the mental processes — during an operation ought to be of practical in- terest. Most of us have experienced, that in a time of indecision, the mind may be unduly receptive to an extraneous idea — a plan is quickly adopted with- out passing the usual muster. When the operation is over, an afterthought brings with it the realiza- tion that an error in judgment has been made'. The experienced operating-room nurse, in a measure, anticipates the surgeon. Needles are threaded beforehand, and the instruments are ar- 102 Guiding Principles in Surgical Practice Function of the Operating Room Nurse ranged on the instrument table according to some logical scheme to which she has accustomed herself. For instance, she may separate into groups, ( 1 ) Instruments for the grasping of structures, and exposure of the field; tissue forceps, tenacula, volsella, retractors. (2) Instruments for the cutting or division of tissues; scalpels, scissors, saws, bone chisels and mallet, rongeur forceps. (3) Instruments for the clamping of blood ves- sels, or hollow organs; hemostatics, clamps for the broad ligament, stomach, bowel. (4) Instruments for tissue-repair; needles, needle-holders, and suture material; Michel's skin clamps; drills and wire; Lane's plates. It is the technical part of the operation which consists of exposing, cutting, clamping and repair- ing, to which her attention is directed. She groups the acts of the surgeon under these headings, as she selects the instruments which are to be held in readi- ness for a particular step. Thus, for example, the initial incision is preceded by draping and the ap- plication of towel clamps; then come a scalpel and two sharp retractors. Bleeding which follows, de- mands sponges and hemostatics; subsequently, cat- gut and scissors. In this way, each act of the surgeon throughout the operation, evokes on her part, a well-directed response. The instruments which are immediately necessary are kept on the Hartley table within his easy reach, and those which become unnecessary are promptly removed. The family physician is often present at the opera- tion. His correct function, is not that of a surgical assistant, but more properly that of a medical con- sultant. In this capacity, he moves in his natural Guiding Principles in Surgical Practice 103 sphere of usefulness, and is thoroughly uncon- strained. His concrete impressions of the chief com- j,^^ Family plaints of his patient, his accurate knowledge of her Physician debilities, idiosyncrasies, and her recuperative powers under various conditions, the effect of pre- vious operations, all may be of value to the surgeon in determining his plan. The presence of many consultants, on the other hand, should scarcely ever be indicated. Many of us have seen this prove to be an embarrassing complication. The extraneous influences which are thus added, serve merely to distract the surgeon, and may, to the patient's dis- advantage, sway him from his wonted course. Be- sides, opinions differ in regard to details of personal experience; many consultants are like many clocks — they are apt to disagree. In dividing tissues and separating structures from each other during an operation, it is not to be over- looked that the more extensive the surgical trauma which has been inflicted, the greater will be the de- mand upon the organism in the subsequent process of healing. When the separation of layers, or the isolation of vessels, nerves and other structures can be avoided, it is usually in point to do so. In this sense, a good dissection may become a faulty opera- Avoidance of tion. The principle applies to numerous operations Dissection which are commonly practised. In the case of an inguinal hernia in the male subject, demonstration of the individual structures of the cord by dissection, except in so far as the technic of the hemioplasty absolutely requires it, is of questionable value. Similarly, it is a decided technical error to isolate the ureter needlessly from its bed, in operation in its vicinity. In general, the extensive freeing and demonstration of vessels and nerves, is not in strict 104 Guiding Principles in Surgical Practice Safe Hemostasis Difficulty Due to Bowel Distension The Embracing Forceps - accord with the fundamentals of conservative sur- gery; the healing process invariably calls for some scar-formation about these delicate organs, which may ultimately lead to constriction or impairment of their nutrition. When a deep blood vessel has to be tied, it is a simple matter to transfix the suture. This precau- tion ought always to be taken against the possible slipping or dislodgment of such a ligature. Tying vessels en masse, is unsurgical ; the hemostasis is imperfect, the grasp of the ligature insecure. Thus, many accidents from postoperative hemorrhage have at one time followed the employment of Tait's fig- ure-of-eight knot, in salpingo-oophorectomy. Marked bowel distention may prove to be quite an encumbrance, on account of its interference with retraction and exposure. It occurs not only in peri- tonitis, that is, in inflammatory conditions, but as well, without actual inflammation, for example, after internal hemorrhage. Of course, no effort on the part of the anesthetist will relieve the difficulty. It calls for adequate posture of the patient, and careful walling-off of the bowel to prevent its continual pro- lapse into the wound. Retraction should always be gentle and elastic. Organs like the brain or liver require particular care. Nerves should not be caught with the ordinary thumb-forceps, but cautiously drawn aside by means of a small hook, or lifted out of the way with a small thumb-forceps with thin blades which are bent slightly at the end so that the structure can be picked up without* contusing it — embracing-f creeps. Finally, surgical wounds which have been in- flicted, must be repaired. The needle which is most universally useful is curved; its curve corres- Guiding Principles in Surgical Practice 105 ponds to one-half of a circle. Its size might be rationally indicated by the length of its cord, in other Choice of words, the distance between the point and the eye. Needles Since much of the work in surgery has to be exe- cuted within narrow confines, a needle with a shal- low curve, for instance, a quarter-circle, or less still, a straight needle, is awkward to introduce and to deliver, during the application of the suture. The path traversed by the semicircular needle, on the contrary, corresponds to the natural turn of the hand and wrist, and the point enters the tissue- planes and emerges from them in a vertical direc- tion. Whether the needle in a particular case is to be round-bodied, or whether it should have a cutting edge, depends on the nature of the structures to be united. If one were guided by theoretical considera- tions alone, the round-bodied needle might be given the preference, because, where it can be used, it appears to subject the tissues to the smallest amount of traumatism; it penetrates by separating, rather than by cutting them. In practice, however, there are salient objections to it. Round-bodied needles can be carried through dense structures only with considerable difficulty, and often at the risk of break- ing the needle. Besides, there is the additional dis- advantage that the smooth, round body easily rotates within the jaws of the needle-holder, unless the lat- ter is supplied with a catch. The usefulness of round-bodied needles, on this account, extends but rarely beyond the repair of surgical wounds of the stomach or bowel, or of a tear or cut in a parenchy- matous organ. For the great mass of plastic surgery, it is best to select needles with a cutting edge. Pro- bably the most generally useful of all, in surgical 106 Guiding Principles in Surgical Practice routine, are those which are quadrangular towards the eye where the needle-holder grasps them, but triangular, with a cutting edge and bayonet point, in the engaging portion — semicircular needles with bayonet points. The so-called sinus needles have flat bodies ; they slit the tissues easily and are readily broken during sewing manoeuvres, because the strain is directed against the shorter and weaker axis of their bodies. Conversely, the curved Hagedorn needle is flattened from side to side, the longer axis of its body is sufficient to resist the bending strain put upon it in suturing, so that it is seldom broken, but it is not well adapted for use in a plain needle- holder. Special needles are the long straight needles with a round body, which are useful for suturing the stomach or bowel, whenever these organs can be lifted up into the wound, so as to obtain ample working-room. Such needles are manipulated by the fingers in the manner of the seamstress, without the aid of a needle-holder. Furthermore, for the anastomosis of blood vessels, some technicians pre- fer to use a "half-curved" needle — a straight needle with a curved point. The curved end facilitates the engagement and delivery of the point, while, with some practice, the straight end makes dexterous manipulation possible without the aid of a needle- holder. While working in the peritoneal cavity, the best prophylaxis against general contamination of the peritoneum, consists in the thorough walling-oflf of Walling-off a the suspicious focus by means of gauze. Should an Pus Focus effusion of septic material take place, its escape into the peritoneal cavity is efifectually barred. Small sponges ought rarely to be used; when a strip of Guiding Principles in Surgical Practice 107 gauze cannot replace them, they should be fed to the forceps by the nurse, one by one, so that two of them cannot be picked up at once, the one being re- turned, while the other is lost in the wound. Bacteria may be carried from the skin to the deeper layers, but cannot readily form colonies in contact with the healthy living tissue. In stagnating fluids, when proper tissue apposition is neglected, and so-called "dead spaces" are left in the wound, there are, however, presented all the conditions fa- vorable to their growth. It is, because blood and tissue-lymph are excellent culture media for path- ogenic organisms, that their accumulation in heal- ing wounds should be scrupulously avoided. This is why, in wounds of the abdominal wall, when the panniculus adiposus is well developed, gaps in the fatty layer must always be closed. For similar rea- sons, after radical operation for cancer of the breast, a drain is inserted into the most dependent portion of the axilla, when the pyramidal space which is left after operation cannot be obliterated by suture, or by the use of an axillary pad. In inguinal and femoral herniae, drains are no longer used, because the spica, when snugly applied, efficiently coapts the fascial strata. The session in the operating theatre may bring with it untoward events. An occurrence such as the fainting of a nurse or an assistant should not be allowed to upset the strict regime. It is unwise, especially for a novice, to attempt the strenuous task which an operation imposes on every one concerned, with a fasting stomach or a considerable burden of clothes. If one of those in attendance requires at- tention, this should be given without, at the same time, violating the asepsis. In complications, in the Fluid Collections and Dead Spaces Fainting of a Nurse 108 Guiding Principles in Surgical Practice Collapse of the Patient Hemorrhage course of the anesthesia, such as collapse, be it cardiac or respiratory, the first thought is always to rid the patient of the residual anesthetic by prompt artificial respiration, while the surgeon protects the operating field with a sterile towel. The manipula- tions are executed by grasping both forearms of the patient near the elbow, and extending them over the head. After a brief pause, they are again returned to the side of the chest to produce a forcible ex- piration. This should be done rhythmically, and at about the rate of natural breathing. The anesthetist must see that the tongue is forward, and no impedi- ment exists in the upper air-passages. A large vessel may be cut or torn while operating. The pedicle of the right kidney is rather short and easily injured while delivering the organ through a lumbar incision. A profuse hemorrhage may occur from the renal vein, the wound is at once flooded with blood, so that nothing can be seen. Counter- pressure with the hand from the front, and a large tampon of gauze packed tightly into the bottom of the wound, may be the only alternative. An intra- venous infusion of physiological saline may have to be immediately started, and little or no anesthetic must be administered for the time being. Generally speaking, death during a serious opera- tion in an enfeebled patient, is not sudden, but gradual. The anesthetist discovers the progressive failing in vitality, and such an indication should be promptly announced. Sudden death during opera- tions, however, may occasionally occur, for instance, as the result of air embolism. The aspiration of air is most likely to take place through wounds in the larger venous trunks in the proximity of the heart, because, in these, during the act of inspira- Guiding Principles in Surgical Practice 109 tion, the pressure becomes decidedly negative. Sometimes indeed, the aspiration of air is followed ^^^ by dilation of the pupil and the breathing becomes "^ ° *^™ labored, but the patient subsequently recovers. At all events, in such an emergency, the first thought is compression of the vein at the site of the injury, or on the heart-side of it, to prevent further aspira- tion. Meanwhile, the field is kept flooded with saline until the wound in the vein can be closed. If measures, as the forcible compression of the chest, combined or uncombined with inflation of the lung with oxygen by means of a tube passed through the patient's nostril, are indicated, and are really of therapeutic value, remains still to be ascertained. from the Operating CHAPTER XI Care of the Patient After Operation The attentive, kindly nurse can do much towards minimizing the discomfort of her charge. Many- Arrival patients sweat profusely after operation, and the wet shirt is promptly exchanged for a dry one, the Room covers are tucked snugly over the shoulders and chest; and, if the temperature of the room is low, or the patient's condition poor, hot water bags are applied at once to the side of the body and lower extremities. A chilling of the surface may mean suppression of the excretory skin activity, and ad- ditional work for the kidney which is already over- taxed. On the other hand, bronchial congestion following neglect, may lead to pulmonary complica- tions which might have been avoided. After the brief vomiting which sometimes follows awakening, the comfort of a soft pillow under the head, should not be withheld. The abdominal wound may be supported when the patient vomits, to lessen the pain caused by this sudden impulse ; a pillow placed under the knees, reduces traction upon the suture. The patient's mouth is rinsed with lime- water or milk of magnesia, to remove the after-taste of the anesthetic; she may be allowed to inhale the vapors from a ball of cotton moistened with alcohol and acetic acid. The dry lips are kept moist; a wet cloth over the forehead and eyes, helps to induce sleep. The cloth should not drip, nor should water flowing from it into the patient's ear, escape (110) Guiding Principles in Surgical Practice 111 notice. During the first twenty-four hours after operation, one or two, or, if necessary, more doses of morphine sulphate, one-quarter grain each, are allowed hypodermatically. The first dose, is usually MQj.„i^in given as soon as the patient becomes restless. The second, not sooner than four hours later, when post-operative discomfort reasserts itself. Finally, on the evening of the next day, a third dose is generally indicated. It is well not to continue the administration of morphine any longer than is necessary. After many abdominal operations there remains on the second or third day, little more than a soreness in the region of the wound and per- haps a dull ache in the back. It is important to analyze the patient's complaint. The occasional, migrating pain in the abdomen, or the sharp twinge that comes and goes, and appears on the second day or later, is usually a gas pain. It has its origin in the paretic intestine, and not in Q^g p^j^ the wound. The simple peppermint enema affords relief, while morphine would be only of transient value, and is not the logical remedy. It is the part of wisdom to avoid promiscuous medication. Per- sonally, I believe that the treatment of a surgical case should be left entirely to the surgeon, all orders being issued by him until the patient is in a condition to be dismissed from his care. Unnecessary division of responsibility leads to a division of the plan of treatment, complicating in- structions to the nurses, and is not for the best interest of the patient. Frequently, the surgeon's lack of knowledge of the dosage and action of drugs, has helped in this regrettable complication. It is rare indeed, that a drug is imperative in a surgical case, but where one is indicated, he should appre- 112 Guiding Principles in Surgical Practice ciate the indication, and ought not to be at sea about the exact dose, vehicle and conditions necessary to insure the desired effect. Axioms worth bearing in mind, are the following : Anodynes and (^) After operation, it is well to spare the Somnifacients rebellious stomach from drugs. (b) Morphine is primarily not a somnifacient, but an anodyne, and the patient sleeps after its use because the disturbing pain has been relieved. (c) Veronal, veronal-sodium, tetronal, trional, sulphonal, and allies, on the other hand, are, strictly speaking, somnifacients and not anodynes. These drugs therefore, cannot replace morphine for post- operative use. (d) Of anodynes allied to morphine, codeine phosphate and dionine are readily soluble in water, and can be given subcutaneously, but the action of these is feeble when compared with morphine, and, the instance in which their postoperative administra- tion might be indicated must be exceptional. No sleep is as refreshing, and as beneficial as the natural sleep. After the first few days when the meridian of pain has been passed, and anodynes have no purpose, it seems to me an error in judg- ment, to yield too readily to the patient's request for "something to make her sleep." A patient who Sleep is resting in bed all day long, cannot expect to sleep as soundly throughout the night, as she was wont to do after a da/ of bodily activity. A nervous unrest produced by anticipation of stitches to be removed, worry about the nature of her operation, or its ultimate outcome, some home trouble carried Guiding Principles in Surgical Practice 113 into the sick-room by an indiscreet visitor, a thou- sand little things, may upset the delicate nervous mechanism of the patient and be the cause of a wakeful night. An artificial slumber produced by drugs, is not going to be of half so much benefit to such an individual as a natural one, following per- haps a cold sponge-bath, or a little mental influence. The question frequently arises : How long shall we wait before catheterizing a patient after opera- tion? In gynecological cases there is not infrequent- ly a reflex dysuria, a reflex retention of urine which disappears after the first micturition. Except in those cases in which the bladder had to be opened during the operation, and there is danger of leakage, there is no reason why one should order immediate catheterization. The secre- tion of urine after operation is naturally diminished, because the patient has lost a great deal of fluid by sweating, and, in addition, she is receiving very little to drink. It is therefore easy to understand that twenty-four hours may elapse, before the bladder is really distended to the point of dis- comfort, and then the patient voids spontaneously after making a slight effort. Some patients cannot void when there is someone in their presence, but are successful after the nurse has left the room; others should have a screen placed around the bed ; others respond when they hear the running of the water at the hydrant; or gentle pressure over the lower part of the abdomen may start urination, or a cold application to the inside of the thigh, or .water from a sponge trickling over the vulva, or gentle vibration or Faradization of the hypogastrium. It may happen that the initial difficulty is overcome after receiving an enema. Some patients, however, Catheterization Dysuria 114 Guiding Principles in Surgical Practice defy every expedient and have to be catheterized regularly, until the moment arrives, when they are allowed to sit up ; and then, voiding occurs, without any difficulty whatever. Where catheterization is necessary, it should be done as infrequently as pos- sible; once every eight hours is, as a rule, sufficient. The vulva and meatus urethrae are rinsed with a little warm, two per cent, boric acid solution; and the catheterization is done aseptically and gently. In the first days after operation it is of importance to note the quantity of urine, but the specimen itself is often of little value for analysis until the first Record of five days have elapsed. The reason is, that post- Urine operative casts may appear in the urine for that length of time, and no reliable opinion of the normal condition of the kidney can be formed from such analyses. The analysis which tells us this, is the one made of an average specimen of urine taken before operation. When a routine analysis is de- sired after operation, the specimen should be col- lected after the fifth day. It is, of course, most accurate to obtain a sample of all the urine voided in twenty-four hours, that is, a twenty-four hour specimen. Where more extensive quantitative an- alyses are expected, this should always be done. But, in practice, it is much more convenient and ordinarily sufficiently accurate, to take equal parts of urine voided in the morning and evening, and mix the two samples to obtain, what might be called, an average specimen. For a period extending from three to five days after operation, the total quantity of urine voided by the patient should be recorded by the nurse. Suppression of urine is an ocacsional cause of death after operation, and any suspicion in this Guiding Principles in Surgical Practice 115 regard demands prompt and serious consideration. If the suspicion is verified, potent eliminative treat- ment has to be instituted, chiefly, I think, by stimu- lating the excretory function of the skin and the bowel surface. Hot bland drinks and a hot rectal infusion are quickly given, and the patient is packed in hot blankets until she begins to perspire pro- fusely. This procedure, simple as it is, and old as the history of medicine, is nevertheless sometimes life-saving in its significance. The usefulness of drugs in such cases is limited; whether it is really an advantage to administer pilo- carpine and similar diaphoretics in conjunction with the physical treatment, remains a disputed point. Some other measures, for instance, the electric light bed-baths, on the other hand, are, to my mind, fre- quently of invaluable service where these can be had. In some patients, at least, the relaxation which follows the active diaphoresis does not seem to be as pronounced after the electric light bath, as it is after most other sweating measures. There are probably as many opinions on the subject of postoperative feeding, as there are sur- geons. I have always believed in simple things, and cherished the hypothesis that nature in her inner workings is pre-eminently simple. The diet depends, in a great measure, on the con- dition of the stomach after narcosis. No doubt, much can be done towards minimizing the amount of nausea and vomiting after operation, by giving adequate attention to certain seemingly trifling de- tails. There should be a proper understanding and co-operation between the anesthetist and the sur- geon. If the patient receives a quarter of a grain of morphine sulphate hypodermatically, half an Suppression of Urine Postoperative Dietetics 116 Guiding Principles in Surgical Practice Gastric Upset after Operation Inanition before Operation hour before narcosis, the anesthetist allows by the drop method the minimum quantity of anesthetic necessary to retain the surgical plane, and regulates carefully the access of air to the mask to prevent, at any moment, undue concentration of the anesthetic vapors, and the symptoms which would arise from crowding the anesthetic ; if the surgeon, mindful of the real welfare of his patient, is willing at times, to suffer the inconvenience of insufficient relaxation of the muscular wall of the abdomen, rather than urge on his anesthetist into crowding the anesthetic, and if he will handle the delicate structures and organs, especially the intestines, gently and as little as pos- sible, he will have gained a great deal towards at- taining this end. Some surgeons are unduly rough in their manipulations ; time seems to them to be the only factor, the operation must be done quickly. But naturally, the result after such an onslaught is often to be anticipated; there is much postoperative dis- tress, vomiting, gas-pain, and a turbulent con- valescence. Another mistake that is not infrequently made, is to starve the patient before operation. With- holding food for too long a period before operation, it strikes me, does not diminish, but rather helps to increase the postoperative gastric upset. The starv- ing body is more readily poisoned by the anesthetic, than a well-nourished one. All that is required, as a rule, is that the stomach should be empty, at least it should not contain solid or coagulable food when anesthesia is induced. A stomach possessing nor- mal mobility, should contain no food-remnants five hours after the ingestion of a meal. In the case of gastric atony, or pyloric stenosis, the stomach might have to be washed to rid it of stagnating chyme. In Guiding Principles in Surgical Practice 117 practice, when the operation is set for 8 o'clock in the morning, the patient usually gets a normal sup- per, consisting of digestible food, on the previous evening, and is allowed some non-coagulable drink in the early morning hours if she is awake. When the operation is to be at 2 o'clock in the afternoon, the patient gets a good breakfast, and some non- coagulable drink at 10. If the patient has not been shocked by brusque handling during the operation, nor saturated with anesthetic, she becomes con- scious promptly, and soon regains her natural tone. But little nausea or vomiting is the rule, and five or six hours after operation, the nurse begins with small quantities of liquids, hot or cold, ranging from a sip to two fluid ounces. The liquid diet of the patient at this period con- sists chiefly of water, hot or cold, weak tea, orange- Liquid Diet ade, lemonade, albumen drinks, barley-, oatmeal- or rice-water, cider and other non-intoxicating drinks. Cow's milk, is, as a rule, objectionable; it readily forms large curds and is difficult to digest; when it is allowed, it should be diluted to one-half with cereal water. The nurse begins the feeding cautious- ly, and with judgment; it becomes her duty to dis- cover in each case, what agrees best with the patient. There is no rule which holds good for all. Some patients have queer idiosyncrasies. Thus, it has happened that a patient's stomach rebelled against everything, until she got the draught of Pilsener beer for which she had asked. In other cases, where the vitality is low, champagne may be given as a stimu- lant, and albumen drinks as a food. Sometimes a tumbler of lime-water or diluted milk of magnesia, though promptly ejected, has a sedative action on 118 Guiding Principles in Surgical Practice the stomach mucous membrane, it seems, and makes it more tolerant than before. As soon as the patient no longer experiences difficulty in retaining liquids, generally twenty-four hours or so after operation, comes the time when she is to be started on her convalescent diet, excepting „ , this is, for other reasons, contra-indicated, as in Convalescent jjigt some operations on the stomach and bowel, where solid food is, for the time being, to be avoided for purely mechanical reasons. Though the patient at this time has but little appetite, she is encouraged to take food. The nurse begins, for example, with custard, or boiled rice, a piece of dry toast and tea, or an egg, soft boiled, or poached, or even a thin sandwich of scraped meat. In her selection, she caters to the patient's preference. If these agree, a piece of roast or boiled chicken, and then a chop with potato puree or milk-rice, can safely follow in the patient's menu. Excess of fats and sweets must be avoided. The stomach is easily upset by fatty foods, while sweets are objectionable because they have a tendency to impair still more the ap- petite, which is already diminished. The convalescent diet to which I refer, might be correctly called a light diet, inasmuch as it includes only food which is easily digested and does not produce a great deal of gas. "Soft diet" is a mis- leading term when used, as it often is, to designate a diet for patients recovering from an operation, since it is not intended that the nurse should be guided in her seletcion of the patient's food by its consistency; it is tlie digestibility that she must con- sider. In fact, many cheeses are soft, but very hard indeed to digest, and no one would, for a moment, entertain the notion of including them in Guiding Principles in Surgical Practice 119 what is ordinarily meant by a "soft diet" ; the term is not significant except, if you will, in the case of an individual who is unable to masticate her food properly because she has lost her teeth. The convalescent diet list excludes cabbage, and leguminous vegetables such as lima beans, beans, peas, lentils, because they are rather difficult to digest, and produce an excessive amount of gas. Radishes, pickles, Worcestershire sauce, mustard and much spice should be avoided. Of fruits, bananas are not well tolerated. Vinegar, that is the acetic acid in it, is very detrimental to digestion ; the ordinary organic acids in fruit, citric acid in lemons for example, seem on the contrary to have a beneficial effect. For this reason may be allowed lettuce, water-cress or dandelion prepared with lemon juice, but not with vinegar. In fact, these leaf vegetables appear to be of certain value in supplying in acceptable combinations iron, sodium and other inorganic elements to the system; the human tissues do not consist solely of proteids, fats, carbohydrates and water. Spinach too, belongs in this category of leaf vegetables; it contains an abundance of useful iron and other salts. It is, however, essential to prepare it properly; that is, with no more water than will steam off during the cooking process. If too much water has been added, and the supernatant liquid is decanted, and poured away after cooking, most of the water-soluble salts, and other substances to which the dish owes its peculiar food value, are lost. It is well that the diet of bed-lying patients be Cathartic cathartic in character. The nurse can regulate the Food patient's bill of fare so that some cathartic food or drink is always interpolated. Fresh fruits, or 120 Guiding Principles in Surgical Practice ' Graham bread at breakfast, or corn-crisp, shredded wheat, puffed rice, or other cereal, or stewed prunes or rhubard ; or, after supper, a glass of thin butter- milk; all stimulate the sluggish peristalsis. On the other hand, constipating foods such as white bread, cake, strong tea, are restricted, or avoided altogther, as the case may be. Notwithstanding, it is the exception, especially among female postoperative cases, that does not require the aid of artificial catharsis or enemata. It is to be anticipated that a patient will tend to be more constipated in bed, than she was out of bed; the great stimulus to peristalsis given by bodily activity is wanting. After hemorrhoid operations and ano-rectal plas- tics, it is merely necessary to restrict the patient to a convalescent diet from which all cathartic foods Constipating j^^^^g j^^gj^ eliminated, and the almost uniform re- sult will be that she remains constipated for five days or longer. In view of this fact, I could never fully understand, why, in such cases, the surgeon should persist in the old routine of giving opium by mouth. Besides this, even the best of these prepara- tions, the deodorized tincture of opium given in a little brandy, is liable to upset the irritable stomach. The patient receives morphine with discretion, but as often as she needs it to make her comfortable, just as in the case of other operations. It is always given subcutaneously, and in a sufficient dose, a quarter grain. Morphine is given hypodermatically solely as an anodyne, not under the impression that it has a material influence in inhibiting bowel peri- stalsis, as does its ally, the crude drug opium when administered in the usual dose and manner. Furthermore, in rectal cases, there is generally not much gained by allowing the bowel to remain Guiding Principles in Surgical Practice 121 inactive for a period longer than five days. The contents of the large bowel Ijecome so inspissated and desiccated, that ultimately their evacuation is accompanied by considerable mechanical difficulty, and perhaps damage to the site of operation. In- deed in these cases, there is less probability of damaging the suture-line on the fourth or fifth day, than later, when the "40- 60-day" catgut begins to dissolve. The only reason for binding the bowels, is in order to keep the anorectal wound or suture- line clean, until at least a superficial protective heal- ing has taken place, and infection is unlikely. This is surely the case after five days have elapsed. In fact, if the wound-lips of the rectal mucosa are apposed with nicety, and this can be best done by using a submucous suture of fine chromic catgut, 000 to in size, and ''40- 60-day" resistance, the wound is superficially, but sufficiently sealed within a few days to protect it quite well from subsequent infection, especially if the bowel movements have been loose. After the fifth day, the bowel evacua- tion should be anticipated by an oil and soap suds enema given through a well lubricated soft rubber rectal tube. The anal and rectal mucosa covered with an oily layer, is less liable to be damaged during the act of defecation. The ideal cathartic to be given by mouth for postoperative use, would be one which is not dis- agreeable to take, and which produces a fluid move- ment with the least amount of griping and distress to the patient. Castor oil, though most children do not object to taking it, especially if sweetened with syrup or honey, is nevertheless a potion to which few adults take kindly. To an adult, it might how- Period of Enforced Constipation in Rectal Cases Drugs for Postoperative Catharsis Formulae 122 Guiding Principles in Surgical Practice ever be given in the historic form, the castor-oil sandwich. Rp. . . Sirupi Rubi Idaei fl. 3ij Glycerini fl.3j Olei ricini fl. Svij Spiritus friimenti or Spiritus Vini Gallici fl.Sij D. Pour carefully into a graduated medicine glass in the order given. The fluids will produce four distinct layers. But at best, it is a bulky dose, and its extemporaneous preparation is too compli- cated. An attempt of mine, to avoid these objections, resulted in the use, for a time, of the following prescription : Rp. Olei tiglii c.p. mxvj. Olei ricini Alcoholis absoluti aa fl. 3ss Olei foeniculi Olei myristicae aa mxxx D. S. Average dose, fifteen drops in a little brandy. Maximum dose, thirty drops. In this combination, the potency of the oleum tiglii is not lost, but its griping effect is reduced to a minimum. The cathartic is very prompt and effectual in its action. The drastic effects of croton- oil administered in the undiluted state, such as blood in the dejecta, I have never observed, even with doses of half a fluid drachm. An objection to the Guiding Principles in Surgical Practice 123 general use of such a cathartic, however, is the fact that it has to be given in an alcoholic medium. Taken in milk, it seems, that at times, its cathartic action is impaired. In the long run, it is calomel still, that is perhaps the most serviceable, for the postoperative, just as in the preoperative routine. It is not the simple stim- ulation of an after-dinner pill, but prompt and reli- able evacuation of the bowel which is here most of- ten demanded. The calomel should be administered in a single dose of three grains to the adult, excep- tionally two grains. It is a mistake to give it in divided doses for this purpose. Given in divided doses, calomel is more prone to produce emesis when the stomach is irritable; more of the mercury- is absorbed, and salivation results more easily. In the rectal case, after the first evacuation of the bowel, the chief difficulty is passed. The nurse sees to it that the patient's diet now becomes cathartic in character in order to stimulate the bowel naturally, and in order to preclude consti- pated movements. After the ordinary laparotomy, or for that matter, after perineal operations as well, in which the rectum is not involved, an evacuative enema of plain water or of 1 per cent, soap suds is ordered after the third day. There is no serious objection to giving such an enema earlier, if the indication should arise. Not uncommonly, on the day following operation, a low peppermint enema, for instance, is administered to facilitate the ex- pulsion of gas which distends the bowel unduly. The evacuative enema besides freeing the large bowel of its stagnating contents, aids in inciting more active peristalsis in higher portions of the gut, Enemata 124 Guiding Principles in Surgical Practice Mild Catharsis Normal Full Diet and thus promotes the expulsion of gas which makes the patient uncomfortable. After the ordinary laparotomy, cathartics by mouth, when given — generally on the fifth day — can be milder and more varied than in rectal cases where the bowel has been kept inactive. The patient here may even indicate the cathartic which she thinks agrees with her the best, and which she has been in the habit of using. A little magnesium citrate, or the aromatic fluid extract of cascara sagrada, or, a simple extract of cascara sagrada pill which contains no harmful ingredients, is not objectionable. The transition to a rational full diet ought to be made when the short period of gas-pain is passed, the habitual bowel activity restored, the tempera- ture is approaching the normal, and there need no longer be any serious scruple about readily upset- ting the patient's digestion by granting her more latitude in her meals. Its greater variety adds a healthy natural stimulus to the patient's appetite and digestion. While it does not overtax the patient's digestive powers, it demands the exercise of the normal digestive function. Tlie normal full diet which is least inimical to the digestive and eliminative organs of the human adult, is not one, it seems to me, consisting largely of meats, nor is it a strictly vegetarian diet, as others would have it. I have myself, for the sake of experiment, lived as a fairly strict vegetarian for a period of five years (1895-1900), and although the term is too short to allow me to draw 'many conclusions as to the effect produced in the human system by excluding animal food, I feel warranted in saying that purely vege- table food, although correctly prepared in a good Guiding Principles in Surgical Practice 125 kitchen, calls for a digestive energy which most of us do not naturally possess, and which is not readily developed even after a number of years of vege- tarianism. Also animals like the dog can be fed, and can exist on vegetable food, but it seems here too, the digestive organs are not quite equal to their task. A healthy English greyhound pup was re- stricted to a vegetable diet, from which all meat was excluded, for a period of three years; the animal relished his food, grew and appeared at first to develop normally, but later signs of subnormal nutrition began to become evident, his hair grew dry and glossless, the musculature somewhat thin, though of good quality, panniculus adiposus scanty so that the outline of the ribs was pronounced. Un- fortunately, I cannot record the corrective influence of a change in the animal's food. Some hardened wretch, soon thereafter, poisoned with strychnia, my mute companion in this little study in vege- tarianism. The normal full diet for a postoperative case, should not be an extreme diet ; it should be a mixed diet in which flesh food is allowed moderately, once a day, or, in smaller quantities twice a day, certainly not oftener. The proper cooking of vegetables is a lost art, and as a consequence perhaps, the aver- age individual eats too much meat. The constipated bowel with fluids stagnating in the caecum and appendix, and the torpid liver would, no doubt, be helped by the cathartic influence of more vegetable food. While aiming to put the patient on the normal full diet as soon as this is feasible, in most cases from the fourth to the seventh day after opera- tion, a few cannot be subjected to such a rapid Vegetarianism Excess of Flesh Food 126 Guiding Principles in Surgical Practice Changes of Position after Operation transition, and may have to remain on a carefully supervised, selected convalescent diet throughout the entire period of their recovery. Occasionally one meets with such a patient, who begins to eat and digest properly the moment she is up out of bed. With few exceptions, the laparotomy case may be placed on her side on the first or second day after operation. Of course, if she is a very adipose woman with an abdomen which overflows the iliac crests, it is wiser to keep her on her back during the entire postoperative period. After a few days such patients begin to become used to this position, and do not feel the restriction as they did at first. After operations on the female perineum, the lateral posture enables the wound to be kept dry by allow- ing the accumulating discharge to gravitate away from the suture line — this point, I think, is vital in obtaining successful union in complete tears of the female perineum. In inguinal or femoral hernioplasties, a lesson is to be learned from child- ren who are wont to lie on the operated side — evidently the position of comfort. Under ordinary conditions there need be no hesitancy in permitting this in the case of adults, except where an operation for hernia has been done on both sides. It should be our endeavor to see how admirably nature often points out the way to us, if we will but study her with a little insight. A sad spectacle is he who looks for therapeutic indications only in books, and neglects to discover them in his patients. The patient's second week — the week of waiting — should, to the 'fullest extent, be made available for her mental and physical rehabilitation. During the day her mind is kept occupied, to prevent undue introspection and brooding. Wire puzzles, Japanese Guiding Principles in Surgical Practice 127 puzzles with complicated dove-tailing, engage the xhe Second hands and brain, or brass-punching, or modeling in Week artist's clay, or folding gauze for the operating- room, are all better than fine needle-work or much reading. A male patient may derive considerable pleasure from a cigar, it is not encouraged but allowed; while another with a constructive bent, begins to while away his time by whittling some chess figures, or a wooden chain. It is sometimes necessary to discriminate between visitors. Mem- bers of the family or friends with a cheerful dis- position are desirable, and may help to modify the patient's mood. After gynecological operations where the median vertical, the mesial rectus, or the semilunar hypo- gastric incision is used, the lower border of the dressing is secured by means of a strip of zinc oxide Methods of adhesive two inches wide, before the patient is taken Retaining the from the operating-room. The strip reaches from Dressing the outside of one hip, to the outside of the opposite one. It overlaps the dressing, about three-quarters of an inch. below, where it is made to adhere firmly to the symphysis, immediately above the vulvar in- cisure. Sponging the area with a little ether or liquor expurgans, aids materially in obtaining good adhesion of the plaster. An oblique incision of about one inch, in the direction of each inguinal fold, makes possible better adaptation, and prevents the plaster from being pulled or lifted away from the symphysis so readily when the thighs are flexed. Laparotomy straps consisting of strips of adhesive plaster one inch in width with tapes attached, two or three on each side of the abdomen, are tied over the dressing to keep it in place. In their stead, a single wide piece of adhesive on each side, lined with 128 Guiding Principles in Surgical Practice rubber tissue, or with a single layer of gauze where it touches the dressing, can be laced in front in the manner of a corset. Nevertheless, in either case, it is well not to discard the traditional plain, or many tailed binder which affords additional support and protection to the wound. In very fat subjects with a large incision, the wound is not supported sufficiently, even with a snugly applied binder, and it is safer to encircle the abdomen with broad (four inch) strips of zinc oxide plaster beginning below and allowing each tour, to be overlapped partly by the next, while the ends cross each other in front obliquely, over the dressing. I have had occasion to regret my neglect to observe this precaution, in a rather adipose patient in whom, on account of the magnitude of the pelvic tumor, a large incision was necessary. During a violent coughing spell, the entire suture-line was burst open, allowing the in- testines, partly covered by the omentum, to escape into the grasp of the dressing. Although the suture had been carefully done by layers, the catgut had cut through the friable tissues, each knot still remaining securely tied. In the case of an inguinal or femoral hernia, the best support is given by a firmly applied spica. The bandage should be not less than four inches wide for the adult, and the bony prominences padded with non-absorbent cotton. In most cases it is indicated to reen force the bandage with a single figure-of-eight tour of adhesive plaster. Unless there has been some complication in the The First normal wound-healing, the first dressing is not due Dressing until the fifth, sixth or seventh day after operation. In laparotomies dressed in the manner described, it is merely necessary, after undoing the tape of the straps or adhesive corset, to reflect the dressing Guiding Principles in Surgical Practice 129 downward over the pubes, when the suture line comes to view. If there is no redness or moisture about the stitches, no tender infiltration to the touch, the wound has healed by primary intention. Indeed, that is what is to be expected if the postoperative temperature chart shows no deviation from the nor- mal aseptic reaction. If absorbable material has been used for suturing the skin, the patient learns with satisfaction, that contrary to her expectation, no sutures have to be removed. Michel's skin clamps call for an early dressing, generally on the fifth day. In case adhesive strips have been used for skin-closure, early dressing is not vital. Silk- worm gut sutures at the angle of a secreting or dis- charging wound, or in flaps which are under ten- sion, as after radical operations for cancer of the breast, or in the perineum, had better be left until the twelfth day. Silver leaf cut into small squares and sterilized in packets of a dozen or more, between two squares of thin wood (J. S. Lewis), has oc- casionally been used to cover the suture-line im- mediately after operation, in order to prevent the gauze dressing from adhering to it. At the first dressing the silver leaf is found more or less minutely pulverized, and where there is oozing from the incision, it tends to create an undesirable crust. The removal of drains of rubber tissue or tubing Drains from aseptic wounds where there is much oozing, is occasionally necessary. Thus after the radical operation for cancer of the breast, drainage of the axilla for 24-48 hours is required to remove the accumulating lymph, and this necessitates an early dressing. At one time drainage was almost a routine after the ordinary hernioplasty. In this case the pressure exerted upon the wound dressing when 130 Guiding Principles in Surgical Practice Temporary Support after Operation the bandage is properly applied, ought to be suffi- cient to prevent the accumulation of much lymph or blood. Much depends upon the proper application of the spica. In obese individuals difficulty in this regard is obviated, by obliterating the gaping spaces in the subcutaneous fat at the time of the operation, by means of a thin absorbable suture. It is surely better, to attend to such details with proper pre- cision while the patient is under the anesthetic, than to be encumbered later at the dressing by complica- tions which might have been avoided, and then attempt to make good a neglect. Where reasonable care and circumspection have been exercised at the operation, the postoperative treatment usually becomes a simple matter as far as the surgeon is concerned. The routine first dress- ing on the fifth, sixth or seventh day after operation includes the removal of skin sutures or clamps or, when an absorbable skin suture was employed, con- sists in little more than an inspection of the wound, and the substitution of a new piece of sterile gauze for the one which has been in contact with the incision. In gynecological cases the protective gauze pad which was reflected for the dressing, is returned to its place, and the laparotomy straps or corset flaps are fastened over it, as before. Only at the second, that is the last dressing, the entire adhesive support is removed, and the skin freed from the adherent zinc oxide by means of benzine, ether, or liquor expurgans. If there happens to be a point in the wound where the apposition was not good and heal- ing was delayed, a tiny bit of sterile gauze and a small strip of adhesive, are all the dressing requires. The area where the plaster has been, is thoroughly Guiding Principles in Surgical Practice 131 powdered by the nurse. A supporting belt need rarely be ordered. The so-called ''straight front" corsets which are now in vogue, are constructed on sounder principles than the old-fashioned type ; the abdomen is lifted from below upward, and adequate support is given to the young and distensible scar. A corset of neat pattern has been constructed which consists of two pieces, one shifting over the other, and which allows more freedom in bending the body forward. It is well adapted to the needs of cor- pulent patients with a pendulous abdomen, who are otherwise difficult to fit properly. The nurse in- structs the patient to apply the corset in the re- cumbent posture, and to lace it always from below upward. Cases of inguinal or femoral hernio- plasty leave the hospital wearing as a temporary support of the recently healed wound, a tightly wound spica. This is reapplied once more as soon as it loosens, which is usually in the course of a week. The question, "When shall the patient be allowed out of bed after an aseptic laparotomy?" has evoked diverging opinions. Some surgeons lay little stress on the stretching of the scar, and the possibility of a postoperative hernia. But it seems unfair to the patient to disregard these factors, and better to retain the average aseptic laparotomy in the recum- bent position for not less than tzvelve days. In the the^PatVent case of a fat individual with poor healing power, an sit Up in Bed? additional week is not superfluous. To keep a patient in the horizontal plane of her bed, does not necessarily imply that she should be immobile. The use of the extremities and changes of posture, pro- mote the venous return and are helpful, rather than detrimental, so long as no strain is put upon the When may 132 Guiding Principles in Surgical Practice Report to the Family Physician incision. Cavil none will, that the patient can be gotten up almost any day after operation, but the salient point at issue is not what can be done, but what is most adequate if the patient's future wel- fare is considered. Indeed, for that matter, it might be safer to allow a patient to sit up on the third day after an abdominal section, than on the sixth or seventh, when the stitches begin to be dissolved. By far the greater number of laparotomies are uncomplicated in their recovery, and can be dis- charged from the hospital on the fourteenth day of their stay. On the morning of the day before dismissal, the patient for the first time assumes the vertical position, she is permitted to sit up in bed. Some patients, particularly anemic ones, are inclined to become dizzy during this first attempt, and a hot, exhilarating drink may be given as a prophylactic measure. In the afternoon, the patient is allowed to sit in a chair. On the morning of the last day, a final revision of her condition is made. She will, by this time, have partly reaccustomed her- self to be up and about, and is prepared for the event of her departure. As soon as the patient is dismissed from the surgeon's care, important data and details concern- ing her condition should be transmitted to the family physician or specialist into whose hands she reverts. It is an attention due the patient, as well as the physician who has to take further charge of her, and now becomes responsible. Perhaps some of the problems concerning the proper ethics to be observed between* physician and surgeon regarding the transfer of a case, may become very much simplified, if both truly agree that the patient's best interest should determine their course. Fever CHAPTER XII The Interpretation of Post-Operative Fever in Aseptic Cases It is a matter of common knowledge, that every operation on an aseptic case is physiologically fol- lowed by a slight rise in temperature, which is not due to infection. The rise in temperature is so definite and uniform in its behavior, that the con- ception of a typical aseptic wave seems well founded. Naturally, the normal reaction is most evident in Aseptic cases with a strictly uncomplicated recovery. In practice, such cases are the exception, and there is therefore usually imperative, a more critical analy- sis of the post-operative fever-curve, in order to distinguish the general trend of the fundamental reaction, from that which is incidental, and due to some complicating factor. But what are the essential characteristics of the typical aseptic reaction? The problem may be approached directly by eliminating at once, from this study, all pus cases, in fact, all cases which have not a normal temperature before operation. As a matter of course, a correct picture of the aseptic reaction can only be expected in a case which is primarily aseptic, and in which even the minor details of asepsis during operation have been watched with particular scrutiny. As a result of such an attempt to define the aseptic reaction, the following deductions may be recorded : (133) Data 134 Guiding Principles in Surgical Practice (1) The mean daily rectal temperature is nor- mally about 99.1° F. The daily fluctuation is ap- proximately 0.6° F. That is, the highest normal reached during the day is 99.4° F. ; the lowest is 98.8° F. (Illustrated in Table I). (2) The mean daily oral temperature is nor- mally about 98.4° F., that is, about 0.7° F., or a little more than half a degree lower than the mean rectal temperature. The oral temperature varies more widely than the rectal; approximately 0.8° F., the minimum being 98° F., and the maximum about 98.8° F. under normal conditions. (3) The difference between rectal and oral temperature does not remain constant in the same patient, as the temperature rises. It is not accurate to compute from the fever-curve, obtained by re- cording the mouth temperature, the corresponding rectal, or vice versa, by adding or subtracting a constant factor. (Illustrated in Table II.) (4) The temperature obtained in the proximity of the surgical lesion, represents more nearly the true reaction, than that obtained at some remote part of the body. When the pelvic or abdominal organs are concerned, as in gynecological operations, and the greater number of operations in general surgery, the excursions of temperature are more correctly indicated by the rectal, than by the oral reading. (Illustrated in Table III.) (5) There is normally a slight post-operative temperature rise which is not traceable to infection — ^the aseptic fever. Guiding Principles in Surgical Practice 135 (6) The maximum rise or acme in the normal post-operative curve of aseptic cases, may occur as early as 4 hours, and as late as 33 hours after operation, without being pathognomonic. The com- puted average time in one series of cases was 18 hours. (Table IV.) As a rule, the maximum rise is reached within 24 or 36 hours — a day, or a day and a half after operation. (7) The average maximum rise is about 100.6° F., and should not exceed 101° F., rectal tempera- ture. (Illustrated in Table IV.) (8) The time of day during which the operation is done has a slight, though neither a uniform nor vital bearing on the post-operative reading. Qg^^.^ (9) The maximum rise or acme may be more or less acute, followed at once by a remission, and this is the rule; or, very rarely, the wave may have a plateau-like summit; exceptionally in such event, the same temperature may persist without any ap- preciable remission, as long as nine hours. (10) There is normally a well defined second rise, a post-maximal rise, on the day following the maximum rise, but it should never exceed the former in amplitude unless there is some complicating factor. (11) Exceptionally a small abortive wave — a pre-maximal wave — may immediately precede the maximum rise. This should not lead to confusion in interpreting the temperature chart. (12) In general, in the wholly uncomplicated case, the temperature waves on successive days may 136 Guiding Principles in Surgical Practice be expected to show a gradual subsidence in ampli- tude; and reach the normal, in the course of five days, or at the end of a week. (13) The daily average temperature, or mean temperature, tozvards the end of the second week after operation, is apt to be a little lower, than that obtained for the same patient before operation. Thus, it is, at the end of the second week, about 98.7° F. by rectum (Table V), and about 98.2° F. by mouth (Table II.) (14) In taking oral temperature, the sources of error are greater, and the individual variations in temperature less pronounced so that they may be overlooked altogether. Oral readings do not repre- sent the actual magnitude of the reaction, when a celiotomy is in question. They do not offer a very satisfactory basis for study. Utilizing these findings the characteristic reaction The Schematic which follows operations on aseptic cases, the Curve aseptic fever-wave may be represented graphically and schematically (Chart I). As soon as the theory that a typical curve repre- sents the aseptic reaction following clean operations, can be considered established, it becomes a simple matter of bedside study to discover the meaning of anomalous fluctuations. Indeed, every departure from the typical aseptic wave, requires its interpre- tation. On the one hand, must be considered devia- tions representing* minor complications which are of no grave import, as for instance, stagnation in the bowel, or onset of menstruation in cases with an old pelvic trouble, a bronchial catarrh, and even Guiding Principles in Surgical Practice 137 a superficial wound-infection; on the other hand, those which are the expression of serious complica- tions, such as a deep wound-infection, peritonitis or sepsis. This conception at once enhances the clinical significance of the temperature record, and suggests a way to the more intelligent reading of it, on the part of the surgeon. To begin with, it seems best to select, for the Actual Curve sake of illustration, an actual case (Chart II), which °* Aseptic demonstrates the normal course of aseptic fever, and embodies all the points already emphasized in the schematic representation of the aseptic wave. Here aberrations in the temperature, which are due to infection, bowel stasis, or other minor complica- tions are absent. By all odds, the most frequent source of slight, or even marked disturbance in the normal reaction after operation, is stagnation in the bowel. Because the period of constipation is at first too brief, the maximum rise itself need not be influenced at all. But indicative, is a slight rise on the fourth or fifth day, which can be promptly corrected by the enema or calomel. This rise may sometimes, however, appear a little earlier, and become alarming on account of its height, especially where the stasis is pronounced, as when the patient's bowel has not been properly evacuated before operation. A chart which illus- Effect of trates this point, is that of a patient, in whom, Bowel Stasis contrary to the rule, home preparation of the* bowel was relied upon (Private Record No. 2301, N. P., 1909). The temperature rose to 104.4° F. per rectum on the third and fifth days; the pulse 138 Guiding Principles in Surgical Practice Influence of Menstruation rate, which was normally 76 to 78, however, re- mained comparatively slow, varying only between 100 and 106 per minute during this time, and the respiration from 22 to 28. After a very effectual washing of the bowel the temperature dropped to the normal. There was no tenderness, infiltration or hematoma, no redness or secretion about the incision, which was found healed by primary inten- tion on the sixth day. It seemed clear that the bowel alone, was responsible for this anomalous reaction. (Chart III.) In some instances, in female patients, a slight rise of temperature occurs, accompanied perhaps by a few nervous symptoms, a sensation of weight and discomfort in the pelvis, and feeble recurrent pain in the back occasionally radiating into the thighs. The disturbance cannot be traced to the condition of the bowel, and may remain obscure, until a few days later, when the nurse reports that the patient is menstruating. The rise probably appeared co- incident with the pelvic vascular hypertension which may precede the actual appearance of the menstrual blood by one or two days. But it does not seem entirely correct to ascribe it to the physiological menstruation. Under strictly normal conditions of the pelvic organs, there should be no secondary rise — post-maximal rise — ascribable to menstrual py- rexia, which exceeds the maximum rise in ampli- tude. A number of observations speak for the assumption that when such a rise occurs, it points to an old iflammatory, toxin-producing focus some- where in the pelvis, which is not completely healed, and the temperature can be explained by the in- Guiding Principles in Surgical Practice 139 creased absorption incident upon the menstrual cycle. It may be a chronic salpingitis for example, which presents no appreciable temperature rise dur- ing the intermenstrual period, but shows a distinct "absorption rise" with every oncoming menstrua- tion. (Chart IV.) The assumption, that in the absence of pelvic inflammation, menstruation itself does not materially modify the typical temperature, is strengthened by the fact that operations performed during the period of menstruation show essentially the same maximum rise, as those done in the intermenstrual time. Thus, for example, after enucleating a number of uterine fibroids, and removing the appendix in a young woman on the fourth day of her menstruation, she continued to menstruate for three days after opera- tion. On the one hand, the inaugurated flow was not interrupted by the surgical measure; on the other, as reference to the patient's previous history shows, its duration was not changed. The operation occurring on the fourth day was exactly midmen- strual in time. Notwithstanding this fact, the post- operative reaction was practically the same as that obtained in other cases operated between periods. The rectal temperature fluctuated between 98.4° F. — 99.4° F. in the twenty-four hours preceding operation. That is, the mean daily temperature was 98.9° F. The maximum rise was reached in twenty- nine hours after operation. It was 101° F. The second rise — post-maximal rise — on the third day, reached 100.2° F., and on the fourth day the acme was 99.8° F. (P. R. No. 3429, C. V.) Before concluding that a fluctuation in tempera- ture is anomalous, it is not to be forgotten that Operation During the Menstrual Period 140 Guiding Principles in Surgical Practice Influence of a Mild Skin Infection More Marked Skin Infections secondary rises occur on the days following opera- tion, but that a complicating factor is to be thought of only when these exceed the primary one. There is another point of interest in the tempera- ture curve of this patient. Although the menstrua- tion had ceased, and there was no bowel stasis, there was a rise to 100.4° F. on the fifth day, another to 100.6" F. on the sixth, 100.4° F. on the seventh, then 99.8° F., followed by a subsidence to the nor- mal. As soon became evident, this slight pyrexia had its origin in the wound. It represented one of the mild skin infections, in which a tiny focus promptly drains itself on the surface. Similar per- turbations occur not infrequently in vaginal opera- tions, or other operations involving the mucous membrane, where it is difficult to obtain satisfactory surface sterility. Such mild wound infections as these cause no marked constitutional distrubance and very likely often escape notice, but there are others which must still be classed as belonging to the group of minor complications, although they present a more elabor- ate clinical picture. In these severer cases, the ex- istence of the local infection may be indicated by some aberration in the temperature very soon after operation ; nevertheless a pronounced rise — 102° F. or 103° F. — accompanied by notable systemic dis- turbances and symptoms referable to the wound, is never likely to occur until the sixth or seventh day. In other words, allowance must be made for a definite period of incubation. The pulse rate and respiration, just as in many other comparatively innocent complications, do not keep pace with the excursions of the fever. To amplify these points Guiding Principles in Surgical Practice 141 reference might be made to the post-operative be- havior of a case, in which beyond all reasonable doubt, the contamination of the wound had its origin in the follicular and glandular skin of the pubic region. (Chart VI.) In this chart, for clinical reasons, but unhappily for numerical comparison with the preceding ones, the mouth temperature only is recorded. The pre- Case operative temperature showed a daily fluctuation Illustrating between 97.2° F. and 98.6° F. per os. The pulse t*" f^*e*,°* ^ Marked Skin ranged from 66 to 72, and the average frequency of infection respiration was 20. The operation was done at ten o'clock in the morning, and up to thirty-four hours after it, the record of temperature was as follows : 6 hours P- 3. 100.2° F. oral 10 " « < 100.4° 14 " it ( 100.8° " P.86R.20 18 " It < 100.2° 22 " « « 99.6° 26 " « it 99.4° 30 " a « 99.4° 34 " « (t 101.2° " P. 76 R. 20 Here the primary or maximum rise is at midnight of the day of the operation, and twenty hours later there is a second rise, which is greater than the first, and is to be considered abnormal. There were at the time no subjective symptoms whatever to lead to the suspicion of a future complication in wound-healing. A few days after operation, how- ever, the profuse sweating of the patient attracted attention, notwithstanding that the summer was exceptionally warm; but there was no complaint of pain in the region of the wound until the fourth 142 Guiding Principles in Surgical Practice day. On the day following this, there were ex- perienced indefinite shifting pains in the neck, knee, wrist and arm, unaccompanied by any swelling of the joints. The pains became more pronounced on the sixth day, when the remittent temperature reached its acme with 103.2° F. per os. Neverthe- less the pulse remained relatively slow, and the heart action normal. The first impression of these symptoms was quite misleading. Typhoid fever or malaria could readily be differentiated, but with much less certainty an atypical articular rheumatism, in its onset. The lower border of the spleen was not palpable, but the organ measured three inches in the axillary vertical. The blood examination showed CeM Coum White cells 18.400 Polymorphnuclear neutrophiles 91.5% Small lymphocytes 5.5% Large lymphocytes 1.0% Eosinophiles 2.0% No Plasmodia ; Widal reaction negative. A faint redness of the wound-line at first, was succeeded after the sixth day by a separation of the wound near its middle, to the extent of about half an inch, with the discharge of a small quantity of odorless pus. After this free drainage the tem- perature gradually subsided, and on the thirteenth day the little granulating gap which reached to the surface of the external oblique aponeurosis, was closed by apposing the wound-lips, and applying sterile zinc oxide strips. The temperature con- tinued to remain normal. Cold Guiding Principles in Surgical Practice 143 In analyzing the effect of the various minor com- plications, intercurrent ailments of slight severity must also be borne in mind. Exceptionally a "ca- ^^^^^^ °^ * tarrhal fever," "la grippe" or "influenza nostras," as the condition has been variously called, may ex- plain an anomaly in the post-operative reaction. Illustrative of this is the temperature of a patient, on whom an abdominal plastic had to be done for a post-operative ventral hernia, a sequel of the old method of treating cases of pyosalpinx by supra- pubic drainage. (Chart VII.) In the primary rise, which persists from the ninth to the eighteenth hour after operation, the ther- mometer registers 100.6° F. per rectum. This in itself need not be considered abnormal. But the second rise on the third day was 100.8° F., that is, apparently greater than the primary rise, and the aberration, with proper reserve because of the slightness of the difference, is taken to indicate some foreign influence. The recurrence of a rise of 100.8° F. on the fifth day is however clearly patho- logical, and the slight pain in the chest, cough and mucous expectoration at this time, explained its source. The usual causes of fluctuations in the typical curve, were absent. There was no tender- ness over the wound-line; no bowel stasis. On the seventh day the temperature reached 102° F. The daily excursion in temperature was from 100.4" F. to 102° F. per rectum. The pulse rate varied be- tween 80 and 108, The cough continued. Examina- tion of the chest showed the typical signs of a catarrhal bronchitis. The variation of the fever on the eighth day was from 101° F. to 101.8° F., and the pulse frequency from 100 to 104. The sputum became greenish in color, and was moderate in 144 Guiding Principles in Surgical Practice quantity. The rales diminished. The next day the temperature dropped from its maximum of 100.2° F. to 99° F. The highest wave was 100° F. on the tenth, and 99.6° F. on the eleventh day, and with the subsidence of the temperature, the cough also disappeared. There can be little question, that the moderate pyrexia was due to an ordinary influenza nostras, of which the catarrhal bronchitis was part and parcel. Finally, with a clear impression of the nature and Major behavior of the aseptic reaction in the uncomplicated Complications case, and of its modifications by minor complica- tions, the way is open to the further study of the influences which more serious complications may exert. In this exposition, I have yielded to the tempta- tion to present a theory, incomplete as it is, and still insufficiently founded. In its application, it should not be overlooked, that it must needs be restricted to those cases which were aseptic and afebrile at the time of operation. With the proper reserve imposed upon it by the cautious worker, it may perhaps be of use, but it would be unscientific and misleading to extend its scope unduly. Table I. MEAN DAILY RECT. AL TEMPERi* lTURES. pre-operative, Case. Minimum. Maximum. Mean. p. R. 3429 C. V. 98.6° F. 99.4° F. 99.0° F. P. R. 3003 T. R. 99.2° F. 99.8° F. 99.5° F. P. R. 2010 L. M. '98.8° F. 99.0° F. 98.9° F. P. R. 3385 P. L. S . 98.8° F. 99.4° F. 99.1° F. P. R. 3228 C. W. 98.4° F. 99.6° F. 99.0° F. Average 98.8° F. 99.4° F. 99.1° F. Guiding Principles in Surgical Practice 145 Table II. DAILY MEAN TEMPERATURE IN ASEPTIC LAPAROTOMY. RECTAL AND ORAL TEMPERATURES COMPARED. Pre-operative Maximum P.O.Temp. Temperature. Rise. 2nd week. Rectal temperature 99.1° F. 100.6° F. 98.7° F. Oral temperature 98.4° F. 100.3° F. 98.2° F. Difference 0.7° F. 0.3° F. 0.5° F. Table III. RECTAL AND MOUTH TEMPERATURES IN THE SAME PATIENT TAKEN SIMULTANEOUSLY NEAR THE END OF THE FIRST WEEK AFTER HYSTE- RECTOMY. P.R.4558E.K. Per rectum. Per os. Differeence, 12 noon. 100.0° F. 99.0° F. 1.0° F. 4 P.M. 99.8° F. 99.0° F. 0.8° F. 8 P.M. 100.2° F. 99.2° F. Table IV. 1.0° F. THE MAXIMUM RISE AND THE TIME OF ITS APPEAR- ANCE. RECTAL TEMPERATURE. Number of Time of Maximum Hours after Case. Operation . Rise. Operation. P. R. 3429 C. V. 3 P.M. 101.0° F. 29 P. R. 2966 K. H. 9 P.M. 100.4° F. 12 P. R. 3385 P. L. S ;. 3 P.M. 100.6° F. 29 P. R. 2010 L.M. 3 P.M. 100.4° F. 9 P. R. 2790 L. M. 3 P.M. 100.4° F. 21 P.R. 695 S.S. 3 P.M. 100.6° F. ■ 9 P. R. 2360 J. T. 3 P.M. 101.0° F. 13 P. R. 2301 N. P. 10 A.M. 100.8° F. 21 Average 100.6° F. 18 Tables 146 Guiding Principles in Surgical Practice Table V. MEAN DAILY RECTAL TEMPERATURE, SECOND WEEK POST-OPERATIVE. Case. Minimum. Maximum. Mean. P. R. 3429 C. V. 98.0" F. 99.4° F. 98.7° F. P. R. 2966 K. H. 98.0° F. 99.4° F. 98.7° F. P. R. 3003 T. R. 98.4° F. 99.0° F. 98.7° F, P. R. 2010 L. M. 98.2° F. 99.4° F. 98.8° F. P. R. 2790 L. M. 98.0' F. 98.8° F. 98.4° F. P. R. 2360 J. T. 98.2° F. 99.4° F. 98.8° F. Average 98.1° F. 99.2° F. 98.7° F. Guiding Principles in Surgical Practice 147 % I 101° 100° S '" ^ ! :^ r""::b: - ra -3 y':"::iC -> ^- ' :": - — op^rY^ 'ON- -ro - i ;.. 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It ^: t :>, :,^i^ -s' M W or O) -^ Co CO ^^ (153) CHAPTER XIII The Treatment of Unclean Wounds Industrial Wounds The same principles that hold good for the clean wound which is inflicted by the surgeon in an aseptic operation, are followed in treating the ordi- nary incised wound of an emergency case. Moisture is congenial to bacterial growth; and clean wounds heal best when they are kept dry. Wounds received in industrial accidents are usually more or less soiled ; but the contamination is germless, or at least in most instances, contains no pathogenic organisms. When the grime, filth, dirt, tar, paint, axle-grease, and the like have been removed from a laborer's injured hand, it is not uncommon to see healing take place by first intention. A little free bleeding from the cut surface may be the best lavage the wound can receive. Thorough, but gentle rinsing with warm boiled water, is an added precaution. The wound is dried gently, strapped, clamped, or sutured, according to the indication, and a dry, sterile gauze dressing is sufficient. If, however, contrary to the impression conveyed by the history of the accident, and the appearance, character, and location of the wound, after a few days have elapsed, local redness, tenderness, infil- tration of the edges, bacterial discharge, or even perhaps, definite constitutional symptoms, such as headache, malaise, fever, show it to be infected; the plan of treatment for unclean or septic wounds Wounds ^^ instituted at once. In fact, whenever the char- acter of the wound appears doubtful, it is an old (154) Unclean and Doubtful Guiding Principles in Surgical Practice 155 but good working-rule, to treat it as if it were infected, until its subsequent behavior gives assur- ance that it is clean. The wound is held agape, and, after thorough rinsing, drains are introduced and in contradistinction to the treatment of clean wounds, a zvet, mildly antiseptic dressing is applied. Tissue-disinfection, that is destruction of bacteria by powerful germicidal solutions, such as formalin, carbolic acid, bichloride of mercury, as it was for- merly practiced, should be abolished in the routine care of unclean wounds. It is a different matter when there is reason to suspect inoculation with a dangerously pathogenic organism such as the tetanus bacillus, as when garden-earth or soil has been in- troduced into the wound. Here local sterilization must be attempted, even at the risk of considerable Local loss of tissue. The electro-cautory needle or Pac- quelin-point are probably most efficacious ; next in order, disinfection with pure carbolic acid, which is subsequently limited in its action by the application of alcohol. In either case, tetanus antitoxin is in- jected circularly about the wound when feasible, after a large dose — not less than 1,500-3,000 units — has been administered intramuscularly in the gluteal region. From a practical point of view, it is convenient to think of three stages in the healmg of unclean wounds. Firstly, a stage of infection, during which the bacterial growth is progressive, the local in- flammation more or less acute. Secondly, a stage of expurgation; the extension of the infection has ceased, acute symptoms have subsided a"nd the dis- charge becomes copious. Thirdly, the stage of aseptic healing, when a clean, granulating surface appears. Sterilization Healing of Uncleein Wounds 156 Guiding Principles in Surgical Practice Stage of Infection and Sedative Dressings If, during the stage of infection, the defensive reaction is marked, and the inflammation is acute, the logical treatment is sedative. The most useful of sedative measures in this instance is the moist, mildly antiseptic dressing. Evaporation of the moisture abstracts heat, cools the surface, and makes the patient more comfortable. In general, water which has been modified by the addition of a mild antiseptic, has been used for such dressings, because unmodified water has no inhibiting attributes and might prove to be congenial to bacterial growth. How well this practice is founded is difficult to say. At any rate, very mild antiseptics such as a one to three per cent, aqueous solution of boric acid, while still unfavorable to bacterial development, are, at the same time, in contradistinction to stronger an- tiseptics, not particularly harmful to the living tissues with which they come in contact. But the gauze dressing must not be allowed to be- come dry, if its antiphlogistic effect shall be pro- longed. A large dressing remains moist longer than a scanty one. When frequent renewal of the dress- ing is out of the question, because it is impracti- cable, as in the large number of dispensary patients ; the dressing may be kept moist in the intervals by the external application of weak solutions of boric acid, boro-salicylic acid or aluminum acetate. An- other method is based on attempts to retain the moisture by restricting surface evaporation — the wet gauze is covered with rubber tissue or other material which is impermeable to air. To me, the correctness of this procedure, in the case of an acute inflammation, is not thoroughly apparent; for not infrequently, instead of being antiphlogistic and se- dative, such a dressing on its removal is found to Guiding Principles in Surgical Practice 157 be warm and distressing from the retention of heat and foul exhalations. If, during the stage of infection, the defensive reaction is sluggish, the inflammation is subacute or chronic, measures tending to awaken greater healing response, stimulant procedures, are in place. In this connection, the stimulant effect of chemicals on living tissue has to be considered. With chemical substances the stimulation may even, to some degree, be selective. Thus, various aniline dyes are used to stimulate epithelialization ; while gauze, impreg- nated with red wash, and similar solutions, for example, appears to influence more specifically the connective tissue containing granulations, which make up the body of the wound. More recently, experiments on tissue hyperplasia and tumor gene- sis, have brought to light the fact that innumerable chemical bodies may act as tissue activators. No doubt the relative inconvenience of applying certain physical agents, such as dry heat from electric lamps, or baking, has been in the way of their wider adoption in the treatment of sluggish wounds. In the main, the utilization of dry heat is more in accord with the general principle, that the healing wound should be kept dry. Here the mace- ration which is produced by wet procedure, some- times proves to be an undesirable complication. Thus the stimulant, poulticing effect of a moist dressing covered with rubber tissue, in conjunction with prolonged hot bathing of the part, is contra- indicated in the treatment of a wound in the dia- betic patient. Moreover, in every instance, it must be borne in mind that where the diminished healing- activity is due to a constitutional cause, no amount Stage of Infection and Stimulant Treatment Constitutional and Local Causes of Sluggish Healing 158 Guiding Principles in Surgical Practice of local stimulation alone, even after the wound has become clean, will suffice to bring about a better healing response. Furthermore, there may be a regional peculiarity, as in varicose veins of the legs. When a wound is inflicted in the compass of the pigmented area, it does not heal readily, because of the pathological vascular condition of the part. Tis- sue activators, or physical agents, can contribute very little towards wound-healing, if the other, more important measures, directed towards emptying the capillary veins, are disregarded. With the arrest in the further progress of the infection, the defensive reaction begins to dominate, and the wound-discharge becomes more copious. Wound-discharge is the result of an effort of the Stage of wound to expurgate itself. It represents the mass lixpurga ion ^£ demarcated and softened tissue about the bac- and Wound Discharge Serial focus — a germ-laden, fluid debris which should not remain occluded. Its presence excites exuber- ant granulations, which disappear when the wound is kept clean and dry. When the wound is shallow, and above all, when the wound-discharge is scanty, there is no dress- ing which is better adapted to bring the wound into a healthy condition than plain, dry, loosely woven, aseptic gauze. Occasionally, for practical reasons only, when a wound cannot be dressed as soon as it should be, or the discharge decomposes with exceptional readiness, a dry antiseptic gauze may be substituted for the aseptic dressing; or, a dry deodorant gauze, when the discharge is foul and disturbing to the patient. When, however, during the stage of expurgation of the wound, the focal accumulation of pus is more Guiding Principles in Surgical Practice 159 or less deepseated, and the discharge is profuse, the gauze drain is often of itself unsatisfactory for the purposes of drainage, and adjunct measures become necessary, such as the use of the wound-wedge, rub- ber tubes, or loop-drains of wire or metal. The reason why dry gauze when employed as a drain is not trustworthy in this instance, is because its fine meshes are rapidly clogged by fhe inspissated dis- charge. Thus, not infrequently, what was intended to facilitate drainage, really impedes it, by clogging the wound-outlet like a stopper. The clinical pic- ture is that of retention, and when the gauze is re- moved the incarcerated pus pours from the wound. Since the inspissation of the discharge in the dressing is due to the evaporation of its water con- tent, it is true, gauze drainage can, where this is in- dicated, be promoted by the use of wet gauze, and by excluding the air by means of rubber tissue to prevent evaporation, or by the continued external application of moisture — methods which are, how- ever, far from being ideal. In large wounds the dif- ficulty is overcome by the introduction, in conjunc- tion with the gauze, of two or more soft rubber tubes with a number of lateral openings. In small wounds the problem assumes a different aspect. In order to preclude retention in these cases, a twirl of gauze or rubber tissue may be placed in one angle of the wound. This is intended to act, not as a drain, in the strict sense of the word, but rather as a wedge which keeps the wound open. Unfortunately this procedure promises more in theory, than its adop- tion actually merits in practice. The small incision is apt to collapse at the side of the drain; perhaps before the bandage is applied, there exists some uncertainty whether it has not already been dis- Devices for Aiding Drainage Rubber Tubes 160 Guiding Principles in Surgical Practice lodged by the premature activity of the awakening patient. It is er.sential that a device for keeping small incisions, wounds and sinuses patent, shall not only be slight in bulk, so that it does not obstruct the path of the discharge, but also of such con- struction, that it can be applied with precision and is not easily displaced. There is a large class of cases, in which the insertion of a drain according to the usual methods is thoroughly unsatisfactory; of these the unfortunate with a suppurative teno- synovitis and many small incisions in the hand, is but one example. A simple, practical method of draining such wounds consists in the introduction into the wound to the desired depth, of loop-drains of thin, flexible metal. Loop Drains These drains are nothing more than variously shaped metal loops with flanged ends. The loop is inserted into the recess to be drained, and keeps it open by virtue of the spring-like action of the metal. The grooved flange-ends grasp the sides of the incision, and retain the drain in place. It is prac- tical to keep various sizes sterilized and in readiness for use; also some narrow strips of metal, ^th inch wide and upward, in case an anomalous cavity requires that one be improvised. This is easily done if the material is thin commercial "tin." All that is needed is a straight scissors, and an ordinary pair of thumb forceps — instruments which are at hand at every dressing. A long, bent loop-drain may also be used in the reversed way in a sinus which is difflcult to drain an'd treat from the bottom. With one, properly applied, it is easier to irrigate the sinus and to introduce disinfectant, antiseptic, or tissue-activating fluids. When a fluid is to be Guiding Principles in Surgical Practice 161 retained in the sinus it is less difficult to insert a plug into the opening between the metal flanges. In applying the drain the loop is simply closed by nearing the flanges to each other, and introduced into the wound by means of the thumb forceps. The loop is then opened until the lips of the wound are sufficiently separated. The rubber tube, as well as the metal loop-drain, both serve the purpose of keeping the wound open, while the gauze dressing itself, by virtue of its capillarity absorbs the discharge as it escapes from the wound. In some regions, as for example, in the ischiorectal, it is exceptionally important that the draining wound be widely opened, lest the pus burrows in various directions from its original focus, and ischiorectal sinuses and fistulae result. In the appendicitis abscess, when the patient, as is often the case, lies on the back, it is the chemical tension alone that causes the pus to rise in the wound, or in the rubber tube which has been in- serted into it for drainage. In this instance, the wound-discharge rises against gravity until the wound is filled, when it overflows into the gauze dressing. If the tube which was intended to help drainage, projects more or less vertically beyond the wound, as such drains generally do, the pus which it contains is simply occluded, and cannot even escape by overflow, since the end of the tube is above the niveau of the pus in the wound cavity. In other words, under such conditions, the tube instead of being helpful, is actually a disadvantage in drainage. It is clear from this consideration, that drainage produced by chemical tension alone, is a drainage by overflow and not a drainage from the bottom of the wound. Chemical tension alone, therefore, is Drains Should Keep the Wound Open The Role of Chemical Tension Gravitation 162 Grinding Principles in Surgical Practice insufficient to keep the wound dry. Should it now be possible to change the existing conditions, so that the forces of gravity may aid chemical tension, the problem of evacuating the residual pus will find a simple solution. Thus, if an ordinary bottle with a constricted neck were to represent the abscess- cavity, and the water in this container the discharge, the easiest way of emptying it is plainly by allowing the force of gravity to act directly; the bottle is turned so that its neck descends below the fluid level. Similarly, gravity may be made to assist drainage, when the wound-opening is brought to a lower level by postural changes of the patient. When this is done, the rubber tubes which were previously de- funct, begin to drain the recesses into which they have been placed; the drainage, instead of being simply by overflow, takes place from the bottom of the wound. It is because of the prime importance of gravita- tion in the expurgation of the unclean wound that, unless anatomically or otherwise contraindicated, the surgeon always opens and drains a suppurating cavity at its most dependent point. Unfortunately the force of gravitation cannot always be made to influence drainage directly by low incision or the requisite postural change. In such a case, particu- larly when the cavity is deep and discharges pro- fusely, removal of the residual pus by drainage in an uphill direction must be considered. First of all, come the methods by which this is attempted by continuous siphonage. The laws un- derlying drainage by siphonage, can be illustrated by means of a bottle containing water and a long drainage tube. As the tube rests upon the edge of the bottle, one end immersed in the water, while Guiding Principles in Surgical Practice 163 the other is outside, an ascending limb within, and a descending limb of the drainage tube without, „. , may be distinguished. But in spite of the fact that the end of the descending limb is considerably lower than the level of the fluid within the bottle, no drainage takes place. Suction, or more accurately speaking, the production of negative pressure within the tube sufBcient to raise the column of wa- ter to its highest point over the edge of the bottle, is essential to start the flow. When the water has once reached the descending limb, it readily escapes by 'gravitation. But the gravitating column pro- duces renewed suction behind it, which causes a second charge of fluid to rise in the tube. Thus siphonage, once instituted, may continue indefinitely until the bottle has been emptied of its contents. If, in such an experiment, the tube is replaced by a piece of gauze, similar observations can be made. The drain may remain indefinitely without causing a flow of fluid from the bottle. The capillary at- traction of the gauze alone is insufficient to carry the water to a point where gravity can begin to act. If, however, suction is started, by pouring water down the descending limb, siphon-action can be ini- tiated which continues until the bottle is empty. Unfortunately, these laws of drainage, striking as they may be in the experiment, have but a very lim- ited application in surgical drainage. Most devices in which siphonage is produced by running water, or by means of an interpolated rubber bulb, or large reservoir from which the air has been exhausted, and which have for their object continuous drainage in the strict sense of the word, are anything but practical. The ordinary suction cup, it is true, may be kept on a discharging wound for a long time; 164 Guiding Principles in Surgical Practice but its action becomes feeble as the vacuum dis- appears. It is really better adapted for inducing local hyperemia, than for encouraging drainage. In practice, therefore, the disposal of the residual pus in instances in which uphill drainage cannot be avoided, resolves itself into efforts at repeated and thorough evacuation at the time of the dressing by means of one of two simple methods, either suction or expression. The I^ t'^s expression method, the accumulated dis- Expression charge is emptied by gentle compression and manip- Method ulation of the pus undermined territory, by means of the fingers of the gloved hand. When properly carried out, it is unattended by any traumatism to the wound. In contra-distinction to the suction method, it has the great advantage that it is simpler in execution, and no special apparatus is required. The notion that pus may in some way be forced into the blood vessels by this procedure, is errone- ous. With all its simplicity, it is none the less effi- cient. It is applicable nearly everywhere where the tissues can be grasped or manipulated with the fingers, and the surface structures are not too rigid and unyielding. In the treatment of the non-tuberculous sub- maxillary abscess which is so common in the im- properly cared for children of the poor under three years of age, and is due to pyogenic infection from the mouth, the use of the expression method is typically illustrated. A little ethyl chloride sprayed on the mask, or a few drops of anaesthol or of ether, just sufficient for a primary anesthesia ; a small incision through the skin, parallel to the natural folds in the neck and over the fluctuating point or the spot of greatest softening; penetration Guiding Principles in Surgical Practice 165 of the soft parts and abscess- wall bluntly, by means of a small forceps, while the tissue is fixed between the thumb and fingers of the left hand; separation of the blades of the forceps to widen the opening into the abscess cavity; simultaneous compression or "milking" of the infiltrated area from without, until no more pus appears ; insertion of a metal loop-drain to keep the small opening patent ; a large dressing of loose sterile gauze. If expression has to be repeated one or more times at subsequent dressings, this can be done without causing much pain, because the inflammation is no longer acute, as when the abscess was first incised; neither does a forceps have to be introduced into the wound, be- cause the drain keeps open the way for the escaping discharge. In this procedure, the protective lining of the abscess cavity is conserved as far as possible ; indeed, the use of the curette within any abscess cavity is obsolete. The suction method varies widely in its applica- tion in the hands of different surgeons. It seems ^yr^tu^"*^*^"" vital, that whatever device is used for this purpose, the degree of suction can be regulated at will; for, in the ordinary suction cup, the vacuum is soon de- stroyed. A serviceable mechanism can be impro- vised by pushing one end of a rubber tube which is about eight inches long and has an internal diam- eter of about ^8 inch, into the open connecting arm of a small glass suction cup; while the other end is slipped over the air-inlet arm of an ordinary suction pump, such as is used, for example, to create a vacuum in the flask of a Potain apparatus for as- pirating the chest. The air-outlet arm of the suc- tion pump is left open. The most useful cup for routine work, is one which measures about two Method 166 Grinding Principles in Surgical Practice inches in diameter and has the shape of a minia- ture bell-jar (F. A. Eschenbaum, Bonn). The suc- tion pump itself is all metal, and every part of the apparatus, tube, cup and pump can be sterilized by boiling with the dressing instruments. The nurse manipulates the pump while the suction cup is held snugly applied to the surface over the wound from which the pus is to be exhausted. The skin becomes hyperemic, is drawn into the cup, and as the vacuum is intensified by continued pumping, the discharge begins to flow from the orifice of the wound. In an unclean post-operative case where the sutures have become infected by the staphylococcus, for example, considerable yellow, odorless pus is at first obtained, two to four ounces perhaps, while later the wound discharge becomes scantier, thin and serous, and shreds of sloughing fascia or the black knots of chromicized catgut partly digested, may be observed to pop through the small drainage opening in the incision-line, into the negative space, under the powerful influence of the suction. When finally an unclean wound has expurgated itself, the discharge has ceased, or is scanty and sterile, and a healthy, granulating surface presents. The Stage of the stage of aseptic healing has been reached, and Aseptic closure of the zvound by apposition may be attempt- ed, in the hope of securing union, just as in the cases in zvhich the wound was clean from the be- ginning. Healing CHAPTER XIV Conclusion Ready and reliable surgical judgment is cultivated by repeated reflection on surgical experiences. In this, a common case may sometimes teach more that is of practical importance, than the exceptional one. Information which is obtained from others and from books, is of great value, but it is very often not half so determining in its influence on surgical reasoning, as one single error which is self- committed. If, in spite of every preliminary, the surgeon meets with an unfortunate experience which is due to an error in his judgment, he cannot conscientiously pass it by without much thought. (167) INDEX. -^ Page. Abdomial pads 33 Manner of using 23 Abscess evacuation by suction method 166 Drainage by suction, appara- tus for 165 Evacuation by the expression method 164 Cavity, conserving the lining of the 165 Absorable sutures 60 Absorption of catgut, micro- scopically 61 Accidents during operation in the differential pressure cabinet 86 Adhesion, peritoneal 51 Adhesive belt, use of the 129 Corset, use of the 129 Strips for skin repair 69 Afebrile periods in endocarditis- 3 Periods in thrombophlebtis . . 3 After care of a surgical case, relation of the family phy- sician and surgeon in the. .111 Air-embolism during operation.. 108 Alimentary tract, bacteria pres- ent in 2 Anaesthol, the administration of 75 The chemical nature of 75 Chief failing in the use of.. 79 Anatomy of _ the_ _ semilunar hypogastric incision 87 Of the mesial rectus incision. 95 Anesthesia 74 With chloroform 75 With chloroforrn, chief fail- ing in conducting 79 With anaesthol 75 With anaesthol, chief failing in conducting 79 Dark blood during 80 Use of the breathing tube during 80 Cardiac collapse during 76 Abolition of hearing during. . 77 Abolition of consciousness during 77 Abolition of reflexes in 77 Coughing reflex during 80 Vomiting during 80 Induction of shock during. . . 78 Estimating the amount of shock after 81 The pulse before and after.. 80 Page. Lime-water for nausea after. 110 Milk of magnesia for nausea after 110 Relation of diseases of the heart to 81 Epilepsy in its relation to. . . . 82 In tuberculous subjects 82 In diabetic subjects 82 With chloroform or ether... 82 For operation on the brain.. 83 In operations for tumors of the larynx 84 With the intratracheal tube in tumors of the larynx 84 By the intratracheal insuflfla- tion method 84 By the Meltzer and Auer method _. . 84 In the positive differential pressure cabinet ......... 85 Relative value of the intra- tracheal insufilation and differential pressure meth- ods of 86 Anesthetic, disguising the odor of the 76 Anesthetist, relation of the sur- geon to his 74 Antiseptic and aseptic wound treatment 14 Appendicitis and inguinal her- nia, single incision for.... 98 Artery, deej) epigastric, in in- cisions in the lower abdo- men .• 95 Articles for the utensil steri- lizer 28 Asepsis, logical 1 Personal _■ 41 Aseptic suture material 69 Operation, fever after 133 Fever curve 133, 136 Fever curve, influence of bowel stasis on the 137 Fever curve, influence of menstruation on the 138 Reaction is changed by com- plications _ 137 Stage in wound healing by- secondary intention, treat- ment during the ..166 Asphyxia, during intrathoracic operation 86 Assistants, suggestions made by.lOl Duties of 100 169 170 INDEX B Page. Bacteria, in the alimentary tract 2 In the genito-urinary tract. . 3 In relation to steam ster- ilization 16 Boiling time required to de- stroy . 33 Bacterial, foci normally within the body 2 Foci at the site of disease.. 3 Bare arms during operation.... 38 Basin for alcohol 28 Bath, effect on the skin by the cleansing 8 Interval after the 8 Binder, the abdominal 138 Blood of dark color during anesthesia 80 Boiling method superior for in- struments and utensils.... 31 Of rubber gloves in alkaline solution 31 Method, time required for sterilizing instruments by the 32 Method, time required for utensils by the 32 Bone healing 49 Union, methods of 69 Bowel distension, hindrance during operation on ac- count of 104 Inertia, postoperative 116 Evacuation after rectal op- eration 131 Stasis, influence on the typ- ical aseptic reaction by. ..137 Brain operation, anesthesia in.. 80 Breathing tube during anes- thesia, use of the 80 C Calomel after operation 133 Carbon tetrachloride 8 Cardiac collapse 76 Care of the patient after opera- tion 110 Cartilage healing 48 Cascara sagrada after opera- tion ...134 Caster oil as a routine cathartic, objections to 131 Catgut sutures, histologically. . 60 Sutures, chemically 60 Digestion 60 Suture, reaction of tissues towards .• • • • 61 Suture absorption, _ micro- scopic changes during.... 61 Sutures, moisture starts ^the dissolution of _• • 61 Resistance, terms used to in- dicate •. ■ • 62 Resistance, terms of relative significance in the human subject 62 Page. Suture, actual period of use- fulness in human tissues of the 63 Suture, water is essential for action of cell enzymes on. 64 Digestion, extracellular and intracellular 64 Suture should be aseptic n'ot antiseptic 66 Suture resistance of "40 and 60 day" most generally use- ful 66 Suture, ■ highly chromicized, preferable to bulky 65 In skin suture, objections to. 68 Sterility depends on the manufacturer 70 Method of sterilization and preservation of , . 70 Tubes, sterilization of the surface of 71 In sealed tubes, effect of boiling on 71 Cathartic diet 119 Cathartic, objection to caster oil as a routine _ 121 Cathartics after operation, the use of mild 134 Cell functions, development and decadence of 45 Specialization and loss of re- productive power 45 Growth is not impaired by specialization 46 Cells, highly specialized, com- pensate by growth not by multiplication 46 Cell growth not cell multiplica- cation in highly specialized cells 46 Enzymes, action on catgut by 64 Chart I, schematic curve of aseptic fever ..147 II, actual curve of aseptic fever 148 III, pronounced effect of bowel stasis on the aseptic reaction .149 IV, slight menstrual wave in the aseptic curve 151 V, effect of normal rnenstru- ation on the aseptic reac- tion 151 VI, influence of marked skin infection on the typical aseptic reaction 152 VII, influence of influenza nostras on the aseptic re- action ; 153 Chemical disinfection 5 Methods for sterilization of dressings 14 Tension, arainage by 161 Chloroform in every day prac- tice, reasons for the use of 75 Safer substitutes for 75 INDEX 171 Page. Chief failing in the use of. . 79 Combinations, chief failing in the use of 79 Or ether for anesthesia? 82 Cicatrical tissue, slight resist- ance of 57 Cicatrix, elastic fibres in the 54 Cicatrization undesirable when excessive 53 Clamps in skin rei)air 68 Cleansing, mechanical 5 Bath 8 Codeine phosphate after opera- tion 112 Collapse, cardiac 76 Of the patient at operation.. 108 Combined methods of skin ster- ilization 6 Incision for inguinal hernia and appendicitis 98 Comparative time required for sterilization 18 Complications, deviations in the aseptic curve due to 137 Conclusion 167 Conservative incision, the study ^ of 87 Consciousness, abolition during anesthesia, of 77 Considerations, general 1 Constipating diet 120 Contamination of sutures through moist table covers. 21 Contents, table of V Co-operation at operation 2 Coughing reflex during anes- thesia 80 Course of the operation 100 Croton oil after operations .122 Cutting instruments, steriliza- tion of 34 D • Death by asphyxia during in- trathoracic operations .... 86 Decadence of cell functions... 45 Delta sponges 22 Development of cell function.. 45 Devices for aiding wound drainage 159 Dexterity in operating 1 Diabetes, relation of anesthesia to 82 Diet after operation 115 Liquid, after operation 117 Convalescent, articles ex- cluded from 118 Convalescent's 118 Fats in postoperative 118 Sweets in postoperative 118 Green leaf vegetables in postoperative 119 Cathartic 119 Constipating 120 Full, after operation 124 Page. Vegetable as opposed to an- imal 124 I'lic normal 124 Postoperative full 124 Differential pressure cabinet, anesthesia in 85 Difficulty in urination after operation 113 Digestion of catgut 60 Of catgut, extracellular and intracellular 64 Dionine after operation 112 Discharge status in surgical cases 132 Discharging wounds 158 Wounds, drainage of 159 Disease, of the heart, relation of anesthesia to 81 Disguising the odor of the an- esthetic 76 Disinfection, chemical 5 Of wounds 155 Dissection in operating 103 Doubtful wounds 154 Douche, vaginal, with iodine.. 13 Vaginal, with tannic acid 13 Vaginal, with lysol 13 Drainage of discharging wounds 158 Of unclean wounds 159 Of wounds, devices for aid- ing 159 Of wounds by means of rubber tubes 159 Of small wounds 159 With loop-drains 160 Factors in 161 By chemical tension 161 By gravitation ._ 162 By continuous siphonage. . ..163 Drains, the use of 129 General object of 161 Dressing materials for wounds. 14 Rotation in operating room.. 38 After operation, the first... .128 Wounds with silver leaf.... 129 In clean cases 130 Discarding the 130 dressings, the use of the pubic strip in 127 Use of laparotomy straps in. 127 Use of adhesive corset in... 128 During the stage of infec- tion, sedative 156 During the stage of infec- tion, stimulant 157 Dressing, stimulant 157 Drugs, cathartic 121 Drying,_ effect of on tetanus bacilli produced by 33 Duties of first and second as- sistants _ 100 Of operating room nurse.... 101 Of the surgeon^ toward the family physician on dis- charging a case 132 172 INDEX ^ Page. Elastic fibre in fasciae 64 Fibres jn ligaments 54 Fibres in the skin 56 Fibres scanty in scars 64 Fibres? Does exercising a young scar help the devel- opment of 58 Fibres, theory of the signi- ficance of 54 Embolism during operation. .. .108 Emergency preparation for op- eration _ 10 Endocarditis with afebrile pe- riods 3 Enemata, postoperative use of.l23 After operation for the re- moval of gas Ill After operation for the evac- uation of the bowel 183 Enzymes, action on catgut by cell 64 Epilepsy, relation to anesthesia ■ of S3 Epithelialization 63 Ether feeding 76 Or chloroform for anesthe- sia? 82 Evacuating pus by the suction method 165 Evacuation of pus by the ex- pression method 164 Eixpression method for evacuat- ing i)us 164 Expurgation of the wound.... 158 Extension of McBurney's _ in- tramuscular incision. Weir's 98 Extrinsic infection 2 Infection, sources of 40 F Fainting at ojjeration 107 Family physician in his rela- tion to the postoperative treatment HI Physician, after discharge, surgical cases report to.. .132 Facial structures, role of elastic fibres in .••;•• 5* Fat solvent menstruum, iodine in a 8 Solvent property of carbon tetrachloride 8 Fatty nature of sweat 9 Fever, preoperative 3 Aseptic 133 Curve, the aseptic 133,136 Curve, influence of bowel stasis on the aseptic 137 Curve, influence of menstrua- tion on the aseptic 151 Curve, influence of influenza nostras on the aseptic. .. .158 Curve, influence of a skin infection on the aseptic. . .152 Foci, latent bacterial 3 Food, cathartic 119 Page. Constipating 120 Full diet after operation 124 Function of the cell, develop- ment and decadence of the 45 Functional compensation _ and scar formation are inde- pendent 47 G Gas pain after operation. .... .111 Gauze sterilized by chemical means 14 Sterilized by heat 14 Sponges 21 Tampons 22 Tampons, the use of 23 Pads, the use of 23 Required for cleansing the skin for operation 24 General considerations 1 Preparation of the patient... 5 Genito-urinary tract, bacteria present in 2 Germicides in wound treatment. 14 Glove, the half- 42 Gloves, sterile 20 Sterilization of 17,39 Wet or dry? 38 Objections to wet 38 Disposal of soiled 17 Objections to 41 Are indispensable 43 Gowns, sterilized 19 Granulation of surface wounds. 52 Granulations, exhuberant 53 Gravitation, drainage by 162 H Half-glove, indication for the use of the 42 Pattern for the 42 Handing sponges to the sur- geon 22 Hands, the surgeon's 36 Cannot be sterilized 36 Should be protected from pus • 40 Provision for cleansing of the 28 Preoperative preparation of. . 37 Hartley table .••••:• ^1 Healing, role of connective tis- sue in 47 Healing of cartilage 48 Of bone 49 Of striated muscle 49 Of smooth muscle 50 Of heart muscle 50 Of nerve tissue 51 Of the peritoneum 51 Of the parenchyma of secret- ing organs 52 Of surface wounds by granu- lation 53 Wounds, elastic fibres ap- pearing in 54 INDEX 173 Page. Of unclean wounds, three stages in 155 Of unclean wounds, stage of infection in 156 Of unclean wounds, stage of expurgation in the 158 Of unclean wounds, the asep- tic stage in 166 Constitutional causes of slug- gish 157 Local causes of sluggish 157 Hearing abolishes during anes- thesia 77 Heart muscle, healing of 50 Disease, relation of anesthe- sia to 81 Hemorrhage during an opera- tion 108 Hemqstasis, reliable 102 Hernia and appendicitis, single incision for 98 Hypertrophy not hyperplasia of highly specializecf cells, compensate a loss of tissue. 46 Hypogastric incision, the semi- lunar 87 . I Illustrations, Chart I, schematic curve of aseptic fever.,.. 147 Chart II, actual curve of aseptic fever 148 Chart III, effect of marked bowel stasis on the aseptic reaction 149 Chart IV, small menstrual wave appearing in the aseptic curve 150 Chart V, effect of normal rnenstruation on the asep- tic curve 151 Chart VI, influence of marked skin infection on the postoperative tempera- ture 152 Chart VII, minor complica- tion due to influenza nos- tras 153 Illustration of the surgeon's half-glove 42 Impermeable wound dressings. 25 Inanition before operation 116 Incision 87 The semilunar hypogastric. . 87 In the lower abdomen, other methods for 95 The_ mesial rectus 95 Indications for the mesial rectus 97 In the upper abdomen, rout- ine 97 The right rectus 98 McBurney's instramuscular. . 98 For inguinal hernia and ap- pendicitis 98 Choice of 99 Page. At the lowest point is help- ful in drainage 162 Incisions, practical 87 Special 98 Incompatibility between skin secretion and disinfectant... 8 Indications for using absorable and inabsorable sutures... 67 For the mesial rectus inci- sion 97 Industrial wounds 154 Infection, extrinsic 2 Intrinsic 2 The stage of 156 Souxces of wound 40 Infections, influence of post- operative skin 140 Influenza nostras after opera- tion 143 Instrument table 21 Sterilizer 33 Instruments are best sterilized by boiling _. _. 31 And utensils, sterilization of 27 Insufflation narcosis, intratra- cheal for intrathoracic operations 84 Intramuscular incision, McBur- ney's 98 Interval after the bath 8 Intrathoracic operations, anes- thesia in ._ 84 Intratracheal narcosis in tu- mors of the larynx 84 Intrinsic infection 2 Iodine-soapsuds sequence 6 Method, radical 6 In fat-solvent menstruum.... 8 For vaginal douche 13 Irrigator apparatus in the op- erating room 29 J Judgment, surgical 1 The basis of surgical 167 K Kammerer's rectus incision... L La Grippe after operation 143 Laparatomy sheet, sterile 20 Straps, use of 127 Larynx, narcosis in operating on the . ._ .." 84 Latent bacterial foci • • • •_ 3 Ligaments, elastic fibre in 55 Linen thread for hollow or- gans 68 Objectionable in skin suture. 68 Liquor disinfectans 7 Expurgans 7 174 INDEX Page Local preparation of the pa- tient 6 Logical asepsis \ Loop-drains 160 Loose aseptic gauze for cover- ing wounds 84 Low incision is helpful in drainage 162 Lysol for vaginal douche 13 M Magnesium citrate after opera- „ tion 124 Major complication, influence on aseptic reaction by a... 144 McBurney intramuscular inci- sion 98 Mechanical cleansing 5 Menstruation, influence on the typical reaction by 138 Metal clamps in skin repair. . . 68 Drains for small wounds. .. .160 Method, sirnplified cleansing.. 7, 10 Of simplified cleansing, as substitute for disinfection. 10 The iodine-soapsuds 6 The radical iodine 10 Of emergency preparation of skin 11 Of emergency preparation of the skin with aqueous lysol 11 Of emergency preparation of the skin with iodine 11 Of emergency preparation of the skin with soap and wa- ter 11 Of preparing the skin for operation, the combined... 6 Of preparing the skin for operation, a new combined 7 Of sterilizing utensils by boiling SI Of sterilizing instruments by boiling 31 Of sterilizing rubber gloves.. 39 Of sterilizing and preserving catgut ,_ 70 Of preparing the hands be- fore operating 37 Of anesthesia in operation on the brain_ 83 Of evacuating pus by expres- sion _. 164 Of evacuating pus by suc- tion 165 Methods of sterilizing the skin, combined 6 Of sterilizing gauze by chem- ical means H, Of sterilizing gauze by means of heat 14 Of uniting bone 69 Michel's clamps _ 68 Minor complications, influence on the aseptic reaction by. 137 Mixed diet after operation. .. .124 Page Moisture starts catgut dissolu- tion 61 Morphine after operation Ill Mucous membranes, prepara- tion for operation of the. . 11 Preparation with tincture of iodine 10, 11 Preparation with tannic acid 11 Preparation with lysol 11 Preparation with soap and water n Muscle, Healing of smooth.... 50 Healing of striated 49 Sheath, elastic fibres in the. 55 N Nausea, eflfect of lime water on post-operative 110 Effect of milk of magnesia on post-operative 110 Needles, choice of 105 Qassification of 105 Nerve Tissue, the healing of . . 51 New combined method of skin sterilization 7 Nurse's outline of preparation for operation 12 List of supplies for one laparotomy 26 List of articles to be boiled in the utensil sterilizer. ... 30 Duties in the operating room 101 Fainting at operation 107 O Object of gauze dressing 24 of sutures 59 Objection to bare arms while operating 38 Objections to methods of skin sterilization 6 To wet gloves 38 Odor of the anesthetic, dis- guising the 76 Oil of rose to disguise the odor of anesthetics 76 Oleum _ tiglii after operation . . . 122 Operating table with sterilizable top 27 Room utensils, classified.... 28 Room nurse,_ duties of. .....101 Room, dressing rotation in . . 38 Rules for safe 4 Room, arrival of the patient from the 110 Operation, Preparation of the patient f or_ 5 Nurse's outline of prepara- tion for 12 Inanition before ••_.... 116 Advantage of nourishing the patient well before 116 Co-operation at 2 Family physician at 102 INDEX 175 Page Provision for cleansing the hands at 28 Basins for sterile water at.. 28 Provision for septic fluids at 30 The choice of needles for... 106 Accessories necessary for soap and water cleansing of the field of 38 Division of labor at 100 Difficult exposure on account of distended bowel during. 104 Retraction and handling of vulnerable structures dur- ing 104 Walling off pus foci during.. 106 Safe hemostasis at 104 Avoidance of stagnating fluids at the site of the... 107 Unnecessary dissection dur- ing 102 Course of the 100 Fainting of a nurse at 108 Severe hemorrhage during an 108 Collapse of the patient dur- ing 108 Air embolism during 108 On the brain, anesthesia dur- ing 83 For tumors of the larynx, an- esthesia in ,_. . , 84 Anesthesia in intrathoracic. 84 With anesthesia in the posi- tive, differential pressure cabinet 85 Death during intrathoracic. . 86 Care of the patient after.... 110 Relations of the family phy- sician and surgeon_ after. .111 Anodynes and somnifacients after 112 Morphine after Ill Causes of wakefulness after. 112 Gas pain after Ill Enema for expelling gas af- ter ......_ Ill Bowel inertia after 116 Enemata after 123 Enema for evacuating the bowel after 123 Difficulties in urination after.113 When to catheterize after... 113 Record of the quantity of urine after 114 Suppression of urine after.. 115 Urme analysis after 114 Factors concerned in the gas- tric upset after 115 Diet after 115 Liquid diet after 117 Convalescent diet after 118 Full diet after 124 Avoiding excess of fats and sweets after 118 Cathartic food after 119 Constipating food after 120 Mild cathartics after 124 Caster oil after 121 ' ' ,. Page. Croton oil after i22 Calomel after .'.123 Use of opiates in rectal cases after j20 Constipating the bowel after „''e'^tal .,.. 120 Evacuating the bowel after rectal 121 Changes of position after. 126 Aseptic fever after 133 Interpretation of fever after.133 Influence of menstruation on the fever curve after 138 During menstruation, influ- ence on the aseptic reac- tion in 139 Influence of bowel stasis on the curve after 137 Influence of a slight skin in- fection on the reaction af- ter 140 Influence of a marked skin infection on the reaction ^after 140 Effect of influenza nostras on the reaction after 143 Pubic strip for dressing after gynecological 127 Use of laparotomy straps af- ter 127 Use of adhesive corset after.. 128 Use of the adhesive belt af- ter 128 The abdominal binder after.. 128 Rupture of suture line after. 128 The use of drains after 129 The first dressing after 128 Dressing of the wound with silver leaf after 129 Sitting up after 131 Second week after 127 Temporary support of the _ young scar after 130 Opiates in rectal cases after op- eration 120 Organs, wounds of parenchsrma of 52 P Packing the sterilizer 18 Pads, abdominal 23 Pails of agate ware for the op- erating room 30 Parcels containing materials for cleansing 24 Containing materials for dressing _ 24 Patient's arrival from the op- erating room . ._ 110 Care after operation 110 Peritoneal adhesion 51 Peritoneum, healing of the.... 51 Peritonitis, aseptic 51 Personal asepsis _. . . 41 Physician's sphere at operation.lOl Pitcher, sterile 29 176 INDEX Page Position of the patient after operation, changes in the.. 126 Positive differential pressure- cabinet, anesthesia in 85 Post-operative care of the pa- tient 110 Shock, estimating the amount of 81 Treatment, relations between the family physician and surgeon in HI Duties of the nurse .110 Use of anodynes and somni- facients, rules for 112 Use of morphine Ill Use of dionine 112 Use of codeine phosphate. . .118 Wakefulness, causes of 112 Use of veronal 112 Use of veronal-sodium 112 Use of trional 112 Use of tetronal 112 Use of sulphonal 112 Gastric upset, factors con- cerned in 115 Nausea, effect of lime water oTc milk of magnesia in 110 Gas pain HI Bowel inertia Ho Use of the enema 123 Use of the peppermint ene- ma _ Ill Difficulty in urination 114 Catheterization .113 Record of the quantity of urine 11^ Suppression of urine .115 Specimen of urine for analy- Changes in position . 126 Rupture of the suture line.. 128 Dressing, the first. •••••• }l° Dressing with silver leaf 1^9 Fever in aseptic cases. 133 Fever, interpretation of..... 133 Bowel stasis, influence on the aseptic reaction by ...137 Fever curve, influences of bowel stasis on the ..137 Fever curve, influence of- menstruation on the.... ..138 Fever curve, influence of a slight skin infection on the.140 Fever curve, influence of a marked skin infection on the • ..:..140 Fever curve, influence of in- fluenza nostras on the 143 Diet 115 Liquid diet I" Convalescent diet i-i? Full diet .••;••; i?o Use of cathartic food... 119 Use of constipating food 1^0 Use of opiates in rectal cases.130 Use of mild cathartics 124 Use of croton oil 1** Use of caster oil i*i Page. Use of calomel. 123 Use of the evacuative enema. 123 Second week 127 Posture of the patient during operation, importance of correct 94 Of the patient in drainage, importance of the 162 Preface I Preoperative inanition 116 Fever 3 Preparation of the surgeon's hands before operating. ... 37 Of the patient for operation. 5 Of the patient for operation, nurse's outline _. . . 12 Of the patient for operation, general 6 Of the patient for operation, local ._ 5 Of the patient, for an emer- gency operation 10 Of the skin for operation. . .6, 10 Of the mucous membrane for operation 11 Preservation of catgut sutures. 70 Pubic strip in dressing gyne- cological laparotomies .... 127 Pulse before and after anes- thesia 80 Pus basins for the operating room 30 Pan for office and dispensary use 30 Avoiding contact with. ...... 39 Foci in operations, walling off 106 Evacuation by the expression method 164 Evacuation by the suction method 165 Q Qualities of suture material.... 60 R Reaction of tissues towards im- bedded catgut ;•■:•• *1 Rectal operations, constipating the bowel after 130 Cases, use of opiates in 120 Operations, emptying the bowel after 121 Rectus incision, the mesial .... 95 Incision, Indications for the mesial 97 Incision, the right 98 Reflex coughing during anes- thesia ; 80 Reflexes during anesthesia, ab- olition of 77 Relation of the. deep epigastric artery to incisions in the lower abdomen 95 Between the surgeon and his anesthetist 74 INDEX \77 Page Repair by wound healing is es- sentially imperfect 47 Reproductive power lost with cell specialization 45 Resistance of catgut suture, terms used to express the degree of 63 Of catgut suture in the hu- man tissue in relation to the animal 63 Responsibility of the surgeon.. 1 Resterilization, object of 33 Effect on tetanus baccilli pro- duced by 33 Retraction of vulnerable struc- tures during operation. .. .104 Rubber gloves, sterile 20 Gloves, method of steriliz- ing ...17,39 Gloves, reason for wearing. . 36 Gloves, objections to 41 Tubes for wound drainage. .159 Rules for safe operating 4 For post-operative use _ of anodynes and somnifa- cients 113 Rupture of the suture line.... 138 S Safe operating, rules for 4 Safety of surgical measures.... 2 Scalpels, sterilization of 34 Scar formation, wound healing and 45 Formation _ and functional compensation are independ- ent 47 Formation undesirable when excessive 53 Tissue, slight resistance of. . 57 Formation in surface wounds and internal organs is sim- ilar 47 After operation, supporting the 130 Scars, elastic fibres in 54 Does exercise encourage the development of elastic fib- rils in 58 Sedative treatment of wounds. 156 Shock during anesthesia, in- duction of 78 Following operation, estimat- ing the_ amount of 81 Silk is objectionable for skin suture _. ._ 68 Silkworm gut for skin repair. . 68 Silver^ leaf, use of 129 Simplified cleansing methods for the skin 7, 10 Cleansing methods to substi- tute disinfection . _. 7,10 Siphonage, wound drainage by continuous _. 163 Sitting up after operation 131 Skin sterilization, objections to methods of 5 Page Sterilization by combined methods Sterilization by a new com- bined method 7 Secretion, relation of the dis- infectant to the 8 Preparation for operation of the 6,10 Elastic fibres in 56 Suture is avoidable 69 Suture, objection to catgut in 68 Suture, objection to silk or unimpregnated linen for... 68 Suture with silkworm gut... 68 Clamps 68 Coaptation by means of adhe- sive plaster 69 Infections, influence on post- operative reaction by 140 Slipperiness of the vaginal mu- cous membrane lessened by the use of tannic acid 13 Of the vaginal mucous mem- brane lessened by the use of zinc sulphate 13 Of the vaginal mucous mem- brane lessened by the use of bichloride of mercury.. 13 Solution No. I for prepara- tion of the skin 7 No. II for preparation of the skin 7 Special incisions 98 Specialization of cell and loss of reproductive power 45 Of cells does not destroy their power to grow 46 Sponges of gauze 81 Tiny 21 Delta 22 Spore forms _ jn relation to steam sterilization 16 Forms, boiling time necessary to destroy 32 Stagnating fluids as culture media 3 Fluids objectionable at the site of an operation ...107 Steam sterilizers, construction of 16 Sterilization, steps in.. 15 Sterilization in relation to bacteria 16 Sterilization in relation to spore forms 16 Sterilization, time required for 16 Steps in the execution of _ the semilunar hypogastric inci- sion _. . . 87 In the mesial rectus incision. 96 Sterile wash and wound dress- ings . 14 Sterility of catgut depends on the manufacturers 70 Sterilizable tops for operating and supply tables 27 178 INDEX Page Sterilization of gauze, by boil- ing 14 Of gauze, by steam under pressure , 14 Comparative time required for 18 Repeated 16 Of rubber gloves 17,39 Of talcum powder 19 Of utensils for operation.... 27 Of instruments for operation. 37 Of scalpels 34 Of catgut 70 Of wounds 155 Sterilized gowns 19 Sterilizer for surgical instru- ments 33 Supply 19 Stimulant treatment of wounds. 157 Strips, skin coaptation with ad- hesive 69 Suction methods for evacuating pus 165 Sulphonal after operation 112 Supply table 21 Tables with sterilizable tops. 27 Surface sterilization of catgut tubes 71 Wounds, healing by granula- tion of 52 Surgeon's responsibility 11 Hands, the 36 Instruments, superiority of the boiling process for sterilizing the 31 Relation to his anesthetist.. 74 Attitude in case oi vomiting during anesthesia 80 Duty towards the family phy- sician on dismissing a case.132 Surgical judgment 1 Judgment, basis of 167 Anatomy of the semilunar hypogastric incision 87 Anatomy of the mesial rectus incision 95 Case, relation of the family physician and surgeon in the after care of a Ill Sutures contaminated through wet table covers 21 Suture tray 21 Material, aseptic 59 Sutures are foreign bodies 59 Are avoidable in the skin. ... 59 Object of 59 Absorbable 60 Suture material, requisite qual- ities of 60 Suture of catgut microscopic • changes during the absorp- tion of 61 Sutures of catgut, moisture starts the dissolution of . . . 61 Suture resistance to absorption, terms used to indicate 62 Page Of catgut in the human sub- ject, terms indicating re- sistance are of relative sig- nificance in 63 Of catgut, actual period of- usefulness of 63 Sutures of catgut, water is es- sential for the action of cell enzymes on 64 Highly chromicized are pref- erable to bulky 65 Fine chromicized catgut to replace in absorbable 65 Suture resistance of "40" and "60 day" most generally useful 66 Sutures of catgut should be aseptic not antiseptic 66 Indications for using absorb- able and inabsorbable 67 Of linen for hollow organs.. 68 Sutures of the skin, objection to catgut in 68 Of silk or _ unimpregnated linen objectionable for skin' union 68 Of skin with silkworm gut. . 68 Of catgut in sealed tubes, effect of boiling on 71 Line, rupture of the 128 Sweat, the fatty nature of 9 T Table of contents V For supplies 21 For instruments 31 The Hartley 23 I, mean daily rectal tempera- ture preoperative 144 II, daily mean temperature in aseptic laparotomies, rectal and oral tempera- tures compared 145 III, rectal and oral tempera- tures in the same patient taken simultaneously near the end of the first week after hysterectomy _. 145 IV, the maximum rise and the time of its occurrence, rectal temperatures 145 V, mean daily rectal tempera- ture, second week post-op- erative 146 Talcum powder, sterilization of. 19 Tampons of gauze 23 Tannic acid for vaginal douche. 13 Technic, dexterous 1 Of the semilunar hypogas- tric incision 87 Of the mesial rectus incision. 95 Of anesthesia in operation on the brain _ 83 Of anesthesia in operation on the larynx 84 Temperature, normal rectal, 133, 136 INDEX 179 Page Temperature, normal oral 131 Relation between oral and rectal 134 Registered most accurately in the proximity of the le- sion 134 Reaction after clean opera- tions 134 After operations, time of oc- currence of the maximum rise in the 135 After operation, amplitude of the maximum rise in the.. 135 Influence of the time of day on postoperative 135 After operation, relation of the post-maximal to the maximum rise in the 135 After operation, the promaxi- mal in relation to the maxi- mum rise in the 135 After operation, influence of menstruation on the 138 After operation, effect of bowel stasis on the 137 After operation, effect of slight infections on the... 140 After operation, effect of marked skin infections on the ...140 After operation, effect of in- fluenza nostras on the 143 Tension, drainage by chemical.. 161 Terms used to indicate catgut resistance 63 Tetanus bacillus, resistance of the 33 Bacillus, effect of drying on the 33 Tetrachloride of carbon 8 Tetronal after operation 112 Theory of the significance of elastic fibres 54 Concerning the interpretation of post-operative fever.... 144 Thermic methods for sterilizing dressings 14 Thread of linen for hollow or- gans ■ • 68 Thrombophletitis with afebrile intervals ; • • 3 Time required for sterilizing instruments or utensils by boiling •• 32 Required for rendering the hands surgically clean.... 37 Tiny sponges V ' • ' V,' V ^^ Tissue reaction towards imbed- ded catgut ;■•••; "-^ Water essential for action oi cell enzymes on catgut 64 Towels, sterile 20 Disposal of soiled i^ Tray for sutures V ' •, c7 Treatment of unclean wounds..l54 Of wounds, sedative loo Of wounds, stimulant lo? Trional after operation 11» Page Tuberculosis in its relation to anesthesia 82 Tube used during anesthesia, the breathing 80 Narcosis in operating on the brain 83 Narcosis, intratracheal, in tu- mors of the larynx 84 Tubes of catgut, boiling the... 71 Of rubber for wound drain- age 159 Tunore of the larynx, narcosis in 84 U Unclean wounds, treatment of 154 Urination, post-operative diffi- culty in 113 Urine after operation, record- ing the quantity of.. 114 Post-operative suppression of.ll5 Analysis after operation 114 Utensil sterilizer 27 Sterilizer, articles to be boiled in the 28 Utensils for _ the operating room, classified 28 For the operating room, ster- ilization by boiling the.... 27 For the operating room, time required for sterilizing by boiling the _ 32 And instruments, steriliza- tion of 27 V Vegetarianism, the question of.l25 Venous blood during anesthe- sia, the significance of.... 80 Veronal after operation 112 Veronal-sodium after operationll2 Vomiting during anesthesia... 80 Volnerable structures, retrac- tion of 104 W Wash and wound dressings, sterile 14 Water is essential for the ac- tion of cell enzymes on catgut 64 Weir's extension of McBur- ney's incision 98 Wet covers as sources of dan- ger from infection 21 Wound contamination, sources of 40 Dressing, sterile 14 Dressing in clean cases 130 Disinfection 155 Doubtful 154 Dressing, final 130 Wounds, industrial 154 180 INDEX Page Wound dressing with silver ^ leaf 129 Support after operation 130 Wounds, three stages in the healing of unclean 155 The stage of infection in sec- ondary healing of .....156 Stage of expurgation in the healing of unclean 158 The stage of aseptic healing of unclean 166 Wound sterilization 155 Wounds, treatment of unclean.154 Sedative treatment of 156 Stimulant treatment of 157 Appearance of elastic fibres in healing 54 Wound discharge 158 Wounds, drainage of discharg- ing 159 Drainage, devices for aiding.159 Drainage by means of rub- ber tubes 159 Drainage of a small 159 Wounds, metal drains for 160 Wound drainage, factors in... 161 Page Drainage by chemical ten- sion 161 Drainage by gravitation 162 Drainage by continuous si- phonage 163 Healing and scar formation.. 45 Healing is an imperfect re- pair 47 Healing, role of connective tissue in 47 Healing, minor role of other besides connective tissue in 48 Healing, constitutional causes of slow 157 Healing, local causes of slow. 157 Wounds of bone 49 Of cartilage 48 Of smooth muscle 50 Of striated muscle 49 Of heart muscle 50 Of nerve tissue 51 Of the parenchyma of secret- ing organs 53 Involving the peritoneum. ... 51 Of the surface, granulation of 53 NW on oo^.^'^ii^iy^.^SITY LIBRARIES (hsi.stx) nU 00 Ncy C.I Guidina iRIinciples in suraical practice. 2002108224