Columbia ©ntbersittp \ tntfjeCttpof J2eto§orfe e ^ COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/aftertreatmentof01bart THE AFTER-TREATMENT OF SURGICAL PATIENTS VOL. I THE AFTER-TREATMENT OF SURGICAL PATIENTS BY "WILLARD BARTLETT, A.M., M.D., F.A.C.S. AND COLLABORATORS VOL. I WITH TWO HUNDRED TWENTY-TWO ORIGINAL ILLUSTRATIONS AND ONE COLOR PLATE ST. LOUIS, C. V. MOSBY COMPANY 1920 Copyeight, L920, By C. V. Mosby Company (All rights reserved) Press of C. V. Mosby Company St. Louis TO THE MEMORY OF MY FATHER AUBELIUS TWOMBLEY BABTLETT, M.D. "WHO EVER CHOSE THE HARDEE WAY, WHICH IS THE PATH THAT CAN BE TRODDEX ONLY BY THE FOOT OF A MAX" (Farnol) PREFACE Fortunately, every mammalian entity is a machine highly en- dowed with possibilities of automatic adjustment and repair. Among the lower animals, those that are wild must depend upon themselves during the period of repair that follows an injury which is not immediately fatal. Our domestic animals, more fortunately situated, do experience a certain amount of external aid in similar times of distress, while man is practically never with- out sympathetic, and in many instances, scientifically directed care, whenever he experiences any deviation from the normal physiologic tenor of his existence. Always granting a correct diagnosis, promptly established op- erative indications, and well appraised pathologic conditions amena- ble to surgical treatment, it is true, in the majority of instances, that the need of after-treatment is in inverse proportion to the quality of work done on the operating table. Be this as it may, some of our patients do perfectly well if let alone, while many of them are made much more comfortable by properly directed after-care, and a few are certainly lost for the lack of it. In this volume, in most instances, the consideration of surgical technic has been omitted ; however, instances will arise in which mention of certain operative details must be made, in order that the therapeutic suggestions may be completely understood. Sur- gical after-treatment has been considered as beginning when the last suture is tied, and lasting until the patient is restored to normal health. My follow-up system, to which attention has been called elsewhere in this work, contemplates a correspondence with every patient for at least one year following the operation, but one can imagine a much more lengthy course of after-treatment in certain individuals, e. g., those who are compelled to live within definite limits after such operations as are performed for the cure of pyloric ulcer. Such a work naturally divides itself into two parts: one which has to do with general subjects, and the other, with the measures of after-treatment as they are applied following operations upon the various organs. One must place some practical limit upon the scope of such a work, hence, no consideration has been given to X PREFACE the postoperative consequences and the treatment of some extremely rare procedures, especially those handled by the sharply restricted specialists. However, it was thought well to give detailed atten- tion to many of the procedures from special fields, which may at times confront the worker in general medicine or surgery. It is hoped that this book will make an appeal to those who, like myself, have at times desired this subject treated more in detail than is possible in the excellent works on general surgery a1 our command. If originality seems to have been claimed for any of the methods herein advocated, or even for the form in which they are presented, it is done with full knowledge that "there is nothing new under the sun" in the field of medicine, and in the hope that faulty informa- tion may not often prevent giving credit for priority when it is due. The procedures which my collaborators and I recommend have practically all proved their worth in an extensive personal ex- perience, still, Ave all have, as will be noted, drawn freely and impartially from the Literature, striving always to be scrupulously fail- in acknowledging our indebtedness to others. It is no less a pleasure than a duty to emphasize in a general way this obligation on our part it' anywhere we may have seemed remiss. Dr. 0. F. McKittrick's chapters speak for themselves; still it is with the utmost satisfaction that T here accord him unstinted praise and appreciation for his untiring efforts while he, as my house surgeon, collected many of the clinical data on which this work is based. Not only am I fortunate, hut the reader as well, thai eleven of the chapters have beeu most graciously contributed by men who are especially qualified to handle i he subjects in question. Their names appear under the titles of their respective chapters. In ad- dition to these writers, I desire to thank Doctors William .1. .Mayo. Charles II. .Mayo. George W. Crile, Stuart McGuire, and Joseph Bloodgood \'<>v inspiration and assistance which has been invalua- ble. Dr. S. I- 1 . Weiinerinan kindly corrected the manuscript of many chapters and \)v. I-\ K. Ilensel proved a painstaking, faithful co- worker in helping place the numerous illustrations. WlLLARD BARTLETT. St. Louis, Mo. CONTENTS VOL. I CHAPTER I The Ideal Postoperative Room (By 0. F. McKittrick) 1 CHAPTER II Records and Charts (By Willard Bartlett) - . . 7 CHAPTER III Preliminary Considerations and Anesthesia (By O. F. McKittrick) . 15 CHAPTER IV Prom Table to Bed (By O. F. McKittrick) 23 CHAPTER V Immediate Effects of Anesthesia and Operation (By O. F. McKittrick) 27 CHAPTER VI Earliest Subjective Manifestations (By 0. F. McKittrick) .... 36 Pain, 36; Thirst, 39; Nausea and Vomiting, 40; Dreams, 45; Mental Aberrations, 45; Complications Arising After Local Anesthesia, 46. CHAPTER VII Later Subjective Symptoms (By Willard Bartlett) 49 Ether Conjunctivitis, 49; Dry Mouth, 50; Painful Tongue, 51; Sore Ja-'.v, 52 ; Sore Throat, 53 ; Painful Respiration, 54 ; Anesthesia Paral- ysis, 55. CHAPTER VIII Sleeplessness (By O. F. McKittrick) 61 CHAPTER IX Hiccough (By O. F. McKittrick) 68 CHAPTER X Headache (By O. F. McKittrick) 74 CHAPTER XI Backache (By 0. F. McKittrick) 82 Xll CONTEXTS CHAPTER XII Shock (By Willard Rartlett) 91 CHAPTER XIII Hemorrhage (By Willard Bartlett) 103 CHAPTER XIV Dilatation of the Heart with Reference to Postoperative Acute Dila- tation (By Willard Bartlett and Riley M. Waller) . . . . 113 Pathology, 115; Diagnosis, 116; Treatment, 116; Summary, 170. CHAPTER XV A.CDTE Dilatation of the Stomach (By O. P. McKittrick) 118 Symptoms, L23; Treatment, 124. CHAPTER XVI PostopeFvATIye Ileus (By Willard Bartlett) 120 Mortality, 120; Pseudoileus, 120; Symptoms, 127; Prognosis. 127: Treatment, 127; Classification of True Ileus, 128; Symptoms and Diag- nosis, 132; Mechanism and Cause of Symptoms, 133. CHAPTER XVII Fat Embolism | . P.y (). F. McKittrick) 139 CHAPTER XVIII Heat Stroke (By O. F. McKittrick) 147 CHAPTER XIX Postoperative Burns I By Willard Bartlett) 150 Depilatory Burns, 150; Iodine Burns, 150; Ether Burns, 151; Hot-water Bottles, 151; Enemas, 152; The Electric Light, 152; X-ray, 153; Ice, 154; Pathology and Morbid Anatomy, 151; Symptoms, 150; Frostbite, 158; Prognosis, 159; Treatment, 159. CHAPTER XX Bed Sores (By O. F. McKittrick:) 104 CHAPTER XXI Postoperative Prolapse op Abdominal Viscera (By Willard Bartlett) 170 CHAPTER XXII Foreign Bodies Lost in the Peritoneal Cavity (By Willard Bartlett) 175 CHAPTER XX] II Fistula (By Willard Bartlett) 187 Treatment, 187; Digestive Tract, 188; Intestine, 189; Complications, 191; Other Varieties ot' Postoperative Fistula 1 , 194. CONTEXTS X1H CHAPTER XXIV Sinuses (By O. F. McKittrick) 199 CHAPTER XXA T Drug Addiction in Surgical Patients (By 0. F. McKittrick) .... 204 CHAPTER XXVI Alcoholism in Its Relation to Surgery (By' 0. F. McKittrick) . . . 211 Delirium Tremens, 212. CHAPTER XXVII Postoferatve Psychoses (By 0. F. McKittrick) 217 Febrile Delirium, 225; Delirium Nervosum, 226; Senile Delirium, 227; Hysterical Delirium, 227. CHAPTER XXVIII Acid Intoxication (By- 0. F. McKittrick) 232 CHAPTER XXIX Dlabetes in Surgery (By 0. F. McKittrick) 239 CHAPTER XXX Nephritis, Anuria, and Uremic Coma Following Anesthesia (By O. F. McKittrick) 247 CHAPTER XXXI Bactefjemia (General Septic Infection) (By O. F. McKittrick) . . . 255 Symptoms, 258; Treatment, 259. CHAPTER XXXII Postoperative Tetanus (By- O. F. McKittrick) 261 Treatment, 266. CHAPTER XXXIII Gas Bacillus Infection (By O. F. McKittrick) 269 CHAPTER XXXIA' Postoperative Pneumonia (By- 0. F. McKittrick) 273 Symptoms, 277; Treatment, 27S; Pleurisy, 284. CHAPTER XXXV Parotitis (By- O. F. McKittrick) 2S7 Symptoms, 289; Treatment, 291. CHAPTER XXXVI Subdiaphragmatic Empyema (Localized). (By O. F. McKittrick) . . 294 Symptoms, 296; Treatment, 297. XIV CONTENTS CHAPTER XXXYII Thrombophlebitis (By O. F. McKittrick) 300 Symptoms, 303; Treatment, 305. CHAPTER XXXVIII Pulmonary Embolism (By "Willard Bartlett) 309 Anatomy, 310; Pathogenesis, 311* Symptoms, 315; Treatment, 317. CHAPTER XXXI X Pylephlebitis (By O. F. McKittrick) 319 Treatment, 321. CHAPTER XL Skin Eruptions (By O. F. McKittrick) 325 Ether Rash, 326; Septic Rash, 326; Erysipelas, 331. CHAPTER XLI Hemophilia and Other Hemorrhagic Diseases (By O. F. McKittrick) 333 Treatment, 336. CHAPTER XLI I Artificial Respiration (By Willard Bartlett and Adolph Rumreich) . 343 Manual Methods of Artificial Respiration, 343; Howard's Method, 343; Silvester's Method, 344; Brosch's Modification of Silvester's Method, 344; Silvester-Howard Method, 345; Schafer's Prone-Pressure Method, 346; Artificial Respiration with Apparatus, 347; Pulmotor, 347; Lung- motor, 347: Meltzer's Pharyngeal Insufflation Apparatus, 347; Intra laryngeal Insufflation, 348; Intratracheal Insufflation of Meltzer and Auer, 348; Laborde's Tongue Traction, 349; Stimulation of the Circu- lation, 349; Heart Massage, 350; Indirect or Intrathoracic Massage, 350; Direct or Intrathoracic Massage, 350; Respiratory Stimulation by Sodium Cyanide, 350; Electricity, 350; Adrenalin, 350; Oxygen Inhala- tion, 350; Position, 350. < IIAPTER XLIII Postoperative Feeding (By .1. W. Larimore) 352 CHAPTER XLIY Reduction of Obesity (By Willard Bartlett and Alfred Goldman) . 3,62 Diet, 363; Mechanical Treatment, 366; Medicinal Treatment, 367. CHAPTER XLV Artificial Nutrition (By Willard Bartlett and M. G. Peterman) . . 369 Nutrition Per Rectum, 370; Gastrostomy, 374; Finney's Diet, 377; Leube's Diet, as Modified by Lockwood, .".77; Jejunostomy, 378; Intra venous, 378; Subcutaneous, .",79; Intraperitoneal, 381 ; Cutaneous Appli- cation, 382. CONTEXTS XV CHAPTER XLVI Cake of the Bowels After Operatiox Other Than Gastrointestinal (By Willard Bartlett) . 383 Constipation, 383; Prophylaxis, 386; Diarrhea, 389. CHAPTEE XL VII Treatment of Postoperative Eetextiox of Urine and Cystitis (By Johx E. Caulk) 392 Effects of Anesthesia, 392 ; Treatment, 393 ; Catheterization of the Male, 394; Treatment of Postoperative Cystitis, 396; Symptoms, 397; Treat- ment, 398; Medical Treatment, 398; Local Treatment, 400. CHAPTEE XLVlII The Treatment of Wounds (By Willard Bartlett) 402 Historical Considerations, 402 ; Principles "Which Underlie Wound Heal- ing, 402; Early Treatment of Aseptic or Closed Wounds, 406; Early Treatment of Infected or Open Wounds, 410; Dakin's Fluid, 415; For- eign Substances, 431 ; Some Eemote Consequences of Wounds, 432 ; Late Treatment of Wounds, 433. - CHAPTEE XLIX Bandaging (By O. F. McKitteick) 440 Head Bandages, 443; Xeck Bandages, 448; T -bandages, 461; Suspens- ory bandages, 461. ' CHAPTEE L The Abdominal Binder. (By O. F. McKittrick) 475 CHAPTEE LI Exercise and Massage (By F. H. Ewerhardt) 483 Massage, 484; General Discussion, 4S4; Physiologic Effect, 485; Tech- nic, 487; Vibration, 495; Portable Apparatus, 496; Stationary Appar- atus, 496; Shaking and Kneading Appliances, 496; Physiologic Effect, 496; Exercise, 497; Physiologic Effect of Exercise, 499; General Out- line of Exercise Treatment for the More Common Indications, 500; Special Exercises for Strengthening the Heart, 504; Hernia, 506; Flat Feet, 508; Joint Disturbances, 511; Early Functional Treatment of Fractures, 513; Paralysis, 515. CHAPTEE LII Hydrotherapy (By F. H. Ewerhardt) 519 Reflex Effects, 520; Special Reflex of Prolonged Cold, 520; Special Re- flex Effect of Short Cold, 520; Special Reflex Effects of Hot Appli- cations, 521; Hydrostatic Effects, 521; Technie, 523; Fomentation, 523; Heating Compresses, 524; Ice Pack, 524; Cold Wet Pack, 525; Hot Wet Pack, 525; Hip or Sitz Bath, 526; Cold Sitz Bath, 526; Pro- longed Cold Sitz Bath, 527; Salt Glow, 527; Xauheim Baths, 528; Grad- uated Tonic Cold Applications, 530; Cold Mitten Friction, 530; The Wet Sheet, or Sheet Bath, 530; Shallow Bath, 531; Cold Douche, 531; Alternating Hot and Cold Douches, 532 ; The Electric Cabinet Bath, 532. XVI CONTENTS CHAPTER LIII Postoperative Treatment by Radium and the Roentgen Rays in Ma- lignancy (By Russell H. Boggs) 535 Carcinoma of the Breast, 536; Carcinoma of the Uterus, 545; Carcinoma of the Rectum, 550 ; Epithelioma, 552 ; Cancer of the Mouth and Throat, 559; Sarcoma, 562. CHAPTER LIV Reamputations (By Willard Bartlett and Walter S. Priest) .... 564 Osteoplastic Reamputation, 565 ; Other Methods of Reamputation, 569 ; Flapless Method of Reamputation, 571 ; Apparent Lengthening of an Arm Stump, 572; Kineplastic Reamputations, 572; Single Motor Flap in Amputation Through the Arm, 574; Double Motor Flap in Amputa- tion Through the Forearm, 574; Amputation of Forearm Providing a Plastic Club Motor, 575. CHAPTER LV Proctoclysis (By O. F. McKittrick) 577 ^ CHAPTER LVI Hypodermoclysis (By Willard Bartlett) 586 CHAPTER LVII Blood Transfusion (By Willard Bartlett) 596 Technic, 599; The Selection of Donors for Transfusion, 624. CHAPTER LVI 1 1 The Reconstruction of the Patient (By Robert S. Carroll) .... 630 The Nutritional Reeducation, 631; The Mental Readjustment, 634. CHAPTER LIX Postoperative Treatment in Children (By Willard Bartlett and J. B. Carlisle) 638 CHAPTER LX Postoperative Treatment in Old Age (By Willard Bartlett and C. R. Fancher) 647 CHAPTER LXI Symptoms and Signs ok Impending Death (By O. F. McKittrick) . . 656 Sudden Death, 659. CHAPTER LX 1 1 Postoperative .Mortality (By Willard Bartlett and P.. L. Adelsberger) 664 ILLUSTRATIONS FIG. PAGE 1. Ground plan of postoperative room, anteroom, and sun parlor .... 2 2. An antislamming device used at the Mayo Clinic 3 3. An iron bedstead used at the Mayo Clinic 4 4. The ideal bed showing the mattress and the arrangement of bed clothes for the immediate reception of an unconscious postoperative patient 4 5. Pillows and rubber slips 5 6. A headrest built in 5 7. Eecord of patient's condition, findings, and operation ...... 8 8. Postoperative orders 9 9. Chart for eight observations daily 10 10. Admission and treatment chart 11 11. Clinical postoperative laboratory record 12 12. Record of posthospital examinations of simple nature 13 13. Position of patient on operating table showing restraining strap across lower limbs 20 14. A mask used for administration of gas and ether combined 21 15. A convenient way of transferring the patient from the operating room to the stretcher or ward carriage 24 16. Ward carriage ready to receive patient from operating table .... 25 17-A. Patient just returned from the operation 26 17-B. Position of patient prior to being lifted into bed 26 18. A convenient method of washing an eye which has been irritated during anesthesia 33 19. A convenient scheme for the early administration of fluids 41 20. Patient's head is lowered in order that blood may gravitate to the cerebral centers and the heart 101 21-A. The simplest means of increasing the amount of blood in the heart and central nervous system Ill 21-B. A posture suggested for shock and hemorrhage where the respiratory apparatus is full of mucus Ill 22. Fat embolism of lung following multiple fractures 140 23. Skin grafts on an extensive burn surface (Color Plate) 160 24. Wire cage to protect skin grafts on burn surface 161 25. Bedsores following myelitis 165 26. Healed bedsores 165 27. Eusty forceps removed from abdomen at a remote period ISO 28. A method of confining the hands used at the Minnesota State Hospital, Eochester 221 29-A. A simple method of tying the feet, which allows the patient to sit up in bed 222 29-B. A useful leg cuff and strap which permits patient to sit up in bed . 222 30. Method of forcing the mouth open for the purpose of forced feeding . 223 xvii Xviii ILLUSTRATIONS FIG. PAGE 31. Showing the probe passing behind the last molar tooth and tickling the fauces, thereby causing immediate opening of the mouth . . . 224 32. Showing round soft pine stick tied in position between the teeth . . . 225 33. A simple scheme for restraining hands and feet only 228 34. Method of restraining the body by means of a sheet 229 35. Straight jacket with comfortable hand arrangement for walking insane patients 230 36. Straight jacket as shown in Fig. 35 combined with confining sheet . . 230 37. The tetanus bacillus 262 38. Opisthotonus 266 39. Applying alcohol to the cup 280 40. Igniting the alcohol 281 41. Three cups in place 282 12. Gauze moistened in equal parts of glycerin and water to prevent the open mouth from drying 291 43. Wrapping the leg in common cotton batting 304 44. The leg elevated and splinted on a pillow 305 45. The extremity protected from the bed covers, and a hot-water bottle ap- plied to the sole of the foot 306 46. Complete blocking of pulmonary artery by embolus 310 47. Pulmonary emboli removed at autopsy 311 48-A. Tributaries of the portal vein 320 48-B. The portal vein 321 49. Apparatus used by Welch for collecting blood serum 340 50. First act in the Sylvester method 345 51. Second act in the Sylvester method 345 52. A convenient scheme for early administration of fluids 353 53. The introduction of liquid food directly into the stomach 375 54. Patient first ensalivates his food and then sends it indirectly into his own stomach 376 55. A convenient wire basket containing the necessary materials for dressing wounds 406 56. Large basket containing materials used in treatment of wounds . . . 407 57. A water bottle which may be maintained at any temperature by means of a stream of water passing through it 407 58. Stitch pulled up and cut through portion that was buried in skin . . 408 59. Dividing and removing superficial stitches 409 60. Method of removing stitch from beneath rubber cover of tension suture 410 61. Cleaning the wound after stitches have been removed 411 62. Acutely inflamed scrotum and penis to which glycerin pack is about to be applied 412 63. Same scrotum and penis after twenty four hours' application of glyc- erin pack 412 64. First step in making cotton pledgets 413 65. Second step in making cotton pledgets 414 66. Third step in making cotton pledgets 414 67. Small covered basins for holding antiseptic solutions 415 68. Washing lip of alcohol bottle before pouring the liquid on a cotton sponge 415 69. Use of ordinary adhesive for holding dressings in place 416 ILLUSTRATIONS XIX FIG. PAGE 70. Attaching gauze tapes to adhesive 417 71. Gauze tapes tied so that adhesive does not have to be pulled off skin when changing dressings 417 72. The Carrel-Dakin glass distributor 419 73. The injection of Beck's bismuth paste 422 74. A convenient cradle under which a large surface may be kept exposed . 423 75. A small shield for exposing a small area 423 76. An automatic glass rubber cupping device 424 77. A positive suction cupping device . 425 78. A convenient way of storing sterile gauze packing in glass tubes . . . 426 79. Granulations covered with gutta percha which protects them from gauze dressings which would otherwise adhere 427 80. The insertion of stitches which are intended to hold gauze packing in place . . . . 428 81. The gauze packing held in place by tied suture end 429 82. Split rubber tube drain as used at the Mayo Clinic 430 83. Fenestruni in a plaster cast as used at the Mayo Clinic 431 84. Injecting local anesthetic under skin of thigh previous to cutting grafts 432 85. Cutting the grafts with a razor 433 86. Spreading the grafts on gutta percha 434 87. Trimming irregular edges of graft and gutta percha 434 88. Grafts in place on a varicose ulcer of the ankle 435 89. Cross layers of gutta percha which fix grafts and their backing in place 435 90. Gauze and adhesive which covers grafts and gutta percha 436 91. Ordinary gauze bandage which covers gauze and adhesive left on forty- eight hours 436 92. Eemoving gutta percha after grafts have remained in place forty-eight hours . 437 93. Open air treatment of grafts after first forty-eight hours' compression 437 94. An attempt to cover an old granulating wound with a bridge of skin . 438 95. Autotransplantation of bone 438 96 Method of cutting a roll of muslin into bandages . 441 97. Boiling a bandage by hand 442 98. Bandage scissors 442 99. A head roller bandage 443 100. A towel folded for bandaging 444 101. First step of applying towel bandage to head 444 102. The completed head bandage, eyes and ears Included 445 103. The completed head bandage, eye (or eyes) excluded 445 104. A roller bandage applied to an amputation stump 446 105. Method of folding towel for bandaging face 446 106. First step of face bandage 447 107. Final step for bandage of face and eye 447 108. Final step in hood bandage for sides of face and head 44S 109. Posterior appearance of hood bandage 44S 110. A simple dressing with gauze support for goiters 449 111. A high neck bandage held up by cardboard inserts 450 112. Simple neck towel bandage 451 XX ILLUSTRATIONS FIG. PAGE 113. Neck and breast bandage as viewed from behind 451 114. A combination neck and breast towel bandage 4-11 115. The towel folded as used in chest bandages 452 116. A towel chest bandage 452 117. Posterior view of chest bandage 452 118. Towel chest shoulder bandage held in place by strip of gauze . . . 453 119. Chest shoulder bandage as shown from behind 453 120. Chest towel bandage with arm included 453 121. Fig. 120 as viewed from behind 45.°, 122. A double towel bandage for chest and shoulder 454 123. Second step of ehest shoulder bandage 454 124. Arm held in position by accessory fold of bandage pinned to lower edge 454 125. Beginning step in shoulder breast bandage 454 126. First stage of Velpeau 455 127. Second stage of Velpeau 455 128. Third stage of Velpeau 455 129. Fourth stage of Velpeau 455 130. A convenient towel bandage for one upper extremity 456 131. Gauze sling for arm 456 132. Gauze sling as viewed from side 456 133. The sling run through a rubber tube to protect the neck from pressure 457 134. A towel folded for purpose of bandaging hand 45S 135. Second step in towel bandage of band 458 136. Pinal step of towel bandage of hand, palmar aspect 45 s ; 137. Final step of towel bandage of hand, dorsal aspect 15 s . 138. First step of towel bandage of thigh 459 139. Second step of towel bandage of thigh 459 140. Towel bandage of leg and thigh 459 141. First step of towel bandage of foot ami ankle 460 1 111. Second step of towel bandage of foot and ankle 460 1 13. Third step of towel bandage of foot and ankle 460 144 Final step of towel bandage of foot and ankle 460 1 15. Single T-bandage 161 146. Double-tailed T-bandage 461 147. Pattingson 's plaster bandage rolling machine viewed from the side . 463 1 18. Pattingson 's plaster bandage rolling machine, viewed from above . . 463 1 l;». Pattingson's scheme for wrapping plaster of Paris bandages in tissue paper 464 150. A device for immersing plaster of Paris bandages 465 151. V device for expressing water from plaster of Paris bandages . . . 466 152. A convenient box for supporting patient during application of plaster cast 467 153. Tricot and felt applied as preliminaries to plaster east 468 154. Applying plaster cast with reinforcement of iron strips 468 155. Using counterpressure on the healthy thigh 470 156. Removing iron supports from the plaster box I7<> 157. A fenestrum for dressing the wound 471 158. A plaster cast split for temporary removal 473 ILLUSTRATIONS XXI FIG. PAGE 159. The ordinary immediate abdominal binder pinned on in the operating room 476 160. An ordinary straight corset. Front view 479 161. Ordinary straight corset. Back view 479 162. The athletic web corset. Side view 480 163. The athletic web corset. Front view 481 164. The athletic web corset laced. Front view 481 165. Effleurage 488 166. Diamond effleurage 488 167. Draining the jugular veins 489 168. Alternate wringing of the flexor muscles 489 169. Kneading of the patella 490 170. Alternate kneading of the flexors of the thigh 490 171. Pulling and pushing of the flexors and extensors of the arm .... 491 172. Thumbs kneading the anterior muscles of the leg 491 173. Anterior frictional kneading of the thigh alternate up and down . . 492 174. Fist kneading of the small intestines 492 175. Circular muscular kneading of the thigh 493 176. Breaking up adhesions 493 177. Cupping 494 178. Hacking 495 179. Illustrating flat foot exercise No 3. Starting position 510 180. Second position exercise No. 3. Complete extension avoiding abduction of foot 510 181. Extreme inversion, then bringing foot back to starting position . . . 510 182. Passive stretching of the arm and shoulder with scapular fixation . . 512 183. Thumb kneading and draining of a Colles' fracture 515 184. Showing apparatus controlling jet douche, needle douche, shower douche, and Scotch douche, and manner of application 531 185. Illustrating electric light cabinet bath 533 186. The direction of skin incision 566 187. Incision through skin, deep fascia, and periosteum 567 188. Periosteum and bone flap elevated 568 189. B'one flap sutured in place after complete division of all structures at a high level 569 190. The stump with flaps sutured 570 191. The drop by drop hypodermic introduction of water, controlled by sight feed 589 192. The needle introduced through a square of gauze 590 193. Needle and gauze held in place by adhesive 591 194-^4. A hot-water bottle in position. B. Novocaine introduced repeatedly during the operation 593 195 and 196. An apparatus for maintaining the temperature of a fluid to be introduced under the skin 594 197. Instruments and material used in direct blood transfusion .... 602 198. Dissecting out the vein 603 199. Placing the waxed black silk cloth under the vein 604 200. Placing bull dog clamps and oiling vein with a lubricant 605 XXI 1 ILLUSTRATIONS FIG. PAGE 201. Vein cut in two, thread put through at one end, hemostat at other . . 606 202. Drawing donor's vein through cannula 607 203. Vein drawn back and tied at second notch on cannula 607 204. Placing and tying recipient 's vein over cannula 60S 205. Citrate transfusion as done by Pemberton 610 206. The Kaliski needle 611 207. The Kaliski needle separated into its component parts 611 208. The transfusion needle introduced by the vein transfixing method . . 612 209. Mixing the blood with citrate solution 613 210. The recipient's vein held up and divided 614 211. A cannula introduced into recipient 's vein 614 212. A form of cannula which may be tied in recipient 's vein 615 213. Introducing cannula into recipient 's vein 616 214. Blood entering recipient's vein 616 215. Funnel tube and a form of cannula which can be used on recipient . . 617 216. The recipient's wound sutured 61S 217. A convenient compress which is included in the ends of the suture . . 618 218. Paraffin coating in process of application 619 219. Blood running into tube from donor 620 220. Blood being driven into recipient 's vein 621 221. The Percy transfusion tube 622 THE AFTER-TREATMENT OF SURGICAL PATIENTS VOL. I. CHAPTER I THE IDEAL POSTOPERATIVE ROOM By 0. F. McKittrick, St. Louis, Mo. One of the important considerations confronting the prospective operative patient is the choice of a room in which to pass his conva- lescence. This is probably a matter of very little import to the or- dinary individual during the first few days of his stay, but soon the newness of his surroundings begins to wear off, he is no longer en- grossed by his postoperative discomfort, and he begins an actual ap- praisement of what is in sight and earshot. The ideal room should be situated above the first floor of the hospi- tal or nursing home, and so arranged as to receive the benefit of a southern exposure for sunshine in winter and breeze in summer. The ideal building is one located upon high ground with long green lawns sloping to the street several hundred feet away, and the win- dows placed so low that the patient, even though in bed, can look out upon the outside world. The noises of the street should not reach the patient, neither should many of those arising within the building. The same may be said of the odors from the serving room or kitchen. The room (Pig. 1) should be so far as practical removed from the service portion of the house. If possible, a private bathroom may be connected with the sick room (an anteroom alone intervening) on the one side, and a sun parlor or porch is to be desired on the other. It is well to have one side of the room adjoining a main hall where the patient can be taken in bad weather for frequent rides and change of scene as he improves. Heavy doors made of solid wood are desirable, since these tend to eliminate unnecessary noise when they are closed. All the openings should be spacious, and a transom over each door and window will be 1 Z AFTER-TREATMENT OF SURGICAL PATIENTS found very convenient. To prevent sudden slamming of doors, a knit cuff may be fastened over the latch (Fig. 2). The size of the room should be at least 13x16 feet, but larger di- mensions are not undesirable. The height depends upon the width and breadth, ranging from 12 to 15 feet. The patient requires at least 1200 cubic feet of air, which calls for 80 square feet of a room, with a 16-foot ceiling; therefore a room of the minimum dimensions will more than accommodate the nurse also. The walls and ceiling both should be glazed so as to permit of fre- quent washing and painted in some solid color. Probably light green HALL Fig. 1. — Ground plan of postoperative room, anteroom, and sun parlor. A, Small bedside table for patient; B, foot stool; C, small stand for nurse; D, straight- back chair for nurse; /:'. rocking chair; F, push button for signaling nurse (note the reading light at the head of the bed next to signal button); G, short straight-back chair in bath room. is the best since this is cheerful and at the same time most restful to the e} r e. Polished oak or pine which is easily kept clean makes the best floor. The heating should be uniform and of a kind which is least disturbing to the patient. No doubt the hot water system gives as much satisfaction as any. The general illumination of the room is besl secured by an inverted reflector hung fairly low from the middle of the ceiling, and con- trolled by a switch at the side of the door. A socket should be located near the floor for a portable electric reading light at the head of the bed, and another socket placed near the dresser, which can be utilized for a fan, heater, examination light or other convenience. The read- THE IDEAL OPERATING ROOM d ing light must be so placed as to be easily manipulated by the patient. In addition to this light, a signal cord is constantly kept within easy- reach at the head of the bed. Every modern hospital room should have telephone connection if desired. The furnishings should be as homelike as is compatible with modern hospital ideas. White enameled iron bedstead (Figs. 3 and 4) and mahogany furniture are very attractive. Such furniture requires frequent cleaning in order to look presentable, and this is an added factor of safety to the patient. A small rug here and there, which Fig. 2. — An antislamming device used at the Mayo Clinic. can be easily taken out and cleaned daily, is all that is necessary for a floor covering. "White scrim sash curtains serve to detract from the bareness which is sometimes apparent in the ordinary hospital room. A bed which is 42 inches wide and 28 inches high from the floor to the top of the mattress gives satisfaction to the patient, though it is somewhat unhandy for the nurse at times. The kind of springs which I have found to give the least trouble from sagging in the middle, and thus causing backache, etc., and also the most easily cleaned and most durable, consists of chain and cross-chain lengths, with wire side line from each end of the bed and with spirals at the end of every separate chain (Fig. 6). The mattress (Fig. 4) that is probably the best for postoperative use 4 AFTER-TREATMEXT OF SURGICAL PATIENTS is one made of curled hair. Pillows for arm or leg rests also made of this material, are desirable, since their contents can be washed or sterilized if contaminated with blood, etc. The ordinary feather Fig. 3. — An iron bedstead used at the Mayo Clinic. The curtains are employed only where there are multiple beds in the same n Fig 4. — The ideal bed showing the mattress and the arrangement of bed clothes for the immediate reception of an unconscious postoperative patient. .J. Rubber sheet covered with linen sheet: B, sheet and two blankets rolled back; C, linen sheet covering whole bed; D, mattress; E. linen draw si pillow may he used for the head for the tirsi few days; however, il can be encased in a rubber slip | Pig. ."> if the requirements of the case so demand. THE IDEAL OPERATING ROOM A headrest (Fig. 6) may be built into the bed. or some homemade apparatus may suffice. The bed should be at least one foot away from the wall, since the air close to the wall is frequently stagnant. It should also be so situated that the foot is nearest the door, while Fig. 5. — Pillows and rubber slips Fig. 6. — A headrest built in. the side is parallel to the windows, which best enables the patient to see out. and at the same time, to escape the glare of a direct light, and any draught which this would ordinarily entail. By open- ing the transoms above the windows and doors a freely circulating 6 AFTER-TREATMENT OP SURGICAL PATIENTS atmosphere can be obtained without unnecessary exposure of the patient. In addition to the bed, a leather couch may be installed (if the size of the room permits) for the use of the nurse at night, or to allow the patient to rest during the day. A dresser with a large mirror is convenient. A small bedside table is very necessary for the immediate use of patient or nurse. A few vases capable of hold- ing long-stemmed flowers may be held in readiness. In rooms with the bath attached, every convenience is supplied for the toilet, but even in those not so equipped, a washbasin installed as a permanent fixture, or an ordinary washstand, is highly impor- tant. This is, however, separated from the rest of the room by a three-paneled screen with light green washable fillings. In most hospitals the largest rooms contain a spacious closet or wardrobe. This is a desirable asset, as many patients arc particular about their clothes and other belongings, and to know they can be properly cared for eases the mind. A large, comfortable rocking chair, and two straight back chairs, with one footstool, complete the furnishings of a most desirable room for the housing of a surgical patient. The above represents the absolutely ideal in its way, while, as a matter of course, the average surgical patient who makes a satis- factory recovery does so amid surroundings which are comparatively inexpensive and unostentatious. CHAPTER II RECORDS AND CHARTS By Willard Bartlett, St. Louis, Mo. A graphic record, properly made out, especial attention being paid to the plotting of the various curves, enables the surgeon to orient himself more readily on the occasion of a visit, than is possible by any other means. Herein lies the chief value of hospital records from the standpoint of the patient. If this is a matter of importance for a single day, it becomes doubly so when a complication arises and the record of today must be compared with those that have preceded it. Accurate records are of undoubted value in that they keep those who make them up to the mark. It is quite reasonable to think that the most useful records are made by the most observing physician or nurse, hence they assume importance when viewed as a part of our armamentarium which is used for purposes of instruction. One has only to mention the possibilities in the way of medicolegal value of accurate and legible records. In no other manner can a surgeon so definitely substantiate his impressions and statements as by referring to them. They have a further indirect value in this connection, as tending to show that painstaking care was exercised even though the result may not have been all that the patient could have desired. Charts and records will vary in kind with the amount and scope of the work undertaken by the individual. It is quite obvious that the clinic which confines itself to private surgical practice will de- velop needs different from those of a teaching clinic which is con- ducted in the interest of medical students or postgraduate physicians ; while the training of pupil nurses is also a factor to be considered, and the appearance of a chart will depend to no slight extent upon their native intelligence as well as upon their previous scholastic training. I submit herein a number of sample charts which have developed in my own work, without assuming that they will perfectly meet the wants of every surgeon, but because I have found them exceedingly useful and hope that they may offer suggestions which will help the reader to develop a system which may exactly fulfill his own needs. It is logical to suppose that the postoperative record of a case com- mences in the operating room just as soon as the wound has been 7 s AFTER-TREATMEXT OF SURGICAL PATIENTS closed. It is my custom to immediately dictate on the so-called Anesthesia Charts (Fig. 7) the findings and operations in the case un- der discussion. An assistant has previously filled out the headings and ANESTHESIA CHART r- s n ™ "\ 8I0M Pressure Lung - Casts Sugar Tiv I 1 HOUR X • ■ U u B ■ I i M :ia b;» » " »jb;»;s;«:< i k at eo l s. r. ■:»i II B B m B P Pulse R*§p •210-190 200-100 i9o.no 180.160 i:o-iso I60-H0-80— 110-130-70— HO- 120-60 - 1JO-I10-SO — 1K>- 100-40— 110— 90-30— 100— 80-tt — 90—70-10 — 80—60 70—50 ' -T ■-;■■■ FINDINGS AND OPERATIONS 7. — Record of patient's condition, findings, and operation. the anesthetist made observations during the time of operation which enable her to quickly plot pulse, respiration, and sometimes blood- pressure curves. There are many forms of chart used for this pur- RECORDS AND CHARTS pose but none seems to have found such extensive favor as the one presented. In a modern clinic one is accustomed to do several operations in a 1 | 3 A a 0<£ J J 2 : c c z 1 1 3 1 X o 5 I 1 1 C 1^ L °-3 1 C r X o en > — m o o 33 o 1 COMPLICATIONS H 1 JL 11 I! 1 V PULSE TEMPERATURE ID sassssssss 3S|82g2SS N r | i Fig. 8. — Postoperative orders. day, hence, it is obviously impossible to keep in mind, until ward rounds are made, all of the therapeutic suggestions which present themselves during the progress of the operation. I have, therefore, 10 AFTER-TREATMENT OF SURGICAL PATIENTS long been accustomed at the end of each operation to dictate on the Hospital Record (Fig. 8) in the lines especially set aside for that pur- pose; Orders after Operation. Where but two temperature, pulse, and SPECIAL HOSPITAL RECORD . • _ ^ -f "1 1070 2S00C 105 MOOD 1M' 22000 ior 20000 • ior itooo ioi itooo ISO 190 ,, ,» ,« ■» 110 1« 90 1» ■0 110 70 100 tO 90 l Fig. 9. — Chart for eight observations daily. respiration observations a day are indicated, this form of chart will be found remarkably satisfactory. The amount of effort devoted to the recording of important items is reduced to a minimum ; for Address- Occupation RECORDS AND CHARTS ADMISSION CHART 11 Medical No Single Married Widowed Nationality- FORMER OR SUBSEQUENT ADMISSIONS MED. NO. (Obverse Side.) TREATMENT CHART DATE MEDICINES TREATMENT DIET REMARKS - | 1 (Reverse Side.) Fig. 10. — Admission and treatment chart. (Courtesy Hospital Standard Publishing Co., Baltimore.) 12 AFTER-TREATMENT OF SURGICAL PATIENTS CLINICAL ANALYSIS SPUTUM ..« ™. .™.™=, ...... .LOO. *;«"" «»..«» STOMACH ANALYSIS „.,. .,.. „.„., „.„.„.. .„.„. '«"" 0.".OT ,!SSSV "ri c . loO0 -,cnoscoP,c.L STOOLS „.,. ...„., - — — r.r.v ,„, .«..«, BLOOD „.„ W...C .,.„o...,. c... Small Mononuclear Large Mononuclear Neutrophilia Eosinophils Baaophile Transit ioncl Myelocytes CLINICAL ANALYSIS i < (bverse Side.) WARD MEDICAL No. URINE „.„ •"- COLO. .„.„.. .P.O. .... ..... .=.,... .to.. .... «... «„,..., ..c.oscop.c.c Fig. 11. — Clinical postoperative laboratorj record. (Courtesy Hospital Standard Publishing Co., Baltimore.) ( Revei RECORDS AND CHARTS 13 instance, the scratch of a pen is sufficient for noting stool, passage of flatus, quantity vomited, total urine, change of dressing, removal of stitches, or the withdrawal of drains. Under complications, space is given for the insertion of the somewhat rare though extremely im- portant words — distention, sleep, pain, delirium, menstruation, hem- orrhage, discharge, unconsciousness, sweating, involuntary urination and defecation, etc. The reverse side of this sheet is ruled and at the top is printed Operator's Notes. Where more detailed observation, especially during inflammatory processes, is indicated, I maintain what is termed a Special Hospital Record (Fig. 9) which permits curves to be plotted, showing rise or fall in temperature, pulse, leucocytes, and blood pressure every three hours. I have not maintained for several years the old-fash- OFFICE VISITS Address Fig. 12. — Record of posthospital examinations of simple nature. ioned bedside notes, which were once so universally used. If fur- ther information is deemed of value I would suggest a so-called Treatment Chart (Fig. 10) which allows the recording of medicines, treatment, and diet, along with a column for remarks which can not be classified. There are many cases involving the gastroenteric tract either di- rectly or indirectly in which the surgeon can keep his bearings only by the use of an Intake and Output Chart. It is especially true where there are grave nutritional changes or in obstruction of the bowels, or where peritonitis prohibits the use of the intestinal tract for the disposal of fluids which must then reach the circulation in some other manner. 14 AFTER-TREATMENT OF SURGICAL PATIENTS It is desirable in not a few instances to make repeated examina- tions of the urine which can, I think, be of the greatest possible value only if recorded on some form of chart similar to the one entitled Clinical Analysis (Urine) (Fig. 11). A comparison of results is thus much more easily possible than if the most painstaking investiga- tions are recorded on separate sheets of paper. In private practice I record every observation of the patient sub- sequent to his leaving the hospital upon a rather convenient card entitled Office Visits (Fig. 12). Three months from the day of the operation, and again twelve months from the same date, the patient receives a letter asking detailed information about his condition and is urged at the same time to write us any questions which may have arisen in his own mind. Every reply to these epistles, as well as all other communications in reference to a certain individual, is kept in a folio devoted to his history and hospital records. Surely no clinical record can be considered complete when the patient leaves the hospital, hence the value of some kind of follow-up sys- tem is now impressing itself more and more in many of our leading hospitals. CHAPTER III PRELIMINARY CONSIDERATIONS AND ANESTHESIA By 0. F. MeKittrick, St. Louis, Mo. The outcome of the postoperative course depends so much upon the proper selection, examination, and handling of the prospective opera- tive patient that we are forced to discuss several problems the correct solution of which is essential to successful work in this field. Con- stant and studious attention to this phase of surgery has done more to eliminate the complications which may arise later than has any other one thing at the disposal of the man in whose charge the patient is placed after the operation. In ''pulling through" the supposedly hopeless cases, by efficient and painstaking after-care, one is impressed by the prompt reaction exhibited in some cases, while in others, all efforts are seemingly of no avail. In every instance where interest in the welfare of the patient has incited sufficient attention to preliminary considerations, uncalled for and unnecessary complications are avoided, which, un- fortunately, are often seen in the patients not receiving these con- siderations. The selection of the patient to be operated necessarily rests, in pri- vate practice with the individual surgeon, and the error of having interfered surgically in an inoperable case, should always be con- sidered before the postoperative treatment is criticized. An examina- tion, independent of the surgical condition, must be made of the lungs, heart, and kidneys. For the busy surgeon, this usually con- sists in an ordinary physical examination as outlined by Cabot, 1 for instance. Other examinations, such as blood pressure, hemoglobin, and clotting time of the blood, are also desirable, and in many cases, imperative. The thoroughness and extent of the examination depends upon the condition of the individual patient. So also is the method of procedure influenced by the nature of the findings. Any abnormal- ities are rectified so far as possible, and the extent of the operative procedure determined. Old, debilitated patients are fed and given large amounts of water under the skin, if necessary. The excitable goiter patient is calmed as much as can be done by diligent care, rest, and medication, and the highly acid urine reduced by large quantities of alkalies, in addition to forced water. No patient, except 15 16 AFTER-TREATMENT OF SURGICAL PATIENTS in dire necessity, is operated in the presence of an acidosis. It fol- lows then, that a high blood pressure is reduced by proper rest and elimination, so long as no untoward results are obtained by so doing, and the diastolic pressure remains relatively normal. It may be added that a hemoglobin below 30 per cent was considered by Miku- licz 2 as being unsafe for a general anesthetic, while Keen,' Da Costa and Kalteyer 4 would consider 50 per cent as the lowest limit. It has been shown repeatedly that ether narcosis produces a decrease in the hemoglobin,"' and this fact alone is sufficient to force pains- taking consideration of the anemic patient. It has also been de- termined that the resistance of the body to bacterial invasion is lowered in that ether decreases the phagocytic power of the blood. Therefore, operations on patients with lowered vitality are deferred as long as the surgical condition will permit, and medical treatment is given to increase the general strength. The successful preliminary handling of the individual about to undergo an operation is not always an easy task. The general prepara- tion for individual eases can not be gone into here, but in the main, it may he said that those patients whose physical findings do not warrant special measures are sent to the hospital the morning of the day before the operation. On admittance they are given a warm tub hath, and provided with a gown which opens down the front and is made of heavy or Light material, depending on the kind usually worn by the patient, as well as upon the season. Cathartics are no longer employed indiscriminately, but the bowels are moved before bedtime hy enema as a rule. A pitcher of water is placed beside the lied, and about one glassful is ordered for every waking hour, and in addition, an extra one to he taken an hour before the operation. The tield of operation is prepared and those who are strong enough and desire to do so are allowed 1o sit up out of bed, so as not to decrease the chances for a good night. If accessary, veronal. 5 to 15 grains, is given in a glass of hot milk at the evening meal. The evening meal is light and consists chiefly of carbohydrates. It may he advisa- ble to employ aspirin, 10 grains, and codeine, 1 grain, one hour be- fore bedtime if there is any pain oi general restlessness. In the morning the patient is rarely allowed out of bed, gets a light breakfast of rice or barley gruel (if the operation is not to be too early), and in rectal cases, an enema of soap snds is given. The patients that do not receive the usual hypodermic of morphine and atropine are allowed to walk to the operating room. At the .Mayo Clinic, where the preanesthetic is not often given, the patients, while waiting their turn to be operated, are ordinarily permitted to mix PRELIMINARY CONSIDERATIONS AND ANESTHESIA 17 freely in a room set aside for this purpose, and the importance of the coming ordeal is minimized by conversation with others. \Vhen the operation takes place before the middle of the morning and pre- anesthetic drugs are used, the patient is kept in bed, no breakfast being given, and is wheeled to the operating table. In either event, water is given freely to ivithin one hour of the operation. In giving preliminary medication we have followed out the ad- monitions of Gwathmey 6 that it should not be used — except in rare instances — in the "extremes of life (under seven or over seventy) ; acute or subacute nephritis ; a state of coma ; in cases where morphine is taken with distress or with disagreeable after-effects and especially in cases of idiosyncrasy; also in very weak and feeble patients and in those with respiratory affection." In such cases atropine alone may be given, % 50 to % o grain, thirty minutes to one hour before the operation, as a rule we employ no medication at all when we give no morphine. The administration of morphine Ys to Y± grain, combined with atropine, % 50 to Yioo grain, is not employed as a routine even in cases that do not fall within the scope outlined above. Such is given hypodermically in selected eases in whom its effects are par- ticularly desired. The good results obtained in such cases are due to the increase of confidence aroused in highly nervous or excitable patients, the lessened amount of ether required, and the decrease of mucous accumulation in the throat. The dose enables the patient to go to sleep quickly and easily, and in many instances allows him a more pleasant recovery from the anesthetic. Often in alcoholics or patients not going under ether normally, an additional hypodermic of morphine Ye grain is given after the anesthesia or the operation has been started. The objections to such medication in many cases should be sus- tained. Herb 7 states that "morphine allays the reflex excitability of the air passages, thus retarding coughing and favoring the re- tention of aspirated blood or vomitus in the trachea or bronchi, which predisposes to pneumonia. Many people are unable to take morphine without distress or vomiting and in such individuals the disagreeable after-effects of ether would be aggravated." She also notes that in cases of accident not only is the volatile and quickly re- movable poison ether to be eliminated, but also the nonvolatile mor- phine. She reminds those men who give atropine for the excessive mucus that the same can be easily taken care of if the head of the unconscious patient is turned to one side and it is allowed to run out at the angle of the mouth. 18 AFTER-TREATMENT OF SURGICAL PATIENTS The promiscuous giving of such medication, no doubt, is to be de- plored, yet the absolute denial in every case can not be countenanced. Sanders, 8 resident surgeon at St. Mary's Hospital, Rochester, Minn., stated that so far as he could see there was absolutely no difference in the results obtained by those operators there who never used preliminary medication and by those who used it routinely. The operation should be performed as early after 7 a.m. as is compatible with convenience. Such a procedure reduces to a mini- mum the results of the mental agitation which every patient under- goes to some extent. The factor, fear, plays a more important role than is commonly surmised. Gwathmey 6 states that over 70 per cent of cases require mental as well as medical treatment to insure the most satisfactory results. He further quotes Keen, 9 who says that "patients whose thoughts are made to run in pleasant channels as the anesthetic is first given usually take the drug more quickly than do those who inhale it in a condition of mental distress. This is par- ticularly true of nervous women and children. When the fears of a patient who is conscious are developed into the terrors of semicon- sciousness, in which the patient imagines the most frightful accidenfs are taking place, it can be readily understood that profound nervous shock is produced." Such a state of mind does not arise alone from the most serious operations but even those of a trivial nature may have the same effects. Often there is no outward sign of this mental state, and the patients may stoutly deny its presence until an ex- amination of the pulse alone reveals the condition. Children and nervous women are not the only sufferers from the fear of the anes- thetic. Strong and robust men are frequently to be added to the list. In this connection it may be added that among the cases re- ported in which death occurred as a result of such psychic stimula- tion, the majority were men. In this connection it may be instructive to recall Bloodgood's 10 case in whom fear of the anesthetic alone caused a fall in blood pressure from 140 to 80 mm. mercury in ten minutes. One of the most strik- ing examples, however, is a ease reported by Probyn-Williams." "A nervous boy nine years old, was plaeed on the operating table preparatory to removing his tonsils and adenoids. The mask was placed over his face and a relative held his hand. Suddenly and before a particle of the anesthetic was dropped on the mask, the patient began to breathe rapidly, drumming with his heels on the table, and saying 'I'm going.' The mask was taken off and at- tempts made to quiet him. but in a few moments he was dead. PRELIMINARY CONSIDERATIONS AND ANESTHESIA 19 Nothing was found to account for the phenomena except the fear which he had experienced." In view of such statistics no opportunity should be lost in en- deavoring to eliminate any mental disquietude which a patient under- goes during the preparation for even the simplest operation. Anesthesia at its best furnishes the only unpleasant recollection of the operation for many patients. A well-trained anesthetist can do considerable towards making the procedure more endurable and should in every instance be retained. He should become acquainted with the patient as soon as he is admitted to the hospital and every effort be made to gain his confidence and friendship. Such treatment will go a long way toward eliminating the fears and misgivings which arise in the mind of the patient as he waits in the hospital for his call to the operating room. During late years women anesthetists, usually trained nurses, have been employed in the largest clinics in this country and the practice has been upheld and even advocated by many of the latest writers. Personally I feel this a good practice, especially if she lives in the hospital and can see the patient frequently. She is more expert than a man in soothing the excited patient especially a female or child, and the male patients will brace up and become men in her presence. Nurses are sympathetic, gentle, quick to observe small details, and the love for the work which is a step higher than their chosen pro- fession urges them on to exhibit every feminine trait which is most serviceable to the individual about to pass through one of the most important periods of his life. During the operation itself she devotes her entire attention to the anesthetic while the lure of the surgical field does not exist for her. The operation, therefore, is watched just enough to inform her as to the amount of anesthetic to be given. Certainly if all women anesthetists were like Florence Henderson at the Mayo Clinic, no objection could be raised against them. On the other hand, a doctor, because of his training alone, has a certain ad- vantage over the nurse. Men who make this work a study and who have natural ability along this line, though rare, are certainly~the more desirable. They are not so apt to become confused in emer- gencies and are generally recognized as more stable than the woman whose physical makeup forces her disposition to be more or less uneven. Keen stated that "personality, intelligence, zeal, and quick wit may easily be worth more than greater knowledge, ' ' and suggests that a woman physician would be ideal. No doubt he is right, pro- vided such a physician as he mentioned could be procured, take for example, Dr. Isabel Herb of Be van's Clinic. However, the ambi- 20 AFTER-TREATMENT OF Sl'RGICAL PATIENTS tions of women doctors to become surgeons may cause them to use anesthesis as a "stepping stone" to surgery as Keen suggested, and thus defeat the xcvy purpose for which they are intended. The selec- tion like so many others of its kind in surgery must necessarily rest with the individual surgeon. The preliminary treatment having been carried out, the patient is brought to the operating room. The stomach and the bladder are empty. The mouth having previously been examined by a dentist and all loose, useless teeth removed, and the month cleansed repeat- edly with some month wash until the time set for the operation, the individual puts himself in the care of the anesthetist. He is now placed on a well-padded table and amply protected from chilling by sufficient covering as directed by tin- experl anesthetist. The posi- tion of the patient varies, of course, according to the operation. At all times it should he as natural and comfortable as possible, allow- ing. 13. — Position of patient on operating tabic showing restraining strap across lower limbs. ing free respiration and circulation. Now is the time to think of nerve injuries which may develop during the after-care and attempt to avoid them by placing the body and limbs so as to escape undue strain or pressure. The usual position is that as shown in the figure above. Backache is anticipated by placing a pillow under the dorsal curve of the spine before the anesthetic is started. A strap is finally placed over the limbs as shown in Fig. L3, and the anesthetic started. The choice of the anesthetic can not be discussed here but there are a few points which deserve attention. It has been found that in the vast majority of eases ether alone can be used with greater safety and efficiency than any other anesthetic or combination of them. In some instances gas and ether or gas alone has been employed. In most instances, however, where ether is not desirable, the local anesthesia makes a most excellent substitute. The details of the anesthesia (Fig. 14) are best described in special works on this subject, al- though a word along this line would not be amiss. Often a patient asks to see the surgeon at the last moment and wants a friend or relative near as lie is about to begin the inhalation PRELIMINARY CONSIDERATIONS AND ANESTHESIA 21 of the ether. In my opinion these simple requests should be indulged provided asepsis be not prejudiced thereby. Preliminary medication having been employed the patient is in a frame of mind to receive kindly admonitions and encouragement from the anesthetist who will not neglect to use all the powers of hypnotic suggestions he or she possesses, while ether is slowly dropped on the mask (that devised by Ferguson is preferred by me). It is the custom of some anesthetists to protect the eyes with a dumb-bell-shaped piece of gutta percha over which is placed a layer of wet gauze as advised by Fowler. 12 Others do not employ any cover- ing, stating that such will only cause ether fumes to remain in the Fig. 14. — A mask which is widely used for the administration of gas and ether combined. proximity of the eyes and thus cause irritation, when if they are left open, the air quickly carries the fumes away. In each case the anesthe- tist should use his own judgment. It is needless to say that all pre- cautions are taken to see that no foreign bodies are left in the mouth ; of course, false teeth, chewing gum, etc., are taken out. No unneces- sary noise or talking is allowed in the room while the patient is still conscious ; the patient gets the full benefit of anything said to him, and at no time is it allowable for him to be left alone for even a mo- ment. A table containing the mouth gag, tongue forceps, towels, ba- sin for unexpected vomiting, strips of gauze, and anesthetist's chart 22 AFTER-TREATMENT OF SURGICAL PATIENTS is placed within reach. As the patient goes under no one is allowed to restrain him or speak to him other than the anesthetist. How often have we seen a restraining hand during an otherwise uneventful anesthesia produce in the patient the wildest delirium, and in every instance the induction of narcosis was delayed! As soon as the patient is ready for the operation the head is turned to one side in order to facilitate the outflow of mucous and a strip of gauze slipped between the teeth and the cheek until one end reaches the last molar tooth, the other end hangs outside of the corner of the mouth. The gauze not only drains excessive fluids from the mouth, but also acts as a plug against Stenson's duct, and therefore inhibits to sonic extent the flow of saliva. During the etherization the Mood pressure is taken off and on if occasion demands it. As shown by Earner, 13 the blood pressure is of greater value in determining the condition of the patient than the rate and quality of the pulse and gives warning of danger five to twenty minutes earlier. Constant even anesthesia is naturally desired; viz., one which keeps the patient at all times well under, yet never in too great danger of respiratory failure. With well-trained teams one will notice the anesthetist stop giving ether when the rectum is being dilated or at such a time in the operation that the operator in putting in the skin stitches will frequently awaken a marked reaction, after which the patient can be half aroused by the time he is back in bed. Bibliography iCabot: Physical Diagnosis. -.Mikulicz: Quoted by Keen. Surgery. sKeen: Boston Med. and Surg, -lour., December, 1!»15. 4Da Costa and Kalteyer: Boston Med. and Sm*g. Jour., June, 1901. sHamburger and Ewing: .lour. Am. Med. Assn., November 8, 190S. eGwathmey: Anesthesia, 1914, p. 373. 7Herb: .'lour. Am. Med. Assn., May (i, 1911. sSanders: Personal communications. sKeen: Surgery, L906, v, 12. loBloodgood: Progr. Med., December, L912. uProbyn- Williams: Clin. .lour.. December 22, L918. i-Fowler: The Operating Room ami the Patient, L913, p. 140. isHarncr: Quoted by Keen. Surgery. The following was also consulted: Graham: Jour. Am. Med. Assn., March 26, 1910. CHAPTER IV FROM TABLE TO BED By 0. F. McKittrick, St. Louis, Mo. Immediately after the operation and during the time the final dres- sings are being placed by the surgeon, the restraint straps are taken off the patient and all blood and perspiration quickly removed from the surface of his body and his gown replaced by one which has been in contact with a radiator throughout the operation. In the meantime the soiled linen in immediate contact with the patient and covering the operating table is pulled from under him and replaced by warm dry, clean sheets. A small blanket being hastily thrown over him, he is gently lifted by two or three assistants and placed upon a stretcher bed, mounted on a four-wheeled cart. In preparing to lift the patient care is taken to first gently roll him towards the assistants, in order that he may be supported by their arms rather than by their forearms. Otherwise too great pressure will be exerted here and there by their hands, which may cause areas of soreness or other discomfort to develop later. Any unnecessary pulling or jerking of the patient must be avoided as such treatment predisposes to vomiting in the semiconscious indi- vidual. Also the horizontal position is to be maintained if possible. Sudden elevation of the head will then be avoided and the danger of syncope very much lessened. It may be well to add here that if, for any reason, it is necessary to carry the patient to the bed, the head of the stretcher is not elevated and in going upstairs the foot is taken first while in going down stairs the 7; ead goes first. One of the best methods employed to remove a patient from the operating table is that which utilizes two long poles which support two pieces of heavy canvas (Fig. 15). These are placed beforehand on the operating table and protected with a rubber sheeting which is then covered by the regular linen sheet. The patient then lies indirectly upon the canvas supports during the operative procedure. The piece used for the upper portion of the body is twenty-seven inches long, twenty-seven inches wide and contains on either side two separate spaces which will allow a large pole, one and one-half inches in diameter, to pass through. The outside space is used for large patients, and the inner space for smaller individuals. The other 23 24 AFTER-TREATMENT OF SURGICAL PATIENTS piece is thirty inches in length, being twenty-seven inches at the top and twenty-three inches at the bottom. It also contains the spaces for the lifting pole, as described for the larger piece. When the patient is ready for the stretcher, the poles, which are seven feet long, are slipped through the spaces prepared for them, one on each side of the patient, and he is easily lifted onto the stretcher by two assistants without danger of the slightest injury. The poles can then be slipped out or left in position and carried on the cart to the bed, where the process is repeated. The stretcher (Fig. 16) which receives the patient is prepared beforehand so that no time is lost in getting him ready for his ride to the bed. In consists of a mattress pad which completely covers Fig. IS. — A convenient way of transferring the patient from the operating room to the stretcher or ward carriage. the to]) of the cart. This mattress is two inches thick and is made of curled hair encased in rubber sheeting. Over this are placed two double half blankets, one within the other, so that the blanket which covers the mattress also covers the middle blanket. This second blanket and the upper half of the first blanket are folded back upon themselves and kept in readiness at the toot of the stretcher. Two towels present themselves, one in the center and the other at the head of the stretcher, for the protection of the bottom blanket from the vomiting, perspiring, or bleeding patient. Over the center towel is placed a binder, or a binder with a T-strap attached and opened FROM TABLE TO BED 25 out ready for use in those cases which require these assets. At the corner, near the head, two other towels are retained for instant de- mand. A pillow is unnecessary. The patient having been laid on the stretcher, the operating room blanket which accompanied him from the table is discarded and the roll of blankets at the foot of the stretcher quickly brought over him. The binder is now fastened over the surgical dressing around the ab- domen and pinned with safety pins, the slack on the sides being obliterated by these same means. The blankets are tucked around him, the cranium and face covered down to the nose with one towel, the chin and neck with the other, and the journey to the room is commenced. A recovery room is very desirable. Instances of postoperative pneumonia and other lung complications are more often seen in pa- Fig. 16. — Ward carriage ready to receive patient from operating table. A, Towels folded back for instant use; B, towel; C, blankets; D, towel; B, binder (usually with T -strap) ; F, blanket; G, linen sheet; H, rubber sheet covering mattress; I, blankets. tients who are wheeled through a long corridor, while those not thus exposed more often escape. However, I consider that most hospitals do not have this luxury, and therefore think of the patient as de- prived of its benefits. On arriving at the room, the foot of the cart is pushed next to the foot of the bed, if the poles have been retained (Fig. 17 A) and are to be employed in lifting the patient from the cart. The procedure is not very practical unless the head of the bed is low and the stretcher carriers can stand at the head and foot of the bed, re- spectively, while placing the patient in bed. If this method is not considered and the patient is to be lifted from the cart and then placed into bed, the head of the cart must first be placed next to the foot of the bed (Fig. 17B). The orderlies, standing between the bed and the stretcher, then lift him as before, simply turn- ing around with the patient during the procedure of putting him to 26 AFTER-TREATMEXT OF SURGICAL PATIENTS bed. It should be impressed upon those handling such individuals to bear in mind that inconsiderate holds and rough handling may cost the patient many days of suffering from bruised muscles or strained Fig. 17A. — Patient just returned from the operation. Apparatus shown in Fig. 15 was used as described on the preceding page. Poles are withdrawn in the direction of the arrows. Fig. 17B. — Position of patient prior to being lifted into bed as described in the text. Head and feet will travel in the direction of the arrows during the maneuver. ligaments. This is at no time a procedure requiring so much haste that proper attention can not be exercised in giving firm and careful support to the unconscious human load as it is placed (not dropped) upon the bed. CHAPTER V IMMEDIATE EFFECTS OF ANESTHESIA AND OPERATION By 0. F. McKittrick, St. Louis, Mo. The immediate dangers and attendant results of anesthesia or operation or both, can not be lightly passed over without some word of comment, since later complications which arise in the after-care can often be attributed to unusual happenings during the time the patient was in the operating room or immediately thereafter. In such instances the two great systems which chiefly concern us most are the respiratory and the circulatory. Respiratory difficulties may be due, according to Probyn-Williams, 1 "to local or central causes. Of the former, obstruction to breathing may arise as a re- sult of the lips and cheeks falling together during inspiration espe- cially noted in the aged without teeth. The tongue, large tonsils or adenoids may also cause serious impairment to the ingress of air. Anatomic abnormalities, inflammatory swellings in the mouth, nose, larynx, trachea, or bronchi, must always be considered when trouble presents itself and preparations undertaken to overcome them by the use of the nasal tubes, intrapharyngeal tubes or in particularly se- rious cases, intratracheal anesthesia." "The first half hour is the period of greatest danger," says Keen, and during this time the anesthetist will have decided on the method best to be used and have it employed by the time the surgeon is called. Difficult respiration often occurs from inspired vomitus or blood. I have seen it repeatedly in patients who, because of the urgency of their operation, could not be properly prepared for the operation, and even in a few patients who were prepared. On one occasion com- plete closure of the larynx occurred from inspiration of an adenoid which had just been cut off and the life of the patient was saved by quick dislodgment of it. Another patient, not so fortunate as was told me, was choked to death by a gauze pack which had slipped out of a cavity communicating with the mouth and following ether- ization suddenly plugged the larynx. Mucus becomes troublesome at times. It alone has caused serious obstruction to free ingress and egress of air, and, in fact, it is a com- mon factor which presents itself during this period. Frequently I have seen an excessive amount occurring even in patients given 27 28 IMMEDIATE EFFECTS OF ANESTHESIA AND OPERATION the preliminary atropine, which tends to decrease its production. Keen tells of three of his patients who almost drowned by the sud- den "inundation of mucus." His first was a boy three or four years old who, after the operation began, started "loud bubbling respira- tion" and became cyanotic without definite cause. He was at once turned upside down by holding bis heels and "frothy watery mu- cus poured in a stream from his nose and mouth." The operation was then continued successfully. His two other cases were adults whose lives were saved by resorting to similar measures. In the former instance a man was placed head downwards by the anes- thetist mounting the operating table and holding him up by the legs while in the latter case the Trendelenburg position was utilized by elevating the foot of the operating table. Keen's treatment of these cases is certainly worthy of remembrance, and may be applied in the early postoperative period. Fowler states that such accidents result from too rapid adminis- tration of ether. Certainly any acute inflammatory condition of the nasal passages will tend to increa e the flow of mucus, hence if for no other reason, a general anesthetic should not be given in such cases. Another local cause for obstructed respiration is spasm of laryn- geal muscles which causes a closure of the superior aperture of the larynx. Buxton 2 states this is especially apt to occur in inflam- matory states of the mucous membrane. The canst 1 of the condition may he due to the irritating ether or some foreign body or bodies coming in contact with the sensitive mucous membrane or due to reflex action incited by operation procedures on other parts of the body. 1 It should he noted also that difficult respiration occurs not infre- quently from faulty position of the patient on the operating table, from assistants leaning on the patient, too tight bandaging of the chest or pleural exudates and that an increase in intraabdominal contents such as large tumors, ascites, etc.. at times are very serious impediments to the free use of the chest ami consequenl perfect aeration of the lungs. The central cause of respiratory failure is due to direct affection of the respiratory center in the medulla, whether it be a part of a general break-down of the circulation from shock or from loss of blood does not materially matter, since the treatment in either event will he much the same. The general treatment of respiratory disorders consists first in se- curing a free air passage for the patient. This is best accomplished IMMEDIATE EFFECTS OF ANESTHESIA AND OPERATION 29 by one who is acquainted with any abnormalities the patient may have before the anesthetic was started. If none exists, the condition may have arisen from some foreign body which can be quickly re- moved. Simply holding up the jaw may be all that is necessary, and occasionally the tongue may have to be pulled forward with a piece of gauze wrapped around the finger. If the breathing has stopped and the patient is becoming cyanotic, the mouth is forced open with the gag. the epiglottis is lifted by the finger, and rhyth- mical traction on the tongue is started. There may be some difficulty in securing the tongue. In such instances rhythmical tractions on the neck will have the same effect. The head is grasped from be- hind and the neck is stretched backward and forward twenty to thirty times per minute. 3 If the patient does not quickly respond to this treatment Sylvester's method is at once resorted to. This con- sists principally in increasing the dimensions of the chest by rais- ing and lowering the arms. The head is lowered and the arms are first pulled forwards, which causes forced inspiration. The arms are now brought clown to the sides, being flexed as they descend, the elbows finally to be utilized in compressing the chest. The maneuver is repeated 18 to 20 times a minute. If there are sufficient as- sistants, the rhythmic traction on the tongue may be employed as well as pressure on the abdomen at the time the elbows are being com- pressed against the chest walls. If the respiratory failure is due to obstruction by some foreign substance, the patient is at once inverted as suggested by Keen. 7 and in addition, direct effort put forth to free the passages from the ob- struction. If the patient is an adult and the Trendelenburg position can not be obtained immediately SehaeferV method may be em- ployed. This consists principally in placing the patient on his belly and rhythmically compressing the lowest ribs. If enough force is ex- erted the patient's abdomen may also be forced against the table which will help to expel the air from the lungs. The process is re- peated about sixteen times a minute. In the presence of such an accident, unnecessary haste is to be condemned. Deliberate and accurate movements over a long period of time will accomplish more than hasty and incomplete attempts to contract and expand the chest. One should not give up too soon, for normal respiration has been established after complete cessation of respiration for more than one hour. 1 If there is any reason to fear that the air is not getting into the lungs from the efforts exerted, a tracheotomy should be unhesitat- ingly carried out. The head being drawn backwards, so as to put 30 AFTER-TREATMEXT OF SURGICAL PATIENTS the throat on stretch, the trachea is secured with the left thumb and finger and an incision starting just below the cricoid cartilage is made one and one-half inches long and extending to the depth of the trachea itself at the first stroke of the knife. About three tracheal rings are now severed, this last incision starting from the bottom of the wound and extending upwards towards the chin. A tracheal cannula is then inserted and tied in place by passing the attached tapes around the neck. Circuhitor}j failure during or after anesthesia may occur suddenly, when it is called syncope, or it occurs as a gradual drain on the re- sisting powers of the organism and appears as shock or hemorrhage. The former coin lit ion was formerly more often seen when chloro- form was extensively used. It appeared in apparently well and robust as well as in weak and sickly patients. Syncope, or sudden paralysis of the heart due to reflex inhibition 5 of this organ, is pro- duced most often during the early stages of the anesthesia, and the deaths occurring before any anesthetic was given were probably due to this affection alone. It is seen after the handling of the ab- dominal viscm or manipulation of the main vessels of the neck. The condition has occurred immediately after the patient is sud- denly raised from the prone position. In most instances myocar- dial rather than valvular lesions are found at autopsy. Henderson 6 states that in a large percentage of cases occurring during ether anesthesia the condition is due to unskilful administration, and es- pecially "it is the sequel of light anesthesia." He thinks the effects are produced by a state of "acapnia resulting from excessive pul- monary ventilation during the stage of excitement." The treatment consists in first stopping the ether, lowering the head, raising the feet, and administering artificial respiration. If the abdomen is already open direct massage of the heart is carried out. The limbs are bandaged witli cotton batting and the head is kept lowered until the patient reacts to the treatment. It may be necessary to give intravenous physiologic saline with a few drops of 1:1000 epinephrin as advised by Sajous. 7 Venesection is carried out for engorgement of the right heart. Vomiting is anticipated in very nervous individuals or in those patients who have not received proper preoperative care or lavage on the table. Lavage is indispensable if blood has run into the stom- ach from a wound in that viscus or anywhere higher up in the di- gestive tract. It becomes of life-saving importance after any opera- tive procedure for the relief of intestinal obstruction. It occasion- ally happens after ether anesthesia that the patient vomits before IMMEDIATE EFFECTS OF ANESTHESIA AND OPERATION 31 he is fully conscious and is off the table. In such cases the head is lowered to prevent by simple down-hill flow possible suction of the vomitus into the trachea. If this is not practical, the head is twisted well to one side and the body lifted over so that the vomitus will run out of the mouth if the expulsive effort of the patient is not sufficient to force it out. Vomiting at this stage is particularly dangerous be- cause of the possibility of respiratory obstruction and inspiration pneumonia. After reflexes have been reestablished, these dangers no longer exist. The early vomited material is thin, watery, and chiefly saliva which has been swallowed during the early stages of the anesthesia. Later on some of the mucus, which is generated by the ether, finds its way into the stomach. Bile is added from the intestines in some cases while the operative procedure goes on, while in others blood from a wound high in the digestive tract may be admixed. In such cases the mouth and throat are first freed of all vomited matter be- fore lavage is attempted, while in the other instances the stomach tube is inserted without further delay. Ordinary tap water is used, since cool water is sufficient to stim- ulate the partially paralyzed musculature and therefore aids the or- gan in expelling any undesirable contents. Care is taken that as much fluid returns as is put into the stomach to avoid acute dilata- tion. Those cases of shock and hemorrhage which require intravenous medication, hypodermoclysis or supportive enemas while on the table, or immediately thereafter, are considered under appropriate special chapters. The bed into which the patient is deposited was previously made up and warmed with hot-water bottles throughout the period the operation was in progress. In preparing a bed which will give the quickest and best service to these patients, it may be stated that it is made up in the ordinary way with the sheet covering the mattress, and a sheet, blanket, and counterpane, in order of their mention, over this. In addition, how- ever, two rubber drawsheets are placed next to the mattress, one at the head and the other at the center of the bed. Between the two sheets a single blanket is placed which is covered at its upper portion by an ordinary linen drawsheet. The hot-water bottles are placed beneath this blanket, and the sheet, blanket,- and counterpane are rolled back to the side of the bed. As soon as the patient is put to bed, the cover is rolled over him and tucked in at the foot, without loss of time or unnecessary exposure. The hot-water bottles are re- 32 AFTER-TREATMENT OP SURGICAL PATIENTS moved just before the patient is placed into bed, to be used again as often as desired. A newer method, but one not so well liked by me, is similar to that above, but lias a linen drawsheet in place of tbe single blanket, and the top covers, being already tucked at the foot of the bed, are rolled back and retained in position here. When the patient comes, all that is necessary then is to pull the covers over him. This hist method is advocated in some of the latest teachings, as the draw- sheet is much easier slipped from under a perspiring and helpless patient than is the blanket. Since the operative case for the first Hew hours often requires a change of bed linen from perspiration, etc., the drawsheet is probably the best, though for those cases in shock, or those operated late in the afternoon, I would not discard the blanket. The anesthetist (Fig. L8) should not desert the patient during the transfer from the operating table to the bed <>r immediately there- after. The mouth is kept free of m ileus, and the jaw pulled forward if necessary to mantain a clear passageway to the larynx, and a basin is kept handy for any emergency. When signs of conscious- ness return and the pulse and respiration are satisfactory, the pa- tient is safely consigned to the care of the nurse. The position of tin patient in bed will depend upon the nature of the operation. In those cases developing considerable mucus during the etherization, and where it is particularly desired to drain the bronchial tree, the ventral position is by far the best 1 have tried. A pillow is placed under the thorax, which allows the head to rest on a lower plane than the chest, and being turned sideways encour- ages, not only \'vcc drainage of mucus, but also the tongue falling to one side gives i'vce and open passage for the air. The diaphragm is not hampered except in the very obese or the aged. Such do not take kindly to this posture, and these individuals are turned on the side, a bedrest or pillow supporting them in this position. The su- pine posture, which is so commonly seen, is not desired if for no other reason than that mucus accumulates in the throat and lungs to such an extent thai frequently the patient passes through many hard days getting rid of it, to say nothing of hypostases. In such patients also I have found it extremely helpful to start inhalations of steam even before the individual is fully awake from the anesthetic. Such will materially assist in the early removal of the accumulated secretions and thus prevent in many cases pul- monary complications. IMMEDIATE EFFECTS OF ANESTHESIA AND OPERATION 66 "Ether is eliminated unchanged chiefly by way of the lungs and very slightly through the kidneys and skin. 6 ,7 With this in view it is particularly important in addition to keeping the air passages free to also see that the air in the room is pure and of even temperature. Usually 68° is found very desirable for all purposes." The recovery from the anesthetic is commonly accompanied by more or less delirium and restlessness. In some cases the patient is excitable ' and noisy, very talkative and thrashes about aimlessly and often his movements are most violent. He should not be restrained at first, but attempts should be made to attract his attention in an effort to persuade him to be quiet. In the meantime the parts of his Fig. 18. — A convenient method of washing an eye which has been irritated during anesthesia. body which have become exposed to the cold as a result of his move- ments are covered, and special precaution taken to prevent unnecessary chilling. In the majority of cases even after the initial delirium has passed and the patient is conscious he will exhibit considerable rest- lessness. By careful observation one is frequently able to determine the cause and at once correct it to the patient's satisfaction. It may be due to concern as to the outcome of the operation or to mental distress previous to the etherization. The reassurance of a kind, attentive nurse will do more to alleviate the restlessness of a patient who is not in pain than will most drugs. The changing of the posi- tion or the moving of a limb, acceding to the wishes of the patient concerning his comfort as to bed clothes, loosening a tight bandage, washing his mouth, placing a pillow under his back, readjusting 34 AFTER-TREATMENT OP SURGICAL PATIENTS those under his shoulders or head, and many other measures carried out even though many are to satisfy childish wishes, arc the en- deavors which satisfy his desire for comfort. If, in spite of every effort to comfort him, the patient becomes worse, he is restrained by assistants just enough to prevent him from becoming chilled from exposure, from injuring himself or others, or doing any damage to his surroundings. In some instances (when short of help) it become-; necessary to put a restraining sheet over his body, but at no time should the minor movements of bis limbs be restricted, as this particularly makes the patient more un- tractable. In these cases it becomes necessary to give morphine un- til quiet is secured. After the effects of this drug wear off, as a gen- eral rule, patients wake up docile and in their right senses. Some of our modern operators do not give a preanesthetic drug, reserving such medication until this period when small doses are continued over short periods of time until the patient is asleep and has passed a comfortable night. Whether medication is utilized for the condition or not it is very important to keep the patient undisturbed by noise; the window- blinds are to be pulled down, the room darkened, and the patient not allowed to talk, but told to go to sleep. Visiting in this early period is prohibited, and so long as the general condition is satis- factory the patient is not disturbed under any circumstances. Kestlessness due to causes other than the anesthesia, such as pain, hemorrhage, shock, etc., is treated under the respective headings. I believe most of the restlessness which in earlier times could not be explained by something in the patient's condition was the result of acid intoxication and should have been treated by earlier feeding. morphine, alkalies, much water, etc. Eowever, in every case this possibility is considered, and in the proctoclysis which is started as soon as the patient comes from the operating room in the work of some surgeons, a five per cent glucose solution in plain tap water is administered. In addition a teaspoonful of sodium bicarbonate is placed in each pint of proctoclysis water for the first twenty-four hours. Sweating is a common occurrence in patients just after operation. Ether in itself dilates the superficial capillaries and the resulting perspiration all over the body during a shorl anesthesia in healthy in- dividuals dues nut cause alarm. However, extensive sweating through- out and after a long and tedious operation is noted with concern even in the most rugged as it is weakening to the patient and often a definite sign of shock, hemorrhage, etc. In the latter instances it IMMEDIATE EFFECTS OF ANESTHESIA AND OPERATION 35 is more or less cold and clammy and has an altogether different meaning from the usual perspiration. In any case where the pa- tient is allowed to sweat profusely the danger of chilling with its subsequent effects is increased and should not be allowed over any length of time, even in the operating room, much less after he returns to bed. In such patients measures are taken to relieve the condition first by avoiding tco much cover after the body has been wiped dry and in some instances atropine hypodermically is employed with good results. In every case the general condition of the patient must be considered and treatment carried out to elimi- nate, if possible, the existing difficulty, such as hemorrhage, shock, etc. Sweating is often prolonged and intensified by the injudicious use of too many oed covers, especially in hot weather. A nurse fre- quently follows out some routine when common sense dictates that she be guided by the amount of moisture on the patient's skin. It has not been uncommon in my experience to find a patient who is only half awake vainly endeavoring to free himself from perspira- tion-soaked linen while his attendant readjusts the blankets with misdirected zeal. Bibliography iProbyn-Williams : Anesthetics, 1901, p. 36. 2Buxton: Anesthetics, 1900, ed. 3, p. 140. ^DePage: Jour, de chir. et. Ann. de la Soe. Beige de ehir., January, 1904. 4Schaefer: Jour. Am. Med. Assn., 1908, li, 801. sEmbley: Brit. Med. Jour., April, 1902. 6 Henderson: Surg., Gynec. and Obst., August, 1911. 7 Sajous: Analytic Cyclopedia of Practical Medicines, 1916, iv, 668. CHAPTER VI EARLIEST SUBJECTIVE MANIFESTATIONS By <). P. McKittrick, St. Louis, Mo. Pain. — One of the first eomplaints made by the postoperative patient on returning to consciousness is pain. This if due to the actual operative procedure should be at once relieved. William J. Mayo taught us long ago to give morphine during the first twenty- four hours for the pain which we make; viz., by cutting, retracting, suturing, etc. The discomfort caused by such procedures is re- lieved best by this drug and it is given by us if there be no contra- indications for its use, regardless of the amount until full relief is experienced or its physiologic effects obtained. The respiration should be watched carefully in every case and if it b< mes less than 12 per minute the <\\'\\ the fact that at this period the patient has less to attract his attention EARLIEST SUBJECTIVE MANIFESTATIONS 39 so that he can therefore center upon himself, or because his senses are more acute at this time, it is difficult to say. Certain complicat- ing lesions we know, are more painful at night, particularly those affecting bone or clue to syphilis. It is well at any rate to bear this fact in mind and to see that such patients are cared for at this time. Any sudden changes in the weather, especially from good to bad, will often elicit aches and pains which can not be otherwise ac- counted for. Pain in the female is much better borne than that in the male. It has been said that response to painful stimulation of all kinds is much more sluggish in them than in the opposite sex. The matter deserves particular attention and it is naturally to be ex- pected that our male brothers will be more or less sensitive on this subject. The second postoperative day should require less anodynes than the first. Rarely is it necessary in this period to give morphine at all except in very small doses and most commonly codeine with as- pirin will suffice for any ordinary discomfort the patient has. As- pirin is given in 5- to 10-grain doses with y 2 to 1 grain of codeine. Suppositories of 1 to 2 grains of opium are very efficacious in pain from operative procedures about the pelvis. These are not needed long and soon the simpler and decidedly less harmful drugs will allay any pain or discomfort that may arise. Thirst. — Thirst, which is of common occurrence after a general anesthetic, can to a great extent be prevented by allowing the pa- tient to drink liberal quantities of water up to an hour before the operation, when I insist on one glassful being taken. This matter must have careful attention, since many unthinking nurses still send all patients to the operating room dehydrated. It is particularly unfortunate that such should be the case since the cause of the thirst in the first place is in great part due to loss of the body fluid through preoperative purgation or to increased urination in some cases from sheer nervousness ; while the sweating, increased mucus secretion, or loss of blood during the operation adds to the dehydration. Finally, the postoperative vomiting with the attendant after-effects of ether together with those of morphine and atropine which inhibit the mu- cus secretion and thereby increase the dryness of the oral mucous membranes, increases the torture from prolonged thirst. Formerly all fluids per mouth were prohibited for the first twenty-four hours, it being considered that such measures would stimulate postoperative nausea and vomiting. Happily such an idea has been superseded by the more sane opinion that the demands of nature should be granted. Consequently, just as soon as the patient is awake his complaint of 40 AFTER-TREATMENT OF SURGICAL PATIENTS thirst is immediately met by giving sips of hot water for the first few hours. The taste of the ether and the sticky mucus and saliva are cleared out of the mouth by allowing the patient to rinse it with equal parts of rose water and glycerin or to this may be added a little lemon juice. If he is unable to do this himself the nurse can swab his mouth out with equal parts of glycerin and 4 per cent boric acid solution. Sometimes a little weak tea is better than the plain water in allaying the immediate effects of the condition. Very soon the hot water can be replaced by cool water, but this given in moderate quantities. The continued use of water in very small amounts is not an especially good practice, as nausea and vomiting are invited and the irritating mucus in the stomach secreted during the operation is not washed out. Fairly liberal quantities of water, on the other hand, do not require so often disturbing the patient, more fluid is absorbed and if the patient vomits the quicker will the gastric mu- cous membrane be cleansed and the normal tone of the musculature again restored. I <■<■ water is severely condemned as a drink, neither should it he used to wash onl the month. In order to facilitate the taking of fluids, a bent ulass tube is placed in the glass | Pig. 19) and the liquid sucked into the mouth without it being necessary to raise the patient. In every case even though the preoperative preventive measures to relieve thirst have been carried out. this phase of the treatment must he considered if there has been a marked hiss of fluids during the operation; physiologic salt solution or distilled plain sterile water should 1h> poured into the abdominal cavity. IF this i> not practical an enema of plain water or hypodermoclysis should he administered on the table. As a routine before the patient is awake, slow proctoclysis of tap water is given by many alone or in conjunction with glucose suffi- cient to make a 5 per cent solution, and to this also at times is added sodium bicarbonate of the same strength. \i\ those urgently re- quiring larger amounts of water quickly, hypodermoclysis or even intravenous injections are employed. Unfortunately, however, the psychology of thirst definitely indicates the swallowing of fluid. Nausea and Vomiting.- Nausea, and often retching and vomit- ing, are particularly common after-effects of a general anesthetic. Usually the vomiting from ether takes place early during the period in which the patient is recovering as noted above, and frequently it is of such short duration that he is unconscious of its presence and does not remember it afterwards. However, not all patients are des- tined to such good fortune, and it is so common to see this conipli- EARLIEST SUBJECTIVE MANIFESTATIONS 41 cation for hours and even days continuously or intermittently that further discussion and attention must he given it. The causes for such a condition can often be traced to the method of ether administration, trauma produced by the surgeon, or un- necessary handling of the patient immediately after the anesthetic. Halperin 3 states "that there is more vomiting from five minutes of an irregular anesthesia than from one hour of an even one. Ex- cessive stimulation by hypodermic injections during anesthesia may be a contributing cause also." A protracted anesthesia and a long fatiguing operation during which extensive handling of the stomach and intestines has taken place certainly adds to the frequency of the Fig. 19. — A convenient scheme for the early administration of fluids. disturbance. Operations upon highly nervous patients or upon those with improperly prepared gastrointestinal tracts are commonly fol- lowed by protracted vomiting. Patients starved to excess without proper food compensation before operation develop an early acidosis (if this is not already present) and rarely fail to exhibit severe nausea and vomiting as a result of this complication alone. After the anesthetic any body movement tends to increase vomit- ing, and this should be borne in mind during the period of imme- diate recovery when the sufferer should be kept absolutely quiet in a dark room and prevented from talking. Nausea and vomiting may be caused by irritation of any periph- 42 AFTER-TREATMENT OF SURGICAL PATIENTS eral branch of the vagus nerve. Buxton says that when it arises "from cerebral or cerebellar conditions it may be due to the head having been kept at too low a level. Unless there is obvious ische- mia of the brain, prolonged depression of the head especially in plethoric persons will tend to produce postanesthetic sickness." Nausea and vomiting may be the result of renal complications such as uremia or the forerunner of some infectious disease such as pneumonia, etc., or may be manifestations of chronic alcoholism, nervous dyspepsia or an actual lesion in the gastrointestinal tract. Beginning peritonitis or intestinal obstruction may be an inciting cause. Reflex vomiting from pressure of drains, packs, headache, etc., can not be too lightly passed over. Treatment first consists, provided there be no specific contraindi- cation, in allowing a liberal quantity of water per mouth. This, as a rule, will be immediately returned, and with it the local irritating foreign substance, whether it be food taken before the anesthesia, or mucus, saliva, blood, etc., which have entered the stomach during the etherization, and not been returned during the initial vomiting on the table or during unconsciousness. The giving of sufficient water by month in these cases can not be too thoroughly impressed upon the timid person in charge of such a patient. One who has gone through it knows the torture of con- tinuing to retch after the stomach has been emptied. It is alle- viated only by allowing one to drink a glassful of warm or not too cool water. This is repeated as often as the patient vomits, care being taken, of course, that the stomach returns as much as it gets, since otherwise an acute dilatation may be caused. I learned a never-to-be-forgotten lesson in the days when no patient was given water for the first twenty-four hours. A woman who suffered particularly from nausea and retching managed to get her hands on a flower pot, which her nurse had just filled with water, and drank the turbid fluid with evident relief of symp- toms after vomiting once more. This suggested a self-evident thera- peutic procedure which has been followed ever since with highly gratifying results. Luke* reports an instance where a young woman drank the con- tents of a rubber hot water bottle "immediately after an ovariotomy, without any apparent discomfort or harm," and others have re- ported similar occurrences, a thing which has done more to advance the present humane treatment of these patients than any other one thing. In instances where it is not desirable to use the stomach lube and EAELIEST SUBJECTIVE MANIFESTATIONS 43 in those whose stomachs have been reasonably well washed by the procedure described above, medication may be resorted to. although not much is accomplished in this way. An ice bag or hot-water bag is placed over the epigastrium. In very nervous individuals a good placebo is the old-time mustard plaster placed over the pit of the stomach. Sodium bicarbonate in 20-grain closes in a little warm water or y i2 to ^§ § T - cocaine hydrochloride 5 may prove of value. A little champagne or ginger ale at times gives relief. Ferguson 6 uses liquid petrolatum which protects the mucous membrane of the stomach against any possible continued excretion of the ether by this viscus. This is considered by him better than olive oil which has been used in such cases, since the latter saponifies and is then ab- sorbed, thus causing a re-excretion, of the ether with its attendant effects. Olive oil. however, raises the resistance of the patient by stimulating phagocytosis according to this same author and it may be used per rectum in 6-ouiiee doses to good advantage. By far the best. and. in fact, the only reliable treatment for this condition, is gastric lavage. Its use on the operating table has already been mentioned. Its continued use after the patient is awake so long as there is any nausea or vomiting in those permitting its employment, can not be too greatly extolled. It is self-evident that some irritating substance must be present in the organ if the desired result is to be obtained. Often a carrying out of the pro- cedure not only relieves the actual distress . of the symptom itself, but also puts an end to the anxiety and restlessness which so com- monly are manifested by these sivfferers. Especially is this true i 1 those instances where the stomach has a tendency to dilate and be inactive. In the cases in which acute dilatation occurs unfortunately this symptom is less marked, the general appearance of the patient, the pulse rate, pain in this region, hiccough, and other less common symptoms being more in evidence. It is needless to say that gastric lavage under such circumstances is most urgently needed. In ad- dition a hypodermic of pituitrin (5 to 15 minims) is advisable. In carrying out this procedure one will always experience more or less difficulty with the patient. The fear of the tube and the dis- comforts it entails, especially in individuals who are unaccustomed to its use, are not to be treated with little concern. A knowledge of the condition of the heart and lungs is very necessary, and most of all, the confidence of the patient must be gained. The procedure should be explained and the results to be obtained discussed with the patient, and his cooperation secured before any attempt is made to introduce the tube. 44 AFTER-TREATMENT OF SURGICAL PATIENTS He is then raised slightly upon pillows, and if it is convenient, turned on his side. A rubber sheet is placed over the bed and around his neck, the sheet extending into a basin on the floor. A towel is kept handy for the operator and a small basin for the patient to spit into. In some very nervous individuals it is advisable to spray the pharynx with a 20 per cent solution of coeaine in order to allay the gagging during the passage of the tube. After one minute the co- caine is spit out and the spraying repeated in five minutes, as ad- vised by Ochsner, 7 permitting the patient to swallow a little of the saliva which will, to a certain extent, anesthetize the esophagus. Poi- soning by the medicine is prevented by the free expulsion of the saliva which accumulates in the mouth during the administration. In the majority of cases such measures are unnecessary, and, as a rule, the tube is inserted without any such elaborate preparation. The head of the patient is grasped l>y the operator, which maneuver not only supports it. but allows a more efficient manipulation of the tube. This instrumenl is now taken from a basin of ice where it Avas placed at the beginning of the procedure and the patient is asked to breathe through the nose and to give undivided at- tention to the admonitions of the operator who will ever insist that lie keep breathing through his nose. The tip of the tube is held by the operator's hand which has just been thoroughly washed (some use rubber gloves), and the other end held down by an assistant near the basin on the floor. The tube is now gently inserted (without lubrication — some use glycerin) straight back into the pharynx and then down the esophagus, the patient in the meantime being asked to swallow. Once in this organ the tube is pushed rapidly downwards until the white line on it is reached (depending on the length of the patient, of course). During the while the patient is being reassured by the operator and continually reminded that all he has to do is to breathe. The necessity of being patient and kind at this time ever though the individual suddenly pulls out the tube is to he impressed upon the operator, since once the patient hums lion- to lake the tube, no further difficulty need be experienced, and the impression made during the first insertion will usually be foremost when the pro- cedure becomes necessary again during the course of the treatment. The tube is now brought to the side o\' the month and held in posi- tion while an assistant fills the funnel of the tube with cool hydrant water and starts the siphonage. If there is any difficulty in getting the water to How, the tube is rotated and it is either pushed further in or pulled out. In some cases a Politzer bulb has been used, or an attached bulb is employed EARLIEST SUBJECTIVE MANIFESTATIONS 45 in sucking out the air, which maneuver will nearly always start the flow ; this tube integral with bulb, however, is not very practical and is not extensively used by me. As much fluid should be returned as is poured into the stomach; the flow is frequently started and kept up by allowing a funnelful to flow in, but before it becomes entirely empty lower it and then pour it full again, the maneuver being repeated until the fluid re- turns clear. It will be noted that the patient himself frequently holds the tube in place better than does any one else. With proper training and care with patients they very soon learn to help them- selves and become valuable aids to the operator. In such instances one person alone can wash any stomach. The stomach should be washed as often as the nausea or vomiting returns, each time washing until the fluid returns clear if it takes considerable water to accomplish this end, so long as the patient is not too exhausted. The tip of the tube should have more than one opening which will often prevent blockage either by contact with the stomach wall or by mucus. Kanavel 8 employs a special tube by means of which continu- ous gastric lavage can be instituted in the most intractable cases. I heartily concur in such a measure, as the strain of having the tube inserted is done away with. I have employed this method in a few cases, utilizing the ordinary stomach tube, but after a time even the most phlegmatic patient tires and begs to have the tube removed. Kanavel 's 8 tube is smaller and more suited for the purpose and should be tried in every intractable case, especially where the inser- tion of the tube is not an easy procedure. It has long been taught that anesthetics should not be given except in the presence of a third person. The reason for such teaching is supported by the symptoms exhibited at times in the postoperative patient. Dreams. — It is common knowledge that dreams occasionally occur during the anesthesia which are honestly believed long after the pa- tient has recovered. This affords a chance for blackmail or other unpleasant developments, hence measures taken to thwart such pos- sibilities are always carried out by the wide-awake operator. The delusions take the form, particularly in neurotic women, of an idea that a sexual advantage has been taken of them while unconscious. It should be added, however, that not only do these nervous women make such charges at times, but that the most refined phlegmatic women have been guilty of the same statements. Mental Aberration. — In the ae'ed and in individuals with nerv- 46 AFTER-TREATMEXT OF SURGICAL PATIENTS ous instability the shock of an operation can be to blame for more or less mental aberration which may suddenly develop during the early period of recovery. It has been said that this is due further to the use of drugs during the operation or in the early after-care. Certainly those mental disturbances occurring after eye operations and which are mostly hallucinatory in nature are due to this cause alone. Sajous 5 states that "excluding the cases due to shock, nervous strain, exhaustion, and drug intoxication, which generally appear within the first twenty-four hours, it is probable that the majority, if not all, of the cases of postoperative insanity coming on within the first week are septic in origin." That it should occur at all is de- plorable, but when it does, the shrewd surgeon will have been forti- fied against the consequences, and will be left unhampered to combat the new condition as best he knows how. For suggestions as to treat- ment, the reader is referred to the chapter on Postoperative Psychoses. Complications Arising after Local Anesthesia. — The complications arising after local anesthesia are not as a rule nearly so many or so frequent as those occurring after general anesthesia. The nature of the complication and the extent of its severity depend upon the operation performed. Since practically every operative procedure which is carried out under general, can also be done under local, both are entitled to the same complications. However, the latter ap- parently entails few of the horrors of the former, and it is generally conceded that the postoperative discomforts and risks are materially less, particularly the dangers of pulmonary disorders. The after-care for the ordinary minor operations need not be men- tioned, since it resolves itself practically into the care of the wound alone. After major operations the same systematic care is exercised as in those patients who have been given ;i general anesthetic. "With these patients who have had a local anesthesia sometimes the first complaint is nausea which often develops into actual vomiting. This is undoubtedly due, in many instance-; to tin 1 morphine so generally given before operations. The same efforts put forth to relieve this condition after a general anesthetic are also carried out here. It is here not so necessary to exhibit much care in giving fluids, since those are nearly always taken with impunity, even when the stomach is temporarily upset by the preceding operative maneuvers a few glasses of cool water will not only clear the mucous membrane thor- oughly of any excessive mucus and gastric juice which had been se- creted, but also will assist in giving added tone to the musculature which has relaxed during the period of mental strain and distress while the patient was undergoing the actual operation. The nausea EARLIEST SUBJECTIVE MANIFESTATIONS 47 usually does uot last long and under the same handling that is af- forded the general anesthetic patients it will clear up in a very short time. Pain is not experienced at all until the effects of the anesthetic wear off, when it becomes excruciating at times. In practically every case more or less pain is experienced in the wound, and measures are taken to relieve it as is done following general anesthesias. Af- ter the first twenty-four hours it becomes less and less, morphine being rarely necessary after this period. The edema and induration about the wound last longer because of the foreign material injected at the operation, and for this reason most attention is paid to the wound itself. In order to alleviate this as much as possible, I em- ploy pure glycerin directly over the wound after the first twenty-four hours, the dressings being kept moist with this chemical for several days, or at least until the swelling and induration have been de- creased to a minimum. Glycerin is not only a hydroscopic agent, but also is slightly antiseptic and such wounds kept bathed in it sel- dom develop in my experience the "fiery swollen appearance" seen occasionally after local anesthesia. It should also be cautioned that this treatment extending over too long periods of time will cause a papulovesicular eruption around the wound edares which predis- poses to infection, and just as soon as this occurs the glycerin must be discontinued regardless of the condition of the deep tissues in close proximity of the wound. Immediately after the operation if it has been an extensive one, the patient will express a sigh of relief and rejoice at the prospect of going back to bed. Once here, it will be only too evident that he is tired out from the strain, which practically all patients un- dergo, and will welcome sleep. It may be necessary to massage his strained and bruised muscles or at least give an alcohol rub in addition to making the patient com- fortable by placing his pillows properly and putting hot-water bot- tles around hini ('always bearing in mind the possibility of burn- ing him). "When his discomforts are relieved, the room is darkened, all visitors excluded, and the patient encouraged to relax, refrain from talking, and attempt to lose himself in sleep. If the exhaustion has not been too great, sleep will come shortly if precautions have been taken to have the bed and room prepared as is ordinarily done for patients who take a general anesthetic. The rest which he thus secures will do more to alleviate the suffering of the worn-out body and mind than will any drug. Morphine in small doses is given to prevent possible pain in the wound disturbing him during this period 48 AFTER-TREATMENT OF SURGICAL PATIENTS of slumber. As a usual thing these patients will go to sleep without any medication, but occasionally one is not so favored. It is a good rule to give with the proctoclysis 30 to 60 grains sodium bromide, to every nervous patient, and to this may be added at times 25 to 30 grains chloral hydrate. An ice bag over the fast and palpitating heart in neurotic patients will do much to quiet this organ and allow rest and perfect recuperation. Light nourishment in any form suggested by the patients is to be allowed at a very early period. Its importance is second to that of sleep only as a means of quieting and restoring the individual who has just experienced an operation under local anesthesia. Bibliography iMurphy: Practitioner's Encyclopedia of Medicine ami Surgerv, 1915, p. 504. zFinney: Address, The Significance and Effect of Pain. Oct. 6. 1914. 3Halperin: New York Mel. Jour.. July. 1911. •»Luke: Guide to Anesthetics, 1 '."•''>. ]•. '.'4. 5Sajo.ua: Analytic Cyclopedia of Practical Medicine, 1916, iv. 668. Ferguson: New York Med. Jour.. June. 1912. "Ochsner: Quoted by Crandon: Surgical After Treatment, 1909, p. 33. sKanavel: Surg., Gynec. and Obst., Oct.. 1! CHAPTER VII LATER SUBJECTIVE SYMPTOMS By Willard Bartlett, St. Louis, Mo. The patient has recovered full consciousness and though his "earliest subjective symptoms" may still be present, he now be- gins to manifest certain conditions which are directly attributable to the manipulation to which he was subjected while still on the operating table or during the period of returning consciousness. They cause at times no little irritation and annoyance to the patient. Such accidents happen in the hands of the most careful surgeon or of the best surgical teams, and apparently can not always be avoided, which fact makes their occurrence none the less deplorable. The sur- geon's embarrassment in many instances is intensified by the pros- pect of a damage suit, a phase of the matter which should not be too lightly passed over by him. Ether Conjunctivitis. — Ether conjunctivitis is rapidly becoming a very uncommon accident, a fact which is indeed welcome to both the profession and the laity alike. This complication has, in my experi- ence, always produced more suffering than has the wound coexistent with it. This is particularly true in all cases where the eyes were not irrigated immediately upon the entrance of the ether. I have most frequently observed it when the eyes were covered with rub- ber, gutta percha or other similar impervious materials. A drop of ether or even ether vapor which once gets under such a covering is held confined there and much damage done in consequence. The results of this accident are usually complained of next day when the patient notes a smarting and burning in the eye affected. On examination one will find an active hyperemia of the conjunctiva, the vessels being prominent and the palpebral conjunctiva being more vascular than usual. Other portions of the conjunctiva become involved later. The lids become swollen and in the most severe cases the conjunctival sac may fill with pus. Under proper treatment the condition does not extend beyond a simple catarrhal inflammation and its duration is short. Cases with more extensive involvement should at once be turned over to an oculist, as the danger of corneal ulcer is imminent. Careful examination of the eyes in patients suf- fering from ether conjunctivitis can not be too strongly insisted 49 50 AFTER-TREATMENT OP SURGICAL PATIENTS upon. I had a patient of this kind threaten malpractice suit at a re- mote period, claiming that my carelessness had resulted in a corneal ulcer. To be sure a scar could hi' seen and the thing was not disposed of until, by mere good fortune. I happened onto the oculist wlco had treated her corneal ulcer previous to our operation. The treatment is first and always preventive. All trained anes- thetists have individual methods of protecting the eyes during the etherization. Personally I have not had one complaint after many thousand anesthesias in which the Ferguson mask has been used and the eyes of the patient left uncovered. If there is any reason to believe that ether has come in contact with the eye. I would advise, as Crandon 1 already has before me, that the eye be irrigated at once with a little warm water, physiologic salt, or 2 per cent boric acid solution. I have on more than one occasion seen a drop of ether fall directly into the eye, but never heard a later complaint where it was followed in a few seconds by irrigation with any of the above liquids or a drop of sterile olive oil. This lubricant, particularly, should be kept in the operating room. When the condition occurs in spite of the measure suggested above, the eyes are irrigated twice a day with 2 per cent boric acid solu- tion and the eyes protected from the light glare, either by smoked glasses, eye shields or keeping the window shades down. During the early stages one may employ with advantage Posey's 2 technic which is carried out as follows: "Several pads of gauze of three or four thicknesses, about the size of a silver dollar, are laid on a block of ice. The ice should be suspended in a receptacle with per- forations in iis bottom, which will permit the water and any secretion from the compress to drain off into a jar beneath it. An ordinary kitchen colander and washbasin will answer very well for this ap- paratus. One of the pads is taken from the ice as soon as it lias been saturated and is applied to the closed lids, removed in a few mo- ments and a fresh one substituted for it. Compresses of absorbent cotton which have been soaked in ice water may also be employed. They should lie squeezed out sufficiently to prevent any of the water trickling over the patient's face and neck." The compresses should not be continued over twenty-four hours, and applied every other hour. The danger is devitalization from the cold which may result in corneal ulcer. Dry Mouth. - -The association of dry mouth with general thirst on awakening from an anesthesia is so intimate that the condition has already been discussed under this head. There is. however, an- other phase to this subject which requires further attention than has LATER SUBJECTIVE SYMPTOMS 51 hitherto been given to it. I refer to the management of the patient while still under the influence of the anesthetic or during the sleep resulting from the preanesthetic drug. It is my observation that an otherwise attentive and capable nurse will allow an unconscious pa- tient to breathe with the mouth wide open and not make an attempt to prevent the mucosa becoming as dry as the skin outside. This can be prevented by the simple maneuver of keeping the orifice covered by a few layers of loose-mesh gauze which are frequently moistened in a solution of glycerin and water of equal parts. Dry mouth occurring later on in the convalescence and not caused by a general loss of body fluids during the operative procedure or an insufficient intake after the operation may be caused by disease of the salivary glands or of the duets, or of both. It may also occur as a local result of the operation itself. A recent case illustrates this point quite well. I removed a carcinoma from the floor of an elderly gentleman's mouth and in the course of the operation de- stroyed all the salivary ducts in this region. By the time healing was complete, his complaint of dry mouth was most insistent. Chew- ing gum, slippery elm. and other remedies were tried in vain until I hit upon the idea of a film of mineral oil (petrolatum liquidum) as a substitute for saliva. The result was astonishingly good; so much so that the patient when seen a year later extracted a tiny bottle from his pocket with the remark, "My mouth never gets dry as long as I carry this and take a few drops of oil every hour or two." The treatment of this condition in addition to that suggested above consists first in finding the cause. This is usually the result of in- sufficient fluids in the body and is remedied by increasing the in- take as already described. In the meantime the mouth is frequently rinsed with cool water, or a cool sponge wet with this medium is re- tained. Another may be applied over the lips. If the inside of the mouth becomes stagnant due to improper cleanliness on the part of the patient from any cause, it is cleaned frequently by the nurse with a swab of gauze saturated in 4 per cent boric acid solution. In ad- dition, once or twice daily olive or mineral oil may be applied in the same manner. Painful Tongue. — The tongue may become affected independent of a dry mouth, and in fact most often gives trouble in those cases where some manipulation of this organ was necessary during the course of the operation. It is necessary as a matter of course that the tongue be held forward during the course of many general anes- thesias to facilitate respiration. If this be done with a crushing 52 AFTER-TREATMENT OF SURGICAL PATIENTS forceps, so much pain and swelling are caused for a few days that the patient may suffer more in consequence of such maltreatment than he does from the surgical wound itself. Considerable pain will be produced even though such clamps are not used but instead instruments especially devised for this purpose such as the Carmalt forceps. The painful after-effects should be considered at the time of the manipulation, and these so far as possible mitigated by a more refined and humane manner of handling this sensitive structure. The anesthetist who grasps the tongue with a gauze strip held be- tween the thumb and forefinger probably does not damage it at all. There are many case in which, however, such gentle measures do not suffice, here I recommend the transverse insertion near the tip, of a slender thread carried by a fine needle. This is far better than the tenaculum used by some anesthetists, which is in turn vastly to be preferred to a crushing instrument. The treatment is simply palliative. The mouth and teeth are kept clean with some antiseptic mouth wash such as liquor antisepticus alkolinus, 4 per cent boric acid or Dobell's solution (diluted one- half its strength). Potassium chlorate, saturated solution, or po- tassium permanganate 1 :4000 may be employed if the condition does not speedily clear up. It may be necessary to hold ice on the swollen tongue for the first clay or so. I have never seen this necessary as the warm mouth washes were sufficient in every case. Silver nitrate in 10 per cent to 20 per cent solution may be used directly on the lesion if it is slow in healing and one of the stronger mouth washes employed several times a day. For any injury of the tongue during convalescence the treatment is the same as the above unless it is so extensive that surgical inter- ference is necessary to control hemorrhage. One patient came under my observation who accidentally fell on the tenth postoperative day. Avhile attempting to walk to the bathroom; she struck her chin and nearly bit her tongue in two. Several stitches were taken without an anesthetic, and a potassium chlorate mouth wash used three times a day for six days, when the wound had healed. A warm boric acid wash was used for a week longer, during which time all soreness and other inconvenience completely disappeared. In the presence of this complication it is best to give the least ir- ritating foods, particularly those soft and warm and free from high seasoning. In some severe cases, as in the one mentioned, the food may be given in liquid form through the nose for a few days. Sore Jaw. — A sore jaw is one of the disagreeable experiences which sometimes go together to make up a never-to-be-forgotten pie- LATER SUBJECTIVE SYMPTOMS 53 ture, when surgical treatment has not been judiciously managed. It is now and then necessary during, as well as after, a difficult anes- thesia, to hold the jaw forward in order that the muscles running from the symphysis to the hyoid bone may hold the pharynx open. This is commonly done with the fingers hooked around the ascending ramus just above the angle, and very slight damage is done provided the pressure is not too long maintained, unless the tips of the fingers are carelessly allowed to slip too far around the bone and infringe upon the deep structures of the neck. Under such circumstances an effect is produced very similar to that for which the jiujitsu wrestler strives, and the patient is caused undue suffering in consequence. The procedure can be varied from time to time with advantage for the patient as well as for the anes- thetist by hooking the index finger over the incisor teeth and the thumb of the same hand under the symphysis and pulling instead of pushing the mandible forward. The treatment in addition to the preventive measure stated above is palliative. The condition usually disappears in a day or so ; it is, however, not always best to await a favorable outcome, but to insti- tute some measure of relief at once. Probably massage is the best remedy at our command, this performed for twenty minutes twice a day will help clear up the worst cases of this nature. Various counterirritants, such as turpentine or some liniment whose princi- pal ingredient is chloroform or ammonia, will also prove efficient in the patient's mind at least. The external application of heat may be tried on those cases where no application of drugs is made. Sore Throat. — Sore throat is particularly likely to follow any operation in which there has been manipulation of the trachea, larynx, etc. "We note it most commonly after thyroidectomy. It may be prevented in many patients by placing them in bed flat on the face, with a pillow under the chest immediately after the opera- tion and leaving them in this posture for several hours or until it be- comes intolerable. A moment's reflection will convince any one that downhill drainage of the respiratory passages is secured in this man- ner ; in fact a surprising amount of mucus and saliva runs out, which in any other position would tend to fill up the bronchial tree, and re- quire, in my experience, some days to be coughed up. Nothing else has compared in my hands with the inhalation of steam for the relief of surgical sore throat. Many other remedies have been proposed, and tried by us, only to be discarded. Some of our patients seem to gain a measure of relief from holding ice in the 54 AFTER-TREATMEXT OF SURGICAL PATIENTS mouth, and others from gargling a mild alkaline solution. The steam is, however, practically unfailing- in its effect. Painful Respiration. — Painful respiration is a serious matter he- cause it often influences the patient to protect himself by limiting the respiratory excursion, with imperfect hum' ventilation and pneu- monia as a consequence. This train of undesirable events is prone to follow the making of wounds low on the chest wall or high on the abdominal wall; especially is this true if such wounds are unduly tender in consequence of inflammatory changes. It may also he caused by violent use of the diaphragm, as in vomiting- or the chest wall may have become injured as a result of artificial respiration or careless handling, while removing the patient to bed, etc. The pres- sure of extensive gauze packing, or of clamps left hanging on the tissues near the diaphragm constitutes an added risk. Little is to be feared from an intelligent patient who will sit up in bed and inspire deeply a few times every hour no matter how much it hurts, but the treatment becomes quite another matter when chil- dren or adults of kindred mental attitude are concerned. I have had no trouble with such an individual provided only 1 could get him interested in the attempt to score a higher record than his nurse when blowing into a tube connected with a mercury manometer. Of course no forceful expiration is possible unless pre- ceded by a correspondingly deep inspiration, hence the value of this little subterfuge becomes apparent at once. The mercury goes higher every hour, the increase in distance being a matter of astonishment to the one who observes it for the firsl time. There are, as a matter of course, surgical patients who are too ill for this sort of treatment. In these only those measures which fulfil the individual requirements can lie instituted. Painful respiration is caused in most instances by pleurisy, but in making the diagnosis of the condition the factors mentioned above must be seriously considered and the probabilities* of an inter- costal neuralgia or actual bruising of the muscular or other tissues must be considered. Schepelmann 3 states that in dry pleurisy, especially, the pain is in- creased on bending the body towards the well side, while in inter- costal neuralgia there is more pain when the body is bent towards the affected side. Treatment consists in first utilizing the apparatus mentioned above, and the patient is encouraged to bear with the discomfort for a few hours at least. Usually the condition improves steadily LATER SUBJECTIVE SYMPTOMS 55 from the first efforts at treatment and no further measure is nec- essary. If there are symptoms necessitating more radical measures as is seen, for instance in beginning pleurisy at times, dry cupping is resorted to at once and kept up twice each day until the distress has ameliorated. Strapping the chest is resorted to when cupping is not employed, but this latter maneuver has never given the relief so far as I have observed, that may be accredited to the former. The cases of intercostal neuralgia may require more than putting the side at rest by means of adhesive straps. When the pain is per- sistent, even in the face of such treatment, it may be necessary in a few rare cases to inject the nerve itself with a mixture first brought to my notice by V. P. Blair. This consists of novocaine, 10 gr., chloroform, 20 minims, alcohol 6 drams, to which freshly dis- tilled water is added until one ounce of the mixture is obtained. It is injected into the nerve sheath by means of a very fine needle. The relief is said to be instantaneous. In carrying out this operation the patient's mental attitude is to be considered, as the distress which it causes is so great occasionally as to even preclude its use. In such cases it will usually be found that the pain can be eliminated by the other simpler means. In true neuralgias, however, the pa- tient will not object to the treatment, especially if the area of in- jection is first anesthetized with a little % per cent novocaine. Localized soreness, not a pleurisy or an intercostal neuralgia, is best treated by massage. Hot applications in the form of the tur- pentine stupe or hot-water bag are also useful. Liniments as em- ployed for sore jaw may be applied where the hot water applica- tion is not practical. Anesthesia Paralysis. — Anesthesia paralysis is usually not a per- manent affliction, though a particularly distressing one and pos- sessed of a medicolegal aspect. This complication is due only indirectly to the anesthetic. The injury itself, which results in functional loss to the various nerves of the body, may be produced by the position of the patient on the operating table or pressure on localized parts of his anatomy. Probably the most common etiologic factor is the careless practice of many anesthetists of allowing an unconfined flaccid arm to drop down and hang for a time over the edge of the operating table. Such treatment frequently causes extensive pressure to be exerted upon the musculospinal nerve while the brachial plexus is also a frequent sufferer from mechanical injuries during anesthesia, this being apparently more often affected than is any individual nerve. 56 AFTER-TREATMENT OF SURGICAL PATIENTS Its frequent occurrence in women compared to men causes Molinari 4 to state that women seem more predisposed to this complication. The injury to the plexus is produced in a variety of ways. No doubt the most common method is the extension of the arms above the head as is so often seen during the use of the Trendelenburg posi- tion. The actual condition as stated by Budinger 3 reveals that dur- ing such a maneuver the trunks of the plexus are pinched between the clavicle and the first rib at the point where these cross the rib. By further extending the arms the clavicle rotates upon its trans- verse axis until in the most extreme extension the posterior superior border becomes the inferior posterior, thereby limiting still more the area between the two bones and particularly compressing the upper and posterior cords of the plexus. In his discussion of this subject he further calls attention to the fact that in some patients there is a peculiar formation of the clavicle and thorax which permits of an increase in pressure during this position. He also found that by bringing the head towards the side of the abducted arm the corre- sponding nerves escaped compression by slipping outwards and from beneath the clavicle. Drawing the head to the opposite side did not produce these same results. Other German 6 authors believe that compression by the transverse processes of the vertebra of the fifth and sixth cervical nerves as they leave the spinal column is a common cause of brachial plexus paralysis. Such an accident is likely to occur they state when the arms are extended over the head during anesthesia. Postoperative paralysis may result from temporary pressure of the head of the humerus on the brachial plexus below the clavicular portion following hyperelevation of the arm over the head with ro- tation inward according to Glitsch. 7 The median nerve is partic- ularly liable to injury as it passes over the head of the humerus in this instance, then while bending the elbow and rotating the arm out- wards, the ulnar nerve is exposed to injury. 8 Traction on the plexus can be brought about by various faulty positions of the arm during operations upon the breast, shoulder joint, etc., also in such in- stances the actual operative procedure is, of course, a matter to be taken into consideration. Paralysis of all the nerves of both arms have been reported. Bern- hart 8 notes such an instance where the arms were maintained above the head during a Trendelenburg position for one and one-half hours. Halstead also observed such a case in the practice of one of his friends. I also once saw a double palsy follow an operation in which both hands were firmly held above the patient's head during an operation of long duration. The malady lasted more than a year on LATER SUBJECTIVE SYMPTOMS 57 one side and several months on the other. In the case observed by Halstead 9 the paralysis disappeared within one year. Such experi- ences tend to make the observer uncomfortable whenever he sees the upper extremities so treated in the course of an operation which might be equally as well performed with them at the patient's sides. Paralysis may result from pressure on any motor nerve in the body. Flateau 10 reported a case of bilateral facial paralysis follow- ing pressure of the anesthetist's fingers. Injuries to various tho- racic nerves may result from the position of the patient. Halstead 9 says "that the lateral or lateroprone position maintained over too long a period may be instrumental in producing compression of the brachial plexus, trunks, and individual nerves, the circumflex and radial being particularly exposed to danger. The popliteal and other nerves of the legs are also liable to injury from pressure of the table during the Trendelenburg position. The patient often hangs with all the weight borne by the lower legs unless shoulder crutches are used. In strapping the thighs preparatory to an anesthesia the possibility of nerve injury exists unless slight pressure be employed. ' ' "The rarity of any similar lesion in the lower extremity coupled with the observation that arms are frequently, and legs seldom, sub- jected to the strain of most unusual positions on the table, leads to the obvious conclusion that the upper extremities should always be rather loosely confined at the recumbent patient's sides when the execution of the operation is not hindered thereby. To be sure, there are conditions of anesthesia, under which the necessary handling of a patient becomes so difficult as to leave the attendants little choice as to just how the arms should be held ; while on other occasions the necessity of keeping some unusual operative field exposed may pre- clude the possibility of an easy position for both shoulder regions. Under such circumstances, of course, the surgeon can only accept the better of the two possibilities and hasten the operative work as much as consistent with thoroughness." "The mechanical factors involved in these cases are in each case so prominent and our efforts to eliminate them so strenuous that other causes of the same condition are almost overlooked. It has been considered especially by a few French observers that the ether itself through its toxic action on the nerves, lowers the resistance to trauma, which predisposes to the paralysis. The condition was more common in the days of chloroform anesthesia and would occur days and even weeks after its administration. Molinari 4 does not consider the theory tenable, nor in view of the evidence in favor of mechanical injury would we consider that the anesthetic played a very important role in the actual production of the malady. The fact that paralyses 58 AFTER-TREATMENT OF SURGICAL PATIENTS occur so long after the operation gave color to the French contention, but at times exactly the same phenomena occur following any anes- thesia." Halstead 9 to whom we owe so much considers a central paralysis which may occur during the administration of a general anesthetic. He states that the condition is rare and that we have little direct evidence as to the cause of the disease. Two hypotheses he says are to be considered: "First, that the lesion is due to ischemic soft- ening, following a hemorrhage. Secondly, that there is a primary degeneration the result of toxic action of the anesthetic upon the cerebral cortex. When hemorrhage is the cause of the paralysis, we must assume an existing sclerosis of the vessels, which give way usu- ally during the stage of excitation of ether narcosis." Instances of this latter accident have occurred more often than the former. Many, no doubt, have accredited it to the narcosis when the condition would have come about had this not been attempted. Buxton 11 noted two patients in whom this happened previous to the operation. Others have also called attention to this malady in the instructions given for the preparative care of their patients. It is possible that a previously deranged nervous system does play a role in predisposing to paralysis, as witnessed by the fact that I recently observed a marked brachial palsy affecting a highly neurotic individual who was carefully watched during the anesthesia, and who experienced none (to our knowledge at least) of the ordinary exciting factors common in these cases. He had a syphilitic history, as it appeared to me. The treatment concerns itself first with the prevention of the mal- ady. If this is kept in mind during the arranging of the patient on the operating table, there need be slight fear as to a good outcome. I never allow the arms to be drawn above the head for any opera- tion. In instances where the Trendelenburg position is used, care- fully and thickly padded shoulder crutches are employed. For breast operations the arm n-sts comfortably on a padded support placed at right angles to the body. For every other operation the patient is carefully observed to make sure that there is sufficient padding under the parts exposed to pressure and a position assumed most comfortable to him and at the same time least objectionable to the surgeon. No one allows a leg or an arm to hang unsupported in this day of preventive medicine. Careful study of the patient, lead- ing to a thorough knowledge of the condition of his nervous and vas- cular systems, will insure measures to correct abnormal conditions and thus prevent most of the paralysis dm 1 to central causes. When the accident occurs despite every effort put forth to pre- LATER SUBJECTIVE SYMPTOMS 59 vent it, treatment must be instituted at once and persisted in until the signs and symptoms have disappeared. In many instances the normal is not obtained for several months after the condition pre- sents itself. The actual measures for its alleviation consist prin- cipally in massage, electrotherapy and attention to the general health of the individual. Pressure and tension are as a matter of course to be avoided, since no patient who is not reasonably comfortable can be expected make a satisfactory convalescence. Pressure may in addition to be- ing a source of discomfort become exceedingly serious, especially when carried to the point of cutting off blood supply. Where ban- dages are used on the extremities, the toes and fingers should be left exposed in order that change in color or temperature may be readily and quickly detected. In case they become blue or cold every con- striction is to be cut at once no matter what other factors come into play, since more than one instance of gangrene has followed the post- operative swelling of an extremity which remained too closely confined. Volkmann's paralysis is a particular form of trouble which occurs in the arm when pressure ischemia is maintained for too long a period in the muscles. The usefulness of many a hand has been lost after the fingers have assumed a claw-like posture resulting from permanent contraction of flexor muscles due to muscle substance being replaced by scar tissue in consequence of the accident just mentioned. Pressure is particularly obnoxious over bony prominences, par- ticularly is this true about the knee, ankle, and heel. An experi- enced dresser is always at pains to carefully and thickly pad these prominent points, as well as all those presented by the bony pelvis, before applying a plaster cast. The heel of a patient who is to remain for a long time in the re- cumbent position should be prevented by padding higher up on the limb, from touching the underlying bed at all. Prolonged contact with the bed is sure to occasion discomfort, and if not corrected, in the course of time is very likely to lead to loss of substance. "We have in many instances been reminded of the fact that more discom- fort and uneasiness may result from such faulty handling of a pa- tient than from the fracture which necessitates his stay in bed. The placing of restraining sheets over the limbs of very lean pa- tients often results in serious injury to the vessels or nerves. In this connection the tourniquet should be mentioned. In rare instances injury to the musculospinal nerve has resulted from insufficient pro- tection of the arm from the constricting band, especially in cases where this has been placed too low down and at a point where this nerve encircles the humerus. 60 AFTER-TREATMENT OF SURGICAL PATIENTS Tension if extreme and too long continued leads to unrest on the part of the patient and at times to much more serious consequences. Stitches which are too tightly tied inevitably cut through and not in- frequently lead to serious nutritional changes along the wound edges. A high abdominal wound if closed with too much tension prejr dices the individual's safety in no uncertain way. The movements of the lower chest wall are greatly interfered with, resulting in de- ficient ventilation of the lung with a consequent marked tendency to pneumonia. I was so unfortunate as to lose one of my early post- operative hernia patients because I overlapped for too great a dis- tance the edges of a postoperative hernia ring situated in the gall bladder region. A second patient in whom a similar error of judg- ment was made seemed to be following the same road when his parox- ysm of coughing broke the stitches with the result that he rapidly improved and demonstrated in no uncertain way the truth of this pathologic reasoning. The amount of tension which may be exerted upon an extremity is almost unbelievable provided merely that the patient be very gradually accustomed to it. In the old days when we applied ten or twelve pounds to an adhesive strap on the skin of the lower leg we considered that we were doing all the patient could expect, and indeed, met at times with decided remonstrance. I have, however, in recent years made extensive use of the bone pin first suggested by Codavilla upon which a pull of fifty pounds lias been exerted after gradually increasing the same for a period of four weeks. I can not say, however, that I have seen a patient thoroughly comfort- able after the thirty pound limit was passed. A great deal more can be done in this direction if one commences before the reparative process has set in, whereas tension measured by only ;i few pounds is apt to cause acute suffering if a fracture is three or four weeks old before the treatment is begun. Full credit is due 0. F. McKittrick for having abstracted all the literature to which reference is made in this chapter. Bibliography iCrandon : Surgical After Treatment. 1909. 2Posey: Sajous' Analytic Cyclopedia Practical Medicine, 1916, iii, 552. sSchepelmann : Berl. klin. Wchnschr., No. 21. 1911. 4Molinari: Internat. Obst. Surg., 1914, xviii. L26. sBiidinger: Arch. f. klin. Cliir., xlvii. 6 Deutsch. med. Wchnschr., 1894. TGlitsch: Zentralbl. f. Gynak., No. 39, 1904. sBernhart: Quoted by Halstead.o sHalstead: Wis. Med Jour., 1907-08, vi, 5-12. iQFlateau: Centralbl. f.d. Grenzgeb. d. Med. u. Chir., xl. nBuxton: Anesthetics, 1900, p. 148. CHAPTER Till SLEEPLESSNESS By 0. F. McKittrick, St. Louis, Mo. Sleeplessness is seen so frequently in postoperative patients that one is more or less inclined to regard it as a normal occurrence rather than a malady demanding careful attention. As a general rule this subject is not brought to the attention of the attending sur- geon for several days after the operative procedure. Usually on en- tering the hospital if the patient is concerned about the operation or is at all nervous or restless, veronal, gr. v, is given at 7 p.m. in a glass of hot milk, the night before the operation. The drugs given for the relief of pain during the succeeding days are sufficient to eliminate any disturbance which would in any way preclude sleep. After the third postoperative day, however, and unless the patient is in the hands of a competent nurse, one often hears complaints that the patient does not sleep at night. It is always to be anticipated that such complications may arise in any patient who has been taken from the ordinary pursuit of life — howbeit an active one — and sud- denly confined to bed. The rest, therefore, secured in the daytime and the periods of sleep snatched off and on during this interval leaves the patient wide awake at a time when, under ordinary cir- cumstances, he would be asleep. A good nurse, expecting such an outcome, will so entertain her patient that the daytime naps are cut short and he is prepared in the most comfortable manner at bed- time. To do this the bed is carefully arranged to the best interests of the patient, the feet kept warm, an alcohol rub given, or often the nurse resorts to gentle massage, particularly of the back. This may or may not be followed by the reading of some light story, either by the nurse or the patient himself. At a regular time the room is more thoroughly ventilated, the lights turned low, and sleep is demanded by the nurse and invited by the patient. In the handling of these patients their individual temperaments and former modes of life are to be minutely considered. It has been said that "direct causes for this malady do not often exist though they can sometimes be found, but indirect causes of many kinds are present in nearly every case. ' ' It becomes, therefore, a dire necessity to know more about a patient's habits before we 61 62 AFTER-TREATMENT OF SURGICAL PATIENTS can arrive at a definite conclusion as to the right course to pursue. The habit of taking several cups of coffee or tea or other stimulating drinks may be one fruitful cause of the condition. Certainly such is to be thought of and properly met in every instance. Occasionally, and particularly in old people or in those accustomed to drink, it is very essential that they are not deprived of their drink at this time, since a cup of coffee or tea or a little hot toddy often brings sleep when other measures have failed. Some patients have the habit of sleeping during the late afternoon. This prevents further sleep until late at night or in the early morn- ing. These patients, of course, are not allowed to pursue this custom when it results in sleeplessness, but are kept awake until the regular hour for sleep. Another cause of sleeplessness in postoperative patients is lack of food. This is seen especially in very thin emaciated patients. The wait from the b' p.m. meal to breakfast is too long. In these eases a glass of milk, a cup of cocoa, or other easily assimilable food is condu- cive to perfect sleep. These patients are more apt to be awake during the early morning hours and the food given at this time is efficacious. In this connection the evening meal is more often insufficient than too heavy as a cause for the patient's wakefulness. Food in itself rarely causes the patient to be awake. It is proverbial that animals sleep better with a full stomach, and the same very aptly applies to human beings. Of course, the diet must be so regulated that the stomach already weakened by the operative procedure is not over- loaded with indigestible Pood, but the practice of denying nutritious food, especially during the daytime, to these patients or even at night, because of the fear that it may cause disturbance in sleep, can not be too heartily condemned. < )n the other hand, the recog- nition of the fact that inadequate food is the cause of wakefulness can not be too emphatically extolled. Worry is indeed a fruitful cause for sleeplessness. Worry about the ultimate outcome of the operation, strange as it may seem, is not so prominent in their minds as the fact that they do not sleep. Such patients usually will have experienced this condition before they entered the hospital and on careful investigation one will rind that they fear some permanent injury as a result of their wakefulness. Often they will state to the doctor that they sleep very little during the night and consequently feel that they are losing hold on the vital forces which are so necessary for their recovery from the operation or even future health. They become very solicitous as to the nature of the malady and implore their physician for relief. They may not SLEEPLESSNESS 63 liave really lost very much sleep but complain of wakening so often during the night and never going back to sleep. It will be noticed, however, that they do finally go to sleep, and the length of time they were awake is only magnified and apt to have been thought much longer than it really was. That the statements of these patients can not always be taken too seriously is borne out by the statement of Walsh, 1 who says that, "We have no idea as to the length of our sleeping periods, and if we awaken a dozen times during the night we are likely to think that we have been wakeful most of the night, though all the wakeful periods may be embraced within an hour, and the rest have been spent in sleep." In these patients I try to verify their statements by having them watched by the nurse whose findings are always more to be relied upon than the neurotic patient's ideas. Occasionally one finds his patient concerned about sleep during the coming nights he is to spend in the hospital. He will start wor- rying and "just wondering" if he is going to sleep when that time comes. If one makes rounds along late in the afternoon he is more apt to see these patients at the time when they are in their zenith of anxiety concerning the sleep they will not get with the coming of the night. This certainly is ridiculous and is trying for those in charge of a sensible patient who is addicted to this miserable habit, never- theless it is one to be reckoned with and combated as best the nurse knows how coupled with whatever therapy the doctor can advise. This class of patients really do lose sleep, not because of any real physical difficulty, but because of the fact that they worry over the insomnia itself which is sufficient to bring whatever dire results such a condition entails. The worry of the effect which the patient imagines insomnia will produce on his mind and body, is another factor which materially adds to the seriousness of the situation. Naturally the general con- dition becomes run down, the convalescence prolonged, and the pa- tient considers that his sleeplessness is to blame for the condition, when as a matter of fact, the fear alone is the cause of his unhappy state. As soon as the thought of impending mental affection is eradi- cated from the patient's mind, the wakefulness will become easy to control. Insomnia, to be true, has occurred during the course of this malady. Personally I have never seen it follow postoperative insom- nia. Walsh states that he has seen it develop as one of its symp- toms, but not even then until other marked signs of mental affection were present. He further states that "Wakefulness is really a passing symptom of functional nervous condition that never leaves serious 64 AFTER-TREATMENT OF SURGICAL PATIENTS effects," an observation in which I can entirely acquiesce when the ordinary postoperative patients are alone considered. Such infor- mation often helps the patient to calm himself, and is one of the ar- guments employed in assisting him to regain a stable equilibrium when other measures as instituted below are utilized to complete the successful treatment of the case. One of the most common causes of obstinate insomnia in cases not operated is errors of refraction according to Pronger 2 who states that it is not the gross errors which so often lead to the condition, but rather the slight ones, such as do not lead to such visual defect as to demand the wearing of glasses for their correction. The con- tinual effort in the use of the eyes leads to a cumulative nervous strain which results in sleeplessness. Unfortunately these patients fall into the hands of the surgeon for various operations, and unless such a cause is considered possible, the patient may suffer unneces- sarily even to the point of a general breakdown, and Pronger states that even suicide has been perpetrated by patients suffering from insomnia due to this cause alone. I have never had such an accident occur though on one or two occasions patients have intimated that this might result if sleep did not become more satisfactory. Clarke'' in supporting Pronger states that the unconscious correction of small refractive errors always leads to waste of the nerve energy sooner in those whose nervous organization is more delicate than in the robust, in whom it may never present itself. This statement, however, should not prevent one from examining the eyes in the latter class of patients when other causes have been exhausted. Gubb 4 in discussing the same subject calls attention to the fact that, not only does this trifling disturbance produce insomnia, but also others even less so will cause the same distressing symptoms. A loaded rectum, especially where there is a tendency to flatulence, tends to excite peristalsis and result in wakefulness. Williams 5 notes that toxemia resulting from a severe colitis may also produce this same condition. In fact the sleeplessness associated with bowel dis- turbance due to operative procedures is well known, probably as a result of autointoxication as well as the increased peristalsis neces- sarily produced. The after observance that the height of the head can not be ignored if sleeplessness is to be avoided in some patients is also brought out by Gubb. The temperature of the room is important. A cool or rather cold room is certainly desirable for a normal sleep, and the free circulation of air is by all means to be obtained. Cold air. how- ever, coming in contact with exposed surfaces of the patient's body SLEEPLESSNESS 65 is not conducive to perfect sleep or future health of the patient, and measures taken to prevent this happening are always observed in postoperative cases. Further causes for sleeplessness may be found and corrected when some of the theories of sleep itself are brought to mind and briefly considered. Savage 6 states that normal sleep depends upon a healthy blood supply to normal nerve cells, particularly these of the frontal lobes. He considers that blood supply to the brain lias most to do with sleep and recalls that sudden loss of this body fluid will produce insensibility, or pressure on both common carotids will cause the same phenomena. Howell 7 found that the brain became anemic and the blood pressure dropped during sleep. The skin in the meantime con- tained an increased amount of blood, which shows that the vaso- motor system is in some way involved. Hill* considers the vasomotor center as the "hub around which turns the wheel of a man's active mental life." Savage suggests that there may be a venous conges- tion which produces a malnutrition of the nerve cells which is as capable of producing sleep as anemia. Miller 9 would consider "" cere- bral stasis"' as a more likely cause of sleep than cerebral anemia the result of the stasis bringing about practically the same cell changes as the former condition. Stoddart 10 supports the theory that there is a carbon dioxide poisoning of the nervous system during sleep. In discussing this theory he recalls the habits of animals in their mode of producing sleep. In every instance the normal supply of oxygen is shut off either by burying their noses in hairy portions of their body and at the same time twisting the body so as to get the minimum amount of oxygen into the lungs. Birds tuck their heads under their wings. Man becomes sleepy in stuffy rooms, and how often one finds pa- tients sleeping with the head completely covered. He directs atten- tion to the fact that patients suffering from diseases in which there is deficient oxidation such as in nasal obstruction, heart disease, ane- mia, etc.. sleep soundly, while those suffering from fever and other conditions in which chemical changes and oxidation take place too readily suffer from sleeplessness. Stoddart has shown that by di- recting a noiseless stream of oxygen to the face of a sleeping patient by means of a rubber tube attached to a tank of oxygen, he can cause the patient to awaken in every instance within forty respirations, even though the stream of oxygen is not allowed to play directly on the face. Bramwell 11 staunchly supports Stoddart in his resuscitation of the carbon dioxide theory of sleep and in the discussion on this sub- 66 AFTER-TREATMENT OF SURGICAL PATIENTS ject lie states that this phenomena is much too complicated a process to present a single factor for its origin. He considers almost all the theories advanced "are equally important and must exist together and at the same moment in order to produce healthy or natural sleep." If there is one theory more important than another, he would place, perhaps, "psychic calm," for "if this is absent two other conditions essential to sleep must also be absent; namely, a lowered or a certain required blood pressure and cerebral anemia or stasis." Bramwell suggests that "patients whose ocular muscles are intact and therefore without danger of strain, should turn the eyeballs upwards, with the lids closed as in sleep. This will promote a feeling of drowsiness" while, as so often experienced by all of us, "to turn them downwards causes an opposite effect, with tremor of the up- per lids and a tendency to squeeze the upper and lower lids together." Treatment further than has been suggested above may become necessary to relieve the minds of these unhappy and often appre- hensive patients. The drug treatment is to be avoided if this is pos- sible. Probably the first measure to be attempted is to find the cause of the condition. This is as important in the convalescent surgical patient as in those sufferers from medical causes alone. Any per- nicious habit is so far as possible, corrected. Hygienic measures as suggested above are rigidly enforced and the patient when fixed up for the night lies perfectly quiet in anticipation of sleep. He at- tempts to leave his mind a blank and no disturbing thought is al- lowed to remain a single moment. Turning the eyeballs upward as suggested by .Mil lee or slighl pressure on them by the nurse may in some instances be conducive to hastening sleep in the very nervous individual whose mind nat- urally is overactive. Hypnotism'- is suitable in some cases, and when intelligently administered has been extremely valuable in some instances. Suggestion is another factor which must not be underes- timated in patients whose confidence and perfect trust has been se- cured by the doctor or the nurse. The gastrointestinal tract should never in any instance be neg- lected. Autointoxication from excretory products is carefully guarded against by keeping the bowels open, giving a carbohydrate diet if an excessive putrefactive process is suspected, and other elim- inative measures actively and consistently carried out. In this connection I would not fail to note the patient's hunger and at once supply food. Usually liquid foods, hot and in some cases a placebo, such as a little nutmeg sprinkled over the fluid will give an additional assurance of the patient's rest after the food is given. SLEEPLESSNESS 67 If ; however, some solid food is demanded, this, too, is not denied so long as actual indigestion does not cause more disturbance. The eyes should not be overlooked in any case where there is any suspicion of trouble. The assistance of an oculist will solve many hard problems in dealing with some of the most intractable cases. Hydrotherapy is often followed by good results. A warm bath be- fore retiring or a sponge by the nurse, followed by an alcohol rub, gentle massage or both, will be rewarded by good results. The value of the hot foot bath resorted to by many patients is well known. Some even employ the mustard bath to the point of getting a general redness, a practice which I have never been compelled to utilize in the postoperative patient. The drug treatment is employed as the final resort. If there is pain, this, of course, is at once relieved without delay. I have found 10 grains of aspirin combined with 1 grain of codeine indeed very efficacious. The codeine is alone repeated if it becomes necessary. Opium suppository (1 grain) will often give relief in abdominal or pelvic cases, and at the same time the patient is not aware of any medication given. Where there is painful peristalsis, paregoric, 1 dram, given each hour will relieve, and permit sleep. Chloral hy- drate, 30 grains, per rectum in a little oil may be employed in those patients not suffering from pain. Paraldehyde, 60 grains, may also be given, either by mouth or rectum. Veronal or sulphonal, 5 grains each, given in hot liquids is frequently employed. The bromides, given during the day and at bedtime, have been used for sleeplessness since medicine first came into existence. I often follow this old-time custom, and in many instances meet with success. The bromides, however, are slow in their action and can not be relied upon in all cases of malady appearing in patients who have gone through a major operation. Bibliography iWalsh: Internat. Clin., 1914, ii, series 24, p. 121. sPronger: Lancet, London, 1914, ii, 1357, also New York Med. Join- 1915, ci, 37. Ohs. 3 Clarke: Lancet, London, 1915, i, 98. tGrubb : Ibid. sWilliams: Virginia Med. Semi-Month., 1913-14, xix, 339. eSavage: Brit. Med. Jour., 1913, ii, 1206. ^Howell: Textbook On Physiology. sHill: Quoted by Savage. aMiller: Bait. Med. Jour., 1913, ii, 1212. loStoddart: Ibid., 1208. nBramwell: Brit. Med. Jour., 1913, ii, 15 to 63. i2Long: Brit. Med. Jour., 1913, ii, 1209. The following was also consulted: Morris: Analytic Cyclopedia Practical Medicine, 1916, i, 10. CHAPTER IX HICCOUGH By 0. F. McKittriek, St. Louis, Mo. Hiccough (singultus, hiccup) occurs frequently after abdominal operations. As a rule, it is an unimportant malady, one characterized by mild and transitory attacks, which cease automatically or else is amenable to the simplest treatment. However, it may be the fore- runner of the gravest complication, whether associated with, or in the absence of, some form of chronic disease, the affection, either in its acute or chronic form, becomes extremely distressing if it per- sists over long periods of time and occasionally this happens despite every effort made to control it. The exhaustion which is necessarily entailed may lead to the fatal termination of an otherwise normal convalescence. According to most observers, hiccough is produced by sudden, in- voluntary clonic contractions of the diaphragm, with which the nor- mal action of the vocal chords fail to synchronize. The unexpected descent of the diaphragm further increases the negative pressure in the chest into the viscera of which the outside air rushes but is partly checked by the nearly closed glottis. The air which enters causes sudden vibration of the vocal chords, the characteristic coarse sound being thereupon emitted. It is considered by some that there is spasmodic contraction of the abductors of the cords which com- pletely stops the entry of the air, hid ('air 1 thinks this improbable. There is a double nervous mechanism which is concerned in hic- cough. According to Sajous, 2 the vagospinal nerves bring aboui closure of the glottis and contraction of the stomach with accom- panying relaxation of the pyloric sphincter. The phrenic nerve con- trols the diaphragm and a (enter which coordinates these movements is supposed to exist in the medulla, its action being stimulated by im- pulses from numerous efferent nerves which are indirectly connected with it. Irritation from the absorption of toxins or from any other source may bring about this condition by stimulation of the phrenic nerves at their origin (in the fourth cervical nerves) anywhere along their course to the diaphragm or in their terminal libers in the under surface of this muscle. Stimulation of the third or fifth cervical nerves, will also theo- retically bring about such a result. It therefore follows that re- 68 HICCOUGH 69 flex stimulation may occur through the branches of the vagus nerve, particularly its gastric terminations, or irritation in any organ or tissue supplied by this nerve, may cause like phenomena. Stimula- tion of other visceral nerves as those to the uterus, bladder, kidneys, etc., or involvement of the peripheral sensory nerves may through reflex action bring about hiccough. Stimulation of the center con- trolling these phenomena may also produce this condition. The most frequent cause is reflex stimulation of the phrenic nerves through the gastric branches of the vagus. Hence very hot or very cold fluids, an excess of condiments in the food whether fluid or solid, overeating, or the retention of undigested food particles in the stomach, distention of this organ or any irritative factor in the intestines, such as feces at times, an enteritis due to parasitic infec- tions, etc., may be fruitful inciting causes. Functional or organic dis- eases of these viscera, associated with an overlying irritated perito- neum, particularly that on the diaphragmatic surface are common causes. Bassler 3 reported two cases of persistent hiccough due to a hyperes- thesia of the stomach. The condition which he named "singultus gastritis nervcsus" was one associated with loss of weight in the pa- tient caused by the constant irritation of the food, etc. The condi- tion is very rarely met, but it may be a source of some obstinate case and should be borne in mind. Persistent hiccough is usually of grave import in peritonitis, par- ticularly if associated with some abdominal malady. In a case ob- served hiccough persisted two weeks just before death of the patient after an exploratory laparotomy in which was found an inoperable carcinoma of the stomach. Although the peritoneum was free at the time of the laparotomy, at autopsy, three weeks later, there was quite extensive involvement. Another case in which persistent hic- cough occurred was seen in a patient suffering from inoperable carcinoma of the bladder. The hiccough developed one week after an exploratory operation and persisted until the patient's demise two weeks later. It usually comes late in a disease and at a time when the abdomen is distended. Particularly is this true in intestinal obstruction, ul- cerative conditions of the intestines, pancreatitis, diseases of the uterus, prostate, or bladder. Marion 4 believes this symptom occurring after operations on the urinary tract is in the great majority of cases, a uremic manifestation ; hence in patients suffering from chronic kidney diseases, this symptom is particularly ominous. The condition may intermit for varying lengths of time, and recurs without apparent 70 AFTER-TREATMENT OF SURGICAL PATIENTS reason ; after several days of suffering during which the patient loses considerable weight, he becomes very much enfeebled. It, however, not infrequently causes death in such cases without the symptoms ever becoming abated. The comparatively frequent occurrences of hiccough in fatal cases where there are extravasations of urine after an operation for the relief of stricture, is, no doubt, due to some associated kidney lesion. Diseases of the thoracic viscera may cause this symptom. Affec- tions of the pericardium or diaphragmatic pleura especially may result in distressing hiccough. Contamination of the blood by toxic or infectious materials such as those produced in pneumonia or gen- eral septic infection may produce this phenomenon. In such con- ditions it seems probable that tbe nerve centers are involved as well as the diaphragm or the nerves themselves. In operative patients who are suffering at the same time from gout or diabetes, the blood, especially, plays an important role. Local irritations from abdominal or pleural pus collections not un- commonly cause irritation of the nerves which supply the diaphragm as do tumors located in the mediastinum, in the neck, or in the lungs by pressure on the phrenic nerve. Green 3 reported a case of hic- cough which persisted for six months and ended in death of the pa- tient. At autopsy ;i small malignant growth was found at the hilus of the lung which evidently had caused the irritation of the phrenic nerve. Hiccough may be due to central irritation or to reflex stimuli in neurotic patients. It may occur in hysterical patients or those suf- fering from epilepsy. Cerebral tumors 6 occasionally bring about such a condition or it may follow shock, some emotional disturbance, or organic functional disease of the nervous system. In a case of per- sistent intermittent hiccough seen, every known measure was em- ployed to stup the paroxysms. The patient's blood was examined for syphilis and showed a negative Wassermann. Certain siyns sug- gested a tabes dorsalis. In spite of the negative blood findings, anti- syphilitic treatment was instituted with prompt amelioration of the symptoms which never returned. Peripheral irritation in neurotic patients may result in tin 1 ap- pearance of these symptoms. I have seen hiccough follow exposure to cold, especially to sudden chilling of the body, after bathing in cold water. 0*Reilly 7 reported a case which was being treated for hepatic cirrhosis; hiccough persisted despite the usual routine treat- ment. Finally the ears were examined and impacted wax was found and removed. The hiccough ceased without further treatment. HICCOUGH 71 Hiccough occurs in too many conditions to attempt to name them. As King has said, it may occur in almost any acute or chronic ex- hausting disease. The condition may be of little importance in the everyday routine of life, but after operation it should be especially enjoined that in every case, the cause of the condition should be de- termined if possible, and this corrected before the patient passes be- yond relief, because of exhaustion or on account of the disease which is producing the symptoms. The remedies employed for the treatment of this malady are legion. This is the best proof we have that no one remedy is effectual in every case. However, the measures which we will men- tion are those known by us to be worth trying under such circum- stances. I have never failed to stop this symptom except on the two occasions mentioned above, and these patients were dying from inoperable cancer. In most cases, the simpler remedies will usually suffice, among them may be mentioned the drinking of one-half glass of water in which a teaspoonful of sodium bicarbonate has been placed, swallow- ing of ice, sucking a lemon, taking a little vinegar or common table salt. Probably one of the oldest and most efficient of the common remedies is the holding of the breath while large swallows of water are taken. King suggested that the patient at the same time stop the ears with his fingers while his nose is held tightly closed. Air is thus prevented from entering the pharynx except through the mouth. If two or three trials fail to stop the symptoms, the tongue should be thrust out synchronous with each respiration, which should now be increased to 30 to 50 per minute. Each respiration should be deep. This however, exhausts the patient and should not be kept up very long at a time. Massage along the course of the phrenic nerves in the neck or counterirritation with mustard leaves here as well as over the epigastrium may prove an efficacious treatment. 8 If the symptoms continue, the alimentary tract should be freed of all ma- terial which can be the causative factors. If the nature of the operation permits, free catharsis may be instituted by giving pur- gatives per mouth, otherwise, enemas will suffice. The stomach should be emptied. A simple emetic such as a teaspoonful of mus- tard in a cup of warm water may be tried at first. Apomorphine, Y 10 grain subcutaneously is particularly suitable in that not only is the stomach emptied, but the act of vomiting causes the diaphragm, to contract violently and this alone may stop the clonic spasms. The tube may be used also for clearing the stomach, and in pa- tients unused to it, this is especially indicated. With the gastroin- 72 AFTER-TREATMENT OF SURGICAL PATIENTS testinal tract cleared out, other remedies can now be tried. Since so many different drugs have now and then acted well in different patients, it is probably advisable to continue the use of other medi- cinal measures. Inhalation of amyl nitrate or injections of cocaine, V-io to %o grain hypodermically, may be tried. By all means force the intake of large amounts of water, in which sodium bicarbonate is freely given. Other measures such as me- chanical interference may be employed. Forceful manual compres- sion of the costal margins of the lower ribs and the epigastrium at intervals of three or four minutes is good, or a tight adhesive binder may be placed around the lower portion of the thorax. Jodicke 9 de- scribes a good method for obstructing the diaphragmatic movements. He forces the intestines up against this muscle by flexing the legs upon the thighs and has them flexed on the abdomen and pressed as firmly as possible against this part of the body. He reported a serious case in which this procedure was successfully employed. The hiccough stopped in ten minutes. The condition is relieved in many instances by the patient placing his arms above his head and then pulling his weight upward in the bed by holding to the head railing. If in spite of all the measures suggested, the symptoms persist, the kidneys may be at fault and measures should be undertaken as described under the treatment of uremia. Should the symptoms still persist, then morphine must be resorted to. It should be given hy- podermically until the full physiologic effects are seen. In one case that I have treated the respiration was cut down to four per minute, while in another it was diminished to only three per minute. One patient was cured and the other temporarily relieved. Caffrey 10 failed to stop the symptoms in a severe ease by using this method, then he injected ',.-,,, atropine sulphate subcutaneously and the symp- toms at once cleared, never to return. The hiccough had persisted four years, and in this time every known remedy had been tried. Chloral hydrate and the bromide-; have been used repeatedly with varying degrees of success. Recently, Segal used epinephrin, 10 drops of a 1:1000 solution, which stopped a hiccough which had lasted eleven days, even in spite of chloroform anesthesia. Lately, Mead 11 reported a case which was cured by menthol after none of the usual methods had brought relief, lie uses 10 drops of a saturated solution of menthol in spiritus vini recti and this is repeated every hour if necessary. In babies, hiccough may be stopped by giving them plain water. Grape sugar or granulated sugar placed in the mouth often stops the malady. In older children, the same measures are used as those HICCOUGH 73 employed for adults, except perhaps the medication. The mechani- cal measures should be persisted in for longer periods of time than with adults. Provoking sneezing may be efficacious. In hysterical or neurotic patients, the treatment as suggested for older children should first be tried. Autosuggestion or hypnotism is indicated. Valerian is especially efficacious. Ether narcosis may be employed as a last resort in the usual persistent case of hiccough which is threatening life, but in these hysterical patients, it should be employed early in the condition. The hiccough rarely returns after the first narcosis. The esophageal sound has been passed successfully in a few in- stances, one such was reported by New 12 at the Mayo Clinic, in over- coming a hysterical hiccough. The patient had been operated sev- eral times, for various conditions among which were appendicitis and stone in the kidney. After each operation, the patient had hic- cough which lasted from one to twelve hours. After the last oper- ation, hiccough appeared at short intervals for four months, after which date it persisted day and night for five months longer. The rate of the hiccough varied from 20 to 72 per minute. During this time many measures were tried to secure relief. C. H. Mayo ad- vised intubation since he believed the nervous condition alone pro- duced the symptoms. Following intubation with the largest size of O'Dwyer tube the hiccough stopped at once. Three hours later, the tube was coughed up and the hiccough started again. The tube was again introduced and remained eight hours in place, after which time it was coughed up but the hiccough did not return. The pa- tient was permanently cured. Intubation therefore is placed on the list of the many remedies for this condition, but no treatment should be left untried in the hope of finding something which will relieve the patient of a symptom which more than once has demanded death for its toll. Bibliography iCarr: The Practitioner, 1911, xxxvii, 519. 2 Sajous: Analytic Cyclopedia Practical Medicine, 1916, v, 530. sBassler: New York' Med. Jour., 1910, xcii, 311. 4Marion: Jour. d'Urol, 1913, iii, 580. sGreen: Med. Klin., July, 1911. sKing: New York Med. Jour., 1911, xciii, 826. ^O'Eeillv: Canadian Lancet, Feb., 1914. sWoodwark: Pract. Encycl. Med. Treat., 1916, p. 316. ajodicke: Med. Klin., May, 1911. iQCaffrey: Jour. Am. Med. Assn., 1913, Ix, 1S79. nMead: Med. Bee, New York, January, 1914. i2New: St. Paul Med. Jour., 1913, xv, 466. CHAPTER X HEADACHE By 0. F. McKittrick, St. Louis, Mo. Headache is one of the most common symptoms with which the medical profession lias to deal. It is natural, therefore, that it should present itself frequently in the postoperative patient, and for this reason we are forced into the discussion of a subject upon which volumes already have been written. However, a certain amount of familiarity with its various forms is essential, in order to intelli- gently carry out adequate treatment when the occasion arises. The disturbance maybe very mild and transient in nature, not indicating any especially important upset in the patient's condition, or it may become quite severe, being the forerunner of some important com- plication. It often accompanies some serious constitutional disease. This symptom arises as a result of an almost unlimited number of disorders, and the mechanism of its production is still one of the unsolved mysteries of medicine. It has been thought to be due to irritation of the terminal sensory branches of the fifth nerve or the vagus branch supplying the meninges. The pain most commonly complained of is a dull ache or throbbing in the head, but frequently it is acute, sharp, shooting, boring or stabbing. It may continue for a number of hours or days, but is more likely to be transient or paroxysmal in occurrence. The location of the pain in the bead is of little importance, accord- ing to Cabot. 1 Ocular headache usually begins or centers around the region of the eyes, whereas that due to inflammation of the frontal sinus, antrum, middle ear, or the periosteum, spreads from a point over the initial lesion. The headache may be confined to the tem- poral, parietal, occipital, or frontal regions on one or both sides, or it may be generally distributed throughout the whole head. It has been generally conceded that migraine is unilateral, but other con- ditions, such as uremia, brain tumor, neurasthenia, etc., may also excite a unilateral headache. It is apparent, therefore, that too much reliance in making a diagnosis of the causative factor or fac- tors can not be placed upon either the kind of pain or the location. For a practical working basis, I agree with Leszynsky- that head- aches should be divided in two classes - functional and organic. Func- 74 HEADACHE 75 tional headaches are so varied and so frequent that to classify them is almost impossible. In this group are included those headaches due to conditions not located within the cranial cavity. Head- aches referable to various constitutional or psychic disturbances are also included in this class. The organic form includes all headaches due to intracranial dis- ease, or disease of the skull. Probably the most frequent form of functional headaches is toxic in nature. Under this class may be mentioned as exciting causes (1) operative concern, (2) ether, (3) fatigue, bad air, (4) insola- tion, (5) constipation and indigestion, (6) infections, (7) poisons, and (8) constitutional diseases. Nervous individuals, and those patients who have worried over the oncoming operation, frequently develop a headache before etheriza- tion takes place. These same patients, because of any divergence from the routine of the postoperative treatment, such as entertaining visitors, sudden anger, disappointment, or what not, are aften no- ticeably victims of this unpleasant complication. Ether headaches very soon follow the narccsis, but do not, as a general rule, persist for a long time. Local anesthesia or spinal analgesia are more lia- ble to excite this symptom than ether, and the effect, in my experi- ence, is far more lasting. Fatigue and bad air do not go hand in hand, though the association is so common in these patients that one can hardly resist the feeling that with abundance of fresh air and sunlight, fatigue would often be delayed. Cabot suggests that the fatigue is due to the circulation of ''fatigue poisons." In summer time, especially, and following a "heat wave," patients develop headaches which seem to be due to overheating. Most of such cases are, more or less, "nervous" and no doubt part of the distress is instigated by this affection. The absorption of the excretory products of the body or fermen- tative or decomposing food within the alimentary canal certainly plays a most important part in producing this condition. Autoin- toxication from this source was long ago demonstrated clinically as a very productive factor in causing headaches. One of the first things to be considered in the treatment of the condition is to thoroughly eliminate these poisons by emptying the bowels and flush- ing the kidneys. Constipation per se does not always cause a head- ache, for patients very often go many days and even a week with- out a bowel movement without symptoms. On the other hand, others are very susceptible, and a very slight irregularity produces severe headache. Gastric or intestinal indigestion will cause headaches 76 AFTER-TREATMENT OF SURGICAL PATIENTS through absorption of the toxic material thus generated, through reflex irritation of the vagus or sympathetic nerves, or from gaseous distention of these viscera, due to the abnormal fermentation of the undigested food. Dizziness frequently accompanies the headaches produced by intestinal intoxication, and the urine in these cases will show an increase in the indiean reaction. A decrease in the alka- linity of the blood, as seen in acidosis, or a retention in the blood of excrementitious substances, as seen in uremic patients, are likely to cause persisting and severe headaches, which are relieved only when the exciting causes are reduced by elimination. Infection or inflammation, accompanied by fever, often produces acute headaches. In postoperative cases, it is usually the result of catching cold. Rarely it is the symptom of some acute exanthema- tons disease superimposed on the surgical operation. The height of the fever, the character of the pulse, and white blood count are im- portant adjuncts in making a diagnosis. The withdrawal of poisons, such as alcohol, morphine, tobacco, coffee, etc., usually exert their effects. It is not infrequently seen in patients long addicted to their use. ami unless the demand is sup- plied, the headache becomes persistent and quite severe. Constitutional diseases such as gout, diabetes, chronic rheumatism, or hypothyroidism may cause headaches at times. Another form of functional headache comes under the heading of the psychoneuroses. This includes (1) neurasthenia, (2) hysteria, and (3) epilepsy. Neurasthenia is fast becoming an obsolete term for vague nervous affections, which apparently have no cause for their existence. Headaches assumed, or in most of the cases actually experienced, are peculiar, in that so often only a fullness in the head, as Leszynsky notes, or a restricting band across the forehead. The disease in- creases in severity with the increased attention given the patient. Hysterical headaches appear suddenly, and apparently are very severe, but of short duration, and are usually localized. Other signs of hysteria may accompany the symptom, such as convulsive attacks, muscular spasms, etc., the condition like neurasthenia is very favor- ably influenced by suggestion. Epileptics frequently develop headaches following convulsions. Tins symptom occurred regularly in one of my patients, the condi- tion, however, lasted but a short time, but the number of convulsions could be accurately ascertained by the number of lime- the headache appeared. Functional headaches due to vasomotor disturbances are fairly HEADACHE 77 common. Changes in the atmosphere, excessive hard mental work or worry, insomnia, venous engorgement from chronic heart disease, coughing, emphysema, or any act or condition resulting in obstruc- tion to the venous return in the neck, 3 may cause the onset of this unpleasant symptom. Cerebral anemia following loss of blood at operation, as a result of posture, shock, or arterial disease, is very likely to produce headache, the severity and duration depending upon the extent of the anemia. Migraine, sick headache, or hemicrania, is a form of vasomotor headaches, which stands alone in its tenacious persistence and se- verity of symptoms. It is said that the immediate cause is a spas- modic contraction of the cerebral, or other arteries, on one side of the head, followed by unusual dilatation of these same vessels. The disease is usually preceded by a few days prodromal symptoms of lassitude, irritability, feeling of fullness in the head, etc. : the head- ache gradually begins, and finally reaches a severity which is almost unbearable for the patient. One side of the head is involved at a time, though both sides may become alternately affected. The attack lasts several hours, and at times several days elapse before the pain disappears. The condition is a periodic inherited one, and a diag- nosis is made by the history, character of the attacks, and location of the pain. The last but very important form of functional headache is the reflex type. This includes the affections of (1) eye, (2) nose and pharynx, (3) mouth, (4) ear, also (5) gastric and menstrual forms. Ocular imperfections are such a common source of headache that they must be seriously considered in every case not responding quickly to treatment. Astigmatism alone is one of the most common causes of persistent headache. It is usually aggravated by overuse of the eyes. Errors of refraction, inflammation of any part of the eyes, iritis, glaucoma, etc., are often followed by headaches. Nasopharyngeal obstructions, inflammations, deformed septum, polyps, etc., are frequently the cause of headache, and especially in the chronic mouth-breather. Carious teeth were found to be a cause of persistent headache in one of my cases. On removal of two teeth, the headache ceased at once, never to return. Impacted cerumen in children has occasioned a disturbing head- ache. This condition has not been observed in any of our adult cases. Gastric conditions producing headache have already been men- tioned, but reflex hunger pain, exhibited in postoperative patients, 78 AFTER-TREATMENT OF SURGICAL PATIENTS is likely to be followed by headache, if the hunger is not appeased within a short time. Menstruation is a common cause of headache, which usually oc- curs preceding or just following it. It is not a hard condition to treat as a rule. Cabot, quoting E dinger, calls attention to headache which has been termed "indurative" and is associated with painful uneven nodules near the insertion of the muscles attached to the occiput. When these nodules disappear under massage, the headache is at once relieved. These indurations have been felt in a few of our cases after operation, and in each case they were accompanied by headache which was relieved by firm, deep, rotatory massage. The cause of the condition is not known, and so far as I have been able to learn, microscopic examination has not been made to explain the condition. The organic headaches present a varying number of causes. Among the first to consider probably, is inflammation or disease of the frontal or ethmoid sinuses. The pain in these cases is most severe in front, and usually worse on the side most affected. Middle ear affections and disease of the mastoid are frequently accompanied by headaches. Diseases of the cranial bones or inflammation of the periosteum cause localized and persistent pain at times. The headache is more likely to be worse at night. Syphilitic periostitis is always a likely exciting cause in such localized affections. Intracranial disturbances, which produce headache, such as in- flammation of the meninges, particularly inflammation of the pia, is very likely to be infective in nature. However, affections of the dura, especially in old people, are likely to be due to syphilis. This type of headache is commonly periodical and paroxysmal in nature, worse at night, and there is usually a history of the disease for long periods of time. Cerebral syphilis produces endarteritis, with gum- matous formation, either on the meninges or within the brain sub- stance. In addition to the headache, other symptoms occur, such as vomiting, paralyses, optic neuritis, and possibly vertigo. Intracranial tumors, other than gummata, are exciting causes, at times, of persistent and severe headache. The pain usually is some- where near the location of the tumor, but occasionally the pain is general. Psychic excitement, stimulation of any kind, straining at stool or coughing, etc., always aggravates the condition. The general diagnosis of the cause of headaches is extremely dif- ficult in a large number of cases, and there is a still greater mini- HEADACHE 79 ber of postoperative headaches in which a diagnosis is not made at all. These cases represent so large a number that it is discourag- ing to even attempt the enumeration of known causes. Of cases which do not clear up under ordinary treatment, and in whom the etiology is obscure I would suggest that Cabot's follow- ing question be asked: ''(a) Is the headache of paroxysmal occur- rence and fixed duration (usually, twelve to twenty-four hours), accompanied by disturbances of vision and great prostration (mi- graine) ? (b) Is the history that of a psychoneurosis ? (c) Does the pain recur at precisely the same hour each day?" In addition to the general physical examination and blood for \Vassermann in sug- gestive cases, he would add the following: "Examination of the eyes (including retinoscopy), (2) blood pressure determination (nephritis, tumor), (3) temperature record (infections), (4) uri- nalysis (albumin, sugar, acetone), (5) examination of the nose and its accessory sinuses and (6) palpation of the insertion of the nape muscles at the occiput." The treatment consists first in an earnest attempt at diagnosis. As Schreiber 4 says: "Each headache has a different meaning, and when one considers that all the infectious diseases begin with head- ache, it is one of the most important symptoms with which we deal." "Abrams 3 says that while the diagnosis is being attempted, the pa- tient should be palliatively treated. Certain preventive measures can be carried out in surgical cases. During an operation the brain is being continually stimulated by the cutting of tissues and nerves which have not been blocked." Schreiber thinks this a very impor- tant cause in postoperative headaches, and in patients subject to this malady, nerve blocking may be attempted before the operation be- gins. At the end of the operation the stomach should be washed thoroughly with cool water, which not only cleans out the irritating ether mucus, but also gives tone to the more or less dilated stomach. The patient is then put into a warm bed. and kept comfortable. Surgical shock is another important cause of postoperative head- ache which Schreiber would overcome by the simple measures above. If headache occurs in spite of the preventive measures suggested, the first attempt at treatment is to get the head cool with ice bags or cold cloths. This causes a constriction of the vessels in the be- ginning, followed by a dilatation of the vessels. At this stage, if the patient so desires it, the ice cap can be replaced by the hot-water bag. The feet are kept hot by means of hot-water bags, from the beginning of the attack, and measures begun to thoroughly clear the gastrointestinal tract. 80 AFTER-TREATMENT OP SURGICAL PATIENTS Large doses of phenacetin, acetanilid, aspirin, etc., which so often are next in order, are not particularly subscribed to by Schreiber, since they are so likely to depress the circulation. He would use in- stead, bromides which arc very efficient in allaying the reflexes and thus are very useful in the migraine form of headache. Migrainin, a mixture of antipyrine with caffeine and citric acid, in doses of 10 to 15 grains is also wry useful. In some instances adrenalin 10 to 20 minims, may be given hypo- dermically. This drug occasionally causes vomiting. The congestive forms of headache, those dim to arteriosclerosis or locomotor ataxia respond particularly well to concussion of the seventh cervical vertebra. Clinically this produces a vasoconstric- tion of the vascular system throughout the body, and especially that of the head. Schreiber states that the results are marked and by examining the fundus of the eye at this time, the vessels can be seen to constrict. He used this method successfully in relieving a head- ache due to a cerebellar tumor, which could not be removed at op- eration. Concussion of the tenth dorsal vertebra, however, causes a dilatation of the vascular system, and is attempted in cases which indicate such therapy. The method should not he employed until the other measures have been tried. The claims are based on clinical observations alone. To concuss the spine, an instrument especially devised by Schreiber, is placed directly over the spinous process of the vertebra and then struck a firm blow with a rubber hammer, which is rein- forced with wood. The blow is repeated ten times, after which a rest equal to five blows is enjoined, and then the process is again repeated. This is continued for three to five minutes. The treat- ment can be repealed ^\vvy three to four hours, and kept up as long as necessary. "In that type of headache which seems to involve the region of the occipital nerve, AJbrams finds the most tender point along the nerve by means of linn pressure with some hard instrument, and then freezes it for three to five minutes with ethyl chloride. In diabetics or very run-down individuals, it is not frozen so lone because of the danger of skin necrosis." Schreiber would repeat this treatment as often as the headache returns. Finally, codeine or morphine may he resorted to if no relief can lie obtained by the above measures. Stewart, however, would try to bring about sleep with the bromides and veronal or chloral, before HEADACHE 81 the opium is administered. Opium certainly should not be used for this condition, since opium addiction is particularly liable to develop in such patients. Bibliography iCabot: Differential Diagnosis, 1916, p. 37. 2Leszynskj: Eeference Handbook of the Medical Sciences, 1902, iv, 547. sStewart: The Practitioner's Encyclopedia of Medical Treatment, 1915, p. 428. ■iSehreiber, Louis : Personal communication. 5A.brams: Quoted by Schreiber. CHAPTER XI BACKACHE By 0. F. McKittrick, St. Louis, Mo. Backache is a symptom commonly complained of the day following a surgical operation. In fact many patients give one the impression that this is their most distressing symptom. It is increased usually when the patient turns in the bed or in any manner twists the back or uses the muscles of this region. The pain is located in either the lumbar or sacral regions or both, and is often accompanied by ri- gidity of the lumbal- muscles as noted by Da Costa; 1 the pain may persist for many days, being a fruitful source of annoyance and even wakefulness in the patient. I believe I have heard this complaint by two classes of patients particularly (a) those who have had a general anesthesia (b) those who were lying flat on the back during the operation. This ob- servation gives color to the theory that the normal curve of the spine is maintained by the muscles and ligaments acting together, hence deep anesthesia, by relaxing the muscles, imposes an undue load on the ligaments which are stretched beyond the normal degree if the patient lies on a perfectly flat table. Severe backache is the result. Other etiologic factors have been propounded by various observers. Among these may be mentioned renal congestion, congestion of the spinal cord, etc. Dunlap 2 states that the position of the patient on a hard flat table without a support causes undue strain on the sacro- iliac synchondrosis, while Kosmark 3 considers the strain on the lum- bar ligaments the paramount cause of backache in these cases. Backache existing in patients longer than the first few postopera- tive days is a matter which demands more thorough attention than is usually given these sufferers. I have seen the malady persist for weeks, bringing about serious delay in the convalescence and at the same time inviting condemnation of the surgeon by the patient, until the cause of the condition was Hound and the correct treatment in- stituted. In these instances the backache, probably first started by the position on the table, is kept up by other causes and condi- tions. Diseases long before cured and which had previously given severe trouble with the back may have been started anew by the operative 82 BACKACHE 83 procedure. This symptom which may have been prominent before the operation (which was probably performed for an entirely differ- ent malady) may cause such severe pain that the postoperative care resolves itself into the treatment of the backache alone. The malady is so commonly observed during the after-care of surgical patients that its cause whether due to the operative procedure or some chronic ailment of the patient must be determined and measures undertaken to alleviate the distress thereby produced. The back- ache may not even be mentioned by the patient until he is allowed out of bed. It matters little to the patient whether the pain is rightfully a postoperative complication ; it is a condition to be suc- cessfully met by the doctor in charge of the case and a systematic study of the condition, therefore, can hardly be overlooked in a work of this kind. The lumbar or sacral backache when not due to any of the causes mentioned above may result from the added strain of the operation on a neurasthenic type of patient whose general vitality may be so lowered as to seriously affect the nerve tone. In such patients, par- ticularly of the female sex, Kosmark calls attention to the fact that any pelvic condition such as inflammations, exudates, tumors, uter- ine displacements, constipation, etc., may result in backache. Even in those individuals not so run down or upset by the operation, pathologic pelvic conditions such as those mentioned above are ex- tremely important etiologic factors and this possibility must not be overlooked in patients who are suffering from backache and who were not subjected to a pelvic or gynecologic operation. During the menstrual period, I have often noted an increase in the severity of the symptoms in an already aching back or a beginning of this malady in patients previously free of pain. In the latter instances the backache usually disappeared with the menses. Oper- ations upon pregnant women are very likely to be followed by severe backache. In my experience I have not found adequate means to prevent this malady regardless of the treatment and care afforded such patients on the operating table. "Williams 4 and others have noted the physiologic relaxation of the various pelvic joints during pregnancy and Goldthwait and Osgood 5 state that possibly always — certainly occasionally, during menstruation — this state of affairs ex- ists. There has accumulated considerable evidence to prove that the pelvic articulations, particularly the sacroiliac synchondroses are true joints, having all the common joint structures as stated by Gold- thwait and O-sgood and "that this being the ease, they are naturally subject to the same diseases and injuries as the other joints. When 84 AFTER-TREATMENT OF SURGICAL PATIENTS this is once appreciated and the character of the articulations is considered, and especially when it is remem'bcred that the exact op- position of these is maintained almost entirely by the ligaments, the surprising thing is not that abnormal mobility and disease of the joints ever do occur but that they do not occur more frequently." In view of these findings it is not surprising that backache should occur often in this class of cases following the added strain on the ligaments from muscular relaxation due to the general anesthetic alone, to say nothing of any malposition the patient may have as- sumed during the operation. In studying the cause of backache, trauma is a factor not to be lightly turned aside. I once knew of a patient aged twelve upon whom a tonsillectomy and adenoid operation was performed, who suddenly the next day developed a most severe backache which ne- cessitated several days' stay in bed. It was finally learned after most thorough examination that the patient had fallen out of bed during the previous night. The operative procedure was carried out at the patient's home and was not in the care of a nurse. This prob- ably accounted for the accident. Other instances have been brought to our attention where the patient sat down too hard or had fallen on the hard hospital floor. In discussing other etiologic factors (ioldthwait and Osgood fur- ther state that ''a mere general lack of physical tone naturally pre- disposes to trouble of this sort, the bones are held in place almost entirely by ligaments and it is not to be wondered at that these re- lax and cause trouble as do ligaments of the knee or foot under similar conditions. "In cases in which definite disease is present the same elements which predispose to the special type of lesion in other joints nat- urally favor the occurrence of the same type in the articulations of the pelvis. "Tuberculosis has long been known to occasionally develop in these joints. The in feet ions form of arthritis may also extend to the pelvis in connection with the more general manifestation of the dis- ease. The same thing is true of the atrophic or the hypertrophic forms of arthritis, although the latter is by far the more common. It is in this hypertrophic form that the joints at times become en- tirely fused and that the persistent sciatica or leg pains are so com- monly seen. These referred pains are probably due to the pressure of the hypertrophic tissue upon the lumbosacral cord as it passes over the articulation." Epstein 6 calls attention to these same diseases, however, affecting BACKACHE 85 the spinal column, as a cause of backache. He ventures the state- ment that the general surgeon has removed appendices, ovaries and performed other laparotomies, where the patient might have been much better served by a spinal support or plaster jacket. As a mat- ter of fact such a mistake was made in Bartlett's clinic re- cently. A male patient, aged 41, was admitted for pain in lower abdomen and back. A diseased appendix was removed, but this in no way alleviated his complaint. On closer examination after the patient had had severe backache for a week, a hypertrophic arthri- tis was discovered in the lumbar vertebra with absolute immov- ability in three of them. A plaster of Paris jacket was applied with perfect relief of all symptoms. In the elimination of the various causes of backache which a post- operative patient may present, gout must not be forgotten. Myal- gia of the lumbar muscles (lumbago) is another source for this symp- tom. The etiology is obscure though it often occurs, according to some observers, in patients with rheumatic predispositions. In con- sidering lumbago, one must differentiate from any early osteomalacia. \Veinstein 7 states that if this latter disease is present, there will be a waddling and uncertain gait and a shortening of the patient's stat- ure. Continuing this subject AVeinstein notes that "the rhachialgia of neurasthenia simulates lumbago, but the etiologic features of the latter disease are absent, and there is no aggravation of pain on straining, while there is usually exacerbation under emotion. Myosi- tis, with gradual onset, presents stiffness or rigidity in the extremi- ties and back. The pains are vague for a while, when they take on a more definite character and become localized in various muscle groups. As the muscular involvement rapidly becomes general, skin lesions and edema develop, the true character of the condition is soon appreciated. Malignant tumors of the cord, such as carcinoma, sarcoma, and myeloma, give rise to pressure symptoms, the signif- icance of which can not long be doubted." A floating kidney may also give rise to backache, especially if as- sociated with a general splanchnoptosis. This latter abnormality alone will give rise to severe backache in the patient out of bed. The "enteroptotic habitus" of Mills, and the nervous and dyspeptic dis- orders will help one to claim this condition as the cause of the com- plaint. Occasionally gallstone colic occurs in the convalescing patient who has been operated for some other ailment. Pain in the right shoulder region remains after the attack has subsided. An engorged liver, a pyloric stenosis, or mediastinal tumors may cause backache accord- 86 AFTER-TREATMENT OF SURGICAL PATIENTS ing to Weinstein. He also calls attention to thoracic or abdominal aneurysms as a cause in some instances. Neuritis even that pro- duced by glycosuria may be a fruitful factor in producing back- ache. A pelvic or ureteral calculus or kidney neoplasm gives rise to severe backache at times. Wollheim 8 states that the frequency of the malady diminishes as the tract is ascended. He also notes that in obscure cases of backache, masturbation must be considered an etio- logic possibility. Attitudes or postures play an important role in backache as has been noted by many observers. Goldthwait and Osgood stated with reference to the pelvic articulations that "when once it is appreci- ated that motion in these articulations normally exists, it is easily understood that such attitudes as standing with extreme lordosis, or sitting with the lumbar curve reversed, as in lounging, must cause strain on the sacroiliac articulations, which if continued will result in the same weakness and relaxation as is seen in any of the other joints under like conditions of strain. In stout persons, either men or women, the drag of the large abdomen causes lordosis with result- ing pelvic joint strain and explains the frequency of the sacroiliac weakness in this type of individual." The weight of large tumors will cause their presence to be felt very likely in some sort of hack pain. I had one ease of elephantiasis of the right breast which gave increasing symptoms of pain and backache in the thoracic and Lumbar portions of the spine. Support of the enlarged breast gave only temporary relief. Permanent cure for the condition was the removal of the tumor. The patient was ad- mitted for a hemorrhoid operation, but the backache was so severe that other operative measures were necessary first to relieve the severe symptoms. Backache due to the changes in the position of the fifth lumbar vertebra condition called by Killian, spondylolisthesis is more com- mon than is probably supposed. Lane 10 considered the malady in coal heavers a normal finding and stated that it was indeed common among the laboring classes. Neugebauer, 11 who has given more attention to this subject than anyone else, thought the condition was produced by a thinning of the interarticular portions of the last lumbal' vertebra as a result of im- proper development or fracture of this portion. Others have since shown that it can occur from fracture of the articular processes with- out the changes in the vertebra. Lane considered in some cases, at least, that the change in the interarticular portion is caused by ex- BACKACHE 87 cessive pressure. Golclthwait 12 has shown, however, that the condi- tion can occur without any destruction in the interarticular portion. In such cases he states that because of the various shapes and fac- ings of the superior articular processes of the first sacral segment, unlocking takes place, allowing the fifth lumbar vertebra to slip for- ward. It is not the marked forms of spondylolisthesis but the slighter forms, difficult or impossible to diagnose, which are to blame for some of the obscure continued postoperative backache. Golclthwait also notes as a cause of some back pain, the variations in length and shape of the transverse processes of the fifth lumbar vertebra and that in the height of the superior aspects of the lateral portions of the sacrum. In some cases one of the processes is so long as to even join the sacrum. In this connection Goldthwait states that ' ' if the process were fused to the sacrum there would, of course, be no motion at this point. If it were free the impinging of the end of this process against the top of the sacrum (often forming a true joint), or the posterior part of the ilium, would not only limit the motion, but also, if repeated, would result in sensitiveness at the point of contact." Another cause for backache, particularly that seen in patients who have just got out of bed for the first time after a prolonged stay, is postoperative flat-foot. It has been known for some time that an extended stay in bed will so weaken the muscles ami ligaments of the leg as to produce the typical flat-foot. This is more common in those cases where exten- sion of the leg from fracture, etc., has been maintained without ade- quate support to the ball of the foot. Ogilvy 13 in discussing the subject of weak feet states that it "may or may not be accompanied by painful symptoms in the feet. The symptoms are those of a tired, aching feeling, referred to the lumbar spine, and are noted after the patient has stood on the feet for some time." An increase in the amount of standing or walking will increase the pain Ogilvy 13 says, while rest always relieves the pain. Continuing, Ogilvy notes that "upon examination of the back alone, there is little evidence of the cause of the pain. The spine is freely movable. There is no spasm of muscle or any other sign of any inflammatory lesion, nor is there any tenderness on pressure, nor deformity. The cause of the trou- ble is, therefore, likely to be overlooked, unless the feet are thought of and an examination of them made. These, when examined, are found to be everted. When questioned, the patient admits that the feet tire easily, are sometimes painful, and that the pain at times extends up the leg. It is of the greatest importance to examine such feet with the patient standing, and it is of just as great importance OO AFTER-TREATMEXT OF SURGICAL PATIENTS to remember that flat feet are not necessary to account for the back- ache caused by foot strain.'' In giving the cause of backache, even though the feet are found defective, Ogilvy states that the "'proper foot balance is lost and the body poise is so changed as to throw an excessive weight strain on the muscles and ligaments in the back, producing a dull, boring pain, which increases in severity as the patient continues to overstrain these structures in standing or walk- ing. When the foot balance is corrected and the foot strain re- lieved, the backache is immediately cured." In some cases after all the possible causes mentioned above have been eliminated and the condition still remains unexplained, it has been suggested by most of the writers on the subject that there must be some peculiarity in development which diminishes the stability of the lumbar and pelvic articulations. Coccygodynia is associated with backache in these cases at times. Pain in and around the region of the coccyx is also noted independ- ently of backache. The affection, peculiar to women, presents un- mistakable clinical features, hut so far as I know there is no definite pathologic condition. The symptom more often appears in married patients, particularly those who have borne children, although it oc- curs in unmarried females. I do not recall a single case where it developed in a postoperative male patient. A history of injury is given in most of the eases although in two very typical cases occurring in our patients, no such etiologic factor eould be elicited. In each pa- tient there was a definite neurasthenic hasis upon which I could place the cause of the condition. The pain complained of was sharp shoot- ing and was intensified on sitting up in bed. sudden rising, or during the act of defecation. In the treatment of pure postoperative backache preventive meas- ures are more important than the after cure, hence one will readily appreciate the value of a well-padded table which conforms as nearly as possible to the outline of the spinal column. When the patient re- turns to hed a roll placed cinder the hack, frequent turnings and al- lowing the patient to move of his own accord will often aid in prevent- ing a seven- backache. In other cases the malady will occur no matter what efforts have been put forth to offset it. When it does appear, massage, alcohol rubs and heat may be applied with marked success. The lumbar spine should he supported with bed rolls, pillows, and other simple measures employed to take as much strain off the lum- bal- ligaments as possible. We are usually aide to gain hut a slight measure of relief from change of position, although it may also be tried. The patient must not be allowed to suffer from this condition BACKACHE 89 during the first few days of his convalescence. Among the medi- cines used to give comfort to such patients none seem to give the re- lief that some form of opium combined with the salicylates will ac- complish. Usually I employ codeine y 2 to 1 grain with aspirin, 5 to 10 grains and repeat the codeine within one hour if the pain is not relieved at once. Warm plain water enemas to be retained as long as possible and hot fluids per mouth are also used in some cases with great measures of success. The bowels and bladder are kept empty during the active treatment. The urine is watched for sugar and general eliminative measures carried out. When the symptom is produced by some gynecologic disorder, the condition is met as soon as practical by methods accepted by the best authorities for the individual disease. The treatment given in individual cases depends upon the extent of the lesion producing the symptoms. In every case the important factor is the diagnosis and if the case presents unusual findings the orthopedist, the neurologist, or the internist should be asked in con- sultation and treatment carried cut as directed by either of them. For acute strain of the pelvic articulations adhesive strips two inches wide are placed from the anterior portion of the ilium on the one side to a similar position on the other side. The strips are overlapped and continued to be placed until the whole lumbosacral region is covered. A pad of felt over the sacral region will often be appreciated as a more or less subluxation of the sacrum occurs in these cases. Golclthwait and Osgood state that in relaxed pelvic ar- ticulations frequently there is not correct opposition in the bones, the malposition being a true backward displacement of the sacrum in its upper part. They would correct such a malady by "hyperextending the spine by means of firm pillows under the lumbar curve or hav- ing the patient lie face downward with only the legs and thighs sup- ported upon the table and the head and shoulders upon another, the body hanging entirely unsupported between. In this position the weight of the body drags the spine forward, which favors the re- placement of the sacrum.'' A plaster of Paris jacket is now applied while the patient is in this position. It may be advisable to place the patient upon the frame as shown in (Fig. 152, page 467) which will allow of more sacral pressure. A spica including both thighs may become necessary in order to hold the pelvic bones in place after they have once slipped back from the malposition due to the relaxation of the ligaments. Goldthwait and Osgood would keep such patients in bed four weeks, then allow them to be out with some sort of remov- able jacket which is to be worn three months longer. The jacket, the 90 AFTER-TREATMEXT OF SURGICAL PATIENTS authors say, should fit well down over the trochanters and be made of stiffened leather or plaster of Paris and applied with the patient standing and the lumbar spine moderately extended. In the relaxations without displacement (and these represent the largest number according to my own observation) the adhesive strap- ping of the back and the jacket stated above are entirely sufficient. At night, when the pain is particularly severe, supports in the form of a bed roll under the lumbar curve or under the side if the patient wants to lie in this position may be used. The cases presenting symptoms due to tuberculosis, hypertrophic arthritis, trauma, lumbosacral disturbances, abnormal spinous proc- esses, etc., are treated by immobilization or in some cases even opera- tion then followed by immobilizing measures. In the treatment of coccygodynia the same general measures as noted above may also be employed. Hot sitz-baths. massage, and ef- forts put forth to discard any movement which will in any way ag- gravate the condition, are to be employed. The treatment, however, is generally unsatisfactory. At times the coccyx has been removed even without relief. Lippens 14 recently advised the injection of 0.5 c.c. of 50 per cent solution of antipyrin in alcohol into the third and fourth sacral nerves. In carrying out the technic Lippens points out that the point of exit of the third sacral nerve is an inch outside of the crest of the sacrum and an inch below the posterior inferior spine of the ilium; that of the fourth sacral nerve is a fingerbreadth lower. The treatment is worthy of trial in intractable cases. Bibliography iDaCosta: Modern Surgery, 1014, p. 1206. zDunlap: New York Med. Jour., 1909, xl. 64. sKosmaik: New York Med. Jour., 1915, eii, 5091. *Williams: Obstetrics, 1912, p. 511. sGoldthwait and Osg 1: Boston Med. and Surg. Jour., 1905, clii. 5-95. ^Epstein: New York Med. Jour., 1915, eii, 761. "Weinstein: New York Vied. Jour., 1915, eii, 707. BWollheim: Am. Jour. Surg., 1915, xxix, 406. "Killian: .Quoted by Williams. loLane: Trans. London Path. Soc. 1885, xxxvi. :;<'>l-:;7v uNeugebauer : Monatschr. f. Geburtsh., u. Gymik.. 1895, i. ::i 7-347. i2Goldthwait : Boston Med. and Surg. Jour., 1911, clxiv, 365. isOgilvy: New York Med. Jour.. 1914. e, 1107. i^Lippens: Gaz. de. Gynec, Paris. 1914, xxix, 177. CHAPTER XII SHOCK By Willard Bartlett, St. Louis, Mo. An historical account of the theories concerning shock, according to Crile, 1 reads as follows : "John Hunter, in 1784, was probably the first to describe shock. "William Clowes, in 1568, Wieseman, in 1719, and Garengeot, in 1723, recognized shock, and attributed it to the presence of some foreign body in the wound or in the blood. "Guthrie, in his work 'On Gunshot Wounds,' speaks of waiting 'until the alarm and shock have subsided,' and details a number of cases. "James Little, in 1795, was the first writer to use the word shock in the sense it is now employed. "Travers, in 1827, described a number of cases of shock, and be- lieved that shock to the nervous system might cause death without reaction. "J. A. Delcasse, in 1834, stated that the effects of violence were transmitted chiefly through the osseous system, whereby the living molecules were separated from each other, especially in the brain, spinal cord, and liver. "Erichsen, in his treatise in 1864, considered shock in railroad and other accidents to be due to the 'sharp vibration that is trans- mitted through everything,' — the immediate lesion being, probably, of a molecular character." We were brought nearer to the modern conception in 1870. "In 1870, Goltz made his classical experiments on the frog and concluded that the shock phenomena observed were due to the vasomotor paral- ysis caused by mechanical violence. "In 1873, Lauder Brunton wrote a monograph on the subject, in which Goltz 's theory was accepted. Hofmeister, in 1885, wrote that malnutrition of the heart, fatty degeneration, general weakness, and loss of blood were the chief factors concerned in the production of shock. Gross describes it as a depression of vital powers, suddenly induced by external injuries, and essentially dependent upon a loss of innervation. "Agnew wrote that it is evident, from a clinical standpoint, that the determining causes of shock must reach that portion of the nerv- 91 92 AFTER-TREATMENT OF SURGICAL PATIENTS ous system from which the heart and lungs receive their motor en- dowments, for the feeble action of these organs is one of the fit observed phenomena of shock." This last quotation from his book brings us close to Crile's own vasomotor theory. A host of other writers have considered the subject in different ways and from different angles, there being up to the present time, no unanimity of opinion as to its exact mechanism. Perhaps the best summary of the subject which has appeared to date is a critical abstract by M. G. Seelig, 2 of St. Louis, on "The Nature of Shock." I shall proceed to quote very liberally from it, feeling that this au- thor's experimental work and exhaustive literature study enable him to produce an authoritative summary of the subject. "For nearly a century investigators and clinicians have been pro- pounding theories and promulgating doctrines that definitely located the cause of shock in an aberration now of this function or organ, now of that. Without exception none of these various theories has stood the tests of searching criticism. It is rational to hope, there- fore, that by passing the various older working hypotheses in review. Ave may at least partially comprehend why they have failed, and likewise orient ourselves in a suitable critical attitude regarding the strength and weakness of the new theory. "How may we explain this constant change of front? On two grounds: In the first place a failure to recognize what was so clear to the elder Gross, namely, that "shock is a rude unhinging of the entire machinery of life." and that we must therefore proceed cau- tiously in attempting to locate the unhinging at the door of any one particular organ or function. Secondly, we find an explanation for the multiplicity of theories in the frequent misinterpretations of ex- perimental data or in the drawing of unwarranted conclusions from properly collected data. For example, to take up the most common type of confirmed faulty reasoning, almost every investigator of shock develops his line of thought around the central point that low blood pressure signifies shock. And so indeed it does, but it has never been proved and should never be assumed that low Mood pressure is the primary causative agency of shock." "The needs of more specific criticism make it imperative to deal critically with the development of the more commonly accepted theo- ries of shock, as we know them today. In order to do this we shall select for analysis the following prevalent doctrines regarding the causative factor in shock, which is stated variously to be: "1. Vasomotor exhaustion and paralysis. "2. Cardiac spasm and eventual failure. SHOCK 93 "3. Inhibition of the functions of all the organs. "4. Deficiency of carbon dioxide in the blood (acapnia). "5. Morphologic changes and eventual partial or complete dis- integration of the ganglion cells. "The theory of vasomotor exhaustion as the essential cause of shock was established on what seemed at the time to be a firm basis by Crile. His argument is based on the facts that the essential phe- nomenon of shock is low blood pressure, and that since there is no demonstrable lesion in fatal cases, and no later effects in those that recover, we must assume exhaustion rather than structural lesions to be the cause of this fall. "The vasomotor exhaustion theory has also been attacked directly by the physiologists, Porter, Henderson, and Lyon, and indirectly by numerous other investigators who bring forward theories of their own — Vale, Kinnaman, Schur, Weisel, Bainbridge, and Parkinson. "Henderson believes that in shock 'the vasomotor center does its full duty almost to the last,' that failure of the circulation is due to the diminution of the volume of the blood, by transudation of its fluid out of the vessels into the tissues, and that there is no 'fatigue or inhibition or failure of any sort in the vasomotor center.' "Seelig and Lyon, in two papers, contest the validity of the doc- trine of exhaustion of the vasomotor centers. In their first paper they measured the outflow of blood from the femoral vein in a nor- mal dog, before and after section of the sciatic nerve. After sec- tion of the nerve the outflow was more rapid, as was to be expected. This same experiment was performed on a dog in shock, and despite the shock the outflow was more rapid after section of the sciatic, even more rapid, proportionally, than in the normal dog, thus dem- onstrating that the vasomotor center was transmitting active tonic impulses through the sciatic, even in a state of profound shock. Moreover, by ophthalmoscopic examinations they determined that the arteries of the retina not only did not dilate, but rather that they actively contracted as the animal went into shock. As joint author in this work, it is only fair for me (Seelig) to state that Erlanger contests our reasoning as regards rate of outflow, and also that we should have proved, but did not, that the contraction of the retinal vessels is really an active, tonic contraction and not a pas- sive one due to empty vessels. In a second paper, Seelig and Lyon attack the problem from a different point of view. They em- phasize the fact that in normal animals stimulation of the central end of the cut vagus causes a rise of blood pressure, and that this rise occurs even when the animals are in the profoundest degree of 94 AFTER-TREATMENT OF SURGICAL PATIENTS shock. Furthermore, utilizing Porter's doctrine of percentage rise, they found that the rise was proportionally as high in profound shock as in the normal animal. In order to exclude all reflex effects on the heart, they cut both vagi and removed the right and left stellate ganglia; but even after these procedures, stimulation of the central end of the vagus was followed by a rise in pressure. These authors conclude from their experiments that the vasomotor centers are active in shock. ' ' Of these theories which account for the mechanism of shock, none has made a stronger appeal to the clinician than the doctrine that cardiac failure is the essential element in the obscure symptom- complex — a principle laid down most emphatically by Boise, al- though Howell also admits cardiac shock, as well as vascular shock. Boise, who bases his views largely on the experiments of Crile, Howell, and Porter, attempts to prove that as a result of ex- cessive stimulation of the augmentor nerves of the heart (due to peripheral trauma) this organ is thrown into spasm ; that, therefore, in shock there is increased systole, decreased diastole, lessened output of blood from the heart, and therefore low blood pressure. The low- ered blood pressure in its turn leads to further decrease in the output, establishing, as it were, a vicious circle. "The heart is compromised in shock, beyond a doubt, but cardiac inefficiency is certainly not the primary cause of shock. "Meltzer, it was, who developed in his characteristically lucid fashion the doctrine of inhibition of functions as the underlying es- sential phenomenon in shock. "Meltzer ventures the assumption that the 'various injuries which are capable of bringing on shock, do so by favoring the development of the inhibitory side of all the functions of the body. ' This predomi- nance of inhibition makes its appearance at first in those functions which are of less immediate importance to lite, and are therefore, less insured by safeguards protecting their equilibrium. With in- creased injury, the inhibition also spreads to the more vital and bet- ter protected functions of the nervous system. "Such a doctrine as this serves well as a physiological hypothesis, but to the clinical mind searching for light it is not very satisfying. "The doctrine of acapnia, viz., that shock is due to a deficiency of carbon dioxide in the blood, was enunciated by Henderson within the past decade, and for a time stimulated much work and much criti- cism. Henderson argues that the traumata that induce shock cause rapid deep breathing (hyperpnea) as the result of pain or excite- ment. This rapid dee)) breathing in its turn causes an undue ventila- SHOCK 95 tion of the lungs, during which ventilation, carbon dioxide is rapidly swept out of the circulation. Furthermore, when viscera are ex- posed, in an ordinary laparotomy, carbon dioxide is exhaled from their surfaces, thus lessening the quantity of this gas in the blood. By blood gas analyses, Henderson claims to have proved this primary contention beyond a doubt. Now carbon dioxide is not, as it is so commonly regarded, merely a poisonous excretion. "When there is a reduction of carbon dioxide in the blood, the walls of the veins relax, the pressure in them falls, blood accumu- lates in them, and only a small amount is transmitted to the heart. Constriction of the arteries may for a time maintain a fair blood pressure. At last the supply reaching the right auricles becomes so reduced that arterial pressure falls, the heart beat becomes quick, the output is small, and severe shock is established. Deficiency of carbon dioxide has another remarkable effect. When the deviation from normal is considerable there is a tendency for fluid to exude from the plasma into the tissues. The plasma therefore becomes con- centrated and the total volume of blood diminished. "The conclusion that acapnia does not suffice as a cause of shock therefore seems to be inevitable, even despite the large quantity of data so carefully collected by Henderson over so long a period of time. ' ' In support of this negative conclusion, Seelig quotes the work of Erlanger, Short and himself. It has become apparent to him as to practically every other clinician interested in this subject, that our every-day observations in practical life make it seem unlikely. In reviewing the ' ' exhaustion hypothesis, ' ' Seelig writes : ' ' This hypothesis assumes 'that animals that are especially capable of being shocked are those whose self-preservation is dependent upon special forms of motor activity; that motor activity is excited by adequate stimuli, through nerve tissue directly. Whatever may have been the origin of the motor mechanism and its adaptive response on stimu- lation, there is in each individual, at a given time, a limited amount of potential energy ; that motor activity following each adequate stim- ulus diminishes the amount of this potential energy; that in any animal, a sufficient number and intensity of the stimuli leads in- evitably to exhaustion or death ; that when the motor activity takes the form of obvious work performed, such as running, the phe- nomenon expressing the depletion of the vital force is termed phys- ical exhaustion ; and that when the expenditure of the vital force is due to stimuli which lead to no obvious work performed, especially 96 AFTER-TREATMEXT OF SURGICAL PATIENTS if the stimuli are strong and the expenditure of energy rapid, it is designated as shock. "The essence of the doctrine lies in the belief that the brain cells are composed of labile compounds capable, when adequately stimu- lated, of converting their potential energy into kinetic. If this power to convert is unduly excited and the cells immediately fixed, stained, and studied microscopically, they show what seems to be a deep overstaining due to an overproduction of Nissl substance. If the excitation is continued, the cells stain much lighter and show an altered relation between cytoplasm and nucleus, as well as altered form; finally, if the excitation is continued further, the cells take practically no stain (loss of Nissl substance) and are altered in form up to the point of actual disruption (Crile). "In order to controvert this conclusion, it is necessary to contro- vert his facts or to show faulty logic in his process of deduction. The facts as they stand arc merely confirmations of similar facts made by such trustworthy workers as Hodge, Hertwig and his school, and Dolley. No one has brought forward concrete data in rebuttal. '"•'rile is concentrated on demonstrating a practical method; and in his very attempl he seems to miss the point that hs aims for. He admits, without so stating specifically, the qualitative similarity and quantitative differences of all afferent stimuli. lie demonstrated that fear, trauma, activity, senility, and numerous other states in- duce brain cell changes exactly similar to those of shock. "He thereby links shock with a conglomerate group of other en- tities all the while that he is striving to isolate it. Possibly the statement that he desires to isolate shock as an entity is a misstate- ment, but Crile's whole line of thought and his general conclusions warrant the belief that he is striving to determine the etiologic factor underlying shock as a definite symptom-complex. "Crile may encounter no difficulty in showing that the condition of shock has a definite morphological representation in the ganglion cells of the cerebellum, but he frequently approaches dangerously near the border line of speculative metaphysical reasoning in his at- tempts to prove that the>e same morphological changes are the prime cause of shock. And thus the problem stands — still unsolved." It is suggested that those (specially interested in the study of the mechanism of shock, read Seelig's exhaustive and thoughtful collec- tive abstract in its entirety, the foregoing being made up simply of ex1 racts from it. The uncertainty which surrounds the subject comes out still more clearly the farther one goes into the literature. As an example of SHOCK 97 this statement, read what no less an authority than Henderson 3 has recently promulgated. "Shock, in the broad sense in which the term is often used, is not a single, clear-cut disorder, but a group of conditions which differ one from another fundamentally. However, owing to the fact that these various conditions resemble one another superficially, they are generally confused. The first problem is to define and distinguish each one." Feeling that "shock" was too broad a term and that one might more clearly define his meaning in terms of blood pressure, Bartlett 4 endeavored at Erlanger's suggestion to ascertain by a direct method whether vasodilatation or vasoconstriction characterizes low blood pressure produced in the dog by trauma. To this end, salt solution under constant pressure was injected into medium sized arteries and the rate of inflow studied as the blood pressure fell in consequence of injury to the cerebrum, the extremities, and the abdominal viscera. After the first set of observations, the trauma was applied more or less continuously to the end of each experiment. In some of these experiments, the femoral artery was selected, It was divided high and a cannula was placed in the distal end. In other experiments, the splenic artery was divided as near the aorta as possible, a cannula was inserted clistally, and all the branches supplying the spleen were ligated, leaving only the large terminal branch which anastomoses with the coronary artery of the greater curvature. As a result of this experimental work on ten animals, there can be no doubt of the fact that the rate of inflow in shock was faster than normally the case, the average increase being 36 per cent. It is concluded, therefore, that decreased vasomotor tone is an accom- paniment of shock. It occurred to Mann 5 that the study of shock was important, since, despite the enormous amount of work done on this subject, a critical review of the literature showed an astounding amount of contradictory experimental data and a great number of diverse conclusions based thereon. He feels that the use of the word "shock" should be avoided, and instead, an accurate and detailed description of the pa- tient's condition should be given. If the term be used at all, it should be applied to the condition in which, without any grossly discerni- ble hemorrhage having occurred, the amount of circulatory fluid is greatly diminished on account of the stagnation of the blood in the smaller veins and capillaries, or by exudation of the fluid and cellu- lar elements of the blood from the same. 98 AFTER-TREATMENT OF SURGICAL PATIENTS Engstacl 6 believes that psychic and physical shock are correlated: that psychic shock may follow a very minor or major operation, be transitory in effect, or remain permanent and wreck the patient's life. The various observations regarding the treatment of shock have been almost as divergent as the theories which were advanced to ex- plain the causes and mechanism of it. ('rile 7 states that ''nitro- glycerin, atropine, saline infusion, digitalis, alcohol, caffeine, cam- phor, ergotin. ether, strophanthus, etc., have so many individual, even contradictory, actions that it would seem that these drugs could not all be indicated in the same condition. In selecting one of these drugs in a case of shock or collapse, would it net first be necessary to know definitely to what the fall in the blood pressure is due? It is due to the exhaustion of the anatomic periphery (blood vessels) ; of the heart; of the vasomotor; of the cardiac center: or of the re- spiratory center; is it an exhaustion or a suspension of function, or has the blood plasma passed through the vessel walls? If it is din to exhaustion of one or more of these centers or organs, would stimu- lation relieve the exhaustion, or would an increased exhaustion fol- low the stimulation.' Would it b< better t<> lash the tired horse or givi it restf "If not all the centers and organs are exhausted, would it be ad- vantageous to stimulate those not affected while the exhausted ones' rested.' Would it be advantageous to restore the blood pressure, as far as possible, by use of harmless mechanical mean-.' "Are not the centers governing the circulation automatic, and are they not all automatically stimulated? And are they not all stimu- lated to tlie point of exhaustion before the final circulatory break-down occurs.' As applied to the centers that are depressed, is it better to depend upon a drug stimulation, or upon automatic stimulation?" "Whatever one may think of (file's explanation of the phenomena of shock, one can not fail to agree with the underlying principles of treatment as advanced by this gifted research worker and surgeon. Shock may at times lie anticipated and prevented by far-reaching and rational preoperative consideration of an individual patient's needs. It is often possible to improve a bad risk, merely by rest in bed and proper feeding, previous to the operation. The condition of many a dehydrated person can be marvelously improved by the introduction of liberal amounts of water under the skin or into the rectum. Of course, no preliminary catharsis should be indulged, in here. SHOCK 99 It is an obvious though much neglected fact that a long and te- dious cross-country or railway journey renders an already sick in- dividual doubly unfit to bear the strain of a major surgical proce- dure before adequate time for rest has been allowed. A preliminary blood transfusion, unless there be active hemorrhage from a vessel that can not be controlled, will accomplish wonders toward improving a patient's condition for operation and now that the procedure has become so common and the technic been so greatly simplified, one is surprised that it is not more often resorted to as a preoperative measure. (As early as 1905 Crile was experimenting along this line.) The surgeon must individualize in many directions ; for instance it is obviously unfair to the chronic alcoholic to send him to the oper- ating table after having been deprived for several days of his cus- tomary stimulant. The same may safely be said of the morphine and other drug habitues. A night 's sleep must be assured to every patient who is going to be operated on the following morning. As a matter of course, mor- phine is our most reliable agent for this purpose. Should there, however, be contraindications to its use, an excellent substitute will be found in the rectal administration of potassium bromide (2 drams) and chloral hydrate (10 drams) in 8 ounces of water. Prophylaxis on the operating table concerns itself first of all with body warmth. It is taken for granted that the temperature of the room should be about 80° F. Crile (personal demonstration) for- merly used an operating table which was heated by water circula- tion, while Robb (personal demonstration) employed a much sim- pler and equally effective plan of accomplishing the same object ; viz., he had a number of ordinary incandescent bulbs attached under- neath the top of the table and turned them on or off at will. Hemorrhage and shock have distinctly different physiologic effects although their clinical effects are often by no means easy to dis- tinguish and may, of course, be mixed in the same individual. How- ever this may be, it will be readily granted that accurate hemostasis, inasmuch as it tends to keep the patient in good condition, is in a way a preventive of shock. While not an advocate of haste in operating, I still believe all ob- servers will admit that the man who takes all of the patient's needs into consideration and gets through an operation quickly will, other things being equal, observe less shock in his clinic than will the man whose work entails long exposure. Still more important, perhaps, 100 AFTER-TREATMENT OP SURGICAL PATIENTS in this connection, are delicate manipulation, gentle retraction, and the "featheredged" dissection of ('rile. Nerve-blocking, even where general anesthesia is used, is un- doubtedly one of the best methods of shock prevention at our com- mand. One of the authors observed an intrascapulothoracic ampu- tation done without blocking of the brachial plexus, by one of the most distinguished operators in America, with the result that the patient, apparently of a strong constitution, died the following night. A few weeks later, he witnessed a much less expert surgeon at his first attempt of this kind; but the brachial plexus had been blocked with cocaine and practically no shock at all followed. Cushing long ago called our attention to the fact that the condi- tion of shock persists as long as centrifugal, depressing influences are given off from a crushed and mangled extremity, the result 01 railway or other similar accident. He very rightly urges, therefore, the earliest and gentlest possible amputation as the most logical means of combating shock. When a patient has returned from the operating room in shock, the first thing to be considered is the conservation of the external body heat, since cold extremities, one of the earliest manifestations of shock, indicate a derangement of the cerebral centers which pre- side over the distribution of heat. The use of blankets, electric warming pads, or the electric light cage are among the readiest means at our command for combating chilling surfaces. If the patient is conscious, hot stimulating drinks, such as tea, coffee, and soup should be administered often and in small quantities. Opinions are divided as to the value of alcohol in this connect inn. The animal experiment of ('rile would tend to show that the lowered blood pressure, characteristic of this condition, is by no means helped by alcohol, but is probably influenced in the opposite direc- tion. In shock, there is every evidence that arterial blood accumu- lates unduly in the large internal veins, leaving a deficient supply for the cerebral centers, and Tor the heart to contract upon, hence it would occur at once even to a beginner to lower the head (Fig. 20) and elevate the foot of the bed. Another move in the same direc- tion is to bandage the extremities and put gentle compression on the abdomen, thereby aiding the return How of blood out of the large veins into the arterial side of the circulatory system and helping to reestablish the disturbed balance in the blood pressure. We have at our command, two drugs which act upon the muscu- lature of the peripheral arterial vessels and thus aid in restoring SHOCK 101 blood pressure. They are adrenalin and pituitrin. The action of the former is exceedingly transient and should be thrown directly into a vein in order that the maximum efficiency of it may be realized. About 10 minims of a 1 :1000 solution are best injected in the follow- ing manner : the needle of a hypodermic syringe filled with adren- alin solution is thrust into the lumen of a rubber tube which is carry- ing salt solution into a vein and thus, in a very simple manner, the drug in dilute form is carried into the circulatory system and rapidly diffused. Since the effect is so transient, the close must be repeated every few minutes until a physiologic effect is apparent, though the systolic pressure must not go over 100 says Corbett. Pituitrin Fig. 20.— The patient's head is lowered in order that blood mav gravitate to the cerebral centers and the heart. Water is given continuously under the skin and into the rectum. is thought by many to have a more sustained and perhaps a generally more satisfactory action. It is given by intramuscular injection. Each original package as put out by the manufacturer, contains one to two doses. Subcutaneous injection of salt solution or, as I think better, of sterile water, is generally advocated in these cases, although it is hardly reasonable to consider this one of the most important factors in treatment. Crile informs me in a recent personal communication that he con- 102 AFTER-TREATMENT OF SURGICAL PATIENTS siders blood transfusion the best remedy which we possess for shock. While this position lias as yet not been generally accepted, still we can not lightly pass over any contribution to the surgery of the vascular system which emanates from this source of so much ex- perimental, as well as clinical, knowledge. The general rules for the use of sedatives apply here as well as elsewhere. They are of undoubted value only inasmuch as they inter- fere with the perception of the various stimuli which may, in the aggregate, add to the general state of depression. Bibliography iCrile, George W.: An Experimental Research into Surgical Shock, J. B. Lip- pineott Co., Philadelphia. -Si'dig, M. G.: Collective Abstract on Shock, Internal Abstr. Surg., 1914. "Henderson, Y. : The Pathology of Shock, Tr. Internal Cong. Med.., London, August, 1913, Surg., Gynec. and Obst. iBartlett, Willard: An Experimental Study of the Arteries in Shock, Jour. Exper. .Med.. 1912, xv, No. 4. 'Mann, F. C. : The Peripheral Origin of Surgical Shock, Bull. Johns Hop- kins Hosp., 1914, x.w. eEngstad, .1. E.: Psychic Shock Following Operations, Journal Lancet, 1914, xxxiv, 5-16. "Crilo, George \V. : Blood Pressure in Surgery, J. B. Lippineott Co., Phila- delphia and London, 190.",. CHAPTER XIII HEMORRHAGE By Willard Bartlett, St. Louis, Mo. Postoperative hemorrhage is one of the most distressing accidents that may complicate the after-treatment of a surgical patient. This is particularly true, if it be the result of an oversight or neglect on the operator's part, and the rapidity with which it sometimes over- whelms the unhappy patient, leaves no time for remedial measures. Hemorrhage may be defined in a number of ways ; viz., Concealed, Open, and Mixed. The first two are self-explanatory, while by "Mixed Hemorrhage," is meant that variety in which the bleeding is primarily within a body cavity or wound defect, and approaches the open type when the blood follows a drain or tampon to the sur- face. Hemorrhage may, of course, be arterial, venous or capillary, if one has the source of it in mind when the definition is formulated, and when classifying according to its causation, it may be due to surgical trauma, pressure decubitus, to ercsions of various sorts, to the progress of a dyscrasia, changing the blood itself, or to a general- pathologic process affecting the vessel walls. Perhaps the most gen- erally useful classification of hemorrhage, from the viewpoint of the operator, is one which takes into consideration the time of onset, hence arise the terms Primary, Reactionary, (Matas 1 ), and Second- ary. Primary liemorrliage, as the name indicates, begins at the time of operation and continues after the patient is put to bed. A striking example of it is seen in the recital of the following case which came under my observation: An attempt was made to ligate the innomi- nate artery for aneurysm of that vessel. The surgeon had just sawed through the clavicle and was trying to elevate it, when a tor- rent of blood gushed out. An effort to control the hemorrhage was made with gauze packs and pressure, but the loss continued during the thirty minutes that the patient lived after the accident. The clavicle was found, at autopsy, to have formed a portion of the wall of the aneurysm, and to have been considerably eroded. This is an example, not only of primary, but also of external, arterial, and pathologic hemorrhage, as well. From this it may be seen that no one classification serves to completely define the type of hemorrhage in many instances. 103 104 AFTER-TPFATMENT OF SURGICAL PATIENTS A very well-known type of primary hemorrhage is seen after the division of kidney parenchyma for any purpose which entails oper- ating on the pelvis. No matter how accurately the defect is sutured, blood almost invariably finds its way down the ureter, and as it passes in the form of a clot, characteristic colic is experienced. A form of primary hemorrhage, pathologic in nature, was seen by us a few years ago when an operator made an extensive incision into a myelogenic carcinoma situated in the upper end of the hu- merus. He was unable to control the bleeding which continued for days, and until the patient was exsanguinated. I know of another instance in which a crucial incision was made through an enormous carbuncle and well into the surrounding edem- atous tissues of the neck. The patient never ceased to bleed until his death some twenty hours later. This was another form of patho- logic primary hemorrhage. A primary hemorrhage of the type due to dyserasia was seen after a common duct operation on a highly jaundiced patient. Every stitch hole, as well as the incision itself, continued to ooze from the time they were made until a blood transfusion was done. The study of reactionary hemorrhage (loosely termed "delayed hemorrhage"), is a source of the keenest interest to the operator, since this type, more frequently than the primary or secondary varieties, is directly under his control and may, in many instances, be prevented if proper care and foresight are exercised. During the time that the patient is regaining consciousness he fre- quently increases the blood pressure ;is a direct result of restlessness, and in consequence, forces blood out of the tiny vessels which had been clamped but not tied, because they remained dry while the pa- tient was perfectly quiet. Many a hematoma, infected or otherwise, will be noted at the first dressing by the operator who does not ligate every vessel during the early stages of an operative procedure. Again reactionary hemorrhage, sometimes of alarming extent, is the variety which comes after the use of spring clamps for the tem- porary control of the blood vessels during operations on the hollow abdominal viscera. This can be most readily proved by stomach lav- age after any gastroenterostomy. Reactionary hemorrhage may be- come a matter of the gravest importance in an instance like the fol- lowing one which I observed: About two hours after a thyroidec- tomy, the surgeon was summoned to the operating room, to find his patient suffocating and the neck enormously distended. The stitches were removed, a large blood clot rapidly evacuated, and one of the ima vessels from which a ligature had slipped, quickly secured. HEMORRHAGE 105 Secondary hemorrhage comes at a time remote by several days at least, from the date of the operation and is common after the sepa- ration of a slough in many situations, and resulted in a high mortality during Percy's earlier work with the cautery in cancer of the cer- vix. He soon found it advisable to ligate both internal iliac arteries as a prophylactic measure. This form of hemorrhage, slight in ex- tent, is perhaps most commonly seen now in the separation of the sloughs, which result from the prevalent use of the clamp and cau- tery operations for hemorrhoids. A secondary hemorrhage, as a result of erosion, was exceedingly common in the preantiseptic clays when hospital gangrene was so greatly dreaded. The authors observed a classical example of it in a patient whose lower jaw had to be removed for carcinoma. He commenced to bleed almost two weeks later from the branches of the external carotid artery; infected material had found its way out of the mouth down into the planes of the neck, and erosion of these large vessels taken place. This man's life was saved by the ligation of his common carotid artery, a procedure which we find has been successful in two-thirds of the cases in which it has been attempted. I have noted an instance of secondary hemorrhage from pressure decubitus of the iliac vessels, in consequence of a rubber drain tube being improperly placed and left too long in the abdomen after an operation for acute suppurative appendicitis. A very common pathologic cause of secondary hemorrhage is arteriosclerosis. The early history of ligation for aneurysm of large vessels is replete with instances in which a fatal termination ensued upon the ligature cut- ting through rigid vessel walls. Secondary hemorrhage was seen when a heavy ligature cut through liver substance five days after the removal of a tumor from the lower border of that organ. The pa- tient was so reduced that she succumbed later to the effects of anemia. The amount of blood in the human body has been variously esti- mated by early writers to be from % up to y 5 of the body weight. Most authors of recent times, however, have agreed with Howell 2 and with Stewart 3 in the statement that % 3 of the body weight consisted of blood. This matter can hardly be considered definitely settled, if one agrees with Crile, 4 who writes : "It must be concluded that with our present knowledge the question is still under judgment. The very nature of the problem makes it a difficult one to solve, and at the best the statement that the ratio between the total blood mass and the body weight is a constant one must be considered to be only very roughly approximating the truth." 106 AFTER-TREATMENT OF SURGICAL PATIENTS It would prove a matter of vital importance to the surgeon to know just what percentage of a patient's blood might be lost and the patient still survive. Of course, circumstances alter cases; especially is this true regarding rapidity with which blood is lost, hence, no general definite statement can be made as to the exact amount which may be lost without causing the death of the individual. Still, most authorities agree with Howell that 3 per cent of the body weight may be lost in blood and the patient recover. Matas states that the loss of one-half the individual's blood will certainly cause his death. A very illuminating statement along this line may lie quoted from Tillmans 5 who writes that. '"After severe loss of blood every sur- geon has seen in a relatively short time — two to three days — threaten- ing symptoms vanish in cases where he expected certain death; and again, on the other hand, some patients go into collapse after the loss of very little blood. Very young children may be endangered by an insignificant hemorrhage, and weakly children a year old have died after the loss of only 250 gm. of blood. In strong adults, who are otherwise healthy, the loss of half the total amount of blood is sure to be fatal. Women appear to stand the loss of blood better than men. The formation of new blood seems to take place more easily and rapidly in them on account of the periodic replacement of the blood Losl in every menstruation (Landois). Pat people and old and weak individuals are very susceptible to the loss of blood. The more rapidly the hemorrhage takes place the more dangerous it is." After performing forty-seven animal experiments for hemorrhage and operating a large number of patients affected by it. Crile wrote: "In all varieties of hemorrhage from normal animals there is an im- mediate tendency to a compensatory or natural recovery. Granting the truth of this statement, the question at once juices as to just what a 'compensatory recovery' is. In other words, what do we mean when we say thai 'compensation' occurs in the course of a hemorrhage ? "Compensation may be defined as being the natural effort of the circulatory system to maintain a normal or at Leasl efficient blood pressure after diminution of the efficient vascular content. The phrase 'efficient vascular content' is used advisedly for the reason of stnsis in the vascular trunks. "Eoughly speaking, compensation is noted in all the grades of hemorrhage until such a degree has been reached thai the vasomotor center is no Longer actively responsive to reflex stimulation, such as burning a paw or stimulating the sciatic nerve. With the hemor- rhage and the fall in the blood pressure the specific gravity of the HEMORRHAGE 107 blood falls. After the hemorrhage has proceeded until there is no effort at compensation the animal unaided rarely recovers. If the blood pressure is raised either by saline infusion, by bandaging, or by the administration of adrenalin, sometimes the centers become more active, and the blood pressure assumes and holds a higher level. "In experiments in which the hemorrhage was continued until there was no spontaneous compensation, and there was no response to reflex stimulation, the animal could rarely be made to recover. There was a marked difference in the final result if an interval inter- vened between the time of the ending of the hemorrhage and the be- ginning of treatment. The longer the interval of low Mood pressure the less marked ivere the effects of treatment. In rapid bleeding the blood pressure continues to fall after the cessation of the hemorrhage. The extent of the recovery depends upon the individuality of the ani- mal and amount of the hemorrhage. The proportion of lost blood to the body weight that animals withstood and recovered from varied considerably in individual cases. This degree of variation seemed to us to be greater than is usually given. In some animals recovery occurred when three-fifths of the estimated blood had been lost, while in others death would occur after a loss of two-fifths. It was impossible to estimate in any given animal with any degree of ac- curacy the proportion of blood to its body weight which it might lose and recover. "What, then, are the secondary factors entering into the fall in the blood pressure and its recovery ? It may be assumed that the pri- mary factor is anemia with consequent lessening of the immediate nutrition of the active physiologic mechanism for the maintenance of the normal blood pressure. Among the secondary factors we may assume that the action of the vasomotor center stands first." Not only do the important nerve centers suffer impairment of function as a cause of acute anemia, but all authorities agree that cardiac activity is satisfactory only as long as there is a sufficient volume of fluid within the auricles and ventricles. The restoration of the blood after hemorrhage was studied by Kiefer, 6 who found that the red corpuscles were restored in number more quickly than was the percentage of hemoglobin. Bierfreund 7 found the regen- eration of the blood to commence within five to twenty days after the rather insufficient loss which is attendant upon the average sur- gical operation. Von Mikulicz 8 studied regeneration after the loss of large amounts of blood and found compensation to be as follows : 1. Less than 1 per cent of the blood mass in two to five days. 108 AFTER-TREATMENT OF SURGICAL PATIENTS 2. From 1 to 3 per cent of the blood mass in five to fourteen days. 3. From 3 to 4 per cent of the blood mass in fourteen to thirty days. Diagnosis. — The diagnosis of an open hemorrhage or one of mixed type where blood follows a drain to the surface, needs, of course, no extensive comment. It becomes quite a difficult matter when the diagnostician is confronted by a patient who appears to be failing rapidly after a difficult and prolonged surgical procedure ; then the problem of differential diagnosis between shock and con- cealed hemorrhage becomes difficult, or as many of our most experi- enced writers agree, well nigh impossible. One instance in my ex- perience shows how difficult it may be to differentiate between post- operative hemorrhage and perforation of a hollow abdominal viscus: An exclusion of the pyloric region, together with a gastroenteros- tomy had been done for ulcer. A few days later, the patient rather suddenly entered a state of seeming collapse, while complaining of se- vere pain in the epigastrium. I naturally feared that a stomach suture line had given way, hence, reopened the abdomen immediately, only to find the upper intestinal coils full of blood. Fortunately, in this instance, conservative treatment resulted in the patient's recovery, while the painful incident demonstrates very well one of the pos- sibilities of error in the diagnosis of concealed hemorrhage. Almost in line with this case was a remark which I once heard W. J. Mayo make, as a part of one of those delightful and instruc- tive clinical talks which he is accustomed to make in the operating room. He was discoursing on shock, and surprised us all by stat- ing, in his cryptic way, that he had usually found the abdomen full of blood at autopsy on patients who had died of shock following an abdominal operation. This points in no unmistakable way to the relative frequency of the two conditions. Matas very well summarizes the leading features in symptomatol- Ogy, when he tells us that the picture varies directly with the amount of blood lost, the rate at which it escapes, and with its location. As a matter of course, the symptoms to be immediately detailed will be more impressive, the larger the hemorrhage, or more rapid the flow, while the symptoms attending the escape of a given amount of blood into an elastic space, like the peritoneal cavity, are much less alarming than those which attend the rapid accumulation of the same amount in the fascial planes of the neck, which enclose the trachea, as happened a few hours after one id' my goiter operations previously mentioned. The effects of acute anemia make themselves known in several HEMORRHAGE 109 ways. The heart muscle gets a decreased amount of blood through the coronary vessels, hence, is unable to functionate in the normal manner. The respiratory center is stimulated by the lack of oxygen and we see the expression of increased respiratory action, which is termed "air hunger." The psychic manifestations of cerebral anemia are anxiety and restlessness. All the while the leucocyte count may be said to rise steadily in a typical case. It might be thought from the foregoing that a diagnosis of concealed hemorrhage is a matter of mathematical certainty. On the contrary, I have seen, at least, one fatal instance in which the patient was perfectly free from restlessness and "air hunger" up to the time of dissolution. The picture of hemorrhage is not complete without mention at least of posthemorrhagic anemia and its consequences. It has, how- ever, no features which distinguish it from chronic secondary anemia in general, hence, no space will be devoted to it here. The treatment of hemorrhage must begin with preventive measures. The finding of a high blood pressure puts one on guard and may limit the extent of a surgical procedure that would seem indicated under the circumstances. If the clotting time of a patient's blood is found to be longer than eight minutes, the surgeon should be on the alert for a dyscrasia, which might allow a comparatively simple operation to assume formidable proportions, because the blood refused to clot in the normal way. Hemostasis is favored by the position of a pa- tient on the operating table. This was vividly impressed upon me while a student in Europe. Lexer, who was then assisting in the Royal Clinic, was engaged in the removal of a Gasserian ganglion and was greatly annoyed by venous oozing. His chief, Prof. Von Bergmann, entered the operating room by chance, and suggested that he complete the operation with the patient in the sitting posture. From that time until the close of the operation, the field remained singularly dry, and the illustration was never forgotten. The prophylactic use of pressure on large arterial trunks during amputations, goes back to the Dark Ages of surgery, while the use of constriction, for example, Esmarch's bandage, in this connection is too well known to need more than passsing mention. Treatment. — The treatment of actual hemorrhage is logically di- vided by Matas into three phases. (1) The arresting of the hemor- rhage; (2) the prevention of a recurrence; (3) the recovery of the patient. The actual arrest of bleeding is accomplished in quite a variety of well-known ways. The application of a clamp and a liga- ture represents the ideal, where this is possible. A gauze tampon, the 110 AFTER-TREATMENT OF SURGICAL PATIENTS application of heat or other cauterizing agents, such as hot water, steam, or a chemical escharotic, to say nothing of extreme cold, may accomplish the desired purpose. Guided by physiologic considerations Sir Victor Horsley checked the bleeding from small vessels by plac- ing tiny strips of detached muscle upon them, thus liberating a fibrin ferment. Among the less well-known local means of arresting hemor- rhage must be mentioned Koeher's eoagulin, of which we read Aviclely differing opinions. Hess' 1 made extensive use of free omental grafts in the control of hemorrhage in injured abdominal parenchymatous organs. One can readily see the advantage of suturing omental grafts around a spleen, as was done by Dr. Kirchner of St. Louis. As a substitute for a gauze pack, which is often difficult and dangerous to remove. Yaeger and Wolgamuth devised a web of a substance similar to catgut, derived from the sheep's intestine, which they successfully paeked into bleeding cavities. The absorbability of this mass naturally commends it to our attention. Hess proposes a new local application for the control of bleeding. Regarding it, I shall quote directly from his conclusions. "Tissue juice made from brain (thromboplastin solution) has proved itself of practical value in controlling hemorrhage wherever it can reach the site of bleeding. * * * It is to be recommended for local use in the parenchymatous bleeding associated with various operations, etc. Where local applications fail, it should be injected into the site of hemorrhage, as in bleeding from the gums following tooth extraction. * * * It is innocuous when given by mouth in considerable dosage, and would seem to he indicated in bleeding from the stomach and from the upper intestine." A number of general means for arresting hemorrhage have been proposed and used with varying degrees of success. Lansberg claims good results for an extract of corpus luteum. while Weinstein reports marked success in twelve cases following hypodermic injections of one-half grain emetine hydrochloride. Schreiber made intravenous injections of 200 c.c. of a 5 to 20 per cent solution of grape sugar, and claims to have checked severe gastric and intestinal hemorrhage by so doing. One to two per cent of gelatin dissolved in sail solution has 1 n rathe/ extensively used as an intravenous injection. However, opin- ions differ as to its efficacy. The prevention of recurrence of hemor- rhage is. perhaps, best illustrated by referring the reader back to an illustration of hemorrhage due to the erosion of a large vessel. After a patient lias been almost exsanguinated by repeated hemor- rhage from a branch of the external carotid, we not onlv succeeded HEMORRHAGE 111 Fig. 21-A. — The simplest means of increasing the amount of blood in the heart and central nervous system. Fig. 21-B. — A posture suggested for shock and hemorrhage where the respiratory apparatus is full of mucus. 112 AFTER-TREATMEXT OF SURGICAL PATIENTS in stopping the bleeding, but prevented any renewal of it by ligating the common carotid artery. One of the most logical and efficient methods at our command in accomplishing this is blood transfusion, which so alters the composi- tion of the patient's blood as to render a recurrence much less likely. It goes without saying that this object is attained by keeping the pa- tient quiet, for which purpose morphine is invaluable. The means which conduce to the recovery of the patient are legion, and most of them exceedingly well known. The relatively little blood that re- mains in the circulatory system must be sent, first of all, to the cen- tral nervous system and the heart, hence, we employ posture (Fig. 21A) and a compression of large veins as has been fully described under the treatment of shock, which see. The same considerations of heat, stimulants, etc., obtain here, as in the chapter just mentioned, therefore, a repetition is avoided at this time. In acute hemorrhage, the volume of fluid in the circulatory sys- tem must, of course, be augmented as early as possible. This must be done with the greatest caution, however, unless the source of bleed- ing is known to have been controlled. Water under the skin or into the rectum is of undoubted value, unless the hemorrhage has been of excessive amount. Under such circumstances, blood transfusion is the only remedy at our command which will save the patient's life. The technic of these procedures has been fully discussed in special chapters on Hypodermoclysis, Proctoclysis, and Transfusion. Bibliography iMatas, Rudolph: Keen's Surgery, Its Principles ami Practice, Philadelphia, and London, 1911, W. B. Saunders Co. -Howell: American Textbook of Physiology, 1900 edition. stewavt: A Manual of Physiology, 1900 edition, '('rile. Geo. W.: Hemorrhage and Transfusion. An Experimental and Clinical Research, New York and London, 1909, D. Appleton & Co. 5Tillmans: Text Book of Surgery, 1901, i. 465. "Kiefer, G. L. : A Study of the Blood after Hemorrhage ami a Comparative Study of Venous and Arterial Blood with Reference to the Number of Corpuscles and the Amount of Hemoglobin, Med. News, New York, 1892, lx, 22Y227. "Yon Bierfreund: Verhandl. d. deutsch. Gesellsch. f. Chir., 1890, xix. Part 2. pp. 159-221. •'Yon Mikulicz: Ueber den Hemoglobingehalt bei ehirurgischen Erkrankun Acute postoperative dilatation is a condition that is often preventable, and can be brought about by one or more recognized factors. (2) That accurate diagnosis and treatment is necessary and essential at the earliest possible moment for the best interests of the patient. Full credit is clue Riley M. Waller for having abstracted all the literature to which reference is made in this chapter. Bibliography lYVertheim : Die Erweiterte Abdominale Operation bei Carcinoma Colli Uteri, Vienna, Urban und Sehwarzberg. 2 Simpson, F. F. : Right-sided Hypertension with Occasional Cardiac Dilatations and Postoperative Complications, Jour. Am. Med. Assn., 1915, lxv, 941-915. E Crile : Keene 's Surgery, i, 79-82. per cent glucose solution. Also continuous hypodermoclysis of physiologic salt solution, or plain, ACUTE DILATATION OF THE STOMACH 125 freshly distilled, sterile water instead of salt solution, may be em- ployed. Under no circumstances, give anything by mouth. Ice held in the mouth, and all water, spat out, or a little mineral oil will keep the mouth from becoming too dry and parched, and will in great measure, assist in allaying the thirst. Every case showing symp- toms and signs of this very common condition, must at once be energetically treated, with infinite care for details regarding the comfort and well being of the patient. When the viscus has returned to the normal dimensions and po- sition, the abstinence from food or drink per mouth should be con- tinued for several hours longer, as everyone with experience knows that even the smallest amount of any fluid may initiate symptoms again. As to the drugs which may be used, probably intramuscular or in- travenous pituitrin is the most efficacious. Bibliography iMiller and Huniley: Tr. Path. Soc, London, 1853, iv, 137. 2 Brinton: Diseases of the Stomach, London, 1859, p. 343. 3 Fagge: Guy's Hosp. Reports, London, 1873, series 3, xviii. *Riedel : Erf ahrungen ueber die Gallen-stein Krankheit mit und ohne Icterus, Berlin, 1892, p. 129. sSchnitzler: Wien, klin. Rundschau, 1895, ix, 580. sConner: Am. Jour. Med. Sc, 1907, cxxxiii, 345. 7Laffer: Ann. Surg., 1908, xlvii, 395. sQiavannaz: Jour, de Med. de Bordeaux, 1909, xxxix, 5. oMuller: Deutsch. Ztschr. f. Chir., 1900, lvi, 490. loPaver: Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1910-1911, xxii, 411. uRuth: Am. Jour. Obst., 1913, lxvii, 530. isBorehgrevink: Surg., Gynec. and Obst., 1913, xri, 662. isLinke: Beitr. z. klin. Chir., 1914, xciii, 360. "Lee: Ann. Surg., 1916, lxiii, 418. isSmith: Boston Med. and Surg. Jour., 1909, clxi, 529. isLichtenstein : Centralbl. f. Gynak., 1908, xxxiii, 615. 17 Robson and Moynihan: Diseases of the Stomach and Their Surgical Treat- ment, London, 1904, ed. 2. isXakahara: Beitr. z. klin. Chir., lxi, 593. isBorehardt : Berlin klin. Wehnsehr., 1908, xlx, 1593. soKivin: Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1911, xxiii, 169. 21 Arcangeli: Quoted by Fagge, Lee, and Linke. 22 Braun and Seidel: Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1907, xvii, 533. ssVon Herff and Kelling: Quoted by Linke. 2*Von Herff: Ztschr. f. Geburtsh. u. Gynak., 1901, xliv, 251. 25Kundrat: Wien. med. Wehnsehr., 1891, Xo. 8. 26 Box and Wallace : Lancet, London, June, 1901. 27 Tissier: Bull. gen. de therap. 1910, clix, 61. 2S Couto: Bull, et mem. Soc. med. d. hop. de Paris, 1914, series 3, xxxvii, 522. 2 9Buehholz: These, Paris, 1912-1913, Xo. 291, p. 120. 3 <>Morris: Boston Med. and Surg. Jour., 1911, clxiv, 564. CHAPTER XVI POSTOPERATIVE ILEUS By Willard Bartlett, St. Louis. Mo. Sir Fredrick Treves 1 wrote, late in the last century, that two thou- sand people die every year in England of intestinal obstruction. More striking- is the recent statement of Roser, that four thousand deaths occur every year in Germany, from this same cause. Ileus had been known, and was recognized even earlier in the his- tory of medicine, but it was not until the end of the seventeenth cen- tury, that its anatomic characteristics were cleared up. AVe have been accustomed to define it as a malady characterized by certain cardinal symptoms; however, most surgeons wili agree with Wilms 2 that it is better to call tbis disease a serious disturbance of the in- testinal motor function, in view of the fact that one or more of the cardinal symptoms are net always present early in the malady. It is difficult to treat this as an entity, since it may lie defined in so many different ways, for instance, it is seen in an acute form, which presents characteristics, wholly different from those of the chronic recurring variety. It may he imnn diati . that is, appearing within a few days after an operation, or the onset may he several years later. Mortality. — The mortality in the postoperative variety of ileus varies somewhat with different authors, hut may be roughly stated as being about •"">() per cent, where reoperation has been undertaken after a lapse of several days; whereas it has been a little less than one-half this distressing figure, in consequence of timely interference. These figures constitute a resume, of statistics by Deaver and Ross, 3 Coley, 4 Xaunyn/' Pilcher, 6 Ruge. r Brown, 8 and Kirchner. 9 Pseudoileus. — Before proceeding to a consideration of true post- operative intestinal obstruction, it seems best to consider separately, the temporary paresis of the intestinal tract, which is so frequently seen following abdominal operations, which varies considerably in different instances, and was long ago given the name pseudoileus, by ( Mshausen. 10 This condition is to be clearly differentiated from true obstruction, although it must be admitted that it may run the entire gamut of severity, from simple distention, to paralytic ileus itself. It is exceedingly common, and in its simplest form, follows the rough 126 POSTOPERATIVE ILEUS 127 handling, prolonged exposure, and undue cooling of the abdominal viscera. There are individuals, so constituted nervously, as to seem particularly susceptible to it. Symptoms. — The symptoms of this condition are distention, and inability to pass gas, with or without the rhythmical so-called gas pains, often nausea, and vomiting. The patient is restless, anxious, and frequently difficult to control. The condition may simulate true intestinal obstruction, but may be often distinguished from the lat- ter by a consideration of all the circumstances which obtained pre- vious to, and at, the operation. Prognosis. — The prognosis is ordinarily good, varying, of course, with the intelligence and discrimination displayed in the treatment, and the condition may usually be considered rather disturbing than dangerous. No doubt spontaneous recurrence takes place in very many neglected instances. Where death results from any cause what- soever, no morbid anatomic condition can be demonstrated, so far as the intestinal tract is concerned. It must be added, that the same thing is true of certain types of true ileus, to be immediately de- scribed, thence the reader will see how difficult it is to always make a hard and fast distinction between pseudoileus and the true condi- tion. Treatment. — The treatment of the condition begins with prophy- laxis, the principal point in this connection being the proper use, or perhaps better, the nonuse, of drastic purgatives, just before opera- tion, says Schubert. The condition, we believe, is seen distinctly less frequently after the use of enemas than after castor oil, immediately before operation. AVe realize perfectly well, that there are condi- tions which demand prolonged and thorough catharsis, but the rou- tine use of these drugs, prior to operating, is often as senseless as is failure to individualize anywhere else, in medicine. After pseudo- ileus has commenced it is frequently not a simple matter to over- come it by the use of cathartics by mouth, since they are vomited almost as soon as given. It is perhaps better to use highly stimulat- ing enemas of a volume so small that they do not add to the patient's distention. In this connection, we have found enemas of pure gly- cerin in doses of one to two ounces, to be most efficient in starting peristalsis. The same may be said of six ounces of freshly prepared milk of asafetide, as enema — the last-named drug has a marked in- fluence in quieting the patient as well. A rectal tube, left in place for a long time, seems to greatly aid some individuals in passing gas. As a matter of course, stomach lavage will relieve distention, and thus minimize embarrassment of circulation, as well as of respiration. 128 AFTER-TREATMENT OF SURGICAL PATIENTS It cau not be too highly recommended for patients who have a dia- phragm markedly pushed upward. A patient who has resisted every therapeutic measure intended for the relief of gas, will often point the way to his own salvation by begging to get out of bed onto the com- mode. We were greatly surprised, in early years, to see such patients freely expel feces in sitting posture, after they had seemed wholly unable to do so in bed. Physostigmine in the large dose of % 5 of a grain, hypodermieally, has proved of the greatest value in my hands, while more recently, pituitrin has been strongly advocated in this connection. Classification of True Ileus. — There are a number of possible classifications, though probably none of them are wholly satisfactory. The one which we shall follow seems to make the subject understand- able and is a combination of those that have seemed to us most logical. I. Dynamic (Functional) Ileus (a) Paralytic. (b) Spastic. (c) Hirschsprung's disease. (d) Thrombosis and embolism of mesenteric vessels. II. Mechanical Ih us (a) Strangulation. (b) Obduration. (c) Volvulus, knots. (d) Caused by Meckel's diverticulum. (e) Kinking. (f) Strictures. A brief analysis of the various forms of (I) dynamic ileus, is per- haps in order: the paralytic variety occurs most frequently by far, in consequence of peritonitis. It also follows pressure upon or squeezing of intestinal coils at operation. Its oriuin is more obscure, when it follows degenerative conditions of the central nervous system, or is seen as a reflex manifestation of acute pancreatitis, hematoma at the root of the mesentery, twisting of an abdominal organ or turn on its pedicle, biliary obstruction, rupture of a solid abdominal viscus, fracture of spine or pelvis, or retroperitoneal suppuration. It is common enough, after urine, bile, or blood has collected in the peri- toneal cavity, and sometimes accompanies intestinal ulceration. It may be added, that paralytic ileus can indirectly complicate diseases of any abdominal organ. The spastic form of dynamic ileus, has been noted most frequently in hysterical individuals. Wilms saw it in a tabetic patient, while POSTOPERATIVE ILEUS 129 Murphy encountered it in a man suffering from lead colic. It has appeared in those afflicted with intestinal worms, and has followed Littre's hernia, not infrequently. Hirschsprung's disease is marked by a most obstinate retention of intestinal contents in the enormously distended colon. The extent of bowel affected, varies greatly in dif- ferent individuals. Thrombosis and embolism of the mesenteric vessels though com- paratively rare following surgical operations is nevertheless one of the most serious complications with which we have to deal. Yirchow 20 in 1847 apparently was the first to describe occlusion of the mesenteric vessels. His work aroused little interest and it was not until 1875 that the clinical picture was adequately described by Litten. 21 Investigations which were now begun in earnest re- sulted in valuable contributions being made to the literature by Cohnheim, Cohn, Oswald, 22 Corner, 23 Falkenberg 24 and others. Un- til 1902, 64 cases of thrombosis were recorded, 49 of these being arterial. Since this time Jackson, Porter, and Quinby 23 have col- lected 214 cases, and given an extensive review of the subject. Re- cently Laplace, 26 Killiani, Woolsey, Greensburg and Parker Syms, have each reported cases suffering from this disease. Sym's case was ready for dismissal from the hospital when this complication devel- oped, ending fatally within a few hours. This affection, according to Corner, is most common, in men past middle life in whom mitral disease is present, though endocarditis equally plays an important part. Arterial thrombosis is most apt to follow operations in those cases associated with arteriosclerosis, endocarditis or atheroma of the aorta, while venous thrombosis usually occurs primary or secondary to thrombosis of the portal veins. .-;_ As to the relative frequency, Corner further states that the arter- ies are five times more liable to be involved than the veins and that the superior mesenteric artery was found at autopsy to be thrombosed 40 times, where the inferior mesenteric was involved once. Occlusion of the vessels of the intestines produces a hemorrhagic infarct in the greatest majority of cases. Depending upon the du- ration of the complication, a simple hyperemia with superficial nec- rosis may occur, or an absolute gangrene of the intestines with per- foration and localized peritonitis with pus formation may be pre- sented. In the most fulminating type, gangrene may occur within forty-eight hours. In other cases this may not be present for several weeks. In most cases fluid will be found at autopsy in the peritoneal cavity while the mesentery swollen and edematous, will contain hem- 130 AFTER-TREATMENT OP SURGICAL PATIENTS orrhages of various sizes between its layers, and there may be marked enlargement of the mesenteric glands. Under II, mechanical ileus, let us consider first, very briefly, the various causes of strangulation. Coils of intestine sometimes become caught after operations, through openings in the omentum, mesen- tery, mesocolon, or broad ligaments. Pathologic strands and bands of all sorts, form frequently, giving rise to a similar accident. Next come the hernias, inguinal, femoral, umbilical, and incisional, to say nothing of the rarer examples, such as those into the obturator opening, and the foramen of Winslow. Obturation implies a plugging of the bowel lumen, in almost any way. We have seen this occur twice following the forming of a fecal stone, twice as the result of an enormous gallstone sloughing directly out of the gallbladder into the bowel, and once, when a gauze pad that had been left in the abdomen, found its way into the intestine. Others have seen it when due to an accumulation of intestinal worms. Obturation may be due to any tumor of the intestinal wall, but particularly to one attached by a small pedicle. There are forms of external pressure upon the intestine, which are difficult to classify, but which perhaps most nearly approximate obturation. The vari- ous forms of intussusception may all be considered under this head. We saw one unusual case of this kind, in which a small cancer at the end of Meckel's diverticulum, caused a complete invagination of this appendage, and acted as the head of the column, down the colon. Volvulus is most common in the small intestine. It can rather easily occur to a sigmoid with a long mesentery, while a volvulus of the ileus-cecal region, with complete obstruction, was seen and suc- cessfully treated in my own hands, by anastomosing the head of the cecum to the sigmoid. Meckel's diverticulum may interrupt the function of the intestine in a variety of ways. I have seen it tied in a knot around a loop of small bowel. It may become adherent and kink the bowel at its at- tachment. It is rather subject to diverticulitis, and can also cause an intussusception. Kinking of the intestine is one of the commonest forms of obstruc- tion. This usually results from adhesions, and is now less common than in earlier times, when the peritonization of stumps and pedicles was given less consideration than is now the case. Strictures are prone to produce a chronic recurring form of ileus. They follow ulcerative conditions, but are much more frequent dur- ing the growth of a carcinoma. Of course, any variety of ileus may attack the patient who has POSTOPERATIVE ILEUS 131 been operated upon, just as it may the individual who is in perfect health, hut certain types of obstruction have been a direct con- sequence of intraabdominal operations, thence I shall devote espe- cial attention to them, while adhering to the general classification of the subject. The dynamic form of the disease (I) is very much more common after operation, because peritonitis of some extent is so very frequently encountered. I have seen instances, too numerous to men- tion, as is unfortunately true of all operators. Paralysis of the bowel occurs where the nutrient blood vessels have been injured at operation : it has followed removal of mesentery tumors, and affected the transverse colon after resections of the stomach, during which the vessels in the mesocolon were damaged. Under II, mechanical form, strangulation is common in certain situations. Small bowel rather frequently slipped through an open- ing in the transverse mesocolon, in the early days of stomach surgery, before we learned to suture this membrane closely around the site of a posterior gastroenterostomy. Numerous strangulations, resulting in death, are on record. The same is true of the internal Alexander operation, and of uterine suspension, in both of which operations, a patulous ring has been left by some operators. After intestinal re- section, the wedge-shaped defect in the mesentery has not always been sutured, and the same accident has resulted. Obturation ileus has been less frequent perhaps, as a postoperative complication. I know of one instance, in which a laparotomy pad of large size was left in a peritoneal cavity, with immediate result- ing obstruction, due no doubt to pressure and something akin to obturation, while a true case of this kind has been cited above, in connection with a gauze pad, which found its way into the gut. Volvulus produces postoperative obstruction most commonly, as a recurrence after unsatisfactory operations for this very condition. Meckel's diverticulum is perhaps uncommonly the cause of this condition during a surgical convalescence. Kinking of the bowel, and obstruction has been most frequent at a remote period after the formation of adhesions to improperly covered stumps in the pelvis. I know of one instance in which a complete ob- struction persisted for years after the sigmoid became attached in this manner. Fortunately the condition was completely relieved by a sec- ondary operation. Too extensive inversion of an appendix stump is known to have resulted in kinking at the ileocecal junction, with such interference as to necessitate a remote secondary operation. The rather modern procedure of removing the gall bladder has been responsible for the duodenum becoming adherent in the defect, so that chronic 132 AFTER-TREATMENT OF SURGICAL PATIENTS pyloric obstruction has resulted, in many instances. We have more than once been driven to secondary gastroenterostomy for the treat- ment of this condition. Strictures, "while uncommon as a cause of postoperative ileus, may be seen after careless suturing, and the production of too broad a diaphragm in the making of an end to end intestinal anastomosis. The very nature of the human bowel makes this accident unlikely, still it is somewhat difficult to avoid in experimental work on the dog. This animal possesses a gut which is exceedingly thick walled in relation to its diameter. Perhaps the most familiar example of remote postoperative ileus, due to stricture, is the variety which fol- lows secondary jejunal ulcer, after gastroenterostomy. It is partial in nature, and is, no doubt, to some extent, the result of spasm. Symptoms and Diagnosis. — The four cardinal symptoms of ileus are inability to move the bowel or pass gas, colicky abdominal pain, feculent vomiting, and meteorism. Tins presupposes a typical out- spoken ease. The patient is anxious, restless, and in evident dis- tress, as a rule. The rate of pulse and respiration are increased, the face is pinched and dusky, while in the later stages, the extremities are cold, and the abdomen likely to be boardlike and tender. This superficial description of the disease holds good for any late case, no matter whether it belongs originally to the dynamic or to the mechanical variety, since obstruction can not remain complete for any length of time without the intestinal wall becoming pervious to germs, which ultimately produce a peritonitis, thus adding the ele- ment of paralysis to the already existing condition. Hence it comes about that a late diagnosis between dynamic and mechanical ileus is impossible. In an early case it should be possible for a trained ob- server to differentiate between the two. A diagnosis of functional ileus will, in any case, be greatly facili- tated by an exact history and a knowledge of all the circumstances which attended the original operation. It may lie said, in general. that there is diffused pain, fever, constipation, an abdomen that is tender all over, and uniformly distended. There is general muscular hypertension. The vomiting, which characterized this con- dition, has long been termed "slopping over," from the fact that it has little projecting force. It is almost incessant, the greenish fecu- lent fluid escaping a mouthful at a time. Pain, of an excruciating degree, has been noted in those cases of dynamic ileus which we have seen caused by interference with intestinal blood supply. So striking has been this manifestation in rare instances, as to lead to an accurate diagnosis. POSTOPERATIVE ILEUS 133 111 early mechanical obstruction, no matter what the exact cause, certain fairly characteristic phenomena are to be noted. The pain is more localized, and definitely cramplike. The tenderness is also confined, while the distention is limited to intestinal coils, which in a thin-walled abdomen, can be readily outlined, and peristaltic waves be quite as readily seen. The muscles are absolutely boardlike, while the vomiting has a projectile quality, which may carry it to a considerable distance. Large quantities are emitted at a time, with evident effort of a distressing nature. The diagnosis of the exact anatomic form of mechanical obstruc- tion must be very rare. One point, not to be forgotten in this con- nection, is that chronic recurring obstruction, especially in an elderly individual, frequently spells cancerous stricture of the large bowel. The subject of diagnosis can not be dismissed without one caution, namely, time should never be wasted in trying to do more than es- tablish a mere differential diagnosis between the dynamic and the mechanical forms of the malady, since the treatment of the two is essentially different. It must be borne in mind that the patient looks to his medical adviser for the speediest possible treatment in this condition, rather than for a completely satisfactory diagnosis. Mechanism and Cause of Symptoms. — We must confess to a rather meager knowledge of the finer details of ileus. We do not know at all, how the reflex forms of the dynamic variety are con- nected with the original lesion, in a given case; indeed, the inflam- matory variety, the one most frequently seen, is not wholly clear to us, since we have no means of telling whether toxic agents directly affect intestinal musculature, or accomplish the same thing indirectly through the sympathetic nerve supply. Murphy and Vincent, 12 after a series of experiments, conclude, in agreement with many other investigators, that the acute symptoms are caused by the toxic substance, which they found in the obstructed loops. Very interesting suggestions as to the cause of death in these instances, have emanated from McLean, 13 who is not satisfied with the toxin theory; but noting, as he does, a marked loss of weight dur- ing the illness, believes death clue simply to dehydration, which oc- curs as a consequence of the persistent and copious vomiting. He substantiates his position by the observation that an obstructed ani- mal which is given saline infusions lives much longer than the con- trol animal which is not so treated. Treatment. — In the treatment of true ileus, as opposed to the somewhat indefinite pseudoileus considered above, one must distin- guish sharply between the dynamic (functional), and the median- 134 AFTER-TREATMENT OF SURGICAL PATIENTS ical varieties, since the entire conception of the two is as different as are the causes. We shall take up the dynamic form first, and reserve the mechanical for separate consideration. As above stated, dynamic ileus results, in the majority of instances, from peritonitis, which under the conditions of modern surgery, is encountered, of course, at the original operation, and not caused by it. In this connection, the prophylactic plan of Andrus 14 attracts attention. This author, after draining a peritonitis case, in which ileus might readily super- vene, attaches a distended loop of bowel to the edge of his incision, and drains it primarily, thus accomplishing in advance, a measure which might later be demanded as life saving. Where postoperative dynamic ileus already exists, the indication is a perfectly definite one, namely, to treat the cause, and in most instances, the ileus will take care of itself, this means that a peritonitis, if localized, must be treated by drainage under local anesthesia, of course, since the in- testinal paresis of general anesthesia can only add fuel to the fire. Peritonitis of a mild degree, or one in which no localization is possi- ble, is nowadays universally treated by the Ochsner method, namely, by placing the bowel at absolute rest, with morphine, and thus pre- venting dissemination. The indication here is clean cut, in that the peritonitis must be treated, rather than the bowels moved. This dis- tinction is, however, not always made, and the tired horse is whipped when he ought to be rested, so to speak. It is not only futile, but little short of a crime to attempt purgation in these cases. By so doing, one succeeds only in embarrassing the overloaded stomach and upper intestinal tract. The chief physiologic need here is for water, since not only is none absorbed from the stomach walls, but hyper- secretion from the upper digestive tract rapidly dehydrates the pa- tient. As long as he "slops over," lavage must be practiced every two or three hours, and his ever-increasing thirst he assuaged by water in the rectum and under the skin. We must not content ourselves with the above-mentioned treat- ment any length of time in the presence of increasingly severe symp- toms, hut after a few hours employ the one sovereign remedy at our command, that is, a fecal fistula. This is, of course, always done under local anesthesia, and may in many instances be advanta- geously combined with drainage of the peritoneal cavity. I think all of us must agree with Thompson, 15 that resection has no place in the surgery of dynamic ileus, when caused by peritonitis, which again reminds us of the importance of sharply differentiating between the two cardinal forms of this malady. When a segment of intestine is paralyzed, in consequence of damage to its blood supply, POSTOPERATIVE ILEUS 135 the patient's life can be saved in only one way, that is, by resection. In one instance, I successfully operated, early in thrombophlebitis of the mesenteric vessels, where there was beginning gangrene of two yards of small intestine. Mechanical ileus, in any of its many forms, demands treatment of a mechanical nature. Wilms, in the most exhaustive treatise ever written on this subject, feels that the prophylaxis consists largely in the prevention of visceral agglutinations and adhesions. There must then be no cooling or drying of areas which it is necessary to handle and expose. Sepsis and limited necrosis must be prevented, and the use of tampons restricted to the minimum, all peritoneal rings are most carefully to be sutured, and exposed surfaces to be painstakingly covered by peritoneum. Very early, gentle catharsis will accomplish wonders towards the prevention of adhesion to damaged visceral surfaces. Eeichekloerfer 16 voices an ingenious suggestion, which may be of value : he gets his patients into a sitting posture as early as possible after abdominal operations, feeling that adhesions which may form, will do less than the usual harm, by holding the patient's viscera in the position to which they are accustomed while he is up and employed. Keilty 17 reminds us that we were on the wrong track, years ago, when we filled the peritoneal cavity with oils and other foreign substances in the hope of preventing adhesions during the reparative period. Given a patient suffering from mechanical obstruction, there are two procedures possible, both of them operative ; one, drainage of the embarrassed bowel, and the other removal of the cause. The choice of procedure is taken out of a surgeon's hands by finding nutritional changes in the intestinal wall. He has then no recourse but resection of the affected area. In the absence of this anatomic change, the general condition of the patient will always be his guide as to whether he shall do a drainage operation or proceed to radical treatment of one of the many definite conditions which may bring about this form of ileus. If an artificial anus is decided upon, it should, of course, be made as low down as possible in the obstructed area, however, it will be done only on a very sick patient, hence the first distended coil that presents itself is usually thankfully chosen by the operator. The ce- cum is by all means to be elected, if the obstruction be low enough, since attachment of it to the abdominal parietes is not at all likely to cause future kinking. This choice has the further advantage of leaving the midline and left side free for a secondary attack upon the ob- structing cause. I have made extensive use of lateral intestinal an- 136 AFTER-TREATMENT OF SURGICAL PATIENTS astomosis as a substitute for feeal fistula, with most gratifying re- sults, in dangerously sick patients where the obstruction was high enough to reveal '"flat," as well as distended, intestinal coils. This is done under local anesthesia, with the utmost ease, and is from the patient 's viewpoint, vastly preferable to a disgusting fistula, but is, of course, not to be undertaken when there is blood in the peritoneal cav- ity, or where other evidence of a nutritional disturbance is present. This procedure is further recommended by the well-known physiologic consideration that a lateral intestinal opening drains only as long as obstruction persists; thence we have every reason to believe that function is often reestablished in any intestinal segment thus tem- porarily excluded. No matter what operation is undertaken, the anesthesia is a mat- ter of the greatest importance. The intestinal drainage can, of course, be done under local anesthesia, but it will be insufficient if the abdomen is to lie explored and a radical maneuver executed. A matter of greatest importance is stomach lavage, just before, and during a general anesthesia, sinee many a patient is drowned in his own vomit, early in the administration of a general anesthetic, in careless hands. The degree of evisceration, while searching for the cause of ob- struction, is fully appreciated only by the surgeon who has learned, through bitter experience, to appreciate the narrow margin of re- sistance possessed by obstructed patients. It is furthermore an un- necessary maneuver, since the entire small bowel can readily be in- vestigated, by replacing it, a little at a time, as it is withdrawn. This pre-supposes a knowledge of the direction in which one is working, but this can be readily acquired by thrusting the hand down to the root of the mesentery, which is disposed almost parallel to the spinal column, and remembering that the current of an attached intestinal loop follows the up and down direction of the mesenteric root. After one has found the obstruction, lie may be aided in his de- cision upon radical measures, by recollecting that von Mikulicz, 18 the master of intestinal surgery, experienced a mortality of 40 per cent, in resection of obstructed colon, but did the same operation in the interval, with only 10 per cent loss. It is a much disputed matter, as to whether one is justified in emptying the intestine on the operating table. No doubt it is theoretically desirable that we rid the patient of toxic material, still one- is surely not warranted in the use of any complicated or time consuming method, which has this end in view. There is, no doubt, a happy medium somewhere between the two extremes. 1 have at times found it distinctly advantageous POSTOPERATIVE ILEUS 137 to puncture intestines in facilitating their return to the cavity. My experience leads me to believe that surgeons have exaggerated the danger of dumping contents of obstructed coils into empty ones, lower down: this is borne out by the experimental work of Murphy and Brooks, 19 who found that absorption was hastened in proportion to intestinal damage. The need of water in the treatment of a patient can not be em- phasized too strongly. It must be liberally given in the rectum and under the skin, as outlined in connection with dynamic ileus. Let us suppose the surgeon to have found a mechanical obstruction in a patient whose condition permits of radical surgery : what he does next must conform wholly to the special needs inherent to the kind of mechanical condition presented. (a) Strangulation is, of course, to be relieved by cutting a band, dividing a ring, or in some other manner releasing the damaged coil and restoring it to its accustomed habitat. It is most difficult to state conditions under which resection is to be done for impending gangrene. My own observations incline me to think that we have erred in being too radical, rather than too conservative. Where there is the slightest doubt about its future, a damaged coil is by all means to be wrapped in rubber, and replaced for twenty-four hours, after which time, if nothing untoward happens, the abdominal wall can be completely sutured. There will, of course, be no question about the treatment of an already gangrenous segment. (b) Obturation necessitates the removal of the bolus in question. I, personally, have removed an enormous stone from the jejunum, a fecal stone the size of a lemon, from the sigmoid, and an obstructing gauze pad from an unidentified coil. (c) Volvulus is usually successfully treated by reposition and fixation, although, in one instance I cured a recurring affection of the ileocecal region by anastomosing the head of the cecum with the sigmoid. (d) Meckel's diverticulum presents so great a variety of patho- logic conditions that it can hardly be briefly treated here. (e) Kinking may sometimes be easily relieved by dividing an ad- hesion or may at times demand a plastic operation, similar to the Finney, or others, which are well known in the pyloric region. (f) Strictures, if benign, are also amenable to plastic operations, but if malignant, they demand resection. The prognosis of mechanical intestinal obstruction is frequently a matter of the utmost uncertainty, since one never knows just when a lethal dose of toxin has been absorbed. I have seen patients grad- 138 AFTER-TREATMENT OF SURGICAL PATIENTS ually sink and die from patent failure of eerebro-vital centers, sev- eral days after an operation, which not only accomplished complete anatomic restoration, but was followed by the restoration of gastro- enteric functions of every kind. Bibliography iTreves: Intestinal Obstruction, 1901, Cassell and Co. -Wilms : Der Ileus, Stuttgart, 1906, Verlag von Ferdinand Enke. sDeaver and Ross: Ann. Surg., Feb., 1915. *Coley, W. B. : Keen 's Surgery, iv, 50. sNaunyn: Keen's Surgery, iv, p. 645. ePileher: Med. News, 1902. -Ruge: Arch. f. klin. Chir., 1910, xeiv, 711. sBaown, J. Y. : Surg., Gynec. and Obst., 1910, xii, 186. 9Kirchner, W. C. G.: Tr. Am. Assn. Obst. and Gynec., 1914. loOlshausen: Handbuch der allgemeinen und speziellen Chiruigie von Pitha- Billroth, 1879. i 'Schubert, G.: Ztschr. f. Geburtsh. u. Gyniik., 191 a, lxxiii, 500; Zentralbl. f. d. ges. Gynak. u. Gelmrtsh. s. d. Grenzgeb. i2Murphy ami Vineent: Boston Med. ami Surg. .lour.. 1911. isMeLean, A.; Postoperative Ileus, Am. Surg., 1914, lix. i lAmlrns, R. < '. : Jour. Michigan Med. Soc, 1915, xiv, 86. isT/hompson: Surg., Gynec. and Obst., 1916, xxii, 688. icReicheldoerfer, L. H.: Postural Treatment of Post-operative Abdominal Ad- hesions, Surg., Gynec. and Obst., 191."., xvi, 755. I'K'cilty: New York Med. Jour., 1915, ci, 549. L8Von Mikulicz: Handbuch der Praktischen Cliirurgie, von Bergmann, von Bruns, und von Mikulicz, Stuttgart, L900, veil, von Ferdinand Enke. iaMurphy and Brooks: A.rch. Int. Med., March, L915, xv. 393. 20 Virchow: Ges. Abhandlungen, pp. 338, 420, 4.11. -iLitten: Yin how's Arch. f. path. Anat., lxiii, 289. "Oswald: Ztschr. f. klin. Med., Berlin, liii. -■'•Corner: Lancet. London. 1904. 24Falkenberg : Arch. f. klin. Chir., lxx, 992 zsjackson, Porter, ami Quinby: Jour. Am. Med. Assn., 1904, xlii, 1469. -'-Laplace: Pennsylvania Med. .lour.. 1912-13, xvi, 690. CHAPTER XVII FAT EMBOLISM By 0. F. McKittrick, St. Louis, Mo. Fat embolism not infrequently follows operations, particularly orthopedic operations, and since the malady has attracted so little no- tice in the country until the last few years, it seems fitting that at- tention should again be called to this important subject. The first contributions to fat embolism date back to the seventeenth century. Lower in 1669 injected 19 ounces of milk into the veins of a dog, the animal dying soon after in a spasm with all the signs of pro- found dyspnea. Later, similar injections 1 were undertaken for va- rious purposes by Clark, Corton, King, Drelincourt, Gaspard and Beck. All these observers reported fatal respiratory disturbances but in none of the experiments were the lungs of the animals examined.. Magendie 2 was the first to inject pure oil into the veins, and as a conse- quence of his experiments, was the first to prove that the lung capillar- ies can be plugged with fluid fat. Weber 3 and Schwick 4 in an effort to determine the effect of various emulsions on the circulation when in- jected intravenously, found that embolism did not follow such a pro- cedure in their series of experiments. By injecting oil into the neck veins of a dog, Virchow 5 succeeded in finding, at the autopsy, many small fat emboli in the lungs and kidneys. H. Muller 6 was apparently the first to discover fat embolism in the human subject. In cases of chronic interstitial nephritis, he is accredited with having found fat droplets in the chorioid vessels. Zenker 7 and Wagner 8 were the first to observe fat emboli in the lung capillaries (Fig. 22), following the accidental fracture of several ribs and rupture of the liver in a man. Considerable interest was now excited and many men investigated this subject, notable among whom were Hohlbeck 9 and von Berg- mann. 10 At this time Busch 11 first definitely proved that the origin of the fat in these cases could be the bone marrow. Some time later Flournoy 12 proved Wagner's theory that fat embolism can occur after injury to the fat containing soft parts while Fritz made an independ- ent demonstration of the same phenomenon. During the latter part of the nineteenth century Schriba 13 collected all the clinical and ex- perimental data on this subject. His article, which appeared in 1879, 139 140 AFTER-TREATMENT OP SURGICAL PATIENTS is probably the most comprehensive work we have on the clinical manifestations of this malady. The condition occurs most frequently following fractures and crushing injuries to the long bones, particularly those of the lower extremities. Operations on joints, surgical interference involving bone or even the forcible straightening of a contracted limb or of ankylosed joints, result not infrequently in fatal fat embolism. It is fair to assume, and the assumption is borne out by the literature, that this accident occurs only where fat is in close proximity to the lesion ; force sufficient to propel the fat into an open blood vessel, being ex- Fig 22. — Fat embolism of lung following multiple fractures. (After Aschoff.) erted. It therefore follows that contusions of the panniculus adipo- sus, hemorrhage into or rupture of the liver or osteo-myelitis pre- dispose to this malady. Patients between thirty and forty years of age, form the bulk of those afflicted, while il is least common in children. This can be very properly ascribed to the fact that fractures occur more often during this period of life in the former, while the medulla of the bone in the Latter contains but little fat. As to the frequency of fatal fat embolism, it should be stated that il occurs more often than FAT EMBOLISM 141 was formerly supposed, though owing to the insufficiency of records it is hardly possible to estimate as yet the mortality rate. 14 Meet 13 collected 113 cases of fatal embolism but in only 11 of this number could he be certain that fat was the causative factor. To these are added two more cases which came tinder his own observation. Beitzke 16 reports a ease of fatal fat embolism occurring within a few hours following a slight contusion to the leg stump, the operation having been performed a year before. Wahncan, 17 Colley 18 and Au- reus 19 each report a case in which fatal embolism occurred following brisement force which was being employed in an effort to straighten contracted limbs due to ankylosed joints. Schanz 20 records a case in which fat emboli produced death following an operation which involved osseous tissue. Byerson reports four fatal cases due to this accident, two to three days following operation. In one case operation was performed in order to correct the deformity caused by a Pott's fracture one week old. Embolism followed after twenty- four hours and death within forty-eight hours. In another case fol- lowing an Albee operation for severe paralytic scoliosis in a boy eight years old, fat embolism occurred in three hours followed by death after forty-eight hours. As a result of foot drop, due to pol- iomyelitis an operation was undertaken to correct the deformity in another case which developed fatal fat embolism twenty-four hours later. The last case was a baby eight months old, operated for congeni- tal club feet, the plantar fascia and Achilles tendon above being sev- ered. The baby developed symptoms of fat embolism after twenty- four hours and died during the following day. By far the greatest number of contributions to this subject are de- voted to experimental studies and to the pathology, 21 all seeming to agree that the globules of fat after becoming established in the blood stream first lodge in the capillaries of the lungs. If the quantity of fat is of sufficient amount, severe symptoms will intervene, resulting very probably in death. If the patient survives the effects of the pulmonary complication and the heart's action is sustained, the fat globules will be forced from the lungs into the left heart and hence into the general circulation. From this they will be removed by the liver and kidneys, and unfortunately the brain and cord, and less frequently by the other various organs. Petechial hemorrhages may appear in the skin while at times ecchyinosis may be seen on the mu- cous membranes and in the conjunctiva. In the experimental cases where fat embolism was produced, Sehriba found the following lesions : ' ' The liver was markedly congested with venous blood, fat cells being 142 AFTER-TREATMENT OF .SURGICAL PATIENTS found throughout the parenchyma along the periphery of, and even within, the acini. The kidneys showed an abundance of fat, the glomeruli particularly were loaded with fat globules and many ec- chymotic areas presented beneath the capsule. The brain and cord especially were the seat of most interesting findings. The coverings of these organs were congested with black venous blood, while the arteries here and there were free from this fluid. However, a cross section of the perivascular spaces showed them loaded with red blood corpus- cles. In some of the cases the brains were only edematous but in a few the ventricles contained serosanguinous fluid, while in others there were found areas of softening. Such organs as the heart, stom- ach, intestines, bladder, muscles and even the skin were found to con- tain fat emboli in a number of other case-,. The retina and especially the chorioid were often involved." Hamig 22 reported five fatal cases of fat embolism of the brain. At autopsy many small ecchymotic areas were revealed in the gray and white matter, in the pons, medulla, and even the central ganglia; par- ticularly in one case were the dura and pia congested and edematous. The clinical picture in fat embolism is fairly well defined. The severity of the symptoms, however, depends upon the organ or num- ber of organs involved. Payr 23 recognized two varieties, one the re- spiratory and the other, the cerebral. In a given ease the most prom- inent symptom would determine to which variety it belonged. Ac- cording to some observers there is usually an incubation period of from twenty-four to thirty-six hours following the operation or ac- cident. 14 In very severe crushing injuries this period may be re- duced to as low as three hours as in the ease reported by Beit/ke. Death itself has occurred within this time, though cases are reported in which it occurred as late as the eleventh day.- 4 The fat. as stated above, lodges in the lungs first. This is followed by difficult respiration, not a true dyspnea but rather an air hunger; there is pallor followed by cyanosis and failure of the circulation with physical signs of pulmonary edema, and the frequent expectora- tion of frothy, blood-stained mucus. The state of affairs continues to increase in severity as the lungs gel more and more edematous and the heart weakens correspondingly. The milder cases will probably only show an air hunger recovering before further pulmonary symp- toms develop. The temperature may go as high as 106 : to 107°. Fat may appear in the sputum and in NO per cent of the cases, in the urine, according to the authors who have reported the urinary find- ings. FAT EMBOLISM 143 As it would be naturally supposed the cerebral type is of less fre- quent occurrence. The entrance of the fat into the cerebral circula- tion is marked by nausea and vomiting, followed by delirium, som- nolence and finally coma, hemorrhage, and thrombosis. Localized paralysis, trismus, and convulsions were noted in some of Hamig's cases, and Schanz reports one instance of hemiplegia. The respira- tions are usually stertorous. The temperature uncomplicated by other conditions is normal or subnormal, and is associated with a rapid weak pulse. Unfortunately there is no specific remedy for this condition. Ac- cording to many observers a considerable decrease in the number of instances can be obtained by bearing in mind the likelihood of this accident and giving careful attention to the prevention. Burger 25 who has studied this phase of the disease on the battle fields of Europe, during the last war, states that the tourniquet is probably the best means we have of warding off fat embolism. He advises its ap- plication in all cases of fracture, severe crushing injuries of the limbs, or general contusions to the bones in those weakened from dis- ease or in the aged. In very severe cases especially with crushing in- juries of the pelvis, he uses Monberg's constriction at the waist line for at least half an hour ; at the end of which time it is gradually loosened. Another precaution is to avoid the moving of such pa- tients to very great distances, as this particularly predisposes to the malady. Premature massage or even the handling of the patient or unnecessary disturbance of any kind may end in dire results. Extensive laboratory experimentation on dogs and rabbits by Ry- erson has shown that fractures and contusions of the bones cause much more embolism than does the performance of a typical Albee bone transplant to the spine, for instance. However, the use of the chisel and mallet in the performance of this operation is far more dangerous than the motor saw. The experiments also showed fatty embolism is markedly decreased by the use of the tourniquet follow- ing all kinds of traumatism. Apparently all authorities are in ac- cord with this view, but up to the present time it has not been used as a routine measure by any one man. If the accident occurs regardless of the above efforts, emergency medical measures as recorded for pulmonary embolism should be ap- plied here. Protracted absolute rest of the affected part must be particularly insisted upon, inasmuch as additional quantities of fat may continue to enter the circulation. The heart's action should be sustained with strophanthus or digitalis during its attempt to force 144 AFTER-TREATMEXT OF SURGICAL PATIENTS the fat globules through the pulmonary capillaries iu an effort to re- lieve the embarrassed respiration. It is a question whether the class of remedies exemplified by ainyl nitrite should be used to force a dilatation of the peripheral and pulmonary vessels since this addi- tional strain may be too great for the already overloaded heart. Later, while the oil is being disposed of by the liver and kidneys, assisted by the process of oxidation and of saponification effected by a ferment in the blood plasma and b}' the metabolic and phagocytic activities of the leucocytes, the medical treatment can be symptom- atic only. Further treatment as proposed in the recent literature is apparently not on a well-defined basis. Czerny 26 in an attempt to assist the blood in forming a soluble soap injected 2 per cent sodium rail innate, but the method received little support. Schanz injects subcutaneously a liter of normal salt solution at the first sign of trouble ; various parts of the body being utilized for this purpose in order, he thinks, to more promptly and effectually accomplish the desired dilatation and flushing out of the capillaries involved. He reports ten cases of fat embolism occurring after operation on the bones with the loss of only one patient after employing this method. While others, notably Beitzke, do not sanction this treatment, I feel that it should be given a trial so long at least as the solution is qo1 given intravenously. It is also advocated by Gangele. Wilms- 7 drained the thoracic duct for four days with recovery of the patient. Tanton 28 recommends this procedure also. They base this action mi the theory that the fat is carried principally by the lymphatic system rather than by the venous. Though the fat con- tained in the thoracic duct may be the metaphorical last straw, Wilms' method receives but little support. Riener 29 advises draining off the venous blood with its admixture of fat by means of a cannula inserted into the saphenous vein and hence into the femoral vein, lie ■siy^ that the amount of fat neces- sary to cause the initial symptoms sufficient for diagnosis, does not always produce death, the fatal dose having not as yet passed the Poupart's ligament. This method is approved by other observers. Tanton would open up the area of injury and remove the accumu- lated hi 1 and t'at. using drainage or tamponade, a procedure hav- ing many advocates. Venesection relieves the heart which is beating against the fat em- boli in the greater circulation and should lie employed in suitable cases. If brain pressure symptoms develop from the venous stasis or hydrocephalus, leeches to the mastoid may be of aid in diverting the fluid. Lumbar puncture may be applied with caution. FAT EMBOLISM 145 After the recovery from the immediate effects of the accident, I would naturally expect a longer convalescence of the patient than without this complication. Dizziness, fatigue, dyspnea, heart dis- turbances or even mental depression may be present for an indefinite time. If such are prominent, however, lumbar puncture supple- mented by hot foot baths, air and sun baths, and revulsive measures should be carried out. The patient must be warned against over-ex- ertions either mental or physical. If possible, give him light work and let his ordinary occupation be gradually resumed. Bissell 30 writes: "It would seem reasonable to conclude that in persons with broken bones there is frequently a remarkable amount of fat in the blood stream, and almost incredible amounts of fat may be in the blood and yet not kill. Further, it might be assumed that the amounts of fat free in the blood stream of persons with broken bones vary from time to time, and it is very essential for any inter- pretation of these results to remember that in no instance was the whole blood examined; that other similar amounts from the same patients (or dead bodies) might have shown a fat content either greater or less, since the fat is not emulsified but is in motion as free fat droplets, and no doubt these vary from time to time in their number and size as well as in their distribution, the blood in some places perhaps being rich in fat and in others poor or with no fat as emboli." BibliogTaphy ^Fromberg: Mitt. a. Grenzgeb. d. Med. u. Chir., 1913, xxvi, 23. sMagendie: Jour. de. physiol., 1821, i, 37. s Weber: Deutsch. Klin., 1864, p. 466. Pitha und Billroth: Handbuch der Chirurgie, i, pp. 84, 85, 95, 98. ^Schwick: De ernbol. adipe liqu. effecta, Dissert., Bonnse, 1864. sVirchow: Dessen Arch., v, 388. eMuller: Erkrankungen der Choriodea, Wiirzburg med. Ztsehr., i, 1860. ^Zenker: Beitrage z. norm. u. path. Anatomie der Lrmgen, Dresden, 1862, p. 31. s Wagner: Arch. d. Heilkd., 3 Jahrg., 1862, p. 241. silohlbeek: Ein Beitrag zur Lehre vonder Embolie, etc., Dorpat, 1863, Dissert. loBergmann: Die Lehre der Fettembolie, Berl. klin. Wchnschr., 1873, No. 33. nBusch: Leber Fettembolie, Virchows Arch. f. path. Anat., 1866, xxxv, 19 Kap. i2Flournoy: Contributions a 1 'etude de L 'embolie graisseuse. Diss., Stratburg, 1878. isSchriba: Untersuch. iiber die Fatt Embolism, Leipzig, 1879. i this subject. To be thoroughly efficacious the light built must come within a few inches of the region to be treated, hence it is readily understandable that the sudden movement of a sleeping patient or ind 1. of one awake for that matter, may bring the glass bulb into immediate contact with the body with the most disastrous consequences. In one instance where the bulb was suspended in ray practice immediately over a Large suppurating appendix wound, a faulty connection gave way. the incandescent bulb fell onto the pa- tient who happened to lie asleep, and before it was removed, a sec degree burn of considerable extent ensued with the result that wound healing was distinctly complicated and lengthened thereby. In other instances where heat is maintained by a number of elec- tric bulbs arranged as in the Gellhorn apparatus, or hanging sus- POSTOPERATIVE BURNS 153 pended far above the patient aud inclosed with him in a specially ar- ranged "burn bed" these may cause superficial burns of the parts of the body exposed. In such beds the temperature is maintained by covering the frame which supports the lights with blankets, oil cloth, or other materials. The degree of heat desired is about 85° C. but occasionally it becomes excessive, and although the patient is very uncomfortable, complaint and examination are often not made until damage has been done. I have seen two instances in which super- ficial first degree burns occurred under such circumstances. In one, a burn of the skin over the abdomen appeared in a woman patient who fell asleep and the nurse, not acquainted with the efficient ap- paratus for developing heat, allowed the part exposed to become so injured that it was several days before the skin assumed its normal appearance. In the other instance a leg having been amputated for indolent ul- cer and the tissues being very slow to heal due to arteriosclerosis, the patient was kept in bed with the stump and lower part of his body kept covered by a frame from which several electric light bulbs were swung at least 16 inches high. The frame was in turn covered by two blankets, the upper portion of the body being outside of the en- closed portion of the bed. Within one-half day the hyperemia be- came so extensive and the pain so severe that it was deemed advisa- ble to discontinue the treatment. The skin over the exposed regions gave all the signs of a superficial burn, and was four days in recover- ing from the effects of this treatment. X-ray. — The x-ray is another factor to be considered in the etiol- ogy of postoperative burns. So often is this method of treatment in- stituted, particularly after operations for malignancy, that it is no more than natural to occasionally expect a complication of this sort. I have seen one or two such instances, though the condition is not so common as one would expect when the number of cases so treated are considered. Probably this is clue to the fact that the nature of the treatment itself requires more expert application than does the usual routine after-care and is therefore handled by a special class of men skilled in their individual work. Sajous 1 in discussing the subject says: "Close proximity to the ray by either covered or uncovered parts results either in superficial or deep inflammation of the skin. It may be observed a few hours after exposure to the rays or may be delayed for several weeks. This form of burning attacks the skin alone in some instances, while in others the deeper structures, as the muscles, tendons, nerves, and bones (periostitis and ostitis resulting) are involved. The effects may remain for days, weeks, or even 154 AFTER-TREATMENT OF SURGICAL PATIENTS months after the application. The x-ray burns are supposed by some to be produced by the action of the ray or by particles of aluminum or platinum reaching and being deposited in the tissues by others, and by yet others to be the result of an interference with the nutri- tion of the part by the induced static charges." The effects of these static charges can be absolutely eliminated ac- cording to Sajous 1 by interposing some conducting material, one readily penetrated by the rays, such as a sheet of aluminum or gold leaf. "As an added precaution we have found it extremely valuable to have treatment administered by an experienced roentgenologist, one thoroughly familiar with the work in hand. Such men inform us that it is not so much in protecting the parts to be x-rayed with alum- inum as the giving of too frequent small doses or a too long exposure at one time." Ice. — The application of ia continuously for several hours may result in the complete destruction of skin with a resulting lesion so similar to a burn that for all practical purposes it is well classed under this common heading. I was recently shown a most extensive burn of this sort by a colleague at the Jewish Hospital of this city. During the course of a pelvic inflammatory disease an ice bag had been continuously applied for many hours directly upon the skin of the lower abdomen until at the expiration of this time nutritional changes had commenced which finally resulted in a slough equal in size to the bag itself. The effect of ice upon the tissues is very rarely as extensive as that here mentioned, still all of us have seen a red, tender edematous area persist for many hours after a too long con- tinned application of this sort. Treatment in this instance should be preventive in nature, the rules underlying it being of such an ex- ceedingly simple nature that their nonobservance is almost inexcusa- ble. An ice bag should under no circumstances be applied directly upon the skin, but should have one or two layers of flannel cloth be- neath it; even then no ice bag should remain in situ for more than two out of three hours at a time. Pathology and Morbid Anatomy. — Prom the pathologic stand- point, the effect on bodily tissues of various caloric agents is essentially the same. The amount and severity of the change depends on the intensity and duration of the agent, the extent and location of the involved area, ami whether the normal equilibrium of the skin is disturbed by local infection or lowered constitutional resistance. It is customary to classify burns in three degrees. First. — Char- acterized by simple erythema and destruction of only the superficial Layers of the epithelium, with occasionally some slight swelling of POSTOPERATIVE BURNS 155 the part. Second. — In this class, in addition to the above there is formation of bullae or blebs filled with clear serum; and considerable swelling. In neither of these classes are the deeper crypts of epi- thelium destroyed, and regeneration takes place with little or no scar formation. Third. — Typical of this degree is the carbonization of the dermis and deeper structures with eschar formation. In this type the ne- crotic tissues slough off, leaving an ulcerating surface which slowly heals by granulation, scar formation, and cicatrization. Accompanying the above changes are the usual manifestations of inflammation with suppuration. Suppuration is furthered by the formation of scabs. Because of the excellent culture medium afforded by the abundant serous exudate and autolyzed necrotic tissue, infection is especially prone to occur, which not only retards healing but seems to favor more extensive cicatrization and contractures. In addition to these local changes, certain alterations in the vis- cera and serous membranes are observed in patients dead of exten- sive burns. Bardeen 2 reviewed the literature on this subject and in addition laid especial emphasis on edema and focal necrosis of lymph- oid tissue with increased cell proliferation. Cloudy swelling and parenchymatous degeneration of the liver and kidney, enlargement of the spleen, edema of the lungs, meningeal and general visceral con- gestion are quite constantly found. Recently Weiskotten 3 has called attention to a condition of edema and necrosis of adrenal tissue which he believes is characteristic of burns. A number of theories have been advanced in explanation of these changes which are discussed in full by Togt. 4 It is probable that hemolytic, cytotoxic and neurotoxic substances are formed in the burned area which bring about the visceral and blood changes as well as the condition of shock so often seen following even compara- tively slight burns. There is considerable disagreement among in- vestigators as to the nature and action of these substances. (For fuller discussion see AVells, Chemical Pathology.) Blood changes are manifested in sluggish circulation and assump- tion of a darker purplish color. The erythrocytes are increased two to four million in fatal and one to two million in nonfatal cases. Fragmentation, clumping, and distortion of the red cells with ten- dency to thrombus formation occurs. There is loss of water, hemo- globinuria and hematuria. The platelets are notably increased with marked tendency to clot on part of the blood. In fatal cases a rapid leucocytosis of 50,000 or more, and in the nonfatal of 30,000 to 156 AFTER-TREATMENT OF SURGICAL PATIENTS 40,000, is found. 5 Coincident with this leucoeytosis there is consider- able destruction of leucocytes. Burns following exposure to x-rays differ somewhat in their path- ology from burns resulting from direct contact with a caloric agent. Here again three general classes may be distinguished : First. — In which there is simple erythema. Second. — In which there is in- flammation with loss of epithelium. Third. — In which there is deep ulceration. In addition to these more or less external manifestations, certain changes occur in internal organs directly subjected to the rays, characterized by destruction of the parenchyma with increased connective tissue formation. Such changes are most evident a w r eek or ten days following exposure. There is intracellular edema, and pyknosis of the cells. Cells of the embryonal type are most easily affected. The changes in the skin and immediately underlying structures are : 6 rarefaction of the superficial layers of the corium with in- creased density in the deeper layers ; hyaline degeneration through- out the corium ; increase in elastic tissue ; vacuolation and hyaliniza- tion of smooth muscle fibers; obliteration of lymphatic spaces; di- latation of superficial capillaries with obliteration of large vessels and deeper anastomosing capillaries, due to proliferation of endothe- lium and thickening of the media with subsequent thrombosis; de- struction of the hair follicles and sebaceous glands following long or repeated exposure; appearance of abnormal cells. It is easy to see that such vascular and lymphatic changes would cause serious nutritional disturbances and as a result there is hypertrophy of the epidermis with keratosis in places, and in other areas atrophy and necrosis which give rise to dry, superficial and deep, indolent ul- cers usually having tough adherent membranes and which heal im- perfectly, leaving hard, poorly vascular scars which tend to break down readily. In some cases repair is never complete. With such areas of necrosis alternating with areas of active epithelial prolifera- tion it is not unusual to find strands of epithelial cells invading the deeper structures and thrombosed capillaries, with formation of ac- tual skin cancer. Destruction of lymphocytes due to action of the rays of blood-forming organs, particularly of the lymphogenous type, is commonly seen. Similar conditions, though not so severe, are seen following exces- sive exposure to radium. Symptoms. — The systemic symptoms which accompany this lesion of first degree are comparatively slight, except in nervous individuals who are markedly influenced by pain. POSTOPERATIVE BURNS 157 It is commonly believed that a temperature of 150° F., or higher, will produce a burn of the second degree, this being especially true if prolonged contact with the destructive agent be maintained for a long time. The appearance of such a burn does not differ very markedly, except in extent, from that of the first degree. The sys- temic symptoms are decidedly more pronounced than in burns of the first degree, this being especially true if an infection, which at times is avoided with difficulty, takes place. While the suffering may at first not be more pronounced than in burns of the first degree, it has a tendency on the other hand, to be of much greater duration. In fact, with nervous individuals it may last almost indefinitely. In a burn of the third degree the systemic symptoms are in pro- portion to the amount of tissue destruction, although pain is not so frequently complained of as in the first two types described, for the simple reason that nerve filaments and trunks have gone the same way of other exposed tissues in the general destructive process. In a few days the slough begins to separate, and if all goes well, granu- lation tissue makes its appearance in the walls of the defect. If a serious infection has been prevented, the granulation tissue normally is converted into a scar, which contains no hair follicles, sebaceous glands, or chorionic villi, but is merely covered by a flat stretch of surface epithelium, the results of ingrowths from the borders of the defect, or else the product of skin grafting. Such scars have two most undesirable tendencies. In the first place, keloids may result from them, or their tendency to contract may produce most hideous and crippling deformities. If the burned area is extensive, the accompanying shock may be very marked. It is quite commonly thought that destruction of one-half the body surface is sure to result in death, although, of course, this de- pends very largely on individual resistance. One can quite easily imagine an individual in whom a very much less extensive burn than that just mentioned, might result fatally. Of course, we do not often see extensive burns during postopera- tive treatment. However, the amount of shock following such an ac- cident, occurring in the course of a tedious convalescence, might be expected to be disproportionately greater. It may be stated in general, that the extremes of life do not bear the effects of burns very well. This holds good for the postoperative, as well as for the ordinary variety. If the burned surface has been extensive, we note that the urine is highly acid, small in amount, contains albumin, and frequently casts. Blackfan and Higgins 7 of the Johns Hopkins Hospital have 158 AFTER-TREATMEXT OF SURGICAL PATIENTS found that there is frequently an acidosis in children suffering from superficial burns. The acidosis may develop within a few hours after the injury, or it may he present as a terminal manifestation. The earliest clinical sign of acidosis is hyperpnea. The laboratory evi- dence of the acidosis was established by diminished alveolar carbon dioxide tension and a diminution of the alkali reserve of the blood. The cause of the acidosis has not been determined definitely. It is not due to the acetone bodies, it may prove to be due to retention of acid phosphates, dependent upon kidney deficiencies. If so, then it is analogous to that occurring in nephritis as has been demonstrated by Howland and Marriott. The acidosis in burns is only one symp- tom and is probably not the cause of death, but its presence indi- cates vigorous therapeutic measures. They simjjvst as the result of their observations that alkalies be given prophylactically after se- vere burns, and when an acidosis, as determined clinically by the hyperpnea, or by one of the laboratory tests, develops, energetic treatment with alkalies be instituted. It lias also been noted by some authors that a transitory glycosuria results in a few eases and it ap- parently is not necessary that the burn he severe to bring about tins complication. Frostbite For want of a better term in describing the action of cold, as we occasionally see it in postoperative treatment, we have adopted the caption "frostbite." Ormsby 8 in discussing this subject states that • - in the first degree injury which usually follows short exposure to extreme cold, there occurs erythema and then swelling after the parts are warmed. During the freezing process there occurs slight pain followed by loss of sensation, and the area presents a pale appear- ance from contraction of the blood vessels. As the circulation is re- stored, hyperemia and edema follow. < Occasionally a more or less per- manent redness supervenes. ••In the second degree the edema and erythema are increased with the production of vesicles and bullae. These undergo involution with- out the formation of scars. "In the third grade gangrene may occur with and without the for- mation of bullae. The frozen part may become insensitive, white, and cold, without the circulation in it of blood and lymph currents. From this condition reaction occurs, with the formation of an eschar, dif- fering according to the severity of exposure to cold. If. however, besides the interference with the circulation, the tissue itself has been destroyed, when reaction occurs the parts fall at once into gangrene; POSTOPERATIVE BURNS 159 or there form bulla?, larger than those described above, filled with sanguinolent serum; or the skin is smooth, marbled with bluish lines, whitish, cold, and insensitive. Gangrene ensues, followed by the well-known phenomena of the 'line of demarcation,' and separation of the dead part, granulation, repair, and cicatrization." Prognosis. — The prognosis of burns or frostbite in the after-treat- ment can hardly be put upon the serious plane which often charac- terizes these lesions at other times, since fortunately, such accidents in the hospital do not result in the extensive tissue destruction often seen in burns of the customary variety. It is well to add in this connec- tion, that it is the extent rather than the depth of a burn which is especially serious, as far as the life of the individual is concerned. The most serious complication likely to ensue after a postoperative burn is an infection. Fortunately, however, for the individual so unfortunate as to be injured within the hospital walls, we are usually in a position to prevent or combat this secondary complication. Tu- dor 9 reminds us of one matter important in this connection, that the anaphylactic reaction which follows the absorption of toxins from burned tissues is not to be overlooked as an important factor in these cases. About the worst prognostic features in postoperative burns are deformities, sears, prolonged stay in the hospital, the patient's dam- aged morale and the heightened tendency to malpractice suits. Treatment. — So many remedies have been proposed in the treat- ment of burns that one can be reasonably sure that not many of them are highly satisfactory. I no longer employ any of the oils, picric acid, or one of the other thousand and one agents which discolor the individual's skin or render his habiliments greasy and unfit for fur- ther use. We have not found a chemical substance which is pro- ductive of immediate relief from pain when used as a local applica- tion. To accomplish this highly desired result, we rely upon mor- phine alone, and know of no other drug which in any measure will take its place. We think of nothing more cruel at this time than the application of a gauze or cotton dressing, which must be changed at intervals and thus subject the damaged and oversensitive tissues to repeated traumata. So far as I can judge at the present time, there seem to be just two reasonable courses open to us in treating a burn, no matter what the degree. Presupposing in both eases that the part has first been put at rest and kept so, we may cover the burned area with paraffin and com- pletely exclude the air, and in this way may obtain the maximum of relief, and at the same time do a great deal toward preventing ac- 160 AFTER-TREATMENT OF SURGICAL PATIENTS eidental infection. While this suggestion is by no means a new one, still. I think we may safely claim for it that one of the many con- tributions, which the genius of the French has made to clinical sur- gery during the great war, is the treatment of burns with a coating of paraffin. Howarth, 10 after much experimenting is convinced that patients are made much more comfortable and that healing is has- tened by daily applications of paraffin, either in the form of a liquid spray or if put on with a brush, or even if applied as a plaster on cotton. The material must be made flexible by a slight modification, the following prescription being suggested. Paraffin, 70 gm. Liquid petrolatum, 3 c.c. "White beeswax, 10 gm. This is to be melted in a double boiler, and applied after the sur- face has been dried by the electric fan, else this layer will not adhere. The second choice, to which I have referred, in the treatment of burns, concerns itself with the immediate exposure of the affected area to the air, the body heat being kept up by means of a number of elec- tric light bulbs swung from the cradle which holds the bed covers off the exposed part, or else the patient is placed in a burn bed. The crusts may be softened by applying every few hours 4 per cent boric acid ointment, which after being retained on the lesion for one hour is again gently scraped off, the patient all the u hilf being kept under the direct rays of the electric light. The object of the light is to act as a drying agent, at the same time maintaining body heat so that a patient, though partly or even completely undressed and exposed, may lie in comfort. In order to gain sufficient heat it is sometimes necessary to replace the tungsten electric light bulb by the old-fashioned carbon filament bulbs, which emit less light but give considerably more heat. Light and heat are further regulated by decreasing or increasing the number of bulbs or more lightly covering- the cradle, depending on the amount of either desired. Ravogli 11 instead of continuing the open air treat- ment, even while the boric ointment has been applied, covers the part with "English Lint." I do not consider this absolutely necessary, at least in many cases, and it may dislodge the various small islands of epidermis which have in the meantime sprung up here and there over the granulations. Let us suppose that in the course of time, all the sloughs have come away or have been removed, and the wound has become clothed with healthy, velvet like granulation tissue. As the epithelium from Fig. 23. — Skin grafts on an extensive burn surface. POSTOPERATIVE BURNS 161 the skin edges creeps over the granulating wound, its progress is hastened by placing each day new areas of Reverdin skin grafts (Fig. 23), which will readily take over the areas of healthy granula- tion tissue. If for any reason the granulations are pale and whitish, as is seen often after x-ray burns, balsam of Peru may be applied along with the treatment discussed above, and here small grafts of the whole thickness of the skin, after the Wolfe-Krause method, may be applied without awaiting for areas of healthy tissue to appear. It will be found that some will take and from around them the gran- Fig. 24. — Wire cage to protect skin grafts on burn surface. ulation will become normal in appearance. In carrying out the skin grafting, the skin should be taken from the patient himself. A solu- tion of y 2 per cent novocaine with 1 :1000 c.c. adrenalin in salt solu- tion being used to anesthetize the skin area. A sharp pair of scis- sors and a pair of small mouse tooth forceps are all one needs in se- curing the grafts. I recall a patient who was severely burned while the results of a bismuth meal were being observed. The lesion, a third degree burn, extended over a considerable region of the back. After months of 162 AFTER-TREATMENT OF SURGICAL PATIENTS treatment with all the methods advised in the foregoing paragraphs, most of the defect was healed. The epidermis regenerated, and fi- nally nicely covered the whole region except for a bat-shaped area four inches long and three inches wide in the center of the small of the back. This was filled in with pale granulation tissue and was ex- tremely painful. This area was excised in its entirety and allowed to fill in wdth new granulation tissue which was indeed slow to de- velop. The part was covered with an ordinary wire sieve (Fig. 24) and the patient allowed up and around out of doors. The new granu- lations were whitish and certainly not healthy in appearance, but the operative procedure had stopped the pain which, of course, is the first factor to consider in these eases. As quickly as the defect filled with the new tissue, Wolfe-Krause grafts were used, with the result that after one or two trials, a "graft took." Around this nucleus the granulations became red and healthy. This permitted more suc- cessful skin grafting and quick covering of the denuded area with normal skin. The systemic treatment is considered very important in burns of any degree. In those of second or third degree, it is imperative that this part of the individual case be not overlooked, while the local management is being carried out. In those cases requiring the open air treatment from the very first, I do not hesitate to give morphine, as it is needed for the first few days; it apparently aids materially in combating the shock. We are not often confronted by a serious acidosis or other form of autointoxication in the relatively restricted burns which occur dur- ing surgical after-treatment; still, it may not be amiss to mention in this connection the fact that the use of sodium solution, morphine, carbohydrate feeding and plenty of water are of use in this connec- tion. In the treatment of injuries due to cold, the same local and general measures may be employed as discussed for like injuries due to heat. At first, cold applications may be applied to the injured surface, as the pain in most cases will be too severe to suddenly cause marked reaction by the application of heat. Full credit is due ( ). F. McKittrick for having abstracted all the literature to which reference is made in this chapter. Bibliography iSajous: Analytic Cyclopedia of Practical Medicine, 1917, viii, 171. zBardeen: Jour. Exper. Med., Is:i7, ii, 501. Also Johns Hopkins Hosp. Eepts., 1898 (7), p. 137. sWeiskotten : .lorn. Am. Med. Assn.. Sept. 8, 1P1 7 : ibid., Jan. 25, 1919. iVogt: Ztsdir. exper. Path. u. Pharm., L912, ii, L91. POSTOPERATIVE BURNS 163 sLocke: Boston Med. and Surg. Jour., 1902, cxlvii, 480. GWolbach: Jour. Med. Eesearch, October, 1909, xxi, 415. Porter: Ibid., p. 357. ^Blachfan and Higgins: Personal communication. sOrmsby: Diseases of the Skin, Philadelphia, 1915, Lea & Febiger, p. 266. sTudor: Internat. Jour. Surg., 1915, xxviii, 286. loHowarth: Surg., Gynec. and Obst., November, 1917. nBavogli: Jour. Am. Med. Assn., 1915, lxv, 293. The following references were also consulted: Abbe: Jour. Am. Med. Assn., July 17, 1915, p. 220. Bernard: Munchen. med. Wchnschr., Jan. 5, 1904. Boland: New York Med. Jour., August, 1913. Brazer: New York Med. Jour., 1913, p. 236. Brooks : General and Special Pathology, Philadelphia, 1916, P. A. Davis Co. Chipman: Jour. Am. Med. Assn., 1915, lxv, 295. Copeland: Med. Bee, New York, May, 1887. Da Costa: Modern Surgery, Philadelphia, 1918, W. B. Saunders Co., ed. 7. Delafield and Prudden: Textbook of Pathology, Philadelphia, 1914, W. B. Saunders Co., ed. 9. Freeman: Analytic Cyclopedia of Practical Medicine, Philadelphia, 1917, F. A. Davis Co., viii, 163. Heithaus : Personal communication. Heyde: Med. Klin., 1912, viii, 263. Jack: Washington Med. Ann., 1911-13, x-xi, 106. Kaposi: Pathologie et traitement des Maladies de la peau, trans, by Besnier and Dayon, Paris, 1896. Keen: Surgery, Philadelphia, W. B. Saunders Co. Kuss: Paris Medical, Feb. 21, 1914. Lieber: Beitr. z. klin. Chir., 1912, lxxxi. Lutz: Bailway Surgeon, July 25, 1899. MacCallum: A Text Book of Pathology, Philadelphia, 1917, W. B. Saunders Co. McArthur: Am. Jour. Boentgenol., 1917, iv, 521. McDonnell: Jour. Cutan. Dis., 1915, p. 312. Parker: Surg. Clin., Chicago, 1917, i, 635. Also Jour. Am. Med. Assn., Aug. 19, 1916. Pfeift'er: Ztschr. Immunitat., 1913, xviii, 75. Pusey: Jour. Am. Med. Assn., 1915, lxv, 295. Beid: Lancet, London, March, 1898. Bosslenger: Internat. med. Kong., Wien, September, 1892. Sequeira: Brit. Jour. Dermat., 1908, p. 140. Sherman: Surg., Gynec. and Obst., 1918, xxvi, 450. Shoemaker: Diseases of the Skin, Philadelphia, 1909, F. A. Davis Co., p. 344. Stelwagon: Diseases of the Skin, Philadelphia, 1916, W. B. Saunders Co. Sneve: Jour. Am. Med. Assn., 1905, xlv, 1. Talmey: The Open Air Treatment of Burns, New York Med. Jour 1914 xcix p. 549. ' ' Tudor: New York Med. Jour., 1918, cvii, 404, 453. Wagner: Zentralbl. f. Chir., Dec. 12, 1903. Wells: Chemical Pathology, Philadelphia, W. B. Saunders Co., ed. 3. Wertheimer: Munchen. med. Wchnschr., 1892, No. 21. Zeisler: Jour. Am. Med. Assn., 1915, lxv, 295. CHAPTER XX BEDSORES By 0. F. McKittrick, St. Louis, Mo. Bedsores have been the subject of considerable discussion and writing throughout the years of medical and surgical advance. It is one ever requiring the most minute attention of those in charge of the unhappy victim and even then, the ultimate outcome may be such as to seriously impede the recovery of infirm patients, particularly after a major operation. The lesion is a local anemia which finally results in moist gangrene due to continued pressure on some particular area. Zipperling, 1 who has recently considered this complication, states that Samuel,- in his study of the effects upon the skin and underlying tissues, was the first to give the name "decubitus" to these lesions. Zipperling in discussing lesions of the spinal cord and brain has observed decubitus develop apparently from tins source alone and refers to Leyden, who, lie says, first made a short mention of "Acute Decubitus" in his text book. Later on Erlr fully described the malady. His writings were soon followed by those of Eulenburg. 1 That injuries and lesions of the cord or brain may cause decubitus has been held true by others although the general opinion that lesions here are more commonly predisposing rather than causative factors has recently been supported by Marie and Roussy. s These men working among the wounded during the last war state that the various paralyses resulting from injuries or lesions of the cord or brain prevent the patient from changing his position as he would otherwise do and that the associated loss of sensation disparages any inclination to move. As a result of this certain parts of his body constantly support his weight and bedsores appear < Figs. 25 and 26). Especially is this true if there is an incontinence of feces or urine. In such patients it is not imperative that the pressure be necessarily very severe or prolonged to cause marked local anemia and final gangrene. Bedsores, therefore, in these patients are indeed very ser- ious since the destruction of the tissues is so rapid and the healing power so limited. 164 BEDSORES 165 Fig. 25. — Bedsores following myelitis. (After Keen.) Fig. 26. — Healed bedsores. (After Keen.) 166 AFTER-TREATMENT OF SURGICAL PATIENTS Decubitus also, is seen in patients with no cerebral or spinal affec- tions, but in those who because of their condition are obliged to re- main in bed for any length of time. The emaciated and otherwise weakened patients are more liable to this affection than those of stouter builds, although this malady may affect any patient who is in bed even for a limited time if there is too prolonged local pressure on the tissues. Thus pressure from an improperly applied bandage, splint, or plaster of Paris dressing may do untold damage within a short time if the accompanying pain complained of by the patient is not heeded. Pressure from bed clothes, particularly over the toes, wrinkles in the sheet or patient's gown, bread crumbs, pins, strings in the bed will cause this complication. Inactivity of the patient, excessive secretions, regardless of the na- ture, predispose to bedsores, especially if the skin is not kept scrupu- lously clean, and even then, the lesion will sometimes occur despite the best nursing. The lesion most usually occurs over the bony prominences corre- sponding to the sacrum, coccyx, or tuber ischii. They occur also over the back, along the spine, on the heel, over the malleoli or point of the elbow. In fact pressure on a part of the body may produce a le- sion in a most unexpected place, depending on the position of the pa- tient. There is first a reddening of the skin which is usually accom- panied by a burning pain more or less severe. Unfortunately at times, very little or no pain is complained of and the sore is found quite by accident, Following the redness of the skin at the point of pressure there oecurs a bluish discoloration, probably spotted at first, which soon changes to a solid brownish or black color. Vesicles or bullae may form here and there over the area, and these finally rupture. Leaving an ulcerating surface which soon becomes necrotic. This necrosis may involve muscles, tendons, and occasionally even bones. A line of demarcation forms sooner or later, and under proper care the tissue sloughs out, the defect healing by granulation. As a rule the bedsore does not become so extensive ; an ulceration of the skin and possibly subcutaneous tissues being its extent, al- though in some cases destruction does not stop even at the bone but passes on into the spinal canal, causing meningitis and death." That dire consequences can occur from these lesions, due to infection or extension of the process must always be borne in mind and measures instituted to combat both these possibilities as soon as the trouble is discovered. BEDSORES 167 Much has been written on the treatment of bedsores. The most important result one can hope to attain is to prevent them. Patients on admittance to the hospital are given thorough cleansing baths with soap and water followed by an alcohol rub (50 per cent) twice each day until the operation. This not only keeps the skin clean, but tends to harden it. They are placed in comfortable beds with smooth uniform mattresses, over which the sheets are kept stretched, and if necessary, pinned to the mattresses to prevent possible creases or folds occurring. The importance of keeping bread crumbs and other foreign particles out of the bed is self evident. The skin must be kept dry, a task not always easy of accomplishment. The pro- verbial rubber sheet on every hospital bed is sufficient in itself to cause some patients to perspire freely, particularly in hot weather. This should be removed in such instances and the clanger to the mat- tress met by using strips of rubber as the occasion demands. Occa- sionally it becomes necessary to replace the rubber sheet with some absorbent material which will dispose of the perspiration as cpiickly as it forms. The value of this procedure was recently extolled: by Smith 6 who though a helpless invalid was bedridden over five years without a lesion developing. In this connection we also freely use boric acid powder, equal parts of boric acid with bismuth subnitrate, or even talcum powder to dust over the body as often as necessary to keep the skin dry. This procedure is also particularly useful follow- ing the sponge bath and alcohol rub. Where there is an inconti- nence of urine a rubber urinal is constantly worn. When the patient is incontinent both as to the feces and urine he is washed, as soon as soiled, with warm water and castile soap, given an alcohol (50 per cent) rub to which alum, 10 grains to the pint, has been added. Ac- cording to Lind 7 this is repeated after every soiling, and if there is any redness of the skin in the regions repeatedly soiled he would apply zinc oxide ointment (U. S. P.) I have found that a mixture of the above zinc oxide, one ounce, cotton seed oil, two ounces, and alcohol, two ounces, is an exceedingly good application for these cases. In fact this mixture may be used twice daily over the wdiole body in patients not so affected and in every instance with the most satisfactory results. It is usually rubbed into the skin morning and night immediately following the bath. The Bradford frame is very valuable in paralyzed patients or those suffering from fracture of the hip. Sucb patients placed on this or some similar device can be turned at will and any pressure points relieved by treatment. In studying the various methods to keep the skin in a healthy con- 168 AFTER-TREATMENT OF SURGICAL PATIENTS dition locally, one must not forget that looking after the general con- dition of the patient is equally important. His general health is carefully watched over and an abundance of food supplied. If this complication arises in spite of every measure skill and com- mon sense can devise to prevent it, one must first invent some means to relieve all pressure and tension from the affected part. Air cush- ions, rubber rings or even a pneumatic or water bed have been em- ployed for this purpose. For those patients greatly emaciated or paralyzed, such beds are indeed valuable in bringing about an equal distribution of the weight. However, these are not always to be had and under such circumstances the mattress may be replaced by a bed of some airy soft material such as cotton, wool or hair, which is thrown loosely into an improvised bedstead. Zweig 9 employs wood wool, the patient being allowed to lie on the loose material which has no covering at all and is confined by the limits only of an old-fash- ioned wooden bedstead. This maneuver, to be sure, is not always agreeable, but may be employed in extreme cases. Pressure from bed- clothes or irritation from the night gown is overcome by the use of cradles, wire cages, and even the application of absorbent cotton 8 placed over the lesion and held in position with collodion is very ad- visable in some instances. Very small breaks in the skin are often protected by simply apply- ing an ordinary zinc oxide adhesive strip directly over the exposed surface. Where the lesion is so large that neither of these remedies is advisable, the pari is kept clean with a saturated boric acid solu- tion or sterile water, and then dusted with boric acid powder. Lind recommends for this purpose aristol one part, boric acid one part, and lycopodium eight parts. The wound is left open and exposed to the air, this portion of the body absolutely relieved of pressure. 10 Bedsores which involve the deeper tissues require more extensive treatment. In such instances the electric Ligb.1 treatment is instituted. The lesion is kept free of crusts, sloughs are pulled off whenever it can be done without bleeding, and the tissue irrigated frequently with Dakin's fluid, boric acid or hypertonic sodium chloride solution. At night a 4 per cent boric acid ointment is placed in the defect and the whole covered Lightly with gauze or else a small wire sieve fas- tened over the part by means of adhesive. The use of adhesive is not desirable 11 in every case as it is very irritating to the skin of some of these patients and in selected cases only is it to be desired even for this simple means. The next morning the ointment is removed lightly with gauze and the electric light treatment resumed. BEDSORES 169 In cases where this treatment is not practical in the usual way the rays of light may be directed into the lesion by means of a concave head mirror. Whenever it is possible to substitute sunlight for the electric light these rays are directed into the wound in this same manner. This was first suggested by Ring. 12 It is remarkable how quickly such lesions heal when all the details of this treatment are persistently carried out. Decubitus of long standing and which show little or no tendency to heal may be stimulated with alternate hot and cold compresses. The granulations be stimulated by rubbing a silver nitrate stick over the surface occasionally. Massage of the adjacent skin is also a valuable procedure. At night the boric ointment is replaced. A mixture ad- vised by Lind follows: silver nitrate one part, balsam of Peru ten parts, zinc oxide ointment one hundred parts, or the balsam of Peru may be used alone. When the granulations have become even with the skin surface, 4 per cent scarlet red ointment replaces all other oint- ments and the light treatment is continued. Multiple bedsores particularly in emaciated or paralyzed patients may require a continuous full warm bath at a temperature of 95° to 100 . 13 The treatment may be kept up as long as desired without appreciable weakening or injury to the general health and when there is marked improvement in the lesions, they are then cared for as sug- gested above. Bibliography iZipperling: Centralbl. f. d. Grenzgeb., d. Med. u. Chir., 1913, p. 187. 2 Samuel: Die tropliischen Nerven, Leipzig, 1860. sErb : Handb. von Ziemssen u. Spez. Path. u. Ther. 1876, xi, p. 120. 4Eulenburg: Lehrbuch der Nervenkrankheiten, Berlin, 1878, 1. Theil p. 343-347. s Marie and Boussy: Bull, de l'Acad. de Med., Paris, 1915, lxxiii, 609. Also abstr. in Internat. Abstr. Surg., 1915, xxi, 29-4. eSmith: Modern Hospital, 1916, vii, 518. 7Lind: New York Med. Jour., 1915, ci, 26. sCrandon : Surgical After-treatment, 1909, p. 284. sZweig: Deutsch. Med. Wchnsehr., 1911, xxxxii. loHigbee: Bef. Handbook for Nurses (Beck), 1913, p. 84. -lEhrenreich: New York Med. Jour., 1915, ci, 27. isBing: Boston Med. and Surg. Jour.. 1906, civ. 629. isNeuwelt: New York Med. Jour., 1915, ci, 75. CHAPTER XXI POSTOPERATIVE PROLAPSE OF ABDOMINAL VISCERA By Willard Bartlett, St. Louis, Mo. Professor Madelung's exhaustive article with its 105 literature ref- erences which appeared in 1905, leaves absolutely nothing to be de- sired so far as this subject is concerned, hence I feel that I can do my readers no greater service than to present a painstaking abstract of it as a chapter on this subject. Madelung 1 up to 1905, was able to find 144 cases in the literature, had 7 in his own practice, and 6 in the practice of several of his colleagues, thus making 157 cases for purposes of study. The accident has occurred after exploratory laparotomies where no decrease in the abdominal contents was made, but what is much more surprising, it lias also been noted after re- moval of the largest tumors. It occurred in the earliest days of ab- dominal surgery, in 1844 for instance, as well as in most recent years with all the modern improvements. It lias occurred in a child two days old and in a woman seventy-one years old. In women it oc- curred 118 times and in men 25 times, while the sex is not given in 14 instances. Practically every form of abdominal and pelvic oper- ation has been complicated in this way. One hundred twenty-four times the incision was in the lower half of the abdominal wall, while in 16 instances it vvas in the upper half, and it has been much more common where the incision has gone directly through the midline rather than through one of the rectus muscles. The danger of this accident seems to lie especially great when the incision goes through .in old scar as noted by Spencer Wells in 1863. As to the time when the wound is most likely to burst open. Made- lung concludes that this is somewhere between the eighth and ninth day. (It should bo noted that the date of occurrence can not always be given since in many instances it was discovered by accident. ) In most instances the entire Length of the wound was found open. In a very few interesting cases the viscera did not come out through the original incision in the muscle but through a fresh tear in this tissue. With the exception of the spleen and pancreas, every ab- dominal viseiis has been prolapsed in such cases. The most frequent of them is the small intestine, with the omentum in second place. In many cases the viscera simply lie between the wound edges without 170 POSTOPERATIVE PROLAPSE OF ABDOMINAL VISCERA 171 being pushed outside the skin level. This was accounted for, no doubt, by fibrinous peritoneal adhesions; often, however, the pro- lapse was of tremendous size. The condition of the mass has varied with circumstances ; incarceration of the intestine being reported only once. It is interesting to relate in studying the etiology that this unfortunate accident occurred most frequently where silk-worm gut alone, silk alone, wire alone, or all of these suture materials combined, have been used. It occurred where layer closure, as well as "through- and-through" sutures were used. In one instance, the intestine slipped out between two through-and-through sutures which had been placed rather far apart. Of course it has occurred where catgut alone has been employed, but Madelung after his extensive study of the subject considers it wrong to conclude that any special suture material or any one suture method protects against bursting of the wound. It was once thought that the too early removal of sutures accounted for it, but the statistics do not bear out this conclusion, since it has often occurred before the stitches were removed. On the other hand, it must be admitted that the wound burst thirty-nine times within twenty-four hours after the stitches were taken out. It has occurred, however, as late as the seventeenth day in a patient whose stitches had been removed nine days earlier. It does not seem to have been caused by leaving a small portion of a wound open for drainage, nor does tamponade seem to have had this effect. (It would seem, then, that the cause of this distressing accident must be sought elsewhere than in the original treatment of the laparotomy wound.) An important causal factor is to be sought in the condition of the abdominal wall. There is danger where it is very thin, especially in a greatly weakened individual or in one who has been starved. Bleeding between the layers may be a causal factor, as may be local- ized infection. In most instances, however, wound healing would appear to have progressed perfectly up to the moment bursting oc- curred. Coughing is surely one of the chief causes of this condition. In 51 out of these 157 cases, it seems to have been chiefly to blame, while in the second place, must be mentioned vomiting, which was the direct cause of the accident 26 times. In some instances the two last-men- tioned factors worked together. Straining at stool is mentioned five times in this connection and tympanites seem to have played a minor role, surprising as it seems. Kapid increase of intraabdominal ten- sion in pregnancy, ascites, and the growth of abdominal tumors has, in a few instances, been responsible. 172 AFTER-TREATMEXT OF SURGICAL PATIENTS It is curious to study the patient's sensations at the moment the abdomen bursts open and to note that they are frequently far from what one would expect. Very few have expresse 1 severe pain or a characteristic feeling of bursting. They have complained rather of general abdominal discomfort and frequently has this been so light or disappeared so quickly that the patient has forgotten to mention it at the time to a nurse or doctor, but has recalled it hours or days later when the prolapse is discovered. Frequently, the first sensation has been that of something warm and moist on the abdomen and thighs. In many instances the most acute questioning has failed to bring out the fact that the patient's attention was ever attracted by any unusual sensation at all. In rare instances, the patient has com- plained of "feeling badly" or shown general disturbances with col- lapse symptoms, etc. As a rule, the general symptoms have remained good throughout, while the occasional patient has expressed the feel- ing of great relief when the stitches gave way. In most cases the ac- cident has been discovered by observing the changed appearance of the dressings. They have been soaked with fluid or bulged to the ex- tent that an examination has been made and the viscera discovered outside the abdominal wall. There can be no doubt that hours and even days have elapsed before many of these patients have come into the surgeon's hands. This is especially true where old thin scars have ruptured. How ridiculous it seems, then, to operate on the pa- tient in his own bed with a show of haste, instead of getting him into proper surroundings. A general anesthetic has been used many times, though it is not at all necessary. When there has been a fecal fistula oi' suppuration in the wall. etc.. careful cleansing of the bowel is necessary. Where an aseptic dressing has covered unsoiled viscera, cleansing is unnecessary and may do harm. Shall we then replace the viscera at all or shall we do it at once? Of course the ideal treatment is replacement with immediate suture. In some instances, however, it is not possible to get the prolapsed contents back into the cavity. and in seven of the cases reported, no attempt at reposition was made. In quite a number of instances this was accomplished, but sutures were not inserted, at least not early in the treatment. Both of these acts were frequently prevented by coughing, meteorism. adhesions, etc. It is worthy of mention that spontaneous reposition took place in the course of weeks or months in those patients who could not or at least who did not have the benefit of this maneuver. In no single instance did the prolapse persist, whence conclusion should be drawn that we must not too hurriedly puncture or resect intestines which we can not replace. POSTOPERATIVE PROLAPSE OF ABDOMINAL VISCERA 173 Prolapsed omentum can be amputated without any further con- sideration. It is of great help frequently to place the patient in the exaggerated Trendelenburg position, while at the same time the edges of the wound are held up and slight pressure exerted on the viscera. It is often necessary, in addition, to extend the original incision as well as to separate adhesions between intestinal coils or between them and the abdominal wall. This produces little or no pain, hence it is necessary to use an anesthetic in especially difficult cases only. In fact, a really sensible patient can aid the procedure greatly by his voluntary efforts. Sometimes a second attempt succeeds after the first has failed, hence the operator is not to give up after a single trial. Some are in favor of freshing the wound edges in the customary manner before suturing is attempted. This latter procedure is some- times exceedingly difficult ; the tissues may be friable and the sutures may cut through or it may be impossible to approximate the edges so that gauze must fill out the defect. Of course every form of second- ary suture has been used in these cases but apparently one method is about as good as another. In many of the cases where reposition has been made without suture, tamponade has been resorted to. The direct consequences of treating this condition as outlined above have been astonishingly slight and the bowels have moved as though nothing had happened. In a few instances, however, hasty attempts at reposition have been attended with serious consequences. Intestine and bladder have both been injured by a rough attempt at treatment. In quite a number of cases, secondary prolapse has taken place though not so often as one would expect, when the original method of treat- ment is considered. Peritonitis has developed in astonishingly few of these cases. The most frequent complications to arise have been those affecting the respiratory system. (No doubt this is in some measure accounted for by the fact that secondary sutures have been supported for a long time by adhesive straps, binders, etc., which have interfered with free movements of the lower ribs and dia- phragm. — Author's note.) The prognosis in such cases does not depend upon the kind of vis- cera prolapsed, or upon the size of the mass, or upon the time which has elapsed before treatment is instituted. One hundred five of the 148 patients whose result is known were reported as completely cured. The scar deserves special mention. It must have been a satisfactory one, since no mention was made at all in most of the histories. It is reported 18 times as having been a perfect one after many years, while it is definitely stated 11 times that no hernia occurred. This 174 AFTER-TREATMENT OF SURGICAL PATIENTS is even true in cases of multiple ruptures even though no suture was employed. In one case the same wound hurst twice, the first time in conse- quence of heavy lifting and the second time two years later (Synak). The bursting of healed laparotomy scars is reported in 16 women and 2 men. In all of these, a most unusual thinning out of the scar had taken place. There seemed to have been very little cause known for this bursting, the patients were surprised and in fact, it occurred twice during sleep. In a few cases, however, there was a slight strain, such as sneezing, coughing, bowel movement, lifting of a weight or jumping from a height. The patient had become aware of his condition, only upon feeling something soft, warm, and moist on the abdomen and thighs. Usually, the tear was of short length, but at times, the amount of prolapsed viscera has been enormous. The prognosis in these instances of remote prolapse must be surpris- ingly good, since not one of the 18 patients died. All of these pa- tients were sewed up, but two, in whom tampon was resorted to. No recurrence took place, and in only one did hernia appear. In only one of the 157 cases is a hernia of such size as to require operation, reported. Impairment of intestinal function was reported only once. It must then be concluded that very little remote trouble is to be expected by the individual who has sustained this accident, as a consequence of his rather horrifying experience. A critical sur- vey of these 157 cases would indicate that immediate death was caused by the accident only 29 times. (The author of this chapter lias been so unfortunate as to have ex- perienced this embarrassing complication seven times. All were clean eases in which reposition and secondary suture within a few hours were carried out without great difficulty. All the patients, with but one exception, were taken to the operating room and completely closed up with through-and-through sutures, ether being used only once. The other six closures were accomplished with seemingly very little pain in the absence of even a local anesthesia. This we credit to very gentle manipulation and the use of exceedingly sharp cutting needles, of the Reverdin type.) BibliogTaphy iMadelung: Ueber den Post-operativen Vorfall van Baucheingaweiden, Arch. f. Klin. Chir., L905, Ixxvii, 347. CHAPTER XXII FOREIGN BODIES LOST IN THE PERITONEAL CAVITY By Willard Bartlett, St. Louis, Mo. Sir John Bland-Sutton once said, in his inimitable way, ''before closing the abdomen count your sponges, instruments, and assist- ants. ' ' It is really surprising that our horror at accidentally leaving foreign substances in the peritoneal cavity or other tissue spaces did not long ago influence us strongly against permanently embedding them as supports, splints, etc. It is only within more recent times that the marked reaction has come against the employment of anything other than structures of an autoplastic nature in the process of surgical reconstruction. All of us, who have embedded Lane's plates, or other nonyielding foreign substances, know perfectly well what an extensive bone atro- phy takes place in their vicinity. The same thing holds good, in a lesser degree of wire sutures, and all the other multitude of non- yielding foreign bodies, which have from time to time been employed with design. Indeed, the greater majority of surgeons, the writer in- cluded, go so far as to shun the use of permanent suture material of any kind in a region from which it can not be readily removed, either by nature or the human hand. It is with no little chagrin that a surgeon confesses to having left foreign bodies in the peritoneal cavity by accident, and when one realizes that such case reports are not published voluntarily in a majority of instances, he is prone to conclude that the accident is far more common than we have usually supposed. No doubt, many an individual has lost his life in consequence of this accident, hence, the number of reported instances grows relatively less in the light of such reasoning. Neugebauer 1 has done more than any other writer to attract the at- tention of the profession to this matter. His study of it came about as a result of his being called upon to make statistical studies, which were used in the defense of two brother physicians, who were accused of this dereliction. The case in question is so instructive, and in many respects so dramatic, that it is quoted in some detail by ex- cerpts taken from Schachner 2 (whose article is worthy of complete perusal by those especially interested in this subject). 175 176 AFTER-TREATMENT OF SURGICAL PATIENTS "Professor Kosinski performed an abdominal seetion upon a pa- tient fifty years of age, for an ovarian cystoma with a twisted pedi- cle. The operation was very difficult on account of numerous ad- hesions and an interrupted narcosis. "After the first few days an elevation of temperature occurred, accompanied with abdominal pains and pains in one leg. An in- flammatory infiltrate was felt. By this time it was discovered that two artery clamps were missing from the instrument cabinet. It was thought that the artery clamps might have been taken by Dr. Solomon, as he had left shortly after this operation to perform an- other in one of the provinces. Nevertheless, the coincidence aroused the suspicion of Dr. Kosinski. that perhaps the missing clamps had been left in the abdomen. "Consequently, six weeks after the laparotomy, he reopened the abdomen to investigate the infiltration, but found neither pus nor the missing clamps. His suspicions were not allayed. However, he con- cluded to wait for further developments. The condition improved after the second abdominal section, although there remained a fistula, which finally closed. "Several weeks passed, but as the convalescence seemed to be re- larded. I))'. Kosinski was again called for a more thorough examina- tion. On this occasion, he felt a hard resistance in the region of the umbilicus. Per rectum and per vagina there was nothing to be felt. His former suspicions were renewed, and he expressed them to the family, stating thai perhaps the hemostats that were missing from the cabinet had been left in the abdominal cavity. "Professor Kosinski insisted that another operation be undertaken and offered to perform the same gratis. The patient had agreed and a room had been prepared for her, but she failed to appear. The family physician had informed her two sons of the nature of the op- eration, to which they failed to give their consent, as they stated they had lost all confidence in Professor Kosinski. "Tlie patient was sent to the health resort. Ciechocinek, with the view of promoting the absorption of the inflammatory exudate. She improved to such an extent thai when her sons told her of the sus- picion of Dr. Kosinski, she would not believe it and ridiculed the idea. "Six months after the first operation, the patient arrived at War- saw from Ciechocinek. Before the arrival at the station, she reached up to get some baggage, and at the same moment, suddenly became faint. The momentary shock soon passed and on reaching home, she entertained her sons until late ;it night. On the following morn- FOREIGN BODIES LOST IN THE PERITONEAL CAVITY 177 ing, she felt extremely weak, and Dr. Frankel was called in, who de- manded immediate operation by Professor Kosinski, and told her sons that no time should be lost. They refused to call Dr. Kosinski, but called in Professor Wassiljew. The latter saw the exhausted pa- tient about midday, and was told of the suspicion of Dr. Kosinski. In spite of the fact that the patient had passed by rectum in all, a vessel full of blood clots, the professor suggested that a radiogram be made, and the patient was removed in a clrosky to an infirmary, where she was led up three steps and remained several hours. Several radiograms were made, but with negative results. The exhausted patient was taken to her home late at night, and the following morn- ing, Dr. Wassiljew, assisted by Dr. Krejewski, performed the abdom- inal section. Partial narcosis was used, and the patient became al- most pulseless. The Douglas pouch was found covered by inflamma- tory bands. A second oblique incision was made above Poupart's ligament, hoping to reach the seat of disturbance extraperitoneally. A large cavity was opened, in which both hemostats were discovered, lying parallel and just above the pelvic brim. Both forceps had forced an entry into the left external iliac artery. The removal of the forceps was attended with a furious hemorrhage, which 1he operator endeavored to control by compressing the aorta. The cavity was tamponed. The patient died upon the table. "The ends of the forceps had punctured the left external iliac artery, when the patient reached up to get her baggage at the rail- way station. A false traumatic aneursym had ensued as the autopsy showed. The lower end of the forceps had perforated the large in- testine and this accounted for the blood passing from the injured ar- tery by way of the rectum. Had the operation been performed when the patient left the railway carriage, or even on the following morn- ing as the family physician had requested, perhaps there would have been a recovery. "The patient, who was suffering from an injured artery, was driven in a carriage to her home ; from there to an infirmary, then marched up three steps to have a radioscopic examination made, with un- satisfactory result, as it appears, owing to imperfections in connec- tion with the outfit. After the unsuccessful attempt, another twenty hours had elapsed before the operation was performed. "The trial lasted four days. There were six experts, two who had made the postmortem examination, to judge the pathological-anatom- ical side. "Neugebauer supplied the statistics that were likely to be called for in the controversy. Professor Pawlow, of St. Petersburg, under- 178 AFTER-TREATMEXT OF SURGICAL PATIENTS took ti> depict what is called a coeliotomy, and the complications and mistakes that are likely to occur. ''Summary: — The direct cause of death in this case was the per- foration of the artery by means of the foreign body. The indirect cause, the refusal of the sons to comply with the request for another abdominal section by Dr. Kosinski; and the loss of time that arose from the trip to Cieehocinek. The trial ended in the acquittal of the accused." A rather striking instance of a similar nature occurred many years since, in the practice of a distinguished St. Louis surgeon. He had operated on a gentleman, who had left the hospital in a reasonably good condition, and not having reported since that time, his satisfac- tory convalescence had been taken as a matter of course. A few months later, the surgeon was in his office one day, when tli is patient walked in. presented an artery forceps, with the inquiry. "■ Is this yours .'" "Of course it is. it has my private mark on it." replied the surgeon. '"That is all I wish to know,*' the patient said. ''It was taken from my abdomen some months after I left your service." In order that there might be no misunderstanding of the patient's intent, he had brought along his legal adviser for the interview, which did not end until a financial arrangement had been consummated, of a nature so satisfactory to all concerned, that the incident never found its way into court. I was consulted not long since by a gentleman who had an inter- mittent biliary fistula. He gave a history of two surgical operations; at the first one gallstones had been removed, although neither pro- cedure had succeeded in relieving him of his symptoms. He was not exactly sure what had been done, nor could we get the technical de- tails of thr previous operations, since my confrere had permanently left St. Louis. Upon opening the abdomen, a large gauze pad was found, occupy- ing a space between the stomach, colon, and under surface of the liver, a site which the gall bladder must have formerly occupied, and into which bile was welling up from below, there being a communication with one of the ducts. The patient stated that his second operation had been of a minor character, and had not at all modified the course of his malady, and it "had seemed unsatisfactory to the operator, hence, one is prone to speculate on tiie interesting probability of the surgeon having left the gauze pad at his first operation, and totally overlooked it during the second performance. It must he very rarely FOREIGN BODIES LOST IN THE PERITONEAL CAVITY 179 the ease that a foreign body left at a first sitting is not removed at the second. I remember very well the first time I ever detected a foreign body which had been left in the abdomen by accident. A colleague re- quested me to explore one of his patients for a very ill-defined symp- tom-complex, which had followed an operation on the pelvic viscera. We were both surprised, and my colleague greatly embarrassed, by finding a very large gauze pad, tightly encapsulated between intes- tinal coils. The interesting thing about this case, and the reason for quoting it is that it exemplifies in no uncertain way, nature's method of spontaneous relief, which must be rather frequently afforded such patients. There was no mistaking the fact that one corner of the thick gauze pad was drawn out and twisted into a conical mass, of which the distal six or eight centimeters were smeared with feces. Upon further inspection of the wound, we found that this gauze cone had been withdrawn from an opening in the intestine into the lumen of which viscus, the gauze was gradually being drawn by peristaltic activity. No doubt, in the course of time, the newly formed cavity, in which the pad lay, would have been emptied and its walls collapsed ; then had the foreign body not obstructed the intestine, it would have eventually been passed out the anus, and quite possibly, never been noted at all by the patient. To one unfamiliar with the subject, this may serve as a striking example of the fact that nature is sometimes more generous to us than we have deserved, in the after-treatment of surgical patients. Almost any surgeon of experience has had his attention attracted to these cases, but no doubt, all of us will be surprised to read for the first time, that Neugebauer 3 claimed that in 1907 he had collected 236 authentic records of this sort. More recently, Crossen 4 published a list of 240 such cases, and he surprised us all the more when he stated that about one-fourth of these individuals died as a result of these accidents. As most of us would suppose, from our limited ex- periences, a gauze sponge was the article most frequently left behind, although the offending matter was a forceps (Fig. 27), or some part of another instrument in about one-fourth of all such reported in- stances. It must be that parts of needles are very commonly lost in the peritoneal cavity. All those who have had experience deep in the pel- vis, know that needles not infrequently break, and occurring as it does, when a part of this small instrument is imbedded in the tissues, one readily understands that a fragment is recovered with the greatest difficulty. 180 AFTER-TREATMENT OF SURGICAL PATIENTS I know a number of operators who have had this unfortunate ca- lamity to befall them, and I do not recollect one who is given to care- less practices, hence, it must be that this accident is rarely the result of carelessness, or to a lack of some system, calculated to prevent just such happenings. One is, therefore, prone to analyze the various in- stances in which the accident has taken place, and if possible, to for- mulate some general rules which may call attention to the reasons they occur. In one case, extreme hasti seemed necessary in the removal of a gangrenous, perforated gall bladder, to the end that gauze packing was placed and supposedly removed, with consideration for only one prime necessity : viz., that the patient must be returned to bed be- fore it was too late. In this instance, a gauze pack was left behind rig. 27. — Rusty oved from abdomen at a remote period. (After Keen). and removed some months later, so it will be noted that foreign bodies are likely to be lost in those operations attended with rather unusual haste. In another instance, a furious h< ihoitIi. 54. Cunningham, Jr.: Recto vesical and Enterovesical Fistulae, Boston, Tr. Am. Urol. Assn., 1915, p. 433. Deaver: Therap. Gaz., March 15, 1913, p. 153. Drueck: Med. Rec., New York, January 3, 191 I. p. L5. Elting: Ann. Surg., 1912, lvi, 71 I. Emmet: Vesico-vaginal Fistula, New York, "Wm. Wood £ Co., 1868. Freeman: Suppurating Abscess, sinus ami Fistula, Ulcer and Gangrene, Keen's Surgery, W. B. Saunders Co., Philadelphia. Frey, Emil K.: Beitrag zur Frage der Entstehung und Behandlung der Fistula Ani, Mtinchen. mod. Wchnschp., 1911. p. Is:,. Hemor and Clostens, John Arderne, P. T. Kegan: Treatises of Fistula in Aim, Trubner & Co., Ltd., London; Henry Frowde, Oxford University Press New York, 1910. Landsman: Ano-rectal Fistula, New Y T ork Med. Jour., 1916, p. 829. Losee: Esophago-tracheal Fistula, Tr. New York. Acad. Med., Am. Jour. Obst., 1914. Matthews: Fistula in Am., st. Louis, Lambert & Co., 1885. (A paper read be- fore the Mississippi Valley Medical Association at Indiana, September 19, 1883.) Niendorf, Erich: Zur Lehre von dem fisteln naeh Mondeville, Berlin, 1896, Gedruckt bei L. Schumacher. Pennington: New York Med. Jour., 1915, p. 785. CHAPTEE XXIV SINUSES By 0. F. McKittrick, St. Louis, Mo. Sinuses are so frequently seen after operations that the proper care and attention of this complication demands more than passing men- tion. In fact timely aid in such conditions rarely fails to bring re- ward in the form of relief of the causative factors with the ultimate cure of the patient. A sinus, as generally understood, is a tract of varying length and size, passing from some point of tissue necrosis or actual abscess to the free mucous or skin surface. In postoperative cases the sinus most usually results from some portion of the wound which has not healed; or where pus has burrowed in parts of the subcutaneous tissues with secondary openings at the body surface. Sinus formation following operations for osteomyelitis is a common occurrence as is also often the case after a pus appendix, though a tract may form after other abdominal, pelvic or thoracic operations. A foreign body left in the abdominal cavity (such as a sponge, etc.) not infrequently is the source of a persistent drainage tract. The sinus will continue so long as the offending material is present, as is the case in the bony sequestrum in the osteomyelitis, and the sloughed off appendix in the pus appendix cases. In other instances the constant irritation of bile, saliva, urine, etc., may be the cause of a persistent sinus. Sinuses may present themselves in surgical wounds as a result of nonabsorbable ligature material, absorbable ligatures which have be- come infected or other irritative factors as a sequela to the operative procedure alone. Foreign bodies, such as dirt, wood, pieces of steel or a bullet may be the seat of annoying discharging tracts in wounds caused by injuries. In any wound where there is improper rest due to muscular movements, or in tissues of low vitality sinuses may per- sist as a result of these reasons alone. In patients with poor general health sinus formation is the rule rather than the exception. Thus in the tuberculous drainage is not even attempted because of this fact. The lesson never to drain a tuberculous lesion was learned long ago in the attempts to handle tuberculous appendicitis in the usual way, which so often resulted in nonhealing of the wound and the de- veloping of a persistent sinus. }99 200 AFTER-TREATMENT OF SURGICAL PATIENTS The treatment first consists in determining the cause of the con- dition and measures undertaken at once to remove it. No sinus will ever permanently close so long as the offending causative factor is left undisturbed. For this reason one must endeavor to keep the external opening free from the crusts which will form over it, and if necessary insert a rubber drain throughout the extent of the tract and from time to time cut away with a sharp pointed scissors the granulations as they become obstructive. The same thing may be accomplished with the silver nitrate stick or a sharp curette. This instrument is indeed, very useful in long tortuous tracts which tend to close by granulation tissue a considerable distance from the out- let. While the tract itself is kept open, nature has a chance to dis- charge any offending material from the bottom of the sinus and to heal the cavity in the usual way. Pus and all other discharges aris- ing from granulating walls, having a free outlet, allows the walls to quickly collapse and soon to be completely obliterated by means of granulation followed by scar tissue. Such a process in the very large cavities may require months to complete its work. During this time one must persist in keeping a free opening for the secretions. If there is any reason to believe that the sinus persists because of some foreign body which has not been discharged despite every effort to give the tract free drainage, one should probe the cavity thoroughly in the hope of dislodging the foreign member, or if it be a piece of gauze or suture, one should entangle it in the instrument and thus remove it. A sloughed off appendix, foreign body left in the abdom- inal cavity or wound will probably require a secondary operation. A sequestrum of bone may also require such radical treatment, though time, without further measures other than those mentioned above, will usually correct difficulties arising from this source. A sinus may persist long after the causative factor has been re- moved. Such is indeed the case usually in those instances where it is necessary to keep a free drainage tract over unusual periods. The walls of the sinus become infiltrated and hardened due to the chronic inflammatory process. Sinuses arising from bone or cartilage natu- rally persist because of the nature of the tissue. This alone prevents collapse of the sinus cavity and therefore forces the defect to be closed wholly by granulation. Constant irritating discharges such as bile, etc., will often cause the sinus to persist. In such instances the granulations often develop slowly and measures must be employed to stimulate not only the granulation tissue itself by scraping the walls of the sinus with a curette until healthy tissue is reached, but also to actually dissect out SINUSES 201 the entire tract and close it with buried catgut sutures. When the bottom of a sinus is so situated that an opening can be made to the outside and thereby give through and through drainage, this should be done. Such a maneuver permits of thorough cleansing with some antiseptic solution and frequent irrigation will discourage bacterial growth and hasten the growth of the reparative tissue. Irrigations of sinuses with 4 per cent boric acid solution or Dakin's fluid three or four times a day is encouraged in those instances where the sinus does not extend into the peritoneal cavity. For sinuses about the mouth, or those resulting from surgical wounds of the neck I usually employ 80 per cent alcohol or % per cent alcoholic solution of iodine once a clay. The same solution may be utilized in any sinus where the solution readily returns. One should never employ solutions which will injure the new tissue along the tract during the attempt to cleanse it of discharge and clear it of bacteria. For this reason the alcohol is permissible but once a day, whereas solutions as mentioned previously may be used much more frequently. When the cause of the condition can be with cer- tainty eliminated, so far as foreign bodies are concerned, other reme- dies in addition to the ordinary cleansing of the tract can be employed with success. In the most persistent sinuses these become necessary if operative interference as suggested above is not to be considered. Among the many suggested remedies, iodized phenol as employed by Cotes 1 may be mentioned though remedies which have proved of value through years of usage, such as Beck's 2 paste, probably should be used. His method was first employed as a diagnostic measure. The paste was injected into sinuses and x-ray pictures taken later to show the tract in detail. It was soon found, however, that following the injection, particularly in tuberculous sinuses, not infrequently the tract would heal without further measures being necessary. It was discovered that the bismuth, being antiseptic, besides forming a network for the granulations to grow in, offered the best medium for the healing of these defects. It also acted as a foreign body, thereby stimulating leucocytosis and by its mechanical action kept the walls of the sinus open. This permitted closure from the bottom upwards. As generally employed, the sinus is injected with a "liquid bis- muth vaseline paste," by means of an ordinary glass syringe (usually 20 c.c.) every other clay until the tract ceases to discharge. The paste consists of bismuth subnitrate, 1 ounce, vaseline, 2 ounces. The two are mixed over a water-bath and the mixture injected while it is at a temperature of 110° to 120° F. It should be put into the sinus under slight pressure so as to fill every part of the tract. After 202 AFTER-TREATMENT OF SURGICAL PATIENTS a few clays, when all discharge has stopped, Beck 2 uses a mixture which forms a much harder paste at body temperature. This forms a more substantial framework, inside the sinus tract, for the granu- lation tissue to fill. To the 3 ounce mixture of bismuth and vaseline, Beck adds 75 grains each of white wax and soft paraffin. Beck 2 states that the tract closes after the employment of the latter paste, and in most instances remains closed, during which time the paste be- comes absorbed and replaced by granulation tissue. Soon after the use of Beck paste in the ordinary sinuses which occur in the body, other than those connected with the thorax, Ochsner 3 demonstrated its value in this capacity, stating that sinuses resulting from operations in empyema cases soon become sterile and rapidly close after injecting the mixture in the usual way. Like all good remedies applicable in medicine, the paste was found not to be useful in every case of chronic sinus, tuberculous or other- wise. Among the other pastes are Mitchell's, 4 which consists of a mix- ture of equal parts of petrolatum and chalk. He states that this paste -will accomplish the same result as the bismuth paste and that it is even more useful, since it contains calcium which is an active chemical and that poisoning is not possible with chalk paste. Blanehard 5 simply employs white wax one part to eight parts of vaseline. In cases where an antiseptic paste is desirable as in viru- lent infections, he adds iodine crystals which have been reduced to a powder by rubbing in a mortar to which 20 per cent potassium iodine solution has been added. Two or three grains of the powder are mixed with the paste and injected into the sinus, using the same tech- nic as with bismuth paste. If x-rays are to be taken of the sinus, Blanehard uses a mixture of f err i-sub carbonate one part to two parts of white vaseline. The mixture is boiled and at the same time it is thoroughly mixed. The author claims to have cured ultimately 65 per cent of old tuberculous sinuses which is as many as those cured by the bismuth; the attendant bad effects of the latter drug such as clogging of dependent portions of the abscesses or sinus walls with the heavy metal or poisoning are entirely eliminated. Sweek G does not use injections of any kind, since he feels that any method as outlined above in killing off the bacteria we destroy the newdy formed granulation tissne. He, therefore, uses a germicidal gas which he causes to pass into the sinus from ten to twenty minutes each day or every other day. depending on the severity of the case. Air is passed through crude spirits of resin and then through the poles of an electric arc, from here into a tin gallon jar from which SINUSES 203 it passes into the sinus. The slight aging the gas undergoes in pass- ing into the jar causes it to have a somewhat irritating effect on the nose and bronchi, but does not irritate the wound to a noticeable degree. Sweek 3 claims that the minute or minute and one-half which the gas requires in passing through the jar so ages it that its bactericidal power is materially enhanced. He claims that the wound healing is not retarded in any degree and that we can expect greater results from this gas than any known germicide. His method should be tried before one despairs in the treatment of this annoying complica- tion. Bibliography iCotes: Brit. Med. Jour., 1911, ii, 15-92. sBeck: Jour. Am. Med. Assn., 1908, 1, 868. sOchsner: Jour. Am. Med. Assn., 1909, liii, 319. ^Mitchell: Jour. Am. Med. Assn., 1911, lvii, 394. sBlanchard: Med. Rec, New York, 1912, lxxxi, 941. eSweek: Interstate Med. Jour., 1916, xxiii, 225. CHAPTER XXV DRUG ADDICTION IN SURGICAL PATIENTS By 0. F. McKittrick, St. Louis, Mo. It is common experience that the average surgeon pays very little attention to drug addiction, if discovered at all, in his patients, and inclines to regard it as a matter which does not concern him. This stand can he defended if the surgeon accepts the responsibility for his work during the operation only, but anything which has to do with the recovery and subsequent well being of his patient should command just the same interest and respect. Bishop 1 holds that the medical profession has regarded the con- tinued use of a narcotic drug as the element of paramount importance in drug addiction and that too little attention has been given to the action of the drug, which produces such a condition, and that the "physical mechanism'' of drug addiction has greater influence in the healing and repair than had been formerly supposed. He points out that very many surgical eases have terminated badly or at least unsatisfactorily, solely because the surgeon failed to grasp the importance of the drug addiction, and his inability to success- fully deal with such a condition existing intercurrently in surgical patients. The medical treatment of narcotic drug addiction has con- cerned itself chiefly in withdrawing the drug. Until this has been accomplished, operators will frequently not attempt any work on a patient, since Mich have been considered poor operative risks, besides being difficult to handle. But such a stand is not justified by clinical facts. "The habitue is not a poor surgical risk merely because he is addicted to his drug." The slowness of recovery and lack of re- pair which have been noted in these cases is not due to the drug of which he is the slave, but rather to the fact that his surgeon is unable to cope with his acquired condition, or in many instances, it is not even recognized. There can be no doubt that such patients have been operated upon and have passed through a satisfactory recovery and convalescence without their addiction even being suspected. Provision is usually made by the wiser "addict" for such emergen- cies and he himself, controls his disease. For it is a disease 2 and "the amount of the drug which the patient must use is of minor importance compared with his functional, nutritional and metabolic efficiency." 204 DRUG ADDICTION IN SURGICAL PATIENTS 205 According to Bishop, the satisfactory recovery of a narcotic addict from a surgical condition depends largely upon his "functional bal- ance ' ' and upon his ' ' organic adequacy. ' ' Such are largely under the control of, and vary with, the extent to which the patient is kept in "narcotic drug balance." It follows, then, that the reduction of the dose of the accustomed drug below the amount which the addict phy- sically needs is not only without justification, but also is harmful to the patient and the result is seriously prejudiced. Why such a condition should present itself at all as a menace to surgical procedure has never been explained. Drug habits have been common since time immemorial. The use of opium has been practiced by the Orientals throughout the ages. These people used it in the be- lief that the drug was helpful to them, and even today, they are still using it in much the same way as the Western peoples use coffee, tea, or tobacco. Its use is mentioned in the Egyptian hieroglyphics, and centuries later in the writings of Homer. Since the beginning of the nine- teenth century, however, chemical study and experimentation have revealed its composition, and since that time, the alkaloids of opium have played a more or less prominent part. The danger of morphin- ism was first recognized in 1866, in France, 3 the hypodermic use of this drug having at that time come into prominence there. In this country, opium as such, is not commonly used. Morphine is the alkaloid of choice. It is said that 85 per cent of habitues take it subcutaneously. Occasionally, codeine or heroin is used instead. Opium is usually smoked, though it is taken by mouth in the form of opium pills or laudanum. Cocaine may also be used by such addicts, the drug being taken by insufflation or by mouth. Morphine addicts, like chronic alcoholics, are divided into two great classes; those who are habitual users and those who use the drug periodically ; the morphine or opium being entirely abandoned in the interval. 4 It is common to find among women 4 periodic addicts to this drug, traceable in most cases, to some pelvic trouble, to recurring attacks of headache or to neuralgia. The habitual user is much more easily han- dled than is the periodic addict. However, the former class is more difficult to treat than the class of patients who have taken large amounts of morphine but for only a short period of time. The symptoms of morphinism can not be fully gone into here, but as seen in the chronic form, there is a change of personality indicated by alternation of mood ; viz., periods of depression, suddenly followed by intervals of euphoria. To this is usually added a capricious ap- 206 AFTER-TREATMENT OF SURGICAL PATIENTS petite, constipation or possibly diarrhea. The nutrition suffers, the subcutaneous tissue gradually shrinks and the skin becomes loose. The face is usually ashen or sometimes deep red in color. The pupils are generally contracted and react poorly to light. There may occur double vision. Hoarseness, thirst, and tremor are common symptoms. If the patient has been deprived of his drug for any length of time, he becomes restless, anxious, and salivation with coryza probably appear; he may become nauseated, and vomit. Disturbances of vision, neural- gic pains and a choreic form of jactitation make their appearance. The pupils become dilated, a stage of wild excitement develops, and, no matter how secretive the man may have been before, he now begs for his drug. The action of narcotic drug- upon the organism reveals itself through inhibition of body function. Glandular activity is arrested and the metabolic processes are markedly diminished. The smooth musculature throughout the body is paralyzed by their action, and since this class constitutes the musculature of the intestinal tract, peristalsis is inhibited. This results in diminution of the intestinal glandular secretion and therefore elimination suffers. This inhibi- tion of function not alone causes a storage of poisonous drug within the body, but prevents the complete elimination of toxic products which are the result of tissue destruction, and interferes with me- tabolism as well. Such a condition. Bishop says, brines aboul autointoxication. He also points oul that "the predominating manifestations of this disease depend upon the extent of the inhibition of function and upon the degr >f autointoxication." The circulatory, digestive and nervous systems are affected by such a condition. The mental deterioration and other symptoms so often ascribed to the '\v\\ 1/4 t° 3 grains of this alkaloid. The action of caffeine on the body is chiefly stimulative. 13 The brain and the whole nervous sys- tem are affected. The heart and the musculature throughout the body are likewise influenced. Moderate closes cause a rise in the blood pressure. Eespiration is increased in rate, and metabolism is considerably stimulated. Gastric juice is increased by ingestion of coffee, though tea has an opposite effect. 14 In addition to caffeine, tea also contains tannic acid and because of this, may produce in- digestion and constipation. Sudden deprivation of either beverage may be followed by extreme nervousness and wakefulness in patients long addicted to their use in excess. Headache is a common symptom following the withdrawal of either drug. Such patients should be given much less than the accustomed amount of the beverage when preparing for an operation. The danger of the operative procedure 210 AFTER-TREATMENT OF SURGICAL PATIENTS is not enhanced or, at least, but slightly ; though during the conva- lescence, the minimum amount of coffee should be permitted. In highly nervous cases and especially in toxic goiter patients, no stimulating beverage is allowed at all. Bibliography iBishop: Am. Jour. Surg., 1915, xxix, 435. 2Kennedy: Ibid., 1914, c, 20. sPowcrs: Wisconsin Med. Jour., 1915, xiii, 431. 4Lichten stein : New York Med. Jour., 1914, c, 962. sBishop: New York Med. Jour., 1915, ci, 402. ePettey: Ibid.; also The Narcotic Drug Diseases and Allied Ailments, Phila- delphia, 1913, F. A. Davis Co. TTown : Hare; Practical Therapeutics. 8Lambert: Jour. Am. Med. Assn., 1913, lx, 1933. aErlenmeyer: Cushny 's Pharmacology and Therapeutics, 1915, Philadelphia, Lea & Febiger. loSeeleth: Jour. Am. Med. Assn., 1916, lxvi, 860. nWhite: Southern Med. Jour., 1915, xiii, 17. isMusser and Kelley: Practical Treatment, 1917, Philadelphia, W. B. Saunders Co. ispincussohn : Miinchen. med. Wchnschr., 1906, No. 2(i. 14 Sajous: Analytic Cyclopedia Practical Medicine 1916, Philadelphia, F. A. Davia Co., iii, 513. CHAPTER XXVI ALCOHOLISM IN ITS EELATIOX TO SURGERY By Q. F. McKittrick, St. Louis, Mo. Alcoholism is found in all walks of life, and occurs in all classes of society — a condition as needless as it is harmful, also one which pre- sents serious difficulties in the way of the successful outcome of a surgical convalescence. Just why this detrimental condition must remain a factor even in the present day surgery, is a secret which the chronic alcoholic in many instances alone can divulge. The reasons for drinking are varied. The habit is begun early in life, usually be- fore the age of 30. 1 but very commonly it is given up between 40 and 65. 2 Unfortunately, those who yield to its clutches and become its slaves are usually of the neurotic type. In such patients, an operation itself being very serious, alcohol does its greatest damage. The two most important classes of alcoholic cases which present themselves for surgical treatment are the constant daily drinkers, who must have their regular portion, and the periodic drunkards who between times probably do not touch a drop of liquor. 3 It is a matter of common knowledge that patients who do not drink get along a great deal bet- ter than do the alcoholics during surgical procedures. The temperate alone possess calmness of body and mind and the ability to respond promptly to stimulation which so often obviates shock. Such a resist- ance to the deleterious effects of an operation is not possessed by those whose vital powers have long been driven by the overstimulating effect of intoxicating liquor. The observation of Cheever. 4 that such patients undergo a ■"laborious and excitable etherization"* is a common experience among all opera- tors. This is not surprising when one considers that once confirmed in the use of alcohol, an individual goes the downward road that leads to complete mental and physical decay. 3 The damaging evidences of the poison are presented in every organ of the body. The brain and meninges at times become edematous, the cells throughout the nervous system degenerate, the arteries become sclerotic and the veins dilate, all of which leads to a '"labored and slow circulation.''' The tissues throughout the organism become hardened and thickened, which necessarily delays absorption, and the natural activities of various cellular functions. There is fatty degeneration of the paren- 211 212 AFTER-TREATMENT OF SURGICAL PATIENTS chyma of the liver, pancreas, and kidneys, in addition to fibrous changes; the mucosa of the pharynx and stomach become thickened and hyperplastic. Such pathologic conditions give rise to symptoms such as tremor, gastric irritability, enfeeblement, physical and men- tal, which gradually grows worse as the years pass; also increased blood pressure and albuminuria. Such a condition is certainly detrimental to the patient who is suddenly brought to face accidents or operative procedures. Even in selected operative cases, no amount of preparation can repair the structural damage already wrought, and the patient is subjected to added danger in consequence. The daily tippler who on rare occa- sions only gets drunk, is a much better risk than the man who peri- odically gets intoxicated. The prognosis Eor the former is. however, much more grave if the operation be accompanied by severe hemorrhage or shock, since the resistance is, without doubt, more or less lowered from the continued use of alcohol. The periodic drunkard presents a somewhat different problem and more serious risk. Not in the habit of drinking daily and probably not thinking about the necessity of preparing himself with his stimulant, he fails to make his weakness known, is admitted to the hospital, no alcohol is given, and he is operated upon for some trivial condition it may be. Bu1 il apparently <\<»^ not matter how insignificant or how serious the operation may be, it is the alcoholic condition of the patient which makes the surgical procedure hazard- ous. The trauma of the operation added to his already altered con- lit ion. breaks down what defenses he maj have. For a few days he may do well, but a prolonged abstinence from alcohol causes him to become restless, nervous, and exceptionally keen to happenings around him; small and insignificant acts of others are irritating to him. Sleep is very poor and he has hallucinations which seem to him dreams and disturb him. although he knows they are unreal. For several days' the patient may be concerned about himself; there may lie a distressed feeling in the epigastrium or sing- ing in his ears which at times may seem to be voices. He may com- plain of dizziness; tremor develops in his hands, and his tongue trembles. Finally, if nothing is clone to avert the Calamity, delirium tremens develops. Delirium Tremens It is common knowledge that delirium tremens is apt to develop in regular drinkers following operation or with the beginning of pneu- monia. It is most common in emergency operations after injuries, ALCOHOLISM IN ITS RELATION TO SURGERY 213 in patients who are chronic drinkers. The patient, however, may never have been in the habit of becoming actually drunk. Following the operation or injury, the patient has an almost sleep- less night. The brief periods of sleep which may occur, are filled with horrible dreams. Morning finds him restless, nervous, tired, suspicious and apprehensive, the appetite is gone and he may or may not crave alcohol. Later on during the day, hallucinations like the nightmares of the night come to him, in spite of the fact that he is wide awake. He may succeed in fighting them down for a few hours, but ultimately he is overpowered and horrors reign supreme. In the usual form of the disease, recognizable symptoms appear after two days or more. The patient is at first quiet, submissive, and his condition may even resemble mild shock. His mind is change- able ; impressions last but a few moments and frequently the patient fears that he is going to die. He is anxious to comply with the wishes of his doctor or nurse, carries out orders, but sometimes with violence. He is restless and nervous, tries to get out of bed, and in- sensible to the pain it may cause him, attempts to walk around in an effort to get away from the hallucinations of fear, persecution, or what nots, which are torturing him. His mind is in a chaos of ever- changing ideas. He talks incessantly, the subject of the conversation with himself being a combination of delirious ideas and fanciful no- tions of things and people about him. He recognizes his friends for a while, but in the uncontrollable, vivid and dreadful hallucinations he soon ceases to know anything or anybody, and regards all people and objects as taking part in his persecution and final destruction. He may fight or injure himself and others in his violent efforts to evade torment. In his panic, he moans, mutters, curses, cries, shouts or prays. He looks fearfully about, suspicious of everybody and everything, and listens as though he heard sounds or voices. He sees objects which appear multiple. These take the forms of various animals, such as snakes, rats, and dogs. In this stage, the patient is obviously physically sick. He is entirely sleepless, perspires freely, the limbs tremble, the head shakes, and the muscles of the face twitch, the pupils are widely dilated and the tongue, which is heavily coated, quivers. As the delirium increases, the tremor abates somewhat. Finally, after many hours, even clays of torture, the patient becomes stuporous, the heart rate gradually diminishes, and after a period of weariness and relative quiet, the patient falls into a deep sleep which lasts from twelve to thirty hours. Following this, he becomes cogni- zant of his surroundings, the hallucinations are gone, and the orienta- tion is complete, still the mental condition is not quickly restored and 211 AFTER-TREATMENT OF SURGICAL PATIENTS for several days, the patient is unable to correctly concentrate his thoughts. In some men there is a reappearance of the delirium during the night, while during the day they remain free. In such patients, any excitement causing mental exhaustion may bring back some of the hallucinations. A good routine preventive treatment has been suggested by Max- well, 7 it consists in giving a dram of paraldehyde in an ounce of whiskey every four hours alternating with 15 grains of veronal. Such treatment is carried out on every patient where there is danger of de- lirium tremens, and, particularly, in those alcoholics in whom an op- eration is performed without adquate preparation. It is kept up un- til a sound sleep which lasts twelve liours is secured. Just as soon as the patient can go to sleep readily, the sedatives are stopped. It usually takes about two days to accomplish this. The treatment is not commenced for eight hours after an operation because of the con- dition of the stomach. In alcoholic cases. mos1 thorough elimination by kidneys, bowels, and skin is continued for two or three days before the operation if there is time for such preparation. In addition, forced feeding with large amounts of liquids is persisted in. The treatment must be symptomatic. 8 These patients have often subsisted so long on alcohol with inadequate food that degenerative change in the heart muscle, arteries, stomach, and other organs have developed, hence danger is not so much in the delirium itself as in the diseased condition of vital organs of the body. In young alco- holics, the alcohol should be withdrawn, but in weak or elderly pa- tients, it can be gradually reduced only. The stomach should be washed, if the surgical condition permits it. and a generous dose of epsom salts left in the stomach. The patient is put into a warm bath, or else sweating is obtained 7 by means of the hot-air bath or hot pack. Potassium citrate 25 grains, is given every four hours, as are large amounts of water by mouth, by rectum, and under the shin to aid the eliminative power of the kidneys. It must not be lost sight of, however, that the patient is to lie treated as one having a degenerated heart muscle and no eliminative measure should be car- ried out which would likely cause sudden dilatation. The blood pressure must be watched closely and stimulants administered to the heart. Pituitrin is useful fur this purpose. Strong coffee can be administered instead of the pure caffeine. Atropine is valuable in marked depression with pulmonary edema, cold and clammy skin. and it may also lessen the craving for alcohol. ALCOHOLISM IN ITS RELATION TO SURGERY 215 In mild attacks, the delirium may be controlled by paraldehyde, 1 or 2 drams repeated every hour if necessary. Chloral in large doses, 30 grains or more may be given per rectum by olive oil. Osier recommends a mixture of morphine (% grain) with chloral (15 to 30 grains) and to these are added tincture hyoscyamus (% dram) tincture ginger (10 minims) and tincture of capsicum (3 minims) water q. s., % ounce. This mixture is given every hour if necessary. The delirium is not cut short, but sleep is secured for some hours, which gives the needed rest to the overworked heart. Intramuscular injections of ergot are also recommended. The solid extract is dissolved in one ounce of sterile water. Thirty drops of this solution are given every two to four hours. It tends to lessen the various congestions and bring about a better equilibrium of the circulation. Recently, Leonard 9 has reported the results of giving intraspinal injections of magnesium sulphate in 12 cases of delirium tremens. Lumbar puncture was done, and varying quantities of the cerebro- spinal fluid (10 to 40 c.c.) withdrawn, depending on the pressure. Following this, 1 c.c. of a 25 per cent solution of chemically pure magnesium sulphate to every 25 pounds of body weight was intro- duced through the lumbar puncture needle by means of a syringe. The treatments were given with the patient in sitting posture, but afterward he was put into the semirecumbent position. These pa- tients required constant attention for twenty-four hours following the injection. Seven developed a paraplegic state in which they lost con- trol of both sphincters. The condition appeared within forty-eight hours. Five cases had retention of urine with weakness in lower limbs and lessened reflexes. The temperatures in these patients rose to 101° to 103°. Since the mortality is so high among such cases and since so little is accomplished at times with sedatives, Leonard feels that one is justified in using this treatment. The delirium and restlessness sub- side very soon following the injection, and the patient is restored to normal within twenty-four hours. Food should be given every two or three hours during the period of delirium or when the patient is awake. Under no circumstances, disturb him if asleep. A little eggnog along with the food may be given in all cases, but in the aged or very weak patients, this is im- perative. Restraint is always bad form. If it is possible to have two attend- ants to watch the patient and keep him in bed, this is better than the use of any artificial means. If necessary, these remedies must be 216 AFTER-TREATAIEXT OF SURGICAL PATIEXTS employed. However, every available means must be exhausted to assure the patient and to gain his confidence before any attempt at force is made. During the convalescence, stomachics, such as ginger, capsicum or mix vomica may be given. Frequent warm baths and careful at- tention to the bowels, massage, early sitting up, calisthenics, fresh air and sunshine will enable the patient to leave the hospital a week or ten days after his attack of delirium if the nature of his operation permits. Bibliography iDana: Inebriety, Med. Rec. New York, .July. 2Kerr: Alcoholism and Drug Habits, Twentieth Century Practice of Medicine, iii. 3Crandon and Ehrenfried : Surgical After-treatment. Philadelphia, 1012, W. B. Saunders Co. 4Cheever: Boston Med. and Surg. Jour.. 1893, cxviii, 253, oLegraine: Tuke's Diet, of Psych. Med. 60sler-McCrae : Modern Medicine, Philadelphia. 1914, Lea & Febiger, ii. 410. 7Maxwell: St. Paul Med. Jour., 1914, xvi, 664. sOsler-McCrae : Modern Medicine, p. 508. ^Leonard: Jour. Am. Med. Assn., 1916, lxvii, 509. The following references were also consulted: Carter: Med. News, March, I s ! 1 ". Sommer: Diagnostick der Geisteskranckeiten. White: Reference Handbook of Medical Science. 1902, v. 81. CHAPTER XXVII POSTOPERATIVE PSYCHOSES By 0. F. McKittriek, St. Louis, Mo. A surgical operation is almost always considered a tragedy. It should, in compensation for the mental and physical suffering in- curred, be followed without delay by a period of comfort and of good health. It really becomes a tragedy when happiness does not appear, but instead new dangers and discomforts present themselves as a re- sult of the operation to increase the gloom, and, finally, the reason becoming dethroned, the fruits of surgical labor are suddenly snatched away. It has long been known that mental disturbances may follow oper- ations. As early as the sixteenth century Pare considered a "spirit- ual calm," essential to the future well being of patients about to un- dergo one. It was not until the beginning of the nineteenth century, however, that postoperative mental excitation was first described by Dupuytren who called the condition "delirium nervosum." A few decades later, Herzog and Siehel, and many others reported cases of insanity following eye operations. In 1865, Van Courtney reported the first case of insanity following ovariotomy. Fifteen years later, Lcjsen and Furstner cited such an instance following hysterectomy. Since that time many observations have been made on the subject. Such papers, however, have appeared sporadically, and both in Amer- ica and abroad, these are for the most part fragmentary, the authors merely reporting a case here and there. Mental derangement of almost every degree and character has been described following surgical operations. It occurs most frequently in adults; in the female more commonly than in the male. Neither children nor the aged escape, though the usual period of life in which this serious complication makes itself known, is between thirty-five to forty-five years. 1 It is hardly possible to say just how often post- operative psychoses will occur. Many psychoses do not make their appearance until after weeks or months. In the series of forty cases reported by Kelly, the majority of the symptoms occurred between the second and tenth days. In eight instances they began almost immediately after the operation. In others, they did not appear for one month. Out of every 1000 patients who undergo laparotomy, 217 218 AFTER-TREATMENT OF SURGICAL PATIENTS four will go insane, according to Da Costa. 2 Of 5000 insane patients, Dewey found only 3 whose minds were sound before the operation. Of the milder mental disturbances which follow operation. Kelly found 50 after 13,000, while Mitchell reported 31 instances in 344 patients. Psychoses arc as common after mild as after severe operations. The anesthetic does not seem to make much difference, the condition occurring alike after ether, chloroform, or gas anesthesias. Instances occur even after local anesthesia as reported by Selberg 3 and also by Grekow. 4 It seems that most of the cases reported in the literature followed gynecologic or ophthalmologic operations. Picque 5 very strongly insists that postoperative mental aberrations are no more apt to follow operations of this character than those on other parts of the anatomy. Indeed. Rohe found that out of 196 cases, 65 followed genital and 35 followed cataract operations, while 96 appeared as a result of operations on other parts of the body. Abdominal opera- tion in which the ovaries are not involved do not particularly pre- dispose to mental disturbances. However, removal of the ovaries or testicles is peculiarly provocative of this condition. A.S to the forms of postoperative insanity, it is claimed that there is no one type. Clinically the term includes those varieties of mental aberration which are related to each other only in so far as they occur in a surgical convalescence. The condition ranges from a mild transi- tory mental disturbance to that of an incurable maniacal state. Some authors make no attempt to determine the s] ial form of disease which has presented itself. Urbach 6 classified his five cases following 106 gall bladder operations as "acute hallucinatory confusional in- sanity." Others have noted melancholia, stupor, delusional state. hysterica] excitement, morbid fears, delusions, hallucinations, etc.. but probably the most common form is acute confusional insanity. Tt is characterized by confusion of thought and incoherence of speech, delirium, at times delusions and hallucinations, alternating with pe- riods of stupor following the mental excitation. There are many factors connected with a surgical operation which may prove fruitful as an exciting cause for insanity which appears at times during the convalescence. The patient may have suffered from severe pain, fear, sleeplessness or exhaustion. lie worries more or less, and the operation is performed under a general anesthetic which leaves him unusually toxic. There is some loss of blood, and shock may appear after the awakening from anesthesia. There is post- operative pain with possibly attending insomnia, anxiety, concern, and even homesickness which is the last straw. POSTOPERATIVE PSYCHOSES 219 There is a predisposition, either hereditary or acquired in all cases of postoperative insanity; 2 the operation and all that is associated with it being only an exciting element which completes the over- throw of the unstable and predisposed nervous system. Histories 7 are not always reliable, since many patients are averse to giving cor- rect details concerning this subject. Many observers believe that these unfortunate patients were in danger of insanity before the operation and would have probably gone insane anyway, sooner or later, when exposed to the chances, worries and changes of life, even had no opera- tion been performed. Da Costa definitely states that a normal healthy individual will probably never go insane following any surgical pro- cedure unless it involved the brain, removal of the testicles or the ovaries. Berkley 8 found that 60 to 70 per cent of those patients now in asylums show such a history, while Kaller, 9 studying the histories of 2273 patients in Switzerland noted 78 per cent with tainted an- cestry. Two very important factors concerned with these mental states are fear and worry. There is evidence in abundance to show that fear can produce all sorts of disturbances in the human mechanism. The patients, it is true, who come to operation, are usually outwardly calm, heroically firm and determined, some even happy at the pros- pect of being freed of their disease, but if one could fathom the in- nermost workings of their minds, in many instances, one would be as- tonished at the damage which this one factor alone has wrought, the harm having been done long before the time set for the operation. In patients not predisposed to mental disorders, either by acquired weakness or by heredity, the danger of permanent mental disarrange- ment is not so great as in those not so handicapped. The operation over, the gloom which surrounds such patients lifts, and the worri- ment promptly ceases. In individuals, however, predisposed to in- sanity, there may be no rally at all even after an operation which promises a life free from the original cause of the trouble, but the condition passes from one of worry to one of actual mental unbalance which may deepen into an insanity incurable by any means within our reach. The prognosis in the first class of cases mentioned above is very favorable, but in the second class, too favorable an outcome must not be expected. The prognosis in general according to MacPhail 10 is 60 per cent recovery, while Werth 11 and Ellbery claim only 50 per cent. Fillebrown 12 considers the outlook very bad for any pa- tient in whom the mental disturbance is anything but transitory. In older individuals, especially those suffering from serious organic dis- 220 AFTER-TREATMEXT OF SURGICAL PATIENTS ease, particularly syphilis, a grave prognosis is always to be given. Crile and his associates have shown good anatomic reasons why such conclusions are inevitable. He finds that patients and animals, which are victims of nervous and physical assaults, suffer practically the same degenerative changes in the brain cells. These cells increase considerably in size, and the cell membrane becomes broken, causing distortion of its shape. The reaction to Xissl's stain is character- istic. An increased amount of this stain is absorbed at first, then as the degree of damage is increased, the reaction to the stain diminishes, so that in the final stages little or no staining is found. The nucleus, nucleolus and cell body having been broken down, a mere mass of cytoplasm alone remains and is incapable 13 of regenera- tion. The number of such cells destroyed indicate the severity of the lesion. Crile and his coworkers have found that the brain cells re- spond in the same way when subjected to overwork, infections, drug poisons, shock, fear or anxiety. Just how the exciting factors bring about such changes in the nerve cells can not be entered into here. A more thorough study in recent years of disorders following operations is proving its importance in that they are rapidly becoming an avoidable calamity. 14 It goes without saying that before any operation, the patient should be known to the surgeon. A thorough history is almost indispensable. If there is insanity in the family or if the patient himself has a his- tory of having been temporarily insane, an operation certainly ex- poses him to very distinct danger of another attack. None but the most urgent operations are justifiable in these cases and the risk should always be explained to the family. In highstrung or nervous individuals, and most patients become nervous in view of an impend- ing operation, the surgeon must maintain a constant attitude of op- timism and encouragement, he must never lose sight of the fact that the patient is to be inspired with confidence. Neurasthenics, if such patients exist, are always bad risks and operations on them should be avoided if possible. If the patient develops symptoms of this dreaded condition after every effort has been carried out to lessen worry, fear, surgical trauma, etc., treatment must be instituted at once. Probably it would be of importance in this connection to mention the following case history: No. 605(>, Miss J. C.j 29. saleslady, two sisters insane. Patient was admitted for goiter operation. Swelling in the neck had started 5 years ago and gradually increased. Xo symptoms of toxic goiter until one year ago when tremor, nervous- ness, palpitation, and tachycardia were noted. These had gradually increased until she presented a typical picture. She complained principally of headache POSTOPERATIVE PSYCHOSES 221 which had been more or less present during the past two months, but showed no other symptoms worthy of notice, except the fact that she was peculiar and did not always answer questions willingly. She was put to bed, a pitcher of water was placed at her side and at least 1 glassful every hour was given her throughout the day. Sodium citrate (20 grains) with one dram of sodium bicarbonate were given three times a day for the first two days. The headache was stopped with aspirin (10 grains), still she was unhappy and worried. Very little shock followed thyroidectomy. The convalescence continued uninterrupted and the patient's mind was clear for four days when she became morose, despondent, and wished to die. Dux- Fig. 28. — A method of confining the hands used at the Minnesota State Hospital, Rochester. ing this day and following night, she was irrational, worried, had frequent cry- ing spells, refused to answer questions, and complained of headache. Early the next morning 800 e.c. of salt solution were given hypodermically, were repeated in six hours. She slept all the following night but the next morning in addition to previous symptoms, became exceedingly stubborn and re- fused to eat. During the next day, she slipped out of bed and roamed over the hospital. She was brought back and carefully watched while 10 grains of aspirin with one grain of codeine stopped her headache and gave her a good night's sleep. Next morning she insisted upon getting out of bed, complained bitterly 222 AFTER-TREATMENT OF SURGICAL PATIENTS Fig. 29-A. — A simple method of tying the feet, which allows the patient to sit up in bed. Fig. 29-B. — A useful leg cuff and strap which permits i_atient to sit up in bed. POSTOPERATIVE PSYCHOSES 223 of mistreatment, started to cry, talked irrationally, and remained very morose and refused food. Two days later, 2000 e.c, of water were given hypodermieally at one time,- which at once stopped the mental excitation, the patient remained quiet throughout that day, and slept well that night. The following morning, she expressed fear of having to go to the asylum with her sisters, and later, tried to escape from the hospital, making it necessary to strap her wrists, Fig. 28. Her breakfast was given her by force, after which she became very obedient, ate her meals willingly, did not object to the straps, and the wouud healed perfectly. On the ninth day the straps were re- moved and at the first opportunity she got out of bed again, wandered about, and became so violent and unmanageable that in addition to strapping her hands, it was also necessary to strap her feet, (Figs. 29A and 29B.) All the preceding symptoms returned, she refused to eat, became morose, and complained of severe Fig. 30. — Method of forcing the mouth open for the purpose of forced feeding. Long flexible probe being passed between the teeth and cheek to the last molar tooth. (See Fig. 31.) headache once more. Her pulse, blood pressure, and temperature remained about normal throughout all the attacks. That night she slept well, having been given 10 grains of aspirin and 1 grain of codeine. Next day the patient was again docile, ate her breakfast, and no outbreaks occurred. Later in the day, she was put in a chair without restraint and during the four succeeding days, she remained quiet, but the condition of her mind did not improve. An alienist pronounced it delusional insanity, and on the twenty- first day she was sent to a private asylum. Most thorough eliminative measures must be attempted in these cases, all the water and alkalies the patient can tolerate being given by mouth, in the rectum, and under the skin. Large amounts of salt solution or plain distilled sterile water given subcutaneously will often 224 AFTER-TREATMENT OF SURGICAL PATIENTS relieve the symptoms and give the patient rest and sleep. It may become necessary for want of attendants to restrain the patient, which should he done only when absolutely necessary, the instruments used being so made that he can not injure himself. Food must be regularly given with sufficient alkalies to keep down an acid intoxi- cation. Difficulty in feeding these patients may be so great that the stomach tube (Figs. 30, 31 and 32), must be resorted to. As to the drugs which may be necessary, bromides are very depressing and Fig. 31. — Showing the probe passing behind the last molar tooth ami tickling the fauces. thereby causing immediate opening of the mouth. A soft pine stick containing a round hole is immediately placed between the teeth as shown in Fig. 32. should be avoided. Opium and hyoscine particularly may he em- ployed. We have had little occasion to use either when the water and alkali treatment is persisted in. The alkalies are given until the urine becomes neutral or alkaline. When such measures do not correct the malady an alienist should lie culled and the further treat- ment directed by him. The patient should not remain long in a general hospital. As soon as the surgical convalescence has been completed, he ought to be POSTOPERATIVE PSYCHOSES 22* moved to a private sanitarium or to his home as thought best by the medical man in charge. Hygienic measures are particularly impor- tant, sunshine and fresh air with clean beds, frequent warm baths, and other measures necessary to prevent bed sores, are indispensa- ble. The surgeon should keep accurate records of such cases and have ample testimony as to what condition the patient was in before and after the treatment. Where the patient suffers from a delusion of persecution, some of these imaginable wrongs may so impress her during the saner moments as to acquire forensic importance and be Fig. 32. — Showing round soft pine stick tied in position between the teeth. The round hole in the center of the stick receives the feeding tube. The patient is thereby prevented from injuring himself and compressing the feeding tube, and consequently can not further resist the proffered food. the subject of serious legal inquiries. While every effort is put forth to help the patient, the surgeon must at the same time make ample provision to protect himself. Febrile Delirium Among the other conditions which may be confused with insanity is febrile delirium. This term has arisen because of the fact that most of the general diseases which cause delirium are febrile. Delirium in itself denotes a state of mental excitement, which comes on suddenly, is only temporary, and is due to a recognizable cause. The mental 226 AFTER-TREATMENT OF SURGICAL PATIENTS manifestation differs in no essential way from some of the acute in- sanities, but it has become customary to restrict the application of this term to certain intoxications, to great exhaustion, or to emotional instability, as in hysteria, etc., to organic disease of the brain or to infections. Very high temperatures frequently cause delirium, as do also dis- turbances of the cerebral circulation, but the effect of the toxic sub- stances in the blood is found to be the cause in the majority of these instances. Delirium does not always follow a high temperature, this condition being seen at times in patients with very little elevation of temperature, as is the case in children or in old people. According to Da Costa, delirium in septic cases usually makes its first appearance in the evening when the patient is between waking and sleeping. It is apt to clear upon becoming wide awake only to reappear when the patient becomes drowsy again. After disturb- ing the patient throughout the night, it will clear up towards morning only to manifest itself later on during the day. Acute mania does not clear up as does delirium, and there is no true lucid interval in the former condition. The onset is not so rapid in mania nor is the degree of illness so intense. In confusional insanity, the same symptoms may be seen as in de- lirium, and these conditions are easily confused. However, febrile delirium occurs during the febrile malady rather than following it as is seen in actual insanity. The treatment is the same as for post- operative psychoses. Delirium Nervosum Delirium nervosum is a term which lias been used to describe a con- dition occurring within the five or six days following an operation, in very nervous people. This condition may follow injury, and hence it is designated, by some, traumatic delirium. Usually there is ma- niacal excitement though in some of the patients, melancholy depres- sion, confusion, or even revelry with subsequent stupor, are the most prominent symptoms. The mental excitement seen in true delir- ium nervosum has a sudden onset. The condition lasts several days and ends just as suddenly as it came. In such a malady, hallucina- tions, illusions and delusions occurs. The condition is apt to be con- fused with confusional insanity, and, in fact, the form with confusion and a tendency to stupor is really an insanity. However, a diagnosis of delirium nervosum is not made until it is certain that the condition is produced by sepsis, acidosis, uremia, etc. The patients usually re- cover if it is purely a nervous phenomena, though at times a patient dies in what is diagnosed as this condition. POSTOPERATIVE PSYCHOSES 227 Senile Delirium Old people do not stand operations well. Many of them sleep badly and are apt to be irritable, restless, excitable, quarrelsome, and even suspicious. In such a state of mind and subjected to the dangers of an operation the aged are predisposed to delirium. No sign of mental deterioration may have been noticed before the operation, though soon afterward grave signs of this complication may develop, and mania, melancholia or delusions arise, which unfortunately, may be the precursors of senile insanity. It is common for such individuals to develop delirium during the night, but the daytime is not always free from the malady. An ele- vated temperature may occur or may not depending largely upon the condition for which he was operated. When he wakens after the anes- thesia, or perhaps hours later, the patient becomes irritable, suspi- cious, restless, inattentive to his surroundings, and soon passes into a state of delirium. He talks and shouts, tries to get out of bed, and if at any time he does succeed 3 wanders off. Frequently there are hallucinations of hearing, and in his excitement from these or other hallucinations, suicide may be attempted. He may become erotic, and commonly he urinates or defecates in the bed. Such delirious con- ditions soon pass away unless a part of true senile dementia. Hysterical Delirium Hysterical delirium is seen in young women at times after an op- eration. It is most common at the menstrual period. The condition is precipitated by fright, overstrain, worry or any violent excitement. It begins suddenly, being preceded by convulsions or these may not occur at all. The patient becomes extremely excited, is very restless, talks loudly but not incoherently, and becomes very obstinate. She will probably cry, scream, lament, implore, and do anything to at- tract attention and pity. She is perverse and is apt to make indecent exposure or use obscene and profane words. It seems that the ex- citement comes in waves and during a lull, the patient may suddenly ask intelligent questions or act normally. The whole condition is one of unreality and strikes one that the patient is pretending to be out of relation with her surroundings. The excitement usually ends after an hour or possibly after several hours, following which there may be lacrimation. In such patients, the visual fields should be examined and the areas of anesthesia which are commonly found in hysteria, sought for. 228 AFTER-TREATMENT OF SURGICAL PATIENTS Fig. 33.— A simple scheme for restraining hands and feet only. POSTOPERATIVE PSYCHOSES 229 Other conditions which cause delirium and which simulate insan- ity can not be too thoroughly studied. Delirium following drug poisoning, delirium of starvation (as in cancer of the stomach or esophagus)., of collapse, of fatigue or of delirium following acidosis, uremia or diabetes must not be confounded with insanity. It would prove a serious mistake to call such conditions as have been named, beginning insanity or to state that some organic brain disease is causing the mental excitement when some minor factor, at times easily diagnosed, is the sole cause. On the other hand, it is a serious blunder not to recognize those who are actually insane and not to have them cared for in a proper way. Fig. 34.— Showing the method of restraining the body by means of a sheet, the end of which is tightly pulled under the bed railing and rolled around it as depicted in the insert. The treatment should carry with it every method which will aid efficiently in preventing the patient from injuring himself. Eestraint (Figs. 33' to 36) is used only when absolutely unavoidable. \Ye have found it a good rule to give, in such cases as in the real insanities, a large dose of water and an alkali. A subcutaneous injection of 2400 c.c. of water at one time will aid materially in quieting a de- lirious patient. Sodium bicarbonate and sodium citrate should be given by mouth and per rectum. These should be kept up until the urine becomes alkaline. The former drug is given 60 grains every 230 AFTER-TREATMEXT OF SURGICAL PATIEXTS four hours while the latter drug is usually administered in 20 or 25-grain doses in same length of time. Ice is applied to the head and warmth to the feet, The bladder and bowels are kept free and diaphoresis is encouraged. pig. 35. — An admirable straight jacket with comfortable band arrangement for walking insane patients, Minnesota State Hospital, Rochester. Fig. 36. — The straight jacket as shown in Fig. 35 combined with a confining sheet, making an absolute restraint for uncontrollable patients. The three straps over this sheet may be of canvas or leather. Dr. Stuarl McGkure gives the following instructions to patients suffering from postoperative neurasthenia when they are discharged from the hospital. POSTOPERATIVE PSYCHOSES 231 Your -wound has healed and requires no further attention. The operation has removed the cause of your trouble, but it will take some time for you to get well. When you get home you should put yourself under the care of your physician. He knows all that was done for you and all that was learned about you while you were in the hospital. Don't continually think about yourself and ask yourself how you feel. You don 't know enough to tell whether a symptom has any significance or not. You employ a doctor. Let him do the worrying for you. Don't worry yourself. Worry is thinking to no end. "Distracted" means drawn two ways. Worry and distraction prevent rest and sleep and result in chronic tiredness. The cure for worry is concentration on something with an end in view. To be wholesome that something must be productive. In other words, you need occu- pation. While at the hospital you had a "rest cure." You now need a "work cure." Try to find some light, useful work that will occupy and interest you. At meal times put aside care. Don't be afraid to trust your digestion. Don't abuse it, but use your stomach confidently. Keep the bowels open by natural means such as a proper diet, an abundance of drinking water, a reasonable amount of exercise and a habit of going to stool at a regular time. Mild laxatives may be necessary occasionally. Avoid stimulants and hypnotics unless prescribed by your physician. On getting up in the morning take a cold sponge bath. On going to bed take a warm tub bath. Sleep with the windows open. Rest in a quiet room for one or two hours in the afternoon. Spend as much time in the fresh air and sunshine as your strength and the weather will permit. Increase exercise as you gain strength, stopping when you get tired and not going until you get exhausted. Please report your condition by mail at the end of three months. If you are doing well the information will help us, if you are not doing well we may be able to help you. Bibliography ^Kelly: Surg., Gynec, and Obst., 1909, ix, 519. 2 Da Costa: Surg., Gynec and Obst., 1910, xi, 577. sSelberg: Beitr. z. klin. Chir., 1904, xliv, 173. 4 Grekow: Annal de Russe chir., 1901, i. sPicque: Bull, et mem. Soc de chir. de Paris, xxiv, 171. sUrbaeh: Wien. klin. Wchnschr., xlvii, 1465. ^Stoner: Iowa Med. Jour., 1912, xviii, 247. sBerkley: Mental Diseases, 1900. sKaller: Archiv. f. Psyehiat., xxvii, 286. iQMacPhail: Brit. Med. Jour., September, 1899. nWerth: Zentralbl. f. Gynak., xxiv, 387. i2Fillebrown : Am. Jour. Obst., 1889, xxii, 32. isMumford: Boston Med. and Surg. Jour., 1910, elxiii, S41. wAikin: Am. Jour. Med. St., 1915, cxlix, 715. The following was also consulted: Rayneau: Congres des Med. Alien et Xeur. Angers, 1S9S. CHAPTER XXVIII ACID INTOXICATION By 0. F. McKittrick, St. Louis, Mo. Acetoimria is of such frequent occurrence in postoperative conva- lescence that it is incumbent upon me to give it extended mention. Its importance is manifested by a symptom-complex of greater or lesser severity, depending upon the amount of retained acids in the body, which condition, for want of a better name, has been termed "acidosis." The degree of this de-alkalinization of the body fluids or acid intoxication may become so great as not only to cause most se- vere symptoms, but even death, in fact this one complication alone is claiming its victims by the thousand. General anesthetics came into use about the middle of the nine- teenth century, and while from the start success attended their use, there soon was noticed a factor which up to this time had never been called to the attention of the experimenters in this field. This new factor appeared two to three days after the narcosis in the form of a profound intoxication, at times accompanied with incessant vomit- ing. As anesthesia became more genera] just so did this new con- dition increase in prominence and severity. An explanation was not forthcoming, and since these toxic patients frequently died in coma, the condition was thought to be diabetes. As fate would have it, the tii'st discovery of acetone was made in a diabetic patient. After this discovery by Peters 1 in 1857, it was repeatedly demonstrated by him in other severe cases of diabetes. Soon thereafter Kaulisch 2 found it present in varying quantities in all stages of this disease, and first described the symptoms of acidosis which was then termed aceto- nemia. Kussmaul 3 in 1874 in describing diabetic coma mentioned the likely importance of the toxic action of acetone as a causative factor. During this time chloroform was the popular anesthetic, and many deaths occurred in which the symptoms of acid intoxication were noted, but the deaths were attributed to other causes. Such cases were reported by Casper, Konig, Volkmann and others. Kast and Mester 4 in 1891 studied the urine in these cases and found among other things hyperacidity. In 1894, Becker 5 working along the same lines but in addition examined for acetone tin 1 urines of about fif- teen hundred healthy individuals before and after operation and 232 ACID INTOXICATION 233 found a pathologic amount in over 60 per cent of the cases following narcosis ; three fatal cases being reported by him. During this same year Guthrie 7 reported nine, more fatalities. A year later Stocker 6 added another case to the list. Other cases were reported from time to time, but in each one chloroform was given as the cause of death. Brewer 55 in 1902 first reported a fatal case which without a doubt was due purely to acid intoxication, in a patient free of diabetes. Two years later Bracket, Stone, and Low t1 ° cited several instances of acid intoxication in nondiabetic patients and gave an exhaustive study of the whole subject. After this work operators seriously con- sidered this possibility and henceforth acidosis assumed clinical im- portance. Bevan and Favill 11 in 1905 reported one case and collected 28 more of acid intoxication following chloroform narcosis. One year later Beesly 12 reported 17 cases in which he mentioned acute and chronic acidosis. Later on Campbell 13 and McArthur 14 each reported fatal acid intoxication following chloroform anesthesia. In 1908 Eice 15 found an excess of acetone in the urine following ether narcosis in 90 per cent of 202 patients who were not diabetics. Of 214 cases reported by Bradner and Keimann 16 in 1915 a pathologic amount of acetone was found in 61.7 per cent of them following ether. In 17 per cent diacetie acid was present, but always in asso- ciation with large amounts of acetone. It has long been known that acetone occurs in minute quantities in the urine and blood of normal individuals. This materially in- creases in amount in fevers, wasting diseases, insufficient carbohy- drate diet, and particularly following anesthesia. The amount of the anesthetic, the length of time given, and the kind of operation ap- parently have no bearing on the extent of the intoxication. It ap- pears after local anesthesia in a high percentage of cases as Gell- horn 17 has recently shown. It occurs more often in women than in men, and is as frequent, in the infective diseases in children, as is fever itself. 18 The formation of the acetone bodies (betaoxybutyric acid, diacetie acid, and acetone) is due chiefly to fat metabolism, with the forma- tion of free fatty acids, and is largely dependent on a reduction of the carbohydrate and protein diet, also in general subnutrition. 10 Where acetbnuria is found clinically, there is often an intestinal dis- turbance which results in a defective nutrition of the body, associated with waste of the adipose body tissue. 19 It follows, then, that the fat which breaks down may be the food fat or as is usually the case, the body fat, But at any rate the immediate cause of the appearance 234 AFTER-TREATMENT OF SURGICAL PATIENTS of a pathologic amount of these bodies is the disturbance of the metab- olism. Experimentally acetone is readily formed from fat or carbohy- drates. Blumenthal and Neuberg 20 produced acetone from gelatin and it is probable that it may be obtained from protein. The first observers thought acetone might occur from breaking down of the proteins, but this was discouraged by von Noorden, Ho- nigmann and others. Recently, however, the question has again been raised by Chapin and Pease- 1 who have demonstrated an acidosis in children from feeding a protein diet in gastrointestinal diseases. Just why acid intoxication develops is a question which has not been definitely decided. An acetonuria does not denote an acidosis though it may be the forerunner of an acid intoxication. This phase of the condition has been studied by von Jacksch, 22 Baginsky, 23 Lo- renz 24 and many others. Baginsky in 1888, showed that the severity of the symptoms were dependent upon the height of the fever and the kind of food allowed. He considered it a disturbance of metabolism. Lorenz in 1890, while agreeing with Baginsky, thought that gastro- intestinal disturbances were the primary factors in creating this un- natural condition. Chapin and Pease. 21 hold that through such dis- turbances the epithelium of the intestinal tract is so damaged by the acids or bacterial products thus produced that the toxins penetrate the membrane. Under such conditions the salts of the food may pass into the blood in such concentration as to act as poison to the body cells. Water is consequently withdrawn, and this produces the thirst so commonly observed in acidosis. These abnormal acids demand an increase of alkalies, which necessarily causes a diminution of them in the blood. With the lowering of the alkalinity of the blood the body cells are damaged and the nitrogen output is thereby increased. Extensive withdrawal of the alkalies and water may permanently damage the body cells with the result that loss of weight, and in in- fants, malnutrition and even atrophy occur after an acid intoxica- tion. Howland and Marriott 2 " 1 have tried to find an explanation for acid- osis in the retention by the kidneys of acids which are the product of metabolism. In support of this view they call attention to the lessened urinary output and suggesl that this may be due to the loss of the acid excretory function. As has long been known there is an increase in the watery content of the stool, during diminution of the urinary secretion. Experimentation is now being carried on to prove this theory, but while we await the result we are as far away from a solution of this problem as were those men of a half century ago. ACID INTOXICATION 235 It must be remembered that the body is constantly elaborating acids as the result of oxidative processes in intermediary metabolism and in order to neutralize these acids there is maintained a certain alkali reserve in the blood. It is derived from the sodium bicarbonate in the plasma and in the corpuscles. The acid and alkaline phos- phates of sodium and potassium are found in the red cells, and the proteins. These constitute the defenses of the animal organism. In addition there is a further defense in that ammonia can be produced and utilized to neutralize acids when these appear in excessive amounts ; the whole being under the control of a central nervous mechanism. Anything which tends to break down these body defenses predis- poses to acidosis. Lorenz long ago showed that fright or hyperex- citability was indeed a fruitful cause of this condition. Bracket, Stone and Low, also found that homesickness, nervousness from too long confinement in the hospital or the excitement of seeing other pa- tients recover from the intoxication of an anesthesia, was a predispos- ing cause. Other causes outside those already mentioned are chronic diseases of the liver, exhaustion from hemorrhage, starvation, fatty de- generation of the muscles, as may occur in paralyzed limbs, and a lowered general vitality as in sepsis, or diabetes. As a rule the symptoms of acid intoxication following operation appear in from one-half day to six days, though the elimination of acid bodies, however, ceases within three days. As was shown by Wil- ber 26 in 1904 and again recently by Marriott, the severity of the symptoms is not dependent upon the amount of the acetone bodies present and a most severe intoxication may be seen without any ma- terial increase in these bodies. Keller 27 and others have sought in vain to find other abnormal acids which would account for the symp- toms. In view of the above facts one should not overlook these cases of intoxication because merely a slight trace of acetone is found in the urine and because the acetone bodies in the blood have not in- creased at all. The patient usually complains of being sick, "so sick all over" and begins to vomit a day or so following the operation or the nau- sea and vomiting from the anesthetic may not as yet have ceased. He is irritable and restless. The appetite has not reappeared and the breath has a sweetish fruity odor. The symptoms may be mild and pass away in a few hours. In very severe cases the patient not alone complains of being sick "enough to die," but looks it. The face be- comes ashen gray, the lips pale and dry, the eyes sunken and glassy. The skin is moist and cold or in some cases is hot and dry and the pa- 236 AFTER-TREATMENT OF SURGICAL PATIENTS tieut may become jaundiced. A temperature from 100 to 103 is likely to be present with a rapid weak pulse. During this state of collapse delirium may be noted, even followed by convulsions be- tween the paroxysms of vomiting. Usually apathy and stupor will be noted later. This quiet does not last long and the patient again becomes restless and active in his delirious state. As the condition increases in severity, the victim passes into a stupor which deepens into coma. The respiration becomes difficult and finally takes on the Cheyne-Stokes type, the heart weakens, and the patient dies without regaining consciousness. Many observers have described a type of acid intoxication which comes about four days after operation, appearing suddenly in pa- rents, particularly children, in whom the convalescence had given no reason for alarm. The sick one suddenly becomes irrational, wildly excited, and uncontrollable. Under powerful medication he may quiet down, only to start up again with a piercing shriek fol- lowed by agonizing moans, he soon develops the symptoms noted above and frequently is dead in thirty-six hours. Space does not permit ;i description of the various tests for acetone. Sellards 28 by removing the proteins from the blood serum with abso- lute alcohol titrated the filtrate with phenolphthalein. Under normal conditions a deep purple is seen, but if acidosis is present, the color is much lighter or even absent. Howland and .Marriott have de- scribed a very accurate method of diagnosing acidosis, particularly in children, by determinating the carbon dioxide tension of the air in the alveoli of the lungs. An increased acidity of the blood stimu- lates the respiratory center to increased activity in order to reduce the carbon dioxide, so that the hydrogen-ion concentration may be kept at a normal level. The carbon dioxide tension in the alveolar air will be the same as the carbon dioxide tension in the blood. Van Slyke more recently has elaborated a method by which the carbon dioxide tension of the blood may be determined. These methods are the most accurate we have of determining an early acidosis. A simple method of determining acetone in urine is that described by Lange. 29 "About 15 c.c. of urine are placed into a test tube and treated with 1 c.c. glacial acetic acid. To this add a knifepoint of ground sodium nitroprusside, dissolve by turning the test tube up several times. Now overlay with strong ammonium hydrate. In the presence of acetone an intense violet ring appears at the line of con- tact. The test will show acetone in % 00 P er cen 1 solution." "Diacetic acid is tested for by adding an excess of 10 per cent ferric chloride to about 20 c.c. of urine in a test tube. The precipitate ACID INTOXICATION 237 which forms is removed by filtration. To the filtrate add more of the chloride. A deep Bordeaux red color will appear in the presence of diacetic acid. The contents of the test tube are now halved and one portion boiled, and compared to the one unboiled. The color lessens due to the breaking up of the diacetic acid. The test in- dicates .04 to .05 per cent of diacetic acid." 30 To anticipate this mystifying disorder it is very important to in- stitute measures of prevention. Such measures were carried out with some degree of success by Wallace and Gillepsie. 31 Their example was soon followed by Brown. 3 - Since then many men have been ac- tive along this line, notable among them being Chile, 33 with his well- known " anoci-association. " Recently Quillian 34 has reported the re- duction of the occurrences of acidosis by carrying out a routine pre- operative treatment. I have for some time given my patients so- dium bicarbonate one-half ounce in water three times a day half an hour before meals for two days preceding operation. Glucose is given per mouth as much as the patient will take and a glassful of water every hour or so up until within an hour of the operation. In addi- tion every effort is made to assure the patient and get him accus- tomed to the surroundings. His habits and mode of living are dis- arranged as little as possible and nothing is allowed to occur which would in any way cause excitement, or concern. The nights are spent in quiet, bromides being given to insure quiet if necessary. In spite of every preventive measure, acetone may appear as in fact it does in the great majority of patients. Following the anes- thetic then in such cases water is started by mouth as soon as the patient is able to retain it, and after a day or so a pitcher is put by the bedside and the patient encouraged to drink a glassful every hour or two. Continuous proctoclysis is kept up for twenty-four hours, plain tap water containing glucose to the amount of 2 per cent being used. An ounce of sodium bicarbonate is added to each quart of proctoclysis, while sodium bicarbonate is given per mouth. Others have advised an enema containing one ounce of olive oil and one ounce of glucose in one pint of tap water, two hours before operation, the whole to be retained throughout the operative procedure. In cases where a violent condition demands more alkali nization, a 2 per cent solution of sodium bicarbonate in plain sterile distilled water is given in a continuous subcutaneous injection. Marriott would give intravenously a 4 per cent solution. Five per cent glu- cose may be given under the skin in the same solution with the al- kali. Morphine pushed to the physiologic effect has almost a specific action. Carbohydrate feeding must constitute our sheet anchor and 238 AFTER-TREATMENT OF SURGICAL PATIENTS will be referred to more in detail in the chapters on feeding, etc. The time-honored custom of giving postoperative patients proteins in the form of broths, with no thought of their physiologic needs, has become so thoroughly ingrained in many of our hospitals that it will die hard. Bibliography iPeters: Quoted by Kraus: Alleg. Path. Lubarsch unci Ostertag, Heft 2, 1895. -'Kauliseh: Prag. Vrtljschr., 1857, xiv. sKussmaul: Ztschr. f. klin. Med., Berlin, vi. *Kast and Mester: Ztsehr. f. klin. Med., xviii, -469. sBecker: Deutsch. med. Wehnschr., 1894, xviii, 469. eStocker: Zentralbl. f. Gynak., 1895, No. 45. ^Guthrie: Lancet, London, 1894, i, 193. sBrewer: Ann. Surg., 1902, ii, 489. sKelly: Ann. Surg., 1905, ii, 161. loBracket, Stone, and Low: Boston Med. and Surg., 1904, p. 151. nBevan and Favill: Jour. Am. Med. Assn., 1905, xlv, 691. i-'Beesly: Brit. Med. Jour., 1906, ii, 1146. JsCampbell: Med. Press and Circular, 1907, lxxxiii, 198. uMcArthur: Intercolonial Med. Jour., Australasia, 1907, xii, 434. isEice: Boston Med. and Surg. Jour., 1908, clix, 47. 16 Bradner and Reimann: Am. Jour. Med. Sc. 1915, cl, 727. "Gellhom: Zentralbl. f. Gynak, 1914, xxxviii, 1204. isHowland and Marriott: Bull. Johns Hopkins Hosp., March, 1916. ifWaldvogal : Centralbl. f. inmere Med., July, 1899. 2"Blumenthal and Neuberg: Deutsch. med. Wehnschr., xxvii. 2iChapin and Pease: Jour. Am. Med. Assn., November, 1916, p. 1353. --Von Jacksch: Ztschr. f. klin. Med., viii. 23Baginsky: Arch. f. Kinderh., 1888, ix, 1. z-iLorenz: Ztschr. f. klin. Med., 1891, xix. 25Howland and Marriott: Am. Jour. Dis. Child., May, 1916, 309. 26Wilber: Jour. Am. Med. Assn., October, 1904, p. 1228. 2"Keller: Malzsuppe, eine Nahrung fur Magendarmkranke Sanglinge, 189S. 288ellards: Bull. Johns Hopkins Hosp., 1914, xxv, 147. zsLange: Miinchen Med. Wehnschr.. 1906. liii, 1764. soMorris: Clinical Laboratory Methods, 1913, New York, D. Appleton & Co. siWallace and Gillepsie: Practitioner, February, 1910. 32Brown: Brit. Med. Jour., 1911, i, 428. ssCrile: Ann. Surg., 1915, lxii, 257. 3-JQuillian: Ann. Surg., 1916, lxiii, 385. CHAPTER XXIX DIABETES IN SURGERY By 0. F. McKittrick, St. Louis, Mo. Glycosuria is a complication which is certainly not desirable in any surgical convalescence. Operations upon patients suffering from this condition are usually not performed without an attempt being made to determine the responsible factors which are bringing this about, and without medical treatment being instituted to correct the abnormality. It is frequently difficult in the presence of surgical necessities to distinguish between temporary or nondiabetic glyco- suria and true diabetes. In fact, as early as 1884 Verneuil 1 stated that no one could definitely say where glycosuria ends and diabetes begins. The present day surgeons look upon sugar in the urine as a serious fact and do not try to differentiate such a finding from true diabetes. Instead, they have inclined to follow out a classification which was probably first suggested by Smith and Durham 2 which, though more or less modified, is about as follows : first, cases in which glycosuria is caused by the surgical lesion ; second, cases in which the lesion causes the surgical condition; third, cases in which the two are in- dependent and do not influence each other; fourth, cases in wdiich glycosuria is a harmful factor and increases the danger of the already existing disease or injury. Of the first class of cases it may be said that glycosuria is not un- commonly caused by the surgical lesion particularly in cases of in- jury or sepsis. Redard 3 suggested that they be classified as (1) in- juries of the central nervous system; (2) cellulitis, lymphangitis, and erysipelas; (3) carbuncle; (4) gangrene; (5) septicemia; (6) injuries such as fractures and operations. To above other operators have added glycosuria as secondary to sloughing new growths, and cer- tain other intraabdominal and intrapelvic diseases. In such cases the amount of sugar ranges from .1 to 2.50 per cent, is accompanied with a more or less albuminuria and an increase of the total twenty-four hour quantity of urine ; these urinary findings being only transitory. Other diabetic symptoms such as thirst, itching skin, etc., were pres- ent in these cases. This condition as a consequence of appendicitis has been mentioned by Da Costa, 4 Leidy, 5 Cohn, 6 and others. In some of these cases the percentage of the sugar was as high as 2.5 per 239 240 AFTER-TREATMEXT OF SURGICAL PATIENTS cent and usually lasted as long as there was any evidence of the disease. Imlaeh 7 reported a ease of pyosalpinx in which all the symptoms of diabetes appeared with the occurrence of the disease and the patient was cured only by removal of the tubes. Strangulated hernias have produced a glycosuria. Neugebauer, s experimenting in an effort to find immediate cause of this complication in such cases, discovered that ligation of the vessels of the small intestines brought about gly- cosuria. Croom, 9 Beyea, 10 and others have noticed this occurring in patients having large tumors and have attributed it in many cases to the increased intraabdominal pressure. In Beyea 's case, the tumor, an ovarian cyst, weighed 58 pounds, and 7 per cent of sugar was found in the urine. C41ycosnria following gangrene has been noted several times in the literature. Phillips 11 in 1902 reported a severe case of traumatic gangrene in which the glucose reached nearly 4 per cent; this completely disappeared with the removal of the affected limb, which in this instance was the left arm. Recently Konjetzny and Weiland 12 have found that in about 50 per cent of fracture cases there is a spontaneous or alimentary gly- cosuria, which like the above is only transitory. However, the symp- toms of diabetes are not noted despite the presence of a hyperglyce- mia. The glycosuria appears at once or it may not occur for a few days l»ut disappears at the end of from fifteen to twenty days. True diabetes rarely occurs; hut, when it does, more thai) six months will have elapsed after the injury. Symptoms of this disease will per- sist permanently. The actual cause of the glycosuria in these cases may he an ana- tomic injury such as fat embolism or a purely functional disturbance. Frequently it is a combination of both. Regarding the second class of cases, "it is doubtful whether dia- betes can directly cause any surgical lesion except vulvovaginitis, balanoposthitis and possibly cataract." The gangrene which occurs in diabetes, according to Phillips, is due to the arteriosclerosis or nerve degeneration which result from the constitutional disease. Carbun- cle and other infections are to be regarded in the same Light. The resistance being lowered in all diabetics, such patients respond very badly to any injury, surgical or accidental. The mortality from op- eration in such cases is still high in spite of the fact that newer forms of anesthesia such as nitrous oxide and oxygen, local infiltration and even spinal analgesia replace ether, while preoperative treatment re- duces the amount of sugar. Seven patients with balanoposthitis were operated by French authors and one died from extensive gangrene, while of 102 operations for cataract Legendre found that 99 were successes. DIABETES IN SURGERY 241 From a surgical standpoint class three is the most important since here are placed the new growths, fractures and other injuries occur- ring independently in diabetics, and especially so since this disease may at the time of the surgical emergency he unknown, as the symp- toms may be intermittent. Phillips reported 32 per cent mortality in operations on the face and mouth for malignancy which occurred in the presence of diabetes. Of the mouth and lip cases alone the mortality was but 25 per cent. In operations on the breast there were 13.4 per cent mortality. On the genital organs 24 per cent, but in simple plastic operations the mortality was nil. The bad results were apparently, due to infection which was of course facilitated by the lowered vitality of the tissues. Abdominal operations including hernia, appendicitis, colostomy for malignant disease in Phillips collection of cases showed a mortality of 26.3 per cent. In operations upon the extremities the mortality was about 33 per cent. These cases included crush injuries, aneurysm neoplasm, and fractures. Fractures occurring in diabetic patients are considered doubly se- rious since nonunion or delayed union is so apt to occur. Von Noor- den 13 stated after a study of the researches of Toralbo, Van Ackeren, and Gerhardt, that diabetics often excrete an excess of phosphoric acid and lime salts over the quantity derived from the food ingested, and that they must come from the tissues of the body. Naturally this can only be from the bones, since an administration of alkalies causes a decrease in the excretion of lime ; Gerhardt thought this was due to increased acidity. Of the cases reported by Smith and Durham more than 50 per cent showed delayed union or nonunion. Phillips cites other cases of nonunion, and while perfect union does occur, he thinks the former is more common. Von Noorden advised the giving of calcium carbonate to all these patients with fracture in an effort to supply the deficiency of lime. Such treatment carried out will no doubt decrease the number of delayed or nonunions. The fourth class of cases includes those instances in which a septic element is already present at the time of the observation. It includes therefore gangrene, localized infections, etc. The question of gangrene is an important as well as an interesting one. The so-called diabetic gangrene is now considered simply a gan- grene occurring in a diabetic patient. Such a term is usually applied to gangrene occurring in the lower extremities. Considerable liter- ature has accumulated on this subject, which has been complicated by the fact that senile gangrene is usually accompanied by glycosuria. Gussenbauer, 14 who has done extensive work along this line, advo- 242 AFTER-TREATMENT OF SURGICAL PATIENTS cates "diet and general palliative treatment first for this condition. The arteries must be carefully watched on both sides of the leg, and if the pulse can be felt distinctly in both the anterior and posterior tibial and dorsalis pedis arteries local removal of the diseased tissue will be sufficient. If, however, a pulse can be obtained in the popli- teal artery only amputation of the leg below the knee may be per- formed, provided the gangrene has not spread beyond the dorsum of the foot and the leg is free of phlebitis and lymphangitis. If at any time in doubt, amputation must be done through the thigh." Ac- cording to the Bartholomew Hospital Reports failure to recognize this rule carries with it a 75 per cent mortality. Otitis media is common in diabetes, infection spreading up from the pharynx which is often in a state of catarrh. The onset is usually sudden and the pain is very severe and persists even though there is a free discharge through the external meatus. The discharge is very apt to be bloody and according to Eulenstein 15 there is great tendency to mastoiditis and necrosis. The disease may run a normal course, but in many instances an extensive cellulitis is present. Cellulitis starting in the bursa olecrani which necessitated amputa- tion of the arm is reported by Spencer, the patient recovering. Naunyn cites an instance of a large thoracic abscess which was soon followed by an abscess of the prostate. Following operation both abscesses healed without further complication. This case bears out Nicholas' 1G observations stated below that glucose favors the pyogenic properties of many microorganisms, while it diminishes their viru- lence. It has been emphatically stated that the urine must be examined for sugar if after an operation the wound for no apparent cause be- comes septic or sloughs. This is frequently found present although absent before the operation; it being a case of latent diabetes, sugar reappears after the general functional disturbance caused by the anesthetic or by the mental effects of the operation. It is well known that sugar when originally present is increased in diabetics under like circumstances. In a septic process, which at times occurs in this condition, is found the Staphylococcus aureus and albus and other pus-producing pyro- genic bacteria. Even molds have been found in such cases by Auche and Dantec. 17 Bujwid 18 showed experimentally that an amount of staphylococci which did not produce suppuration if suspended in an indifferent though sugarless fluid, when suspended in a similar though sugar-containing fluid did produce it. He also demonstrated that no suppuration ensued if the injection of a subminimal amount of staph- DIABETES IN SURGERY 243 ylococci into an animal were followed by the injection of normal saline fluid, whereas the injection of a sterile solution of sugar was attended by suppuration. If the sugar solution was withheld until the staphylococci disappeared from the blood, no suppuration resulted. These experiments were substantiated by similar ones of Nicho- las and Ivarlinski. In addition Nicholas showed that sterile water produced as much damage if injected into the cellular tissue as did the sugar solution. But if an amount of staphylococci sufficient to kill an animal in a few days was injected, and followed by a so- lution of sugar, either the animal was not killed at all or only after a much longer period, also a large abscess made its appearance in- stead of a small one or septicemia. Ferrero also agrees with these findings that sugar diminishes the virulence of microorganisms but in- creases their pyogenic properties. From the foregoing data it will be seen that a majority of major operations haye been and can be performed with success on diabetics. The percentage of mortality is 27.7 as reported by men who have col- lected the material on this subject. Such a percentage includes all kinds of cases which without glycosuria would give a high mortality. In ordinary cases in which there has been a preliminary treatment the mortality is hardly half this. Even in emergencies the percentage is not more than 20 to 25 per cent, the percentage of sugar is not always a criterion, since fatal results have followed from coma when sugar was temporarily absent, and cases with large amounts of sugar have recovered. 19 The treatment of patients suffering with this complication must be- gin before the operation is started. The general treatment of the dis- ease can not be entered into here, but while this is being carried out, the following rules as observed by most operators are important to remember. "1. No operation save of the most urgent nature is to be performed if there is over one gram of ammonia excreted in twenty-four hours. "2. Acetone and cliacetic acid must be eliminated from the urine even if the ammonia is normal before a surgical procedure is at- tempted. "3. Much albumin is a contraindication to operation and even a small amount is of bad prognostic import. "4. Operation may be performed at once in cases of large pelvic tumors, where there is reason to believe the glycosuria is caused by the intraabdominal pressure, while in malignancy or in emergency operations a very guarded prognosis should be given." 244 AFTER-TREATMEXT OF SURGICAL PATIENTS During the operation the most rigid asepsis is carried out, and the operation finished as quickly as possible, under an anesthesia of ni- trous oxide and oxygen. 20 In all operations which can he performed under local anesthesia, this is the procedure of choice. Ether and chloroform are to he avoided if possible. The after-treatment includes the general measures for elimination. Large amounts of alkalies are given whether acetonuria occurs or not. Morphine and codeine must not be withheld and the diet should con- tain some carbohydrates, as too Long and too strict exclusion of this food favors acetonuria. If the amount of sugar in the blood increases while that in the urine diminishes, sodium bicarbonate should be given at once intravenously. Neuritis is a frequenl complication in diabetic patients. In ad- dition to making every effort to eradicate the sugar from the blood, massage and electrical stimulation is here indicated. Perforating ulcers which at times follow the neuritis are treated as in any other nicer; the font bathed frequently in warm water and kept elevated and exposed to an electric light which is contained within a screen which covers all. Gangrene has already been mentioned. Tu diabetics particular care must be observed not to get hot-water bottle burns. The limbs must be kept warm and the blood circulating freely by massage. If suf- ficient warmth can not be maintained by this method, the electric light treatment will prove an efficient means of combating the diffi- culty. If amputation is indicated, the rule of Gussenbauer 14 men- tioned above, must be carried out. Pruritis can be controlled by frequent bathings followed by a lo- tion composed of glycerin, tannic acid and sulphurous acid 1 ._. to one dram each to tl nm-e of distilled water. An ointment of 10 grams of menthol in an ounce of vaseline may be used instead. The treatment of localized infections of the skin such as boils, etc.. is discussed elsewhere (q. v. . Other complications such as albumi- nuria, digestive disturbances, etc.. are treated by trying to eliminate the cause of the diabetes The most important and most serious of the complications of dia- betes is coma. Three types have been recognized: 21 Kussmaul's "air hunger" type or dyspneic coma is the most frequent of the three. There are usually premonitory symptoms of lassitude, headache, epi- gastric pain and occasional vomiting. The patient becomes restless, excited, and his speech gets thick and finally incoherent. The senses grow duller and duller and he eventually lapses into deep coma. The sufferer becomes dyspneic, at first inspiration is affected, later expira- DIABETES IN SURGERY 245 tiou and then the respiration becomes stertorous. The respiration is usually regular and not increased, but is very noisy, being heard a considerable distance. The circumference of the chest greatly in- creases with each inspiratory effort, this demand for oxygen being the reason for the name ' ' air hunger. ' ' The pulse becomes fast, small in volume, and of low tension. The breath has a fruity odor, the urine is loaded with acetone and all kinds of casts associated with albumin and there is general cyanosis. Death usually occurs within forty-eight to seventy-two hours. The alcoholic form begins with headache and symptoms suggesting alcoholic intoxication, the speech is thick, the pulse rapid and the patient soon goes into coma, without any distressing respiratory symp- toms. Diabetic collapse which is sometimes noted begins suddenly. The patient complains of great weakness which is followed by drowsiness. The face becomes livid, the lips blue and the extremities cold; the pulse which is threadlike is around 130 to the minute, the respirations are shallow, slightly quickened, but not dyspneic. The drowsiness de- velops into sleep which deepens into coma in which the patient dies ; there is no fruity odor to the breath, no acetone or diacetic acid in the urine. The collapse is believed to be due to heart failure induced by myocardial changes. The cause of diabetic coma is attributed by Huchard, Kirstein, Corsuda and others to an acid poisoning. These acids though present in the normal blood are neutralized as has been discussed in the chap- ter on acidosis. In this condition, however, the acids become so increased in amount that neutralization is impossible and the blood, being unable to carry out its functions, coma develops. When actual symptoms of coma have set in. the treatment is almost hopeless, and the rule that prevention is better than cure is nowhere better illustrated than in this complication. Intravenous injection of a liter of I per cent sodium bicarbonate solution is used after 200 to 400 c.c. blood have been removed: in addition subcutaneous infusion of 2 per cent sodium bicarbonate may be employed. Continuous proctoclysis of 2 per cent glucose solution in tap water should be kept up. Large quantities of milk should be given by mouth at least 500 to 1000 c.c. to which 100 grams of levu- lose are added, being used in 24 hours. Alkalies should be pushed until the urine is made alkaline. This, however, is hardly possible according to most observers. The temporary results are often encour- aging, the respiration becomes more quiet and the patient may even regain consciousness. But in the cases which have been reported 246 AFTER-TREATMENT OF SURGICAL PATIENTS there was a recurrence of the coma in a few hours and death occurred in less than two days. The treatment of diabetic collapse is the same as that carried out in shock (q. v.), which if persisted in usually prevents a fatal result. Bibliography iVerneuil: Diabete e1 traumatism^ Bull, et mem Soc. de Chir. de Paris, 1884, p. 373. 2Smith and Durham: Guy's Hosp. Sept., 1892, xlix, 343. sEedard: Bull, de l'Acad. de med., Paris, 1894, series 3, xxxii. ues from the mouth. The pulse gets rapid, weal; and irregular, while Cheyne-Stokes ' respira- tion is the rule. Incontinence of feces and urine may be prevent during the attack-. After a \'<'w minutes the muscles become relaxed, the patient takes a deep breath, and after a short period in which he is dazed, will awaken wondering what has happened. If however, he was in a stupor before the convulsion, sleep, stupor or deep coma will follow. The treatment is based upon the assumption that the poison which is at work is a nitrogenous produd which fails to be properly excreted by the kidney-. In such eases a diet suitable to this particular con- dition lsas usually already been carried out. Active elimination through the kidneys, bowels, and skin is the best means we have \'.rr the combating of this condition. Water must be forced as described under anuria and at all times a liberal amount of alkali must be sup- plied, sodium bicarbonate and sodium citrate being most generally used under the skin or intravenous as a matter of course. (See Acidosis. While this treatment is being carried out the heart must be sup- NEPHRITIS, ANURIA, AND UREMIC COMA 253 ported with some preparation of digitalis, which is a diuretic as well as a cardiac stimulant, the amount depending upon the symptoms. Willson would employ lumbar puncture early in the course of uremia and repeatedly, if necessary, to accomplish the lowering of the systolic blood pressure. The good results obtained by him and others by this means very strikingly confirm Cathelin's 17 conclusions that there is a constant intercommunication between the blood circu- lation and the cerebrospinal fluid by means of lymph vessels. The following postdiospital instructions are handed to e\^ery high blood pressure patient by Dr. Stuart McGuire : 1S Your wound has healed and needs no further attention. From a surgical stand- point you are well. From a medical standpoint you still need observation and treatment. Your watchword should be "Moderation." This is not because you are an invalid, but to avoid becoming one. Go slowly. Moderation will serve you in the wear and tear of life like oil to a good machine. Work easily; exercise lightly. Shortness of breath is a signal to slow down. Be temperate in all indulgences. Avoid excitement; cut out worry. Eat sparingly— finish a little hungry rather than replete. Better five small meals than three large ones. Take meat not more than once clay, and sparingly then. No meat extracts. Limit salt. Highly seasoned foods are not desirable. Vegetables, fruits, bread, cereals, and milk should constitute your staple diet. Tea and coffee should be used moderately if at all. Your use of alcohol and tobacco should depend somewhat on your former habit. Decrease rather than increase. Drinking water should be neither limited nor forced. Keep the bowels open. Take Epsom or Carlsbad salts once or twice a week, if necessary, to make them a little free. Secure ample rest. Betire early and sleep late. Be a little lazy. Exercise regularly but not violently. Avoid straining at stool. Cold baths had better not be used. Warm or tepid water is preferable. Turkish baths should not be taken without the advice of your physician. He is fully acquainted Avith what has been done for you and what has been learned about you while you were at the hospital. You should consult him at reasonable intervals. Many men and women have done the best work of their lives, working under similar limitations. Flease report your condition at the end of three months, by mail. Tf you are doing well the information will help us. If you are not doing well, Ave may be able to help you. Bibliography iKemp: NeAv York Med. Jour., November, 1899, p. 732. ^Thompson: Brit. Med. Jour., 1900, i, 833. 3 Buxon and Levy: Ibid. ^Grondahl: Deutsch. med. Wchnschr., 1905, No. 25, p. 1005. 5 Allen: Local Anaesthesia, Philadelphia, 1914, W. B. Saunders Co. 254 AFTER-TREATMENT OF SURGICAL PATIENTS eGwathrney: Anaesthesia, New York, 1914, D. Appletou & Co. 7Rathery and Saison: Compt. rend. Soe. de biol., 1910, i, 18. sThompson : Brit, Med. Jour., March, 1906. oGrube: Arch. f. d. ges. Physiol., cxxxviii, 601. loThomas: Journal-Lancet, 1915, xxxv, 667 uBasham: Tr. West. Surg. Assn., Denver, December, 1914. i^Da Costa : Modern Surgery, Philadelphia, 1914, W. B. Saunders Co., p. 1291. isEdebohls: Med. Eec, New York, December, 1901. i4Tyson: Med. Eec, New York, July, 1911. isErtzbisehoff, Arch. Generales de Chir., April, 1908. iGWillson : Jour. Am. Med. Assn., July, 1905. i7Cathelin, Presse med., 1903, iii, No. 90. isMcGuire: Southern Med. Jour., 1916, ix, 251. CHAPTER XXXI BACTEREMIA (GENERAL SEPTIC INFECTION) By 0. F. McKittrick, St. Louis, Mo. The entry of pathogenic bacteria into the blood stream, followed by their growth and proliferation, is one of the most unfortunate in- cidences which may arise during a surgical convalescence. It is in- deed a serious complication, one which sometimes causes a fatal ter- mination after an otherwise favorable prognosis. The term bacteriemia probably more clearly defines the true nature of the disease than the older appellations, septicemia or sepsis, which were used during the earliest periods to designate this condition. It is common knowledge that bacteria are present in the mouth, nose, upper air passages, gastrointestinal tract in all animals, where they are constantly brought by the air, food and drink. They are also found on the skin, about the hair, and within the sweat and se- baceous glands. The urogenital tracts of men and animals also pre- sent their goodly share of these microorganisms. Despite the con- tinued presence of the bacteria on the external and internal surfaces of the body invasion of the mucous and cutaneous covering of same is not to any marked degree accomplished, which results in the tissues and the blood, lymph, etc., being practically sterile. 1 The lowering of the patient's resistance through operative proce- dure or by any other means invites the microorganisms to attack. Under these circumstances each of the anatomic regions named, be- comes in addition to the operative wound, a possible portal of entry. For its defense, the body possesses a "protective mechanism" which consists in the main both of mechanical and biological factors. 2 Bac- teria which are already present and have become active destructive agents through conditions mentioned above or through the occasional visit of microorganisms which are seen only under such circumstances, are met by the mechanical defense of the body first. These, however, are always active even under normal conditions, for example, the skin and mucous membranes, so long as they are intact, form the most efficient barriers the body presents. Mucous membranes are further aids in this respect in that they are, for the most part, situated in protected locations, and are in some instances reinforced with cilia, which materially assist in the mechanical defense. 3 The eye is pro- tected from infection by the mechanical factors involved in winking, 255 256 AFTER-TREATMENT OF SURGICAL PATIENTS while the lacrimal secretions carry away material which may have entered. In spite of the close proximity of the air and other agents which carry bacteria, the conjunctival sac is sterile in 69 per cent of the cases. 1 The respiratory tract, though intimately associated with air laden with bacteria, is practically sterile below the glottis as shown by Jundell. 5 Meltzer believes this is explained in part by the action of the cilia, which throw back the bacteria that may have passed the glottis, while those which even the cilia fail to stop, are taken care of by the lymph nodes in the vicinity. He cites the obser- vations of Loomis and of Pizzini who have found living tubercle ba- cilli in 40 per cent of peribronchial glands of patients possessed of nontubercnlons lungs. The further attempt of the body to eliminate as many as possible of the invaders is seen in the action of the various sphincters, which prevent, to a certain degree, the crowding of the individual cavities with bacteria. The tears, saliva, and mucus, etc., remove the microorganisms which pass the sphincter sentinels or else kill many through bactericidal powers.'' The number of saprophyt- ic and pathogenic bacteria which are present in the upper alimentary canal are but small indeed, compared to the myriads which infest the large intestine. While it is true most of these microorganisms are harmless and even useful as an aid to digestion, many are patho- genic but their deleterious influences are outweighed by the action of the nonpathogenic. The intestinal mucous membrane plays a most important role in keeping these bacteria confined, yet according to Adami, 7 many are brought into the system proper through the agency of leucocytes which are contained in the lymphoid tissue of the intes- tinal tract. He has shown that not only the lymph nodes of normal animals constantly afford cultures of bacteria, but also properly pre- pared organs, such as the liver, kidney, etc.. from these same animals will reveal pathogenic as well as nonpathogenic bacteria. s The net work of lymphat Lcs and lymph nodes'' throughout the body const itute another mechanical defence, too well known to require extended men- tion. The further action of the mechanical measures for defense is exemplified in the carrying out of the body, at least some of the in- fecting agents, by means of the secretions and excretions such as the bile, sweat, and urine. 1 " Cohnheim" considers the secretions of the body the chief agent of defense in removing the bacteria from the body, to which Meltzer does not agree. However, he says that it is a general consensus of opinion that the toxins which always accom- pany these infections are excreted freely through these channels. As to the biological defensive mechanism of the body, it has been shown repeatedly that if relatively virulent bacteria are introduced BACTERIEMIA 257 into the blood stream of a healthy animal within a comparatively short time, not only do they disappear from the blood, but also from the organs of the body as well. 12 However, a like number of the same microorganisms introduced into an animal with some necrotic lesion as shown by Cheesman and Meltzer 13 or even with chronic heart or kidney disease or other chronic ailment as shown by Flexner soon produce general bacteriemia and death. The power of the body fluids and living cells to kill and dispose of bacteria has been known for some time. 14 The alexins or "defen- sive proteins" which have been shown to possess marked bacterici- dal powers, are the most important defensive ingredient of the body fluids. The leucocytes are the cells most prominent in bacterial de- struction, though other cells of the mesodermal type are frequently actively engaged in this work. Through positive chemotaxis, the leu- cocytes are attracted to the invading bacteria, and overpowering them, finish the destruction through phagocytosis. The normal invasion of the body by these various bacteria, Meltzer believes to be beneficial ; he says it means an immunization only against larger numbers of these same bacteria during periods of lowered resistance. Probably he has sounded a great truth : viz.. constant immunization makes general septic infection a rare occur- rence. I feel that it applies especially well to postoperative cases. The microorganisms which most often incite septicemia are the Staphylococcus aureus or Streptococcus pyogenes or both. Less fre- quently the Staphylococcus albus. In some cases the colon bacillus or pneumococeus are causative factors. C4eneral infection, however, has followed the invasion of the blood current by the gonococcus, Micrococcus tatragenus. tetanus bacillus or Bacillus pyocyaneus. The condition may occur as a result of a general infection from any of the acute infectious diseases which can complicate a surgical convales- cence. In all cases of suspected septicemia, blood should be taken for ex- amination at the onset of the symptoms. If negative, it should be taken again in a few clays. The early observers along this line, much more frequently secured positive blood cultures than the later ob- servers. Welch 15 showed this was clue to faulty technic among the former class of men. He has demonstrated that the Staphylococcus albus is frequently, if not constantly, present in the deeper layers of the skin, and that it can not be destroyed by the ordinary methods of cutaneous disinfection. It is. therefore, necessary to secure the blood under aseptic precautions from a vein, preferably the median basilic. The blood is aspirated by a sterile glass syringe, 5 to 10 c.c. blood 258 AFTER-TREATMENT OF SURGICAL PATIENTS being taken. Five c.e. is immediately placed into agar tubes, kept fluid at 42 C. at the bedside. Half the number (eight) after being thoroughly mixed with the blood are slanted and cooled. The other four are plated. Bouillon tubes (two can also be inoculated with the same amount of blood. The material can now be incubated and in twenty-four hours or sooner, be examined. The prognosis must always be guarded, but it should be hopeful, 16 since so much depends upon the virulence of the infective bacteria and the resistance of the patient. Many other factors also come into play which on the whole, make the prognosis most unfavorabh pecially when the many possible complications are considered. The finding of the Staphylococcus albus in the blood is not particularly serious as Welch has pointed out and Bernheim, 17 Sittmann, Pe- truschky and others have reported eases which recovered when pure cultures of streptococci or staphylococci were found in the blood. Pneurnococci are particularly virulent, but cases recovering from this infection have also been recorded. 18 Symptoms. — The symptoms of this condition are varied but a typi- cal case would run about so. Usually on the third postoperative day. the temperature rises to 102 c or more. There are chilly sensations which may or may not be followed by chills. The patient may feel miserable. Sudden drafts or movements of the bed covers cause hot flushes. The patient i- vexed, irritable, and in many instances seri- ously concerned, as though he scented danger of no little importance. There is likely to be headache, nausea, pain in the limbs, back, or a general '•ache'* throughout the body. Thirst is pronounced, the mouth becomes dry, the lips parched, and the tongue coated. Resl ness and sleeplessness are marked. One of the distinguishing features of this disease is the prostration. Its extent depends, of course, upon the virulence of the infecting microorganism. As the case progresses, the fever is soon followed by a cold sweat during which the tempera- ture falls to subnormal at times. There are usually morning re- missions and evening exacerbations. The prostration increases from day to day. Vomiting is the rule. The appetite is destroyed and there may be diarrhea. The urine is scanty or may be suppressed. The temperature fluctuates as a rule, often rising very high just be- fore death. The pulse is fast, soft, small and easily compressible. In the aged, particularly, will be seen twitching of the muscles of the hands and feet subsultus tendinum) or twitching of other muscles over the body, while in children, convulsions are the rule. Delirium alternates with stupor, which final]}- develops into coma, and usually closes the scene. Toward the end. the facies become hippocratic, pre- BACTEREMIA 259 senting the characteristic hollow temples, pinched nose, sunken eyes, with the cold, clammy, leaden skin. In patients who live any length of time, there is great emaciation, loss of muscle tone, accompanied with pressure pains or toxic pains of neuritis or both together which cause the patient to cry out in agony. The operative wound, if it he the seat of infection, will present the cardinal symptoms of inflammation. But in many cases the focus of infection will not be in the operative wound. In such patients, the diagnosis may at first be overlooked. However, the history of the case and the physical examination in con- nection with the symptoms will decide the question even in the face of repeated negative blood cultures. The spleen and liver become enlarged, petechia are found here and there over the body, and the abdominal muscles are board like, if there be accompanying peritonitis. In patients who are overwhelmed with the disease, a leucocyte count will reveal a leucopenia. This is always in my experience a grave sign. In cases of good resistance, however, there will be a marked leucocytosis. Treatment. — The treatment first consists in draining and thor- oughly cleaning up the focus of infection if this is possible. After thoroughly opening and draining the wound, continuous irrigation with Dakin's fluid or a hypertonic salt solution is instituted as soon as bleeding from the operative procedure has stopped. The work must be done under local anesthesia. The patient should be isolated to prevent infection spreading throughout the hospital and every care exerted to ward off contamination of the attendants. The tem- perature is controlled by cool sponging of the body and an ice cap to the head. For the restlessness and general discomfort, gentle massage and alcohol rubs are in order. The extremities must be kept warm, even if wrapping in cotton batting is necessary in addition to the hot-water bottles. The vomiting is controlled by the tube, one which can be left in continuously if nausea and vomiting are particu- larly bad. Let the patient assume any position which is comfortable. Keep up continuous hypodermoclysis, of 1,000 c.c. every 6 hours, using plain freshly distilled sterile water or salt solution. The lungs must be watched for edema in which event, the water is discontinued and atropine sulphate, % 50 grain, is given hypodermically every three hours until the danger signs disappear. Use 3 per cent glucose per rectum if the stomach can not tolerate food. If one should be so fortunate as to retain nourishment, frequent feedings of the most nourishing food should be given. Under any circumstances, give continuous proctoclysis, employing plain tap water in which has been 260 AFTER-TREATMENT OP SURGICAL PATIENTS placed 60 grains of sodium bicarbonate to the quart. The heart should be stimulated with some form of digitalis which is also a diuretic. If the condition becomes chronic, the patient is given some good tonic and exposed as much as possible to sunlight and air. He should be treated in this respect the same as are cases of pneumonia, bron- chitis, etc. I have derived no benefit from vaccines or sera of any bind in acute cases though i have no desire to discourage their use in subacul ■ chronic conditions. One striking resull was recently reported by Freemen in the treatment of chronic pyoeyaneus infection. Bibliography iDelafield and Prudden: Text Book of Pathology, New York. 1914, Win. Wood & Co. 2Meltzer: Tr. Congress, Am. Phys. and Surg., I! v, li'. sBowditch: Boston Med. and Surg. Jour., 1876. iLochmitz: Arch. i. Angenh., xxx. sJundell: Arch. E. Physiol., 1898. sMctehnikoff : immunity in Infectious Diseases, Trans., 1905. "\i!;niii: Jour. Am. Med. Assn., December, L899. -Aihimi: Brit. Med. Jour., January, 1914. oManfredi: Virchows Arch. f. path. Anat., 1899, civ, 335. loFuetterer: Berl. klin. Wchnschr., L893, No. 3. nCohnheim: Quoted by Mel1 i ■ I ". u x + < > 1 1 and Torrey: Jinn. Med. Research, L906, sv, 5. i •'•■( 'liccsin.-ni and Meltzer: .lour. Exper. Med., iii, p. 533. L4Werigo: Am. Pasteur, 1894, viii. i5Welch: Tr. Cong. Am. Phys. and Surgs., 1891, vii, 1. i6Smith: Keen's System of Surgery, i. i7Bernheim: Jahrb. f. Kinderh., 1896, xliii, 208. iswhite: Jour. Exper. Med., 1899, iv, 125. CHAPTER XXXII POSTOPERATIVE TETANUS By 0. F. McKittrick, St. Louis, Mo. Tetanus occasionally follows operations even in this day of modern surgical asepsis and technic. It is a disease, infectious in nature, and one characterized by tonic and clonic convulsion, the muscles of the jaw being first affected. The process extends to the trunk and then to the extremities, finally involving every voluntary muscle in the body. As a postoperative complication, Wilms 1 found five cases after herniotomy during the years from 1868 to 1879'. In 1886, Olshau- sen 2 collected 4.9 cases following ovariotomy. Four years later Phil- iyss 3 added 61 more cases complicating this operation, which he had collected during the years preceding 1890. In 1891, Brunner 4 re- ported this condition appearing after a goiter operation. Five years later Santos-Fernandez 3 observed tetanus in one patient after enu- cleation of the eye. In 1897, Yon Cackovic 6 collected 60 cases and Rose 7 during the same year collected 58 cases of tetanus after laparot- omies. In 1901, Picherrin s collected 98 cases after operations, upon the female organs and seven years later, Zacharias 9 added 72 cases more. Peterson 10 in 1910, reported 19 cases which he had collected during the last twenty years. Previous to the year 1890, the reported instances of tetanus after op- erations occurred more frequently after laparotomies ; more than half of these being ovariotomies. This date, however, pretty nearly marks the beginning of the aseptic area and since that time, there has been a marked decrease in the instance of this complication. However, the ratio between the cases of tetanus in which the peritoneal cavity was opened and those in which this portion of the body was not in- volved, is about the same now as during the preantiseptic period ac- cording to Peterson. The instance of the disease is more frequent in some localities than in others, but it may occur in patients situated on any part of the globe, occurring in every race, and especially in the negro. The age and the sex of the patient have no influence in the disease. Accord- ing to Anders 11 tetanus in. the United States is most prevalent in Pennsylvania, northern New York, New Jersey, Long Island, Vir- 261 262 AFTER-TREATMENT OF SURGICAL PATIENTS giuia, Georgia, and southern Louisiana. It is also more frequently met in Indiana, Illinois, and southern California than in the rest of the states of the Union. Tetanus itself has long been known. During the age of Hippocra- tes, the condition was recognized, and at that early date, the disease was considered to have a predilection for the nervous system; how- ever, no progress was made in the study of this condition until the latter part of the nineteenth century when Sternberg 12 showed that he could produce the symptoms of the disease in animals by inject- ing dirty water. In 1884 13 these same symptoms were caused in ani- mals by injecting pus from a patient suffering from tetanus. Nicolaier 14 during the same year described the tetanus bacillus, Fig. 37. — The tetanus bacillus. but it was not until 5 years later that a pure culture of this micro- organism was obtained by Kitasato. 13 The tetanus bacillus 10 is long, slender, and mobile, often appearing in pairs; a spore develops at one end which gives it a club-shaped appearance (Fig. 37). It stains readily with ordinary stains, grows at room temperature in the regular culture media, is strictly anaero- bic, and develops rapidly in an atmosphere of hydrogen. The ba- cillus is easily killed with ordinary antiseptics, but the spores, unlike Hie bacillus, are very resistant to chemical disinfectants, to heat, or to drying. According to most observers, exposure to n temperature of 100° C. for 5 minutes will kill the spores; or a 1:1000 bichloride solution will destroy the spores in 10 minutes; a 1 per cent silver POSTOPERATIVE TETANUS 263 nitrate solution in 1 minute, or 1 :1000 solution of the same in 5 minutes. The bacilli are very widely distributed, their normal habitat being in manure, garden soil, dust of the streets, walls, etc., but especially in the intestinal tract of animals. As found here, their virulence is most marked, which, however, diminishes in proportion to the length of time they are outside the intestines. 17 The sources of infection in postoperative cases according to Speed 18 are: the operator's hands, the instruments, dressings, air, ligatures, or the patient himself. Of these avenues of infection, all are so evident that discussion is probably unwarranted, save of the last two, which have until lately, been obscure points. From the above, it is not surprising that catgut, which is made from the intestines of animals, should be a source of tetanus infec- tion. There is good proof on both sides of this question, but with the development of newer and better methods for sterilization, smaller size catgut is being used, and the danger from this source is more and more becoming lessened. Richardson 19 collected 21 cases of post- operative tetanus in which catgut was considered at fault. It was thought that many of these cases came from localities in England where tetanic sheep were known to be and it was naturally supposed that the sheep gut caused the infection. Later investigation proved that the catgut had all come from Germany and that the catgut which was examined from 14 of the patients, contained no bacilli. In 19 of the 21 cases collected by Richardson, the operation was a laparot- omy and the bowel was handled more than usual or else sutured. Richardson mentions in this same article the experience of one oper- ator who performed five abdominal operations one morning and used in each case the same preparation of catgut. Two patients developed tetanus, but the other three escaped. On the other hand in support of the view that catgut is the source of infection, Peterson, after extensive experimentation with catgut, in order to prevent just such a calamity after a postoperative case of his own stated: "I fear that many operators who report cases of tetanus after clean operations have fallen into the same error as I in their attempts to absolve the catgut from any part in the causation of the disease. At first sight it seems reasonable to say it could not have been the catgut, because the same material was employed in other cases with no bad results. Kuhn, however, has shown the fal- lacy of such an argument. He asserts that catgut is made from the intestines of sheep which exist under different conditions and vary greatly in health. Every catgut thread contains fibers from four or 2,64: AFTER-TREATMENT OP SURGICAL PATIENTS five different sheep. Just one of these fibers may contain the tetanus bacillus, while the others may be free from this particular germ. He further states that the sanitary conditions of the slaughter houses and factories from which the catgut comes are notoriously bad, ex- posing the raw material to all kinds of contamination." In June, 1909, Matas 20 reported two cases of postoperative tetanus following the ingestion of uncooked vegetables. He directed atten- tion to the danger of this infection even after clean operations on patients in whom the wound may become contaminated with fecal material. This condition may accompany operations in the region of the genitourinary organs of cither sex. the sacrococcygeal or ano- rectal regions, operations involving the inner surfaces of the thigh, legs or any o1 her region of t lie body which may come in contact with fecal discharge. Matas' ideas <• ierning the origin of tetanus infection have been supported by many observers. Among those 1 may be mentioned Speed, who has gone a step further, however, in that he has promul- gated a theory based on his own observations and on the experimental and biological work which has been done on this subject; viz., that the few instances of postoperative tetanus which develop in spite of every preventive means are due to tetanus carriers. He thinks it very probable thai some human beings carry and excrete the organism for long periods of time. Considering such individuals ;is surgical patients, he s;iys, "Their greatesl danger is to themselves because after operative procedures which permit fecal contamination of the wound, tetanus may be inaugurated. This is particularly true of ab- dominal operations where the gul is bruised or roughly handled and opportunity for tetanus development ensues in accordance with the pathologic requirements." Formerly it was taughl that tetanus was not an infection in the sense that the bacilli entered the blood stream or any organ. The toxins produced by the growth and proliferation of the organisms which were present within the wound were alone considered the agents which produced the symptoms. During recent years, however, the bacilli have been found in lymph glands, 21 in the blood stream, 22 in muscles, in the spinal canal, in nerves and even the brain 23 itself. of patieids infected with tetanus. Positive cultures of the tetanus bacillus have been grown on several occasions from the blood of pa- tients suffering from this disease. It mattered little whether the blood was taken at the site of the infection or from some other region of the body. Sclinitxler-' obtained the bacilli from a lymph gland as well as from the blood stream and succeeded in getting positive POSTOPERATIVE TETANUS 265 results by animal inoculation from both these sources. According to Meyer and Ransom 25 the toxin produced by the tetanus bacilli reaches the spinal cord through the agency of the motor nerves only, but Jacobson and Pease 26 state that other nerves are involved as well, since the toxin is present in the blood and lymph as well as in the axis cylinders of the motor nerves which are especially affected be- cause in the lymph spaces their bared endings are particularly ex- posed to the poison. Once in the cord the motor cells are attacked, pathologic changes being produced as noted in other infections and the toxin ascends the motor tracts to the medullary centers where further destruction of the nervous tissue is consummated. Meyer and Ransom further state that the basis of this disease is a spreading irri- tation of the motor neurones of the cord, which produce the tonic contractions of the muscles, and an extreme reflex excitability due to poisoning of the sensory neurones which causes the clonic convulsive seizures. The symptoms of this dreaded disease appear within ten days in four-fifths of the postoperative cases reported by Peterson as col- lected since 1890. In the remaining one-fifth, the initial symptoms did not appear until the eleventh to the twenty-second day. The usual incubation period of the tetanus bacillus is from 3 to 5 days. It is considered that the shorter the incubation period the more in- tense will be the symptoms and the quicker will be the fatal termina- tion of the disease. Elvler, 27 who had contracted the disease while operating on an infected patient, lived to tell of the symptoms which he experienced. He stated that the earliest manifestations of it were very short and transient in nature, and were attributed to the healing wound. This felt hot and uncomfortable and darting pains were noted before any swelling or redness occurred. Among other important symptoms he mentioned headache, sleeplessness, restlessness, difficult respiration, dizziness, chilly sensations, with frequent and difficult urination. Later the symptoms assumed the form which have been considered characteristic of the malady. Stiffness of the jaw is most commonly first to be noted by the pa- tient. This is very soon followed by stiffness of the neck. As the disease progresses, other muscles become involved until finally every voluntary muscle in the body is stimulated to tonic contracture. Any sensory stimulation such as drafts, sounds, lights, even the touching of the bed or the contact of the bed covers will cause clonic seizures in addition to the tonic convulsions from which the patient is already suffering. There is constipation, and in some instances retention 266 AFTER-TREATMENT OF SURGICAL PATIENTS of urine clue to sphincter spasm. Irritation of feces or urine or at- tempts at deglutition will bring on sudden fearful clonic convulsions in which he may injure himself. Teeth are frequently broken and muscles ruptured during the hardest spells. Naturally such a dis- ease will cause the patient to assume all sorts of hideous postures (Fig. 38) which are temporarily exaggerated during the clonic con- vulsions, but probably the worst feature of the whole picture is the clearness of mind which the patients possess throughout the entire period of suffering, even until the end. Death occurs usually within four days in patients whose symptoms appeared within ten days of the operation, but one case reported by Peterson lived twenty-five days. The mortality as shown by a study of his cases is 85 per cent. Treatment. — The treatment of this disease first seriously concerns itself with preventive measures undertaken to offset such unfortunate * tnus. occurrences. Matas recommends that patients about to undergo op- erations which involve areas subject to fecal contamination should abstain from such foods as vegetables or fruits which have not been thoroughly cooked. In addition, fret' catharsis three or four days before should be instituted. In cases where such preparation can not be made or in patients living in Idealities where the disease is es- pecially prevalent, Matas advises a prophylactic dose of antitoxin. If, in spite of such treatment the symptoms appear, or even if there is a suspicion of such a condition, the patient should be moved into a darkened room which is well ventilated. I'vrr from the ordinary noises of an institution, and cwvy effort should be put forth to ex- clude possible sources of peripheral irritation. At once, administer pi to 30 e.c. of antitoxin subcutaneously near the draining wound if one is present; but if the fluid scrum be not available,. 1 gram of POSTOPERATIVE TETANUS 267 the powder dissolved in each 10 c.e. sterile water may be used in- stead. Such a close should be given every 6 or 8 hours until there is improvement. Then half of this amount is administered and as the symptoms abate the amount is still further cut clown and the in- terval of administration increased. Give plenty of soft solid or liquid foods with liberal amounts of al- kalies. If deglutition causes severe pain or brings on convulsions, feed the patient per rectum. It may be possible to partially anesthe- tize the pharynx with cocaine. After this measure, food can be intro- duced through a stomach or nasal tube. If the wound has healed, particularly one about the extremities, it should be opened widely and large cigarette or rubber drains placed in every angle. The wound is then washed out with 1 :1000 silver ni- trate solution, or tincture of iodine which has been diluted to one- third its strength with alcohol. After a few hours when the bleeding stops, remove the dressing and irrigate continuously with Dakin's fluid, leaving only a few layers of gauze over the wound to assist in caring for the drainage. The affected portion is then placed under a cradle which supports several electric light bulbs or else exposed di- rectly to the sun's rays. Careful attention should be given the bowels, as detailed under the headings "cathartics" and "enemas." Water freely given by mouth, by rectum or under the skin will greatly aid urination. Sleep and rest is secured by giving per rectum chloral hydrate or chloretone in warm olive oil; 30 grains of the former or 60 grains of the latter, may be given at one dose. It may be necessary to em- ploy some form of opium to get the desired rest and sleep. In violent cases of tetanus, 40 to 50 c.c. of antitoxin is given as above. "Walther 28 has recently noted that closes as large as 760 c.c. have been administered within twelve hours. "He recommends intra- spinous injection which he claims gives better and quicker results and much smaller amounts of the serum are needed. Following the injection, he places the patient with the head clown for a short period of time. Magnesium sulphate may be employed for the constant mus- cular contractions which will soon exhaust the patient unless relieved. Burge 29 has recently reviewed the work on this chemical which has been shown to be an efficient agent for stopping pain and producing sleep. Kocher 30 has reported good results from its use. He employs 10 c.c. of a 15 per cent solution of the chemically pure salt. If the severity of the case warrants it, 2 to 5 c.c. of a 25 per cent solution are used, repeated two to four times during the twenty-four hours. It is usually given subcutaneously, but if quick results are imperative, 268 AFTER-TREATMENT OF SURGICAL PATIENTS this dose may be given intravenously or intraspinously. Calcium chloride, an antagonist of magnesium may be administered to pa- tients receiving- this treatment, which endangers the respiratory cen- ter at times. Magnesium sulphate should be given only to the point of controlling' the convulsions, though some stiffness of the muscles will still he present. Kocher says that so long as this rule is followed, the respiratory center will not he paralyzed. The drug should not he given in quantities in excess of 1% grains of magnesium sulphate to 2\o pounds of body weight during the twenty-four hours. Chil- dren, especially, do not take kindly to this treatment, and particular care must be observed in its use among them. Patients in whom satisfactory results are not obtained with the antitoxin, chloral, ehloretone and magnesium sulphate, should ac- cording to Hercher 31 he given 15 c.e. of ether in 750 c.c. normal salt. The dose can he repeated as often as indications warrant. Bibliography iWilms: Quoted bj Speed: Surg., Gynec. ami Obst., 1916, xxii. 147. iOlshausen: Eandb. f. Frauenkrankheiten, L886. sPhillyss: Med. Chir. Tr., 1892, bcxv, 135. *Brunner: Beitr. /.. klin. Chir., L891, xii. Santos-Fernandez: Rev. gen. d'ophth., 1896. 6Von Cackovic: Centralbl. .1. Chir., 1897, xxiv, 728. "Rnsr: Der Starrkrampf beim Menschen Deutseh. Chir., Lief s . L897. sPieherrin: Jour. Med. de Bordeaux, 1901, p. 52. ''Zarliai ias : Miinchen. med. Wehnschr., 1908. ^Peterson: Jour. Am. Med. Assn., 1910, liv, 11". nAnders: Jour. Am. Med. Assn.. July, 1905. aberg: Manual of Bacteriology, New York, Wm. Wood & Co. I arle ami Rattone-: Grior della R.Acad, di Med. di. Torino, 1884. L*Nicolaier: Deutseh. Med. Wehnschr., 1884. i5Kitasato: [bid., 1889, xv, 635. isDelafield ami Prudden: Text Booh of Pathology, 1914, New Fork, Wm. Won. I & Co., p. 286. ' •Snurnni : Verhandb. d. X. internat. Med. Cong., Berlin, 1890. isSpeed: Surg., Gynec. ami Obst., 1916, xxii, 117. isRichardson : Brit. Med. Jour., 1909, i. 948. ■Mains. Tr. Am. Surg. Assn., wii, 10. 'I'urtrr and Richardson: Boston Med. ami Surg. Jour., December, 1909. 22Reinhardt: Centralbl. i. Bakteriol., Ixix. 583. 23Haegler: Beitr. z. klin. Chir., 1889, \. No. 1. -'S.-imit/.lci : Centralbl. t Bakteriol., xiii. »i7«.'. Meyer ami Ransom: Arch, exper, Path. u. Pharmakol., 1903. 26 Jacobson and Pease: Ann. Surg., September, 1906. 27Elvler: Quoted by Da Costa, Modern Surgery, 1914, Philadelphia, W. I;. Saui dcr- Co.. p. 206. 28Walther: Bull, el mem. Soe. ^\r Chir. de Paris, 1915, \li. 1904, 29Burge: Jahresb. f. Arztl. Portbild., 1915, \i. .".. "Kocher: A.bstr. Intermit. Jour. Surg., l!»lii. xxii. 31 Hercher: Miinchen. med. Wehnschr., 1915, lxii, lli'ii. CHAPTER XXXIII GAS BACILLUS INFECTION By 0. F. McKittrick, St. Louis, Mo. Since the days of Lister, gas bacillus infection has so decreased in frequency as to be considered now as one of the rare complications following surgical procedures. The condition was described as early as 1853, by Maisonneuve, 1 who gave it the name of "gangrene foud- royante." Pirogoff 2 in writing on this same subject in 1864, consid- ered the affliction an "acute gangrenous edema." Later on it was re- vealed that the disease could be transmitted, but it was not until 1891 that the cause of this malady was made known through the dis- covery of the Bacillus aerogenes capsulatus by Welch. 3 Two years later, Fraenkel 4 described the organism which produced "gas phleg- mon" which proved to be the same as the one described by Welch. Further investigation by others demonstrated this microorganism in wounds characterized by the formation of gas, and the identity of the bacterium became established. Nothing of material importance has been added to the work of Welch on this subject, except Dunham's discovery in 1897, that this microorganism produces spores. Bacillus aerogenes capsulatus (gas bacillus) is rather large, short, thick and sometimes curved with rounded ends. It grows in the ordi- nary media at room or body temperature only under strict anaerobic conditions. In this respect, it resembles the tetanus bacillus. It is a spore-forming, nonmobile organism which takes the ordinary aniline dye stains and is Gram-positive. It is often encapsulated and some- times forms chains. It is readily killed by exposure to 58° C. tem- perature for ten minutes. The growth of the bacillus brings about a splitting of the protein or sugar which results in a gas being formed consisting mostly of hydrogen ; carbon dioxide and nitrogen are also present. It burns with a pale blue flame. The natural habitats of the organism are the soil, and the intestinal tract of animals. It has been repeatedly demonstrated in the feces of man. Infection with this microorganism in postoperative cases is rare, yet it occurs often enough to demand attention. It most frequently follows emergency operations on patients with crushing injuries, par- ticularly of the lower extremities. Coal miners, trainmen, soldiers and laborers especially exposed to the soil are more apt to be the vic- 269 270 AFTER-TRF.ATMI'.XT OF SUttGICAL I'ATII'.XTS tims of this malady than the regular hospital operative patient. Swan, 5 Bolby and Rowlands'' and many others have recently reported the condition following all sorts of injuries and operations necessitated by the same, in the great World War. In every case, however, the tissues were either badly bruised or else contaminated with dirt, or both. Tissues whose resistance has been lowered by contusion or de- prived of the normal blood supply have been shown by all investi- gators on the subject to be especially good media for the growth and development of the Bacillus aerogenes capsulatus. Operations about the groins, inner portions of the thighs, upon the male or female uro- genital organs, in the anosacral region, or in any portion of the body where fecal contamination is possible, may result in this infection. It has followed appendectomy and other operations upon the gastro- intestinal tract. Curettage following abortions has also been compli- cated by this disease. Of the cases reported by Blake and Lahey 7 three were crushing injuries to the extremities, four were compound fractures, and one a laceration of the scalp. In each instance the wounds were contaminated with soil. One followed opening of a deep gluteal abscess and one occurred after amputation of the leg in a diabetic. In 1011, Hewitt^ reported ten more cases. These were the result either of wounds becoming contaminated with dirt and necessitating operation or the infection developed in several trauma- tized wounds which later required operation. Gilpatrick 9 reported this complication after a hemorrhoid operation with opening of an ischiorectal abscess. Hewitt says the rarity of this infection in such eases is due to leaving the wound Avide open, the bacillus being unable to grow in the presence of oxygen which the air contains. He further states that such infections do not develop in very many eases of soil contaminated wounds, hence it would seem that purification of tissue and injured blood supply favor bacillus aerogenes infection owing to weak or absent resistance. The presence of this microorganism on amputation slumps without infection in other reported eases, he says, bears out his conclusions. Recently. Dudgeon 10 stated that gas gangrene is produced by this infection alone in "especially abnormal tissue." Otherwise ordinary suppura- tion will result. He obtained cultures of the bacillus from cases of peritonitis, puerperal fever, bone abscess and cystitis, in which no evidence of this condition was apparent. The symptoms are those of a severe toxemia. In the milder eases, there is a slight rise of temperature and pulse, but the patient appears much more ill than the physical examination denotes. The wound presents a dark, thiekish, bloody discharge in which a few bubbles of GAS BACILLUS INFECTION 271 gas may be present. The wound is not red, but appears to be covered with a decomposing black blood clot from which gas bubbles may be pressed. There is a vile, penetrating, pungent odor as of stagnant blood enclosed in a cavity, which very soon will permeate a whole hospital ward. The immediately surrounding skin is brown in color, and looks ecchymotic except for the fact that there is no mottling. In more severe types of the infection, the patient not only looks sick, but on examination, will instantly convince one that he is se- riously ill. The temperature is high (104° F.) with a rapid pulse and respiration and before the dressings are removed from the wound, the odor will man}' times confirm suspicions as to the real nature of the trouble. The incubation period of the bacteria being only twenty-four hours, the disease progresses rapidly. "Within a few hours, the wound will look as though a hot iron has been seared over its surface, being dry and black, or it may present a grayish slough. 11 At the end of twenty-four hours, swelling is very marked, the skin is drawn tense and becomes shiny. Palpation elicits crepitus due to the gas within the tissues. At the end of forty-eight hours, if the pa- tient lives this long, the face assumes a "greenish pallor," the ex- pression is anxious but he rarely complains of any pain. The nature of the infection produces necrosis and with the pressure of the gas, nerve conductivity is, no doubt, seriously interfered with, this ex- plaining the absence of pain. s The temperature and pulse remain high until the end. This is probably due to the additional infection with other microorganisms. The gas dissects along the fascial planes and follows the lines of least resistance. The tendons, ligaments and fascia resist the infec- tion, but the injured muscle certainly furnishes good media for the rapid growth of the bacillus, hence pulpifies early. The lymph glands are rarely affected, probably due to the rapidity of the disease. Nausea and vomiting occur late, as does the delirium which is an indication of a general infection. Recovery is not the rule after the third day. The mortality has gone as high as 90 per cent among soldiers in some past wars. Recently, Gamble 12 reported 45.5 per cent mortality in a small number of patients. Bell insists that it should be nil if treatment is instituted early enough. The treatment for this condition starts at the time the patient is received if the nature of the case causes suspicion of such a compli- cation developing. The wound must be thoroughly cleansed of all foreign particles. In these cases of crushing injuries or fractures contaminated by dirt or grease to prevent this infection wide and deep 272 AFTER-TREATMENT OF SURGICAL PATIENTS incisions should extend through the muscles and down to the bone; large rubber or cigarette drains should be placed in every one of them; each wound should be continuously irrigated with Dakin's fluid, or a hypertonic sodium chloride solution. A cradle can be placed over the parts and the wound exposed to the rays of electric light bulbs. At the first sign of the disease, at once start a stream of oxygen into every recess of the wound by means of catheters, in addition to the treatment already outlined. If in spite of the oxygen and the con- tinuous irrigation, the disease progresses, there is nothing left, ac- cording to most writers, but to amputate the extremity high up (for it will most likely be in an extremity), and keep the stump open. maintaining the stream of oxygen. Amputation is still a debatable procedure in this disease as it set ins to me. At the St. Louis City Hospital in 1910-1912 several patients were lost after amputation, then a number of successes were scored under rather similar circumstances where no amputation was done. Bibliography LMaisonneuve : Gaz. med. de I'aiis. Is.".:;, p. 592. apirogoff. Grundziige der allgemeinem Kriegschr., Leipzig, 1864, p. 867. 'Welch and Nuttall: Bull. Johns Hopkins Hosp., 1892, Hi, p. 81. tFraenkel: Uber Gasphlehmonen, Eamburg and Leipzig, 1893. -Sw.-in : Lancet, London, 1914, ii, 1 l'il . 6Bolby ;iikI Rowlands: Lancet, London, 1!>14. ii, 1161. "Blake ami Lahev: Jour. Am. Med. Assn.. 1910, liv. 1671. sHewitt: Jour. Am. Med. A.ssn., 1911, lvi. 960. aGilpatrick: Boston Med. ami Surg. Jour., 1910, clxii, 741. icDudgeon: Lancet, London, 1914, ii. L385. uBell: British Med. Jour., May 1.1. 1915, p. 843. ^Gamble: Internat. Join-. Surg., 1916, xxviii, t02. CHAPTER XXXIV POSTOPERATIVE PNEUMONIA By 0. F. McKittrick, St. Louis, Mo. The occurrence of pneumonia in postoperative patients has always been considered a serious complication, probably, one which the sur- geon considers first, and measures taken to prevent this one accident alone may be seen during the course of operation in any hospital on the globe. Experience has long ago taught that a disease, so destructive to life, and yet one so easily preventable, commands serious attention. In spite of the modern methods of operating and the infinite care exhibited in surgical patients, in order to prevent the disease, there are still evidences that more can be done to further decrease its in- stance. The efforts already put forth have cut the number of cases reported to a small item compared to the many thousands of individ- uals who are yearly subjected to the knife. Statistics are of little value, but may give some idea of the frequency with which the condi- tion occurs in the hands of the very best surgeons. Beckman 1 found pneumonia 27 times in reviewing the complications which occurred in 6.825 surgical operations at the Mayo Clinic dur- ing the year 1913. Risley, 2 in 1910, reported 15 cases of pneumonia occurring after 1000 consecutive laparotomies at the Massachusetts General Hospital, and 5 cases, after 920 other operations, not lapa- rotomies, on various portions of the body. Quite recently, Whipple 3 collected 42 cases out of 1002 operations performed at the Presbyte- rian Hospital. Booth 4 found 23 cases out of 2612 performed at the Roosevelt Hospital; Bancroft 5 discovered 15 cases out of 1413 op- erations performed at the New York City Hospital; and Derby 6 col- lected 11 cases out of 3120 operations performed at the St. Luke's Hospital, all in Xew York City. The percentage is therefore very small, ranging from .04 per cent reported by Beckman, to 2.2 per cent reported by Whipple. The figures are indeed low, and probably do not present the true incidence of the condition, since it is to be remembered that the opera- tions were performed under ideal conditions. Whipple after making careful clinical, as well as bacteriologic ob- servations, concluded that the cases of pneumonia should be divided 2/4 AFTER-TREATMEXT OF SURGICAL PATIENTS into three groups: Group I contains those patients who were in a good physical condition before the operation, and in whom the disease developed from the first to the fourth postoperative day. lie found that 79 per cent of the cases fell into this group. Group II is made up of patients who came to operation with pneu- mococcus infection in other parts of the body, excluding the lungs. This group claimed 7 per cent of his cases. Group III included those patients who developed pneumonia (a) as a terminal complication; (b) in the presence of other severe in- fections, (c) or in the feebler senile patients in whom this disease appeared in the late days of the surgical convalescence. It has been generally conceded that bronchopneumonia is most often the type which is seen in these cases. Beckman, however, showed that 15 of his eases were lobar pneumonia. Derby stated u pages 2!)4 and 732. Bibliography iBeckman: Surg., Gynec. ami Obst., 1914, x\iii. 553. -Rislcy: Boston Med. and Surg. Jour., 1910, clxii, 77 3WMpple: Med. Bee, New York, 1916, lxxxix. 581. tBooth: Ibid., 582. Bancroft: Ibid., 583. 6Derby: Ibid., 582. "Snjous: Analytic Cyclopedia Practical Medicine, 191<>, vii, .">•".."). ^Chapman: Ann. Surg., 1904, p. 700. 9Meara: The Treatmenl of Acute [nfectious Diseases, 1916, p. 63. loEyermann: Personal communication. ^Thompson: Med. Rec, New York, April, 1911. i2"Van Zandt: Texas State Jour. Med., December, 1912. isMathison: Brit. Med. Jour., November, 1910. wNauwerck: Deutsch. Med. Wchnschr., 1895, xxi, L21. i s.-ijniis: Analytic Cyclopedia Practical Medicine, 1916, \i. 153. i6Robin: Med. Press and Circ, February, 1912. nBiesman: Quoted by Sajous. isKulenkamp: Deutsch. Med. Wchnschr., August, 1909. L9Bibergeil: Arch. J', klin. Chir., 1905, Ixxviii, 339. -"Burnham: Surg., Gynec. and Obst., 1914, xix, 468. ziDexter: Cleveland Med. Jour., February, 191 t. 22Englebach arid Carman: Am. Jour. Med. Sc, December, 1911. 23Morse: Boston Med. and Surg. Jour., December, 1900. 24Forchheimer : Jour. Am. Med. Assn., January, 1907. • Gee and Harder: Albutt and Rolleston's System of Medicine, 1910, v, 535. The following was also consulted: Emerson: Arch. Int. Med., May. 1909. CHAPTER XXXV PAROTITIS By 0. F. McKittrick, St. Louis.. Mo. Inflammation of the salivary glands, particularly the parotid, occurs occasionally after operative procedures, especially those in- volving the pelvic organs. The complication, as a rule, is of very serious import, one demanding instant attention regardless of the fact that it may at first appear innocent and apparently occasion- ing no alarm. The literature on postoperative parotitis is limited, few men hav- ing considered the subject worthy of the study it most certainly deserves. Fowler 1 stated that he had seen it occur eight times in patients after undergoing laparotomies. Four of these cases were observed after operations upon the adnexa, one after operative inter- ference for extrauterine pregnancy and two after operations for appendicitis. "We have seen this complication develop five times. Twice in patients operated for appendicitis, one being a most violent suppurative case. Once after intestinal suture (ileal) and abdominal drainage three days, following a kick in the abdo- men by a horse, once after removing a single pyosalpinx. during the course of a general puerperal septicemia. The last case to develop a parotitis Avas a cancer of the rectum in which an anterior left- sided colostomy was done. At the same time a Kraske was per- formed. Blair 2 has treated this condition in three postoperative cases. One occurred after operation for suppurative appendicitis and two others following operative procedures for inflammatory pelvic dis- turbances. This disease occurring in patients other than those convalescing from surgical procedures does not concern us here. However, it is so freqnenty associated with the infectious diseases such as typhoid fever, cholera, typhus, scarlet fever, pneumonia, erysipelas, dys- entery, etc., and other infectious conditions such as septicemia or pyemia that it is not surprising that it should occur so frequently in the cases presenting some abdominal inflammation. Acute inflammation of the salivary glands, by far most commonly noted in the parotid, is due to infections either metastatic in na- 287 2SS AFTER-TREATMENT OF SURGICAL PATIENTS ture or ascending up the excretory ducts. Any infectious process such as mentioned above may be an inciting factor. Local condi- tions within the mouth certainly add to the predisposition for in- fection. During any operation performed under a general anes- thetic the salivary secretions decrease in amount following the firsl stimulating influences. For the first few days the patient is given a liquid diet which neither entails actual use of the jaws nor stimulation of the salivary secretions. As a result the inac- tive glands, whose resistance has already been lowered by the opera- tive procedure, invite invasion from the myriads of microorgan- isms retained in the mouth. Their entry through the excretory ducts is soon followed by mosl active proliferation within the substance of the gland which furnishes an excellent soil for growth and development. Direct trauma from ulcerated teeth or manipula- tion by the anesthetist may occasionally be followed by this condi- tion. In this connection trauma of the abdominal viscera, of the tes- ticle or ovary or of the other pelvic organs, has occasioned a paro- titis. CrandalP stales thai it has been observed in facial paralysis, neuritis, diabetes, and even from poisoning due to mercury, to lead, or to the iodides, It has also occurred in the course of rectal feed- ing, a matter which deserves attention. 4 Crandon 5 notes that ''it may follow any injury or disease, but it is more frequent after injuries and operations on the pelvic organs than after diseases in any other part of the body." Prom the experiences "( others parotitis in the surgical conva- lescent appears more frequently in women.' 1 All of Fowler's cases and two of Blair's were of this sex. (if my own. however, only two were women. Rhodes 7 has recently reviewed the literature of subacute and chronic inflammations of the salivary glands, not postoperative. His findings in Hie forty cases reported, seemingly do not bear out the general opinion thai the female is more liable to the disease than the male. Probably the fad that more w n undergo opera- tions than men accounts for the apparenl discrepancy. Rhodes stales that "the condition, if not bilateral from the start, tends to become so," but more than one pair of the glands were not involved except in two of the cases reviewed by him. In these he noted that all the salivary glands were affected. He also found that the parotid glands were involved in 56.4 per cent, the submax- illary glands in 30.7 per cent, tin' sublingual glands, 7.(i ])er cent, and all the "lands in 5.3 per cent of the cases reported. PAROTITIS 289 The course of this disease is about one week in postoperative eases, but unless treatment is instituted, the disease remains longer and always tends to progress, though a few instances have spon- taneously subsided. It is not advisable, however, to await such a favorable outcome, but the worst should be expected and prepared for in every case. Rhodes states, concerning the subacute and chronic types that "there is apparently no tendency to abscess for- mation. In fact abscess formation would appear to be confined to cases of obstruction by stone and metastatic infection." Post- operative parotitis being the result, in the majority of the cases, of this latter condition, the complication mentioned above certainly is to be expected. Symptoms. — The symptoms appear usually within three to ten days after the operation, though in one of Fowler's cases they did not appear until eighteen days. There occurs a rise in temperature with an accompanying rise in pulse rate and in most of the cases the individual is extremely ill. The temperature continues to rise until 104 or 105 degrees is reached. Very soon a swelling, usually just in front of the lobe of the ear. is seen, since as Blair has said, the capsule is less dense here and (as mentioned before) the paro- tid gland is more frequently involved. Later the whole gland be- comes affected, causing the face and cheek to swell and the lips and eyelids to become edematous. In the most severe cases the swelling may be so rapid that the edema quickly obscures the real cause of the trouble. The skin may present a shiny appearance or even discoloration, the whole picture being that of an acute septic process which is localized in the side of the face and neck. The pain from the start is most intense owing to the resistance the tense capsule offers to the swelling gland. In the vast majority of the cases pus formation soon occurs. An examination of the parotid papilla reveals this region of the mouth swollen and as Blair has interpreted it, the congested mucous membrane lining of the duct may be noted at the apex as a dark red spot. Saliva will have ceased to be excreted in many instances and on gentle pressure pus may be easily expressed. In the worst cases extensive sup- puration takes place, the pus burrowing in every direction. Un- less liberated by early incision, the external auditory canal is fre- quently the first to be broken into, though invasion of the deep cer- vical and thoracic tissues, the retropharyngeal space and even the maxillary joint may quickly occur. Blair notes that through the olivary foramen the infection may enter the cranial cavity. Throm- bosis of the veins here or in other portions of the body may result. 290 AFTER-TREATMENT OF SURGICAL PATIENTS In the milder class of cases there may be only a localized swell- ing which disappears within a few days or else develops into a localized abscess within the gland substance. In the severe cases, however, the diffuse suppuration which is almost always seen in those patients with poor resistance and otherwise debilitated, is simply in many instances, the beginning of the end, and the most extensive measures employed in combating the difficulty can only be palliative. The prognosis depends upon the condition of the pa- tient at the beginning of the outset of symptoms. "When these appear late in a complicated convalescence in a well preserved patient even the most severe infection does not prove fatal. In those individuals already weakened by disease, debilitated and presenting some suppurative condition in the abdominal cavity the prognosis is extremely grave and unless thorough and prompt sur- gical measures are at once undertaken the patients almost always die. Of the eases reported by Fowler, however, none died and only one of the eases presented a bilateral infection. In my own experi- ence such a fortunate outcome was not seen. Two of the patients and the one was the case of ruptured intestines following trauma, a boy of sixteen died within four days after the first appearance of the gland affection three days after the operation. The other was the case of puerperal septicemia in which salpingectomy was done and the general postoperative course was uneventful until the fifth day when the temperature which had been normal two days shot up to 103° with attendant soreness and swelling in the region of the right parotid gland and neck. The patient rapidly became prostrated and within thirty six hours there was marked fiuctuation just below the parotid. Considerable pus was drained, but twelve hours later the swelling not having decreased, but rather increased, particularly in the parotid region, extensive incisions were made in every direction and the gland capsule widely opened. In spite of this the patient succumbed after a few days of intense suffering from general septicemia. Both these cases presented only a unilateral parotitis. The three patients who recovered had a bilateral affection and in each in- stance the glands were widely drained after the Blair technic within twelve hours after the beginning of the infection in each of the parotid glands and the adjacent regions. The operations were carried out under gas anesthesia and were quickly done, the wounds being left wide open with gauze drainage only. Blair's postoperative cases were also less fortunate even than PAROTITIS 291 ours. Only one of his cases recovered, the other two dying of a general septicemia despite the most radical exposure of the in- fected regions. Treatment. — The treatment is first and always preventive. It has been our custom to allow patients to chew gum, beginning the first postoperative day and continuing to do so until they start to take solid food. The mouth is kept scrupulously clean by washing with some alkaline antiseptic mouth wash and scrubbing the teeth twice a day. The patient is given a bread crust or some other solid food to chew to stimulate the salivary secretion and other digestive secretions in order to avoid this possible complication. Patients who are prone to sleep with the mouth open or those subject to mouth breathing, particularly when recumbent, are protected by Fig. 42. — Gauze moistened in equal parts of glycerin and water to prevent the open mouth from drying. keeping six layers of 15 x 15 mesh gauze (Fig. 42) moistened with a solution of half water and half glycerin over this orifice. Such a maneuver prevents the dryness of the mouth and the attendant dangers occurring in these patients. If in spite of these measures infection occurs of the parotid, Mtiller's 8 suggestion may be tried during the preliminary study of the condition. This consists in gently massaging the parotid to determine whether any pus ex- udes from Stenson's duct. If this is present, it is carefully ex- pressed. If pus is not obtained according to Mtiller there is no reason to suspect metastatic parotitis and massage must not be en- 2f)2 AFTER-TREATMENT OF SURGICAL PATIENTS tertained. In the meantime ice is applied directly over the region of the injection. Blair states that "if suppuration occurs it will usually be on the third or fourth day and be accompanied by an increase of all symptoms. This is the proper time for radical treatment. If es- pecially tender or softened spots can be found, these may be opened by an incision down to the capsule. A round-nosed conical artery forceps should then be inserted, but in the presence of severe symp- toms the surgeon should not wait for definite fluctuation, which owing to the tenseness of the capsule, may never be evident. In such cases radical treatment may be urgently necessary within twenty-four hours after the first appearance of the symptoms. Here in the absence of any local softening, an incision should be made just in front of the ear from the zygoma to the angle of the jaw down to the capsule and the flap forcefully drawn forward with sharp hooked retractors. If there is edema of the neck the incision may extend to the clavicle through the deep cervical fascia, the trunk ami branches of the seventh nerve lie deep in the gland, near its posterior part, and will not be injured by any carefully made incision. "In this way. nearly the whole gland can be exposed. By in- cisions carefully made through the capsule, the swollen gland will be permitted to expand, which will increase its blood supply and lessen the danger of gangrene. "If pus does not come on opening the capsule, the substance of the gland can be explored at various points by inserting a round- nosed artery forceps, no1 overlooking the prolongation of the gland that runs forward with the first part of the duct. If more radical exposure of the capsule is made, the latter should be incised in a number of places, thus decreasing the tension in every part of the gland. Failure to do this in one of the writer's cases made it later necessary to reopen the capsule of that part of the gland that runs forward with the first part of the duct. The operation requires but a few minutes under a gas anesthesia, and the wound is packed Avide open." When the submaxillary or sublingual glands are involved they are incised and allowance made for free drainage. The wound later is to be treated as any other infection, and as it begins to granulate, careful attention should be given the skin edges to keep them approximated with adhesive to avoid extensive scarring. As a ride very little scar follows such operations if the proper atten- tion has been given the healing wound. PAROTITIS 293 Bibliography iFowler: The Operating Eoom and the Patient, Philadelphia, 1913, W. B. Saun- ders Co., p. 196. 2Blair: Med. and Surg., March, 1917, p. 34. sCrandall: Sajous' Analytic Cyclopedia of Practical Medicine, 1917, viii, 68. 4Fenrick: Brit. Med. Jour., 1909, i, 3 297. sCraudon and Ehrenfried: Surgical After-treatment, Philadelphia, 1909, W. B. Saunders Co., p. 263. sPaget: Lancet, London, 1SS7, i, 314. 7 Ehodes: Lancet-Clinic, 1915, cxiii, 211. sMiiller: Quoted lay Crandall. CHAPTER XXXVI SUBDIAPHRAGMATIC EMPYEMA (Localized) By 0. F. McKittrick, St. Louis, Mo. The misnomer subphrenic abscess is an uncommon affection, as Jopson 1 lias rightly stated, bui a perusal of the literature will readily convince one that it must be reckoned with. Localized col- lections of pus which are situated immediately beneath and in eon- tact with the diaphragm are found following operations, particu- larly operations for appendicitis. The condition was described as early as 1829 by Wright 2 and one year later Graves and Stokes reported a patient dying from this complication. Barlow and Wilks 3 in 1845 were the first to distin- guish between the signs referable to perforating gastric ulcer and pneumothorax. Later on other cases were reported by Duehek, 4 Bamberger, 5 and Bernheim. 6 Von Volkmann in 1879 first operated for the condition and since that time many men. including Patsch, 7 Taylor." Fitz 9 and Leydon, 10 have reported cases, particularly fol- lowing appendicitis. Of late years Treves 11 has reported 6, and Ross 1 '-' ol instances following appendectomies. The causes of this complication besides those already mentioned are varied indeed. Anything capable of producing local peritonitis beneath the diaphragm may give rise to a subdiaphragmatic ab- scess. Following appendicitis, perforations of the stomach and duodenum, come liver abscesses, suppurative cholecystitis, peri- nephritis, pancreatitis, perforation of the colon, etc. The condition has also followed tonsillitis, influenza and boils. The mode of infection of the subphrenic spaces following disease of the appendix especially has keen carefully worked out from ana- tomic, clinical, and experimental standpoints by Barnard, 13 Lance." and Cosentino, 15 respectively. They agree that it is a pari of the genera] peritonitis (the cases of true localized subphrenic abscesses being excluded). Infection may be carried by the blood or it may occur by direct extension up the lower peritoneal fossa by lym- phatic extension either up the righl retroperitoneal cellular tissue or up the lymphatics around the deep epigastric artery to the falci- form ligament. In rare instances the portal vein served as the me- dium through which the infection occurred. According to Ross 294 SUBDIAPHRAGMATIC EMPYEMA 295 extension up the peritoneal fossa is by far more common. Barnard has divided all subphrenic abscesses according to their location as regards the falciform and lateral ligaments. By this arrangement he recognizes anterior and posterior intraperitoneal abscesses on each side and right and left extraperitoneal abscesses. A right anterior intraperitoneal abscess would then be located between the upper surface of the right lobe of the liver and the diaphragm. The one posteriorly would be bounded by the liver and gall bladder in front and the abdominal parietes behind. A left anterior intraperitoneal abscess or splenic abscess would be bounded by the diaphragm above, the liver below and to the right, and the spleen on the left. The one posteriorly would be situated in the lesser peritoneal cavity. A right extraperitoneal subphrenic abscess lies in the space be- tween the layers of the coronary and other peritoneal ligaments of the liver. The left extraperitoneal abscess would have like boundaries on the left side. Others, however, feel this distinction is hardly necessary and have excluded the extraperitoneal spaces. Taking the suspensory ligament as a dividing line, then, those abscesses of appendiceal, hepatic or duodenal origin, are located to the right of this liga- ment; while abscesses arising as a consequence of gastric perfora- tion, or inflammation of the pancreas or spleen are found to the left. The mesentery of the transverse colon prevents the downward extension of the process and the colon with the omentum walls off the abscess from the greater peritoneal cavity. Recently Judd 1G has called attention to the extraperitoneal spaces in their relation to pus from the kidneys. He states that though it may be difficult to determine clinically which one of the pouches contain the infec- tion, a detailed knowledge of their boundaries is important. He further adds that one or more of the spaces may be involved at the same time. In the majority of cases the abscess occurs on the right side. In nearly all of twelve cases reported by Barnes and in 29 of Ross' cases was the location in this region. Subdiaphragmatic abscess occurs more often in men than women, the time of life being around the third decade. It is comparatively rare under 14 years of age, occurring only once following 500 con- secutive operations for appendicitis reported by Ross. In 3391 such consecutive operations this same author found the condition to occur in .8 per cent of the cases. On 410 consecutive autopsies, Kelly and Hurdon 17 found the malady 13 times; in more than 50 296 AFTER-TREATMENT OF SURGICAL PATIENTS per cent of the cases the affection was appendiceal in origin. Lance collected 94:5 cases of subdiaphragmatic abscess, 222 of which were duo to acute appendicitis. Piquand 18 reviewed 890 instances of this condition and recorded 191 as being due to appendiceal affection. Of the cases reported by Judd, 9 were associated with appendecto- mies, 7 with gall bladder operations, 7 with ruptured duodenum, 4 with ruptured gall bladder, 2 with perforating gastric ulcers, 1 with genera] peritonitis, 1 with a tuberculous lesion elsewhere in the body, four with focal infections and one following an operation on the stomach. The contents of the abscess varies with the organ involved. The ])iis may contain bile, carious bone, or caseous material, but usually it is very foul, as is the fact when the appendix is primarily involved. In many of the cases pis alone or gas with but little pus may be present. Various reasons are ascribed for this but it is probably due to bacterial proliferation, the colon bacillus being usually found. Symptoms. — The symptoms of subphrenic abscess vary from those of a very mild infection with practically no rise in tempera- ture and pulse and no leucocytosis, to the most severe type of peri- tonitis. Usually the patient will complain of pain in the right side in attempting to take a full breath, ('hilly sensations are followed by chills, fever, sweating and the pain increases in severity so that the patient is able to take only very shallow breaths. A cough de- velops with the irritation of the diaphragm. A leucocytosis now occurs and the patient settles down to a siege of sepsis. On ex- amination an involvement of the base of the lung will be found, but there may or may not be dullness. Later on, however, there will appear an area of dullness in this region with lessened breath sounds and fremitus. It must be remembered that the line of dull- ness will curve upwards in this condition in contradistinction to fluid in the pleural cavity. At times these sm-ns may be noted an- teriorly and in addition pleural friction sounds may be present. As the condition progresses there may be flattening of the inter- costal spaces or bulging of the chest wall itself. The swelling may appear in the epigastrium or below the border of the ribs and be associated with a local edema, depending upon the location of the pus. The outline fluid will not change with different postures of the patient, bul will remain in one position. Neither will the heart be dislocated as is seen at times in pleuritic effusions, unless possibly it is pushed upwards. In .1 of the 21 eases reported by Koss com- ing to autopsy there were purulent pleurisy. SUBDIAPHRAGMATIC EMPYEMA 297 Abdominal symptoms do not always occur due to the deep loca- tion of the abscess; when present, however, pain and tenderness will be noted and the mass may be felt in the epigastrium. The pain as stated above is usually a pleural pain and elicited abdom- inally by deep palpation. The cases in which symptoms were de- layed for months, reported by Ashhurst 19 and Meisel 20 showed a more or less sudden onset and the complication was apparent as a grave abdominal condition. When this complication presents itself, as early a diagnosis as possible should be made. Since the abscess so often contains gas which may be mistaken for a pneumothorax or even for a hollow viscus, it may not be possible to make a diagnosis without first free- ing the stomach of gas by means of a stomach tube and then ap- plying the aspirating needle to the affected side. This can give important evidence as to the location of the pus. If the abscess communicates with the pleural cavity the needle will move up and down with the respiratory movements ; or by immersing the end of the needle in sterile water one may be able to see the expulsion of gas with those movements of the diaphragm. These signs will fail at times due to the localized paralysis of the diaphragm caused by the inflammation or pressure of the fluid upward. Adhesions may also produce the same effect, Only the most careful study of the individual case will effect even an approach to a diagnosis. The leucocytes in Judd's case ranged from 8,800 to 22,000. The dura- tion of the disease varied from three days to ten months. In four of his cases the x-ray was used to good advantage in distinguish- ing between this condition and others above the diaphragm. Treatment. — The treatment consists firstly in anticipation of this complication during operations, appendicitis with pus behind and to outer side of the ascending colon. The prone position 21 with suffi- cient flank drains in such cases will aid materially in preventing a subphrenic abscess from developing. This position is better than the Fowler immediately following the operation, since the heart is not put on an additional strain, while drainage is definitely assisted by the influence of gravity. After twenty-four hours the patient lies on the right side as much as possible. When the drainage ceases, he can assume any position, though he is enjoined from lying on the back very long at a time during any phase of the con- valescence. In spite of these preventive measures the condition may occur. It should always be suspected in any such case which shows more toxic symptoms than can be accounted for. An early diagnosis made 298 AFTER-TREATMEXT OF SURGICAL PATIENTS by the aspirating needle or any other means at our command will materially lessen the severity of this complication. The prognosis is thereby improved though it is serious enough under any circumstances. Depending upon the virulence of the infection, the patient may die within a few hours or he may live several months. Recovery may result by rupture of the abscess into a bronchus directly or indirectly by way of the pleura. The abscess rarely empties itself into any of the abdominal viscera or ex- ternally. Death is most apt to occur from sepsis. The mortality depends upon the origin of the abscess and upon the date of operation employed for its relief. If such measures are attempted early, the mortality is around 16 per cent ; but if de- layed as late as three weeks, it goes above 50 per cent. If, how- ever, no operation at all is done the mortality varies from 55 per cent to 7'2 per cent according to Sonnenberg and Sachs, respec- tively. Of Judd's cases, 11 died due to the extension of the process to the liver with the formation of multiple abscesses which could not be adequately drained by any operative procedure. Under local anesthesia vide and free incisions should be made in an effort to get adequate drainage^ According to Ross the va- rious operations for this condition are classified in three groups. The abdominal operation may be carried out below the ribs, in the epigastric region or in the loin, depending upon the location of the abscess. The subplcural route consists in resecting the tenth rib in the midaxillary line and traversing the diaphragm below the pleu- ral reflection. Probably the transpleural route is the one preferred by most op- erators. The technic, as employed by Elsberg, consists in resecting the the ninth and tenth ribs s ewhere between the scapular and axil- lary lines. The surfaces of the pleura should be carefully sewed together to prevent pus from disseminating throughout the thoracic cavity. Large rubber tubes should be employed and the patient treated Hie same as an empyema case. No matter where the drain is inserted, the patient must be so placed that the opening coin- cides with the dependent portion of the body. The most effective and complete drainage is secured in this way alone. Bibliography iJopson: Ar.-li. Pediat., L904, xxi. No. 2. zWright: Am. Jour. Med. Sc, 1829, iv, 353. •'■Marlmv and Wilks: London Med. Gaz., L845, i. X". 5, p. L3. *Duchek: Prager Vierterjahreschrift, 1853. sBamberger: Verhandl. der phys. tried. Gesselschaft zu Wiirzburg, 1858, iii, L23, SUBDIAPHRAGMATIC EMPYEMA 299 eBernheim: Virchow-Hirsch Jahresbericht, 1874. TPatsch: Loc. cit., 1882, p. 300. sTaylor: Guy's Hosp. Beports, xix. sFitz: Tr. Assn. Am. Phys., i, 1886. loLeydon: Beii. klin. Wchnschr., Nov. 14, 1892. "Treves: Operative Surg., London, 1905. i2Boss: Jour. Am. Med. Assn., 1911, lvii, 526. "Barnard: Brit. Med. Jour., 1908, i, 371. "Lance: Gaz. d. hop., Paris, 1909, lxxxvi, 63, 99. isCosentino : Polielinieo, Borne, 1907, xix, sez. ehir. pp. 251, 386. isJudd: Journal-Lancet, 1915, xxxv, 621. i^Kelly and Hurdon: Boston City Hosp. Bept., 1905. isPiquand: Bev. de cliir., 1909, xxxix, 150. isAshhurst: Tr. Phila. Acad. Surg., 1910, xiii, 154. soMeisel: Miinchen med. Wchnschr., 1909, lvi, 1411. siGhent : Jour. -Lancet, 1916, xxxvi, 194. CHAPTER XXXVII THROMBOPHLEBITIS By 0. F. McKittrick, St. Louis. Mo. Postoperative thrombophlebitis is of such common occurrence that it enters into the experience of every surgeon, and yet, not- withstanding the advance in postoperative treatment in recent years, it is still so common and the consequences may he so dire that it remains a bete noire of the surgical profession. This condition occurs most frequently after abdominal opera- tions, bu1 it may 1'ollow operations on distant parts of the body. 1 It is especially common after operations on the uterus and adnexa and in operations about the rectum. This condition rarely occurs be- fore the age of puberty, and with the greatest frequency after thirty. Thrombophlebitis develops in clean, as well as septic cases; 1 the thrombosis forming at times far from the operative field. The left (due to the righl common iliac artery crossing in front of the left common iliac vein I femoral vein and the veins of the calf and thigh arc most commonly affected, though the external iliac, the common iliac, the mesenteric, and the portal veins have been in- volved in this malady. From a study of a large series of statistics, thrombophlebitis occurs in from .81 per cent to 3.6 per cent of all laparotomies. Burnham 2 reported the former, and Friedman, 3 the latter figure. It was also noted that the earliest onset of tin' dis- ease came after four days, and the latesl onset after twenty-eight days. Generally debilitated or anemic subjects, those who have suffered from profuse ami prolonged Menorrhagia due to the pres- ence of a submucous fibroid, or those who have been suhjected to a prolonged operation, formed the bulk of the patients affected as above. I saw fatal disease of the long saphenous vein follow an operation near a varicose ulcer. More than sixty years ago Virchow called attention to throm- bosis; ami although he did Qot distinguish it from coagulation, 4 his studies were early confirmed by numerous experimental and post- mortem observations by others, chief among whom were, Cohnheim and Colin: when with this work Ave place Welch's classical review of "Thrombosis ami Embolism" published in ]^!i!), we have listed most of the significant literature on this subject. 5 Today the meaning of the term has changed and by thrombosis 300 THROMBOPHLEBITIS 301 is meant the formation and organization, during life, of a blood clot in a vessel. The mechanism is so simple, as it is taught at the present time that we wonder why it was necessary for Virchow to establish the self-evident fact that injury to a vessel or changes in the blood sufficient to cause clotting at some particular point might be followed by dislodgment of a piece of the solid clot, and this broken off mass be carried on by the blood stream, until it reached a vessel too small for it to pass through, then stop. It is also plain that the blocking of a vessel by this solid mass would stop the cir- culation through this vessel, and give rise to disturbances of great importance, or of little importance, depending on whether or not this vessel supplied an organ, the function of which was necessary to maintain life. Increased coagulability is probably not alone re- sponsible for thrombosis, though Wright and Knapp, 6 in 1902 stated that thrombosis, particularly after typhoid, was due to in- creased coagulability of the blood, as the consecoience of the high calcium content which they attributed to the milk diet. The modern theory, which is generally accepted, is in accord with the teaching of Eberth and Schimmelbusch, who belieA'e that the blood platelets play a prominent part in thrombosis, but little or no part in coagulation. On the other hand, fibrin and its pro- geners although normally active in coagulation, play only a minor part in the formation of a thrombus. Blood platelets, numbering from 180,000 to 780,000 per c.mm., according to Bizzero, although normal constituents of the blood, are the originators of the typical thrombus. They may collect about a foreign body or following a slowing of the blood stream, collect upon the damaged wall of a vessel. This agglutinative process takes place only in the circulat- ing blood, for there is no thrombus formation when a vein is doubly ligatured and excised, according to Baumgarten. Following the throwing down of the blood platelets there is a rapid accumulation of polymorphonuclear leucocytes, and to this nucleus is added fi- brin mixed with red cells. Aschoff states that a change in the character of the blood is nec- essary for thrombus formation. He holds that the location of the thrombus is determined by slowing of the blood stream, or by the widening of the vein, with resulting eddy formation ; from repeated examinations of the blood Burnham concludes that there is no de- crease in the coagulation time in postoperative thrombophlebitis, and while it has been suggested that an increased viscosity will cause a slowing of the blood stream, it has not been sufficiently tested in postoperative eases. Bachman has shown that it is in- 302 AFTER-TREATMENT OF SURGICAL PATIENTS creased in infectious diseases, especially typhoid, while it has been definitely proved that in those diseases in which the blood platelets are increased, thrombosis is common. Chemical changes may influence the formation of thrombi. Sahli and Egnet showed that they did not form after the injection of leech extract, since the blood was rendered noncoagulable, while Sehimmelbusch, on the other hand, was able to cause a formation of experimental thrombi after destroying the coagulability of the blood by the injection of peptone. FaueheauxV belief that the increased sodium content of the blood due to a temporary insufficiency of the kidney, may be a predis- posing cause, is not convincing. Albanus 8 gives as prevailing causes for thrombosis after laparot- omies, "sepsis, heart derangements, pressure of tumors on veins. cooling and handling of blood vessels while the abdomen is open; the effect of narcosis on the heart, the recumbent position and the pres- sure of a bandage." Infection apparently plays a part, though no definite proof can be cited for or against this. Heidemann lias called attention to the period of incubation and holds the entire process to be infections in character. Klein argues against this and points to the afebrile cases as an argument against infection: but as pointed out by Fromme, many slight rises of temperature may be overlooked, and moreover, infection may occur without any febrile reaction what- ever, Lubarsch could demonstrate organisms in only 20 out of 215 cases. After an examination of a large number of records it is impossi- ble to exclude the process as a result of the milder self -limiting types of nonpyogenic inflammations. That it may be initiated by mechan- ical or chemical factors or both is doubtless true, but the course and symptoms of the disease are too typical of infections to allow of any other conclusion in most instances. Then it seems to me, as it was also suggested by AVilson 10 that the most important factors concerned in extensive postoperative thrombosis are the following:* (a) Injury of the vessel Avails. Injury to the intima by cutting. ligating or clamping causes a rapid deposite of a fibrinous throm- bus, formed as depicted in the theory of Eberth and Schimmel- busch. The deposit confines itself within an area close to the in- jury, the endothelium quickly extends, and after a few days covers it entirely, thereby preventing portions becoming detached and *Much of the following is taken from Wilson's article. 10 THROMBOPHLEBITIS 303 forming emboli. However, there are other instances in which this limitation fails to occur and the small attached thrombi develop into large loose ones through the agencies of other factors. (b) Slowing of the blood stream. Following operations the ra- pidity and volume of the current in the veins are materially les- sened for a considerable distance nearest the first incoming venous radicals. The patient being kept quiet and in the recumbent pos- ture causes a slowing of the heart's action and diminishes its force, thereby causing a general slowing of the blood current throughout the entire vascular system. This, according to Opie, produces a disarrangement in the blood cells, the white cells and platelets reaching the periphery of the stream tend to attach themselves to the vascular walls. In the presence of obstacles or marked expan- sion of the vessel a whirling motion, as shown by von Reckling- hausen, may be set up which further tends to the retardation of the blood stream and to the deposition of its elements as thrombi. (c) Destruction of corpuscles from toxic substances. From the high percentage of postoperative thrombosis and embolism follow- ing gall bladder operations and the behavior of cases suffering from severe secondary anemias and hepatic diseases, to say nothing of thrombosis in carcinoma cases, it is fair to assume that some toxic substance or substances not definitely known are present in the blood. (d) Bacteriemia. It is now fairly well established that bacteria and their toxins are the chief causes of extensive postoperative thrombosis, many thrombi which we formerly regarded as "maran- tic," in the light of the last decade of pathologic advancement, we now know are of infective origin. It is readily conceivable that bac- teria in the blood stream may have their virulence sufficiently reduced to prevent them setting up a local phlebitis until aided by postopera- tive traumatism of the intima, by postoperative slowing of the blood current, or perhaps even by the effect on the leucocytes of a pro- longed general anesthetic. Symptoms. — The symptoms of thrombophlebitis depend upon the location of the thrombus. In rare instances in which the portal vein is involved, the course is very rapid, marked by extreme prostration, chills and an irregular high temperature. The condition simulates very closely that of acute peritonitis. There is usually tenderness along the outer border of the right rectus muscle, enlargement of the liver and spleen and at times jaundice may be present. Such a condi- tion following appendectomy is highly suspicious of pylephlebitis. Af- fection of the mesenteric artery is more common, and from the statis- 304 AFTER-TREATMENT OF SURGICAL PATIENTS tics, the sudden onset of acute pain, more or less diffuse over the entire abdomen with a decided rigidity with vomiting, usually blood stained, and in the very early stage, diarrhea with bloody stools, are the most constant symptoms. 11 Gerherdt 12 notes in addition to the above, ileus, fluid in the abdomen, a rapid fall in tem- perature and a large palpable mass between the layers of the mesentery. Fortunately where the condition is most common the symptom-complex is pathognomonic. Blood clots in the veins of the Fig. 43. — Wrapping the leg in common cotton batting. pelvis or lower extremities, offer no symptoms to attract attention so long as they are not infected. When infection occurs, however, a mild initiative chill is noted, followed by a temperature probably 103° C. with a corresponding pulse. At the point of the lesion there will be tenderness and swelling and the whole limb on the affected side may become swollen and painful. If the saphenous vein is in- volved, the veins distal to the affected portion stand out like cords, their course being marked by the \'ci\ lines upon the skin over them, due to the accompanying Lymphangitis. THROMBOPHLEBITIS 305 Treatment. — In view of the facts elucidated above, the treatment of thrombophlebitis concerns itself first with the prevention of this condition. The following suggest themselves:* (a) The reduction of vascular traumatism to a minimum at op- eration by the conservative occlusion of vessels and the provision of free drainage to prevent later external pressure on the vessels. (b) The encouragement of very early free movement on the part of the patient, as soon as the nature of the operation will permit ; if it can be clone early enough to prevent the formation of extensive thrombi, it would seem most desirable. If, on the other hand condi- Fig. 44. — The leg is kept elevated and splinted on a pillow. tions are such as to lead to the suspicion that extensive thrombi have already formed before the early movements of the patient were pos- sible, it would then seem more desirable to keep the patient as quiet as practical in a recumbent position to prevent a dislocation of the already formed thrombi. Just when to allow the patient out of bed under such conditions depends upon the experience and skill of the surgeon. No one can estimate the time required for the formation *Much of the following is taken from Wilson's article. 10 306 AFTER-TREATMEXT OF SURGICAL PATIENTS of extensive postoperative thrombi in any one case. We do know, however, that loose thrombi are readily dislocated by a very slight exertion on the part of the patient. (c) The preoperative administration of drugs to increase the co- agulability of the blood, as, for example, calcium salts; while these tend to produce an increased coagulation time there is no evidence to show that they are of value in thrombosis. (d) Measures looking toward the reduction of bacteriemia are certainly indicated as a preoperative precaution. For the prevention of thrombosis the cautery should be used wherever possible at the operation to destroy the local foci. If the invading organism can be isolated, autogenous vaccines may be made and preliminary vac- cination be carried out. Fig. 45. — The extremity is protected from the lied covers, and a hot-water bottle applied to the sole of the foot. Where the condition lias already occurred, absolute rest in bed must be carried out for five or six weeks. Under no circumstances should the patient lie allowed but the slightest movements. Particu- larly after the third week when the clot has become brittle and Likely to disintegrate should the patient be enjoined from getting out of hed or straining at stool. The bowels can be kept normal with min- eral oil given during the meals and if necessary enemas to enhance the action of this mild drug. THROMBOPHLEBITIS 307 The leg should be wrapped (Fig. 43) in cotton and elevated (Fig. 44), hot-water bottle applied to the foot (Fig. 45), and after the acute symptoms have subsided, over the site of the lesion also. Until then ice should be placed here. Pain will thereby be relieved ; but if this is not sufficient,, opium may be resorted to. If necessary the vein may be opened and drained. The following history may be of in- terest. February 28, 1916, Mrs. S., age twenty-four, was operated for tuberculous peritonitis and a double salpingectomy was done. The operation was quickly performed, produced very little shock, and the patient was returned to bed in good condition. The temperature was 101° at operation with a corresponding pulse; and continued so high for four days following. Urination was normal, bowels were moved with glycerin enemas on the second day and there were scarcely any gas pains. In the meantime frequent feedings of thick liquids were carried out, the food was taken with a relish and the patient felt so well that on the night of the third day she asked to sit up on the morrow. The following morn- ing the temperature had dropped to 98.6° with a pulse of 90, and her request was about to be considered favorably when suddenly, about noon, patient noticed a stinging pain on the inner side of the ankle, which, after an hour or so, extended along the inner side of the leg and thigh. Pressure along the course of the in- ternal saphenous vein was unbearable. The afternoon temperature was 102.4°, but there was little change in the pulse. The whole limb was well wrapped in cotton batting and elevated on a high stack of pillows. A wire cage placed over this protected the dressing from being disturbed by the bed clothes. An ice cap was placed over the lesion in the thigh and a hot-water bag at the foot. The pain was relieved at once by this treatment which never varied (except the ice cap was replaced at the end of the third day by a hot-water bag), as long as there were any indications of the lesion remaining. For nine days the morning temperature remained 101° while the afternoon temperature continued to reach the 102.4° mark. All the while patient was at perfect ease; two days following the accident the diet was increased to a general one, and a day or so later it was forced, carrots and spinach being given in abundance. At all times there was a good supply of water, sodium bicarbonate being given at times to prevent a possible acidosis. Bowels were kept open with glycerin enemas, 2 ounces every second day unless there was a movement without them. On the ninth day of the disease and the fifteenth following the operation, the temperature fell to 99°. From this time on there was very little fever. The 'limb was gradually lowered and after four more days' stay in the hospital with the limb horizontal, the patient was able to get out of bed, and as soon as the equilibrium became estab- lished (one day up and about the hospital), she went home. Xo further compli- cation or untoward symptoms developed following the use of the limb. I at- tribute the quick recovery to immediate attention to the phlebitis, thereby pre- venting nature from forming but a small thrombus. Bibliography iBull: Beitr. z. klin. chir., 1912, lxxxii, 345. ^Burnham: Ann. Surg., 1913, lvii, 151. 3 Friedman : Quoted by Burnham.2 ^Virchow: Gesanrnielte abhandlungen. Frankfurt a. M., 1856. 308 AFTER-TREATMENT OF SURGICAL PATIENTS sWelch: Allbutt's System of Medicine, 1899, vii, pp. 155-159. '■Wright and Knapp: Med. Cliir. Trans., London, 1903, No. 1. ^Faucheaux: Paris These, 1905. sAlbanus: Beitr. z. klin. Chir., xl. olvlein: Arch. f. Gvniik., xeiv, No. 1, p. 1911. loWilson: Ann. Burg., 1912, hi, S09. uLaplace: Pennsylvania Med. Jonr., 1913, xvi, . 172. sStelwagon: Jour. Cutan. Dis., 1907, p. 117. ^Crawford: Therap. (i;st.. 1915, hud, 6 isPanton and Adams: Lancet. London, Oct. 1!>09. CHAPTER XLI HEMOPHILIA AND OTHER HEMORRHAGIC DISEASES By 0. F. McKittrick, St. Louis, Mo. The control of hemorrhage is naturally of paramount importance in operative patients. Usually, very little trouble is experienced in bringing this about, but occasionally patients are operated on account of the urgency of surgical condition, without the surgeon knowing that they suffer from some constitutional malady which makes hemostasis difficult or even impossible. Of the diseases which predispose to hemorrhage apparently through delayed clot- ting of the blood, hemophilia stands out in bold relief. This dis- ease was first investigated by Nasse in 1820. It fulfills a law, known by this investigator's name which implies that the affliction is lim- ited to males, being transmitted from one generation to another through unaffected females. It is an hereditary malady, clinically characterized by great delay in clotting of the blood, following traumatic hemorrhages. Other members included in the family of hemorrhagic diseases, which differ widely in their pathologic con- ditions, but present hemorrhage as a common symptom, are the various purpuras, hemorrhagic diseases of the newborn, jaundice, the grave anemias, and other conditions associated with infections or chronic ailments. The purpuras are probably the most impor- tant class of diseases, next to hemophilia with which we have to deal. In purpura, the hemorrhages are spontaneous, small petechia appearing in the skin in various portions of the body. The blood clots within nearly the normal 1 time, though the platelets are di- minished, which in hemophilia are normal. Like hemophilia, how- ever, purpura may be a family disease. Any doubt arising as to the identity of one or the other may be quickly cleared up through subjecting the blood vessel walls to increased pressure by means of a tourniquet. Hemorrhages will occur in the skin of patients suffering with any hemorrhagic diathesis; 2 These fail to appear in hemophilia. After considerable study of the hemophilic tendency in families, Addis concluded that clinically, the cases fall into three groups ; 3 in the first appear those cases which are scarcely ever free at any time from some sign of the disease, though no trauma was suffered 333 331 AFTER-TREATMENT OF SURGICAL PATIENTS greater than those which come in everyday events. In the second group trivial accidents alone do not lead to prolonged hemorrhage. In the third group, injuries which were out of the ordinary were followed by continued hemorrhage. Addis further stated that the only practical difference between patients of this group and ordi- nary individuals was that hemorrhage persisted longer in the hemo- philiacs. Sajous 4 adds that the families are often large and the blondes are particularly affected. He states that it is more common in Germany and among the Jewish people but that it is encoun- tered in all civilized countries and especially in the United States. It is interesting to note that the disease may not only complicate a surgical convalescence but also that it may be the cause of the operative interference. Schwartz 3 recently reported sanguineous infiltrations in the iliac fossa, and especially in the rectus sheath, which led to appendiceal symptoms and subsequent operation. Hemorrhages may occur in the joints, producing swelling, pain, and fever, following some slight exertion. Hemotomata may appear in various regions of the body due to trauma which may have been so slight that the patient failed to recall it. Such tumors arising within the psoas muscle or other obscure regions, may simulate other conditions which are urgently operative, the true nature of the disease not being manifest until the blood tumor is discovered. The hemorrhagic diseases have not as yet been satisfactorily classified since the causes of the conditions are not known, and even in hemophilia, which disease has been more thoroughly studied than the rest, Morawitz and Lossen are contented to say that "we have to deal with an inherited chemical degeneration of the proto- plasm of the formed elements of the blood and perhaps of the whole organism. ' ' G The coagulation of the normal blood is explained by many dif- ferent theories, probably the most dependable one being that of Morawitz, and one which is supported by Wright, that in normal individuals, the blood clot is formed in the following manner: thrombokinase in the presence of calcium salts converts throm- bogen into thrombin and this converts fribrinogen into fibrin, which is the essential feature of the blood clot. The enzyme throm- bokinase is not present in the circulating blood but is formed through the breaking up of the leucocytes during hemorrhage and from the injured cells in the wound. Fibrinogen, thrombogen and calcium are present in the circulating blood. The existence of the fibrin ferment, fibrinogen in the blood has been definitely demon- strated. It is a protein body which forms .22 per cent to .4 per cent HEMOPHILIA AND OTHER HEMORRHAGIC DISEASES 335 of the plasma. 7 The thrombogen has never been isolated though it is believed to occur in the circulating blood. The thrombin ap- pears only after the blood is shed, hence it seems reasonable to suppose that its constituent elements must have existed in the cir- culating blood, and are therefore termed thrombogen. Thrombin has been thoroughly studied by Howell. The presence of calcium in this medium has long been known. The existence, however, of fibrinogen, thrombin, fibrin, and calcium is definitely proved. Thrombokinase and thrombogen occur only in theory. Just how thrombin is formed is still a matter of controversy ; even the mode of action of thrombin on fibrinogen is not understood. Whether it is a ferment action, a chemical or a physicochemical action is still a question. 8 It naturally follows that an abnormal clotting of the blood could hardly be explained if the normal mechanism is not understood. However, many theories have been advanced to explain the phenomenon. Morawitz and Lossen say the delay in the coagulation time is due principally to insufficient formations of the fibrin fer- ment factors, especially the thrombokinase. The same view was held three years before by Sahli 9 who stated that he could not tell which of the cellular elements of the blood was lacking but he con- sidered the thrombokinase was not available in normal amounts. Addis 10 reported in 1910, 12 cases of hemophilia in which the pathol- ogy had been studied. The coagulation time in all was from one to two hours, and the only constant factor present so far as pa- thology goes, was the delay in the coagulation of the blood. He thinks this is due to the slow action of the thrombogen in chang- ing into thrombin even in the presence of normal amounts of throm- bokinase and calcium salts. In his opinion, hemophilia is probably due either to an absence of, or to too small amounts of, or to some change in the thrombogen. Howell also considers the thrombogen at fault. Wright 11 considered delay in coagulation time was due to lack of calcium. Kahn 12 studying two hemophiliacs, one an hereditary "bleeder" and one who had no such history but was considered a sporadic type of this disease, by metabolism studies showed the calcium content of the blood normal in the typical hemophiliac while in the atypical case, it was decreased. Adminis- tration of calcium diminished the coagulation time in the atypical, while it even increased it in the true hemophiliac. There was no derangement in metabolism as measured by the intake and out- put of nitrogen, sulphur, and calcium in the true hemophiliac. He concludes that "there are certain bleeders in whom the disturbing 336 AFTER-TREATMENT OF SURGICAL PATIENTS factor seems to be a lack of calcium content of the blood and an inability on the part of the organisms to assimilate properly, the lime from the food." The prognosis is particularly grave during the first year as Et- linger 13 has shown. The disease frequently disappears at puberty, in mild cases. Boys are worse risks than girls. 14 With sufficient care, patients live until middle life, the longer the patient lives, the greater the chance of out-living the tendency. The prognosis in each individual case should be based on the patient's history and that of his family. 13 Treatment. — The treatment of such conditions naturally is em- pirical and will remain so until more definite causes have been found for these diseases. In the meantime, we consider the first step toward the successful handling of these unfortunate patients is to be on the lookout for their appearance, and if possible, diag- nose the condition. All careful surgeons, before any operative procedure, examine their cases so far as possible for such disorders of the blood in order to escape the misfortune which comes as consequences of operating upon such patients. Even after most thorough histories and physical examinations, patients occasionally first present this complication during the operation. Only the most urgent opera- tions are performed on known hemophiliacs. However, the clotting time being normal, almost any operation is undertaken regard- less of other preoperative findings. Hess says this is a mistake. He thinks that too great stress is laid upon the clotting time, espe- cially of blood taken in the usual way, i.e., from a cut in the skin. He considers it far more important to get the clotting time of blood taken directly from the blood vessels themselves. In addi- tion, puncture wounds should be noted for absence or presence of hemorrhage. In patients whose history points to this condition, we heartily recommend Hess' advice, otherwise we prefer to ex- amine the blood from a cutaneous puncture, several separated drops having been placed upon a clean glass slide. At the expira- tion of one minute, a pinpoint placed in one drop of blood will show a fine thread of fibrin if the blood coagulates so soon. If not, use another drop and repeat t lie maneuver until a thread appears and note the time. The fibrin should appear within three to five minutes. According to Morris, 15 among the best methods of determining the clotting time is one which utilizes the apparatus of Brodie and li'ns^ell as improved by Boggs. 16 Morris says that results nearly HEMOPHILIA AND OTHER HEMORRHAGIC DISEASES 337 as uniform have been obtained by Hinman and Sladen, 17 who use a modification of Milian's idea. Since the apparatus required in the latter method consists of a plain glass slide and a millimeter rule only, we have used this method in cases requiring a more ac- curate determination of the blood clotting time. The method con- sists in aseptically obtaining blood from a blood vessel as sug- gested by Hess. Several small drops are placed upon a clean glass slide, by touching the undersurface of the slide to the hanging drop. The slide is turned quickly to prevent the drops from flowing and then placed over the millimeter scale. All the drops are wiped away except those measuring 4 and 5 mm. in diameter. The slide is held vertically and the profile of the drops watched. They first sag as would a tear, but as soon as coagulation takes place, uniform convexity appears. 15 It is also worthy of note that through trans- mitted light, the dependent portion of the drops appears the denser. When coagulation has occurred, the center of the drop assumes this density. The presence of a clot is confirmed by use of the pinpoint or by transferring the whole drop to a piece of cloth. Ac- cording to Morris, 5-millimeter drops alone should be used in de- layed clotting since the error due to evaporation is thereby markedly decreased. The mean coagulation time of all the 4 and 5 mm. drops of unknown blood, is taken for the result. The blood must clot below 8 min. to be considered normal with this method; usually normal blood does not clot in less than five minutes. In Addis' 12 cases of hemophilia, the clotting time was from 15 to 85 minutes. In Morawitz and Lossen's case, the blood took 110 minutes to clot completely. Blood taken from the veins of such patients, 2 c.c. or more and placed at a temperature of 20° to 22° C, will not clot for hours. The hemostatic measures which have been employed in the past are numerous. Excluding the direct measures, such as ligating the bleeding vessels, tamponading, etc., and considering drugs alone, the lactate of calcium is probably of most value, since in some of the instances the hemorrhage was associated with a lack of this mineral in the blood. These cases alone, however, can be benefited by such medication. Calcium will even increase the delay in the clotting time in some cases and its use should not be continued over too long a time. Thyroid gland, 3 to 5 grains, three times a day has been suc- cessfully employed by Delace, ls Rugh, 19 and others, both as a pre- ventive and as curative means, particularly in hemophilia. Re- cently Witte's peptone has been highly praised by various Euro- 338 AFTER-TREATMENT OF SURGICAL PATIENTS pean writers. Nolf and Herry 20 advise the injection of 10 c.c. of a 5 per cent solution in 0.5 per cent sodium chloride. The mixture is made by adding 5 grams of peptone, 0.5 grams of sodium chloride to 100 c.c. distilled water. Its properties are not altered by ster- ilization and it is given snbcntaneoiisly. Considerable pain is noted at times at the site of the injection with elevation of temperature. It is rarely necessary to repeat the close more than once, usually after a day or more has elapsed. Nobecourt and Tixier 21 who probably have had the most experience with this treatment, give four to six subcutaneous injections of 3 to 5 c.c. of the solution at each injection two to three days apart. This can be given before operation or following it, but in either event, four to six weeks should elapse before a second series is given. Following this rule, no untoward symptoms developed after its use. Intolerance to pep- tone lias been reported, however, but it followed the administra- tion over too long a period of time. 22 The use of fresh human serum has long been held to be the best agent for controlling this malady. It is asserted by some that Witte's peptone is better than serum but until it is proved, fresh human serum will remain the most efficient means we have to com- bat the dangers which follow operations upon patients with hemo- philic tendencies. The investigations of Weil have resulted in this form of treatment. However, almost three years before Weil published his work, Bienwald, 23 Felz and Pigot, 24 Fry 25 and others had used fresh serum successfully in almost hopeless cases of hemorrhage due either to hemophilia or other of the hemorrhagic diseases. Weil's 26 observations were based upon the treatment of eleven cases of hemophilia in some of which the preventive use was made of the serum. He also used it in cases with marked pri- mary and secondary purpura and in other hemorrhagic diseases, and concluded even at that early date (1906) that "fresh serum is an effective remedy for the arresting of hemorrhage in all dys- crasic states, in fact more effective than any other, including cal- cium salts." Weil's work was quickly confirmed by that of Elica- garay 27 and soon its use became general. Fresh sera from the rab- bit, cow, ox, goat, and horse, were used and found effective. Baum 28 could not agree with all the findings of Weil but stated that he considered serum Avas indicated in all hemorrhagic conditions and would expect good results from it, except possibly in true hemophilia. Following the injections of fresh serum, other stock sera were used and in some cases with good results. Diphtheria antitoxin, 2S HEMOPHILIA AND OTHER HEMORRHAGIC DISEASES 339 tetanus antitoxin, 29 antistreptococcic 30 serum and. other sera of various kinds were tried, but none with universal success. After extensive trial of sera, it was found that the serum from the ox, goat, and dog were particularly apt to produce anaphylaxis and it became so universally known that Trembur 31 in 1910, stated that the kind of serum should be changed at the slightest sign of such a condition. During the same year, Broca 32 considered the use of animal sera permissible for the arrest of hemorrhage in cases of true hemophilia only. One year later, Moss and Gelien used large intravenous doses of defibrinated blood which they hoped would not only furnish the element necessary to cause the coagulation of the blood, but also relieve the marked anemia. Duke 33 considered the cause of the uncontrollable bleeding due to a deficiency or to an absence of the platelets in the blood in some of the hemorrhagic diseases at least. He therefore advised blood transfusion as the most efficient method of overcoming the condi- tion. There can be no cpiestion of this being the ideal method easy of accomplishment. Satisfactory results have been reported by Goodman, 34 Murphy, 35 and others, in cases which no doubt would have terminated fatally if this procedure had not been resorted to. Welch 36 in 1910 was so successful in treating hemophilic babies with fresh human serum that others have again revived its use. Among those who have employed this method in operative patients may be mentioned Meyer, 37 who used it as a preventive measure in cases of chronic jaundice and as a hemostatic in postoperative hemorrhages in such patients. Tilton 3S also used the fresh human serum successfully as a preventive treatment in such cases. The amount of fresh human serum to be given depends on the individual case. In hemophilic babies, Welch gave 10 c.c. of the serum subcutaneously, repeated two and three times a day, but would give this dose every two hours if necessary. He states that the error most commonly made is the giving of too small doses. Meyer gave 30 c.c. subcutaneously three times a day for the first day, 30 c.c. each day for three days more just before the operation, and 30 c.c. during the operation. If there is a tendency to bleeding during the convalescence, the injections are continued. Usually 100 c.c. are given during the first day hemorrhage is noticed and the dosage gradually diminished until there is no further oozing. If the serum is given intravenously, the dosage is not so great; Weil would cut the amount in half as compared to the subcuta- neous injection. Welch positively states that serum sickness does not arise from 340 AFTER-TREATMEXT OF SURGICAL PATIENTS the use of this serum but on the other hand "it is a perfect food already digested and ready to be taken up and utilized by the tis- sues and cells of the body." The subcutaneous injections do not cause pain and are most readily absorbed. In securing the serum for injection, the donor must he healthy. Fig. 49. — Apparatus used by Welch for collecting blood serum. It is preferable to have a Wassermanu done if possible. The col- lection may be easily accomplished by means of an apparatus which Welch first described in 1!)1<), and which is shown in Fig. 40. The needle of No. 19 caliber, is plunged into the median basilic vein HEMOPHILIA AND OTHER HEMORRHAGIC DISEASES 341 and the blood collected in the flask. "When the desired amount is obtained, the flask is placed in a slanting position in a basin where it remains four to six hours. After this time, the serum will have separated and will be ready for use. Locally, the same agents may be applied to the oozing surfaces as have been discussed for subcutaneous or intravenous use. If any of the stock sera are at hand, they may first be applied. It is not advisable to depend on any chemical, since none have proved trustworthy and the most efficient we have (adrenalin) may even cause a worse hemorrhage after the temporary effects wear off. Probably the quickest means at the surgeon's disposal, is to place fresh human blood on the surface. Sayer 39 recently stopped bleed- ing by applying a few drops of his own blood and other instances are reported in which relatives gave blood which was utilized in this way. 23 The thrombokinase, which seems necessary for coagula- tion may be supplied by kneading the tissues around the wound or by placing fresh tissue juices into it if fresh serum can not be had readily. 40 As a last resort, while fresh human serum is being secured for in- ternal medication, the bleeding surface may be seared with the cautery which is not at a red heat. Hahn reported two cases of hemorrhage from the gum and in which this most radical measure saved life. Constitutional treatment should be continued several days after the local bleeding has stopped and general measures instituted which will help the patient regain the lost hemoglobin. Bibliography iHess: Bull. Johns Hopkins Hosp., 1915, xxvi, 264. sFrugoni and Giughi: Semaine mecl., January, 1911. s Addis: Quart. Jour. Med., October, 1910. *Sajous: Analytic Cyclopedia Practical Med., 1916, v, 415. sSchwartz: Paris Med., October, 1.912. eMorawitz and Lossen: Deutsch. Arch. f. klin. Med., 1908, xciv, 110. 7 Moss and Gelien: Bull. Johns Hopkins Hosp., 1911, xxii, 273. sHowell: Am. Jour. Physiol., 1910, xxvi, 453. 9Sahli: Ztschr. f. klin Med., lvi, 1905. "Addis: Brit. Med. Jour., Nov. 5, 1910, p. 1422. ii Wright : Quoted by Kahn.12 isKahn: Am. Jour. Dis. Child., 1916, ii, 104. isEtlinger: Jahrb. f. Kinderh., 1901, liv, 24. lOsler-McCrae : Modern Medicine, 1914, iv, 727. isMorris: Clinical Laboratory Methods, New York, 1913, D. Appleton & Co., p. 261. "Internal;. Clinics, 1908, i, 31. I'Hinman and Sladen : Bull. Johns Hopkins Hosp., 1907, xviii, 207. isDelace: Jour, de med. de Paris, January, 1898. isRugh: Ann. Surg., May, 1907. 342 AFTER-TREATMENT OP SURGICAL PATIENTS soN/olf and Horry: Rev. de med., February, 1910. 2iNobecourt and' Tixier: Bull, med., Paris, October, 1910. 22Lereboullet and Vaucher: Bull. Soc. de Pediat, de Paris, 1914, iii, 132. 23Bien\vald: Deutsch. med. Wchnschr., 1897, No. 83. 24Felz and Pigot: Gaz. Hebdomadoire, 1897, No. 83. 25Fry: Med. Rec, New York, 1898. zeWeil: Lancet, London, March 7, 1907; also Med. Rec, New York, August, 1908, p. 322. 27Elicagary: These de Paris, 1907. 2sBaum: Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1909, xx, 1. 29Toussaint: Brit. Med. Jour., Apr. 6, 1907. soLommel: Centralbl. f. Inn. Med., 1908. xxix, (377. siTrembur: Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1910, xxii, 1. 32Broca: Lancet, London, 1910, ii, 203. 33Duke: Jour. Am. Med. Assn., 1910, Iv, 1185. 34Goodman: Ann. Surg., 1910, lii, 457. 35Murphy: Boston Med. and Surg. Jour., 1908, clix, 865. 36\Velcli: Am. Jour. Med. Sc, 1910, cxxxix, 12. 37Meyer: Surg., Gynec. and Obst., 1911, xiii, 1"_. 38Tilton: Med. Rec., New York, September, 1910. 39Sayer : Jour. Am. Med. Assn., Jan. 13, 1912. 40Gressot : Ztschr. f. klin. Med., 1912, lxxvi, 3. ullahn: Munich med. Wchnschr., May, 1913. CHAPTER XLII ARTIFICIAL RESPIRATION By Willard Bartlett and Adolpli Rumreich We will here consider artificial respiration as a resuscitatory measure. The historical development of the procedure will not be entered into here. Resuscitation, which consists almost entirely of methods of arti- ficial respiration, becomes called for in cases of suspended anima- tion from any of a number of causes, such as excess of chloroform or ether anesthesia, morphia narcosis, acute cocaine poisoning, drowning, electric shock, gas poisoning (carbon monoxide), suf- focation, increased intracranial pressure (e.g. r with hemorrhage, meningitis, etc.) Respiratory embarrassment under general anes- thesia will be chiefly kept in mind though most of the same general methods are applicable in respiratory failure due to any of the above causes. Artificial respiration in its application to thoracic surgery will not be considered here. To be effective, artificial respiration, no matter by what method it is effected, must be instituted early, immediately after respira- tion has failed, if possible. It is also indicated, of course, whenever signs of impending cessation of respiration develop on the operat- ing table. In ail eases of suspended animation, the probability of restoration decreases, as someone has put it, in an arithmetical progression from the moment when spontaneous respiration ceases. The lungs and heart possess a considerable degree of irritability, 1 and the respiratory centers have a stronger resistance than other parts of the nervous system, 2 but the weak point is the brain. After ten to fifteen minutes of complete circulatory failure, brain func- tions are not recovered. In chloroformed dogs the time limit is even less. 3 In man, recovery is. very uncertain beyond a ten min- ute interval. However, as the heart may beat for some time after respiration has ceased, so faintly as not to be detected, efforts at resuscitation should be persevered in. Manual Methods of Artificial Respiration Howard's Method. — In this, known also as the "direct method," the principle is active expiration by compression, and passive in- 343 344 AFTER-TREATMENT OF SURGICAL PATIENTS spiration by the recoil of the thoracic wall. The patient is placed in the dorsal position, and a support, such as a pillow, is placed under the hack, which produces hyperextension of the spine and renders the subcostal margin prominent. The operator places his hands over the prominent subcostal margins, the palms being be- low the margins, the fingers in the furrows between the ribs, and exerts pressure. The diaphragmatic ribs are thus depressed, the abdominal contents push the diaphragm upward, and the spine is partially straightened. The recoil after release of the pressure effects inspiration. With this method an abdominal type of respira- tion is produced. Advocates of it claim as an advantage that the blood is forced through the pulmonary circulation. Silvester's Method. — This was termed by the originator the "physiologic method." The patient is in the supine position. The operator stands at the patient's head, and seizing the bent arms above the elbows, lifts them towards the patient's chin, thus ren- dering the pectoral muscles taut. This effect is increased by evert- ing or laterally rotating the arms as they are lifted. The arms are then carried back towards the patient's ears; the humerus and shoulder are thus used as levers and the anterior wall of the chest is raised upward and forward. The 1 arms are held thus extended for a second or two; expiration is then produced by pressing the patient's arms firmly against the lateral Avails of the chest. The rate should be about fifteen times per minute. Brosch's Modification of Silvester's Method. — 1. After the arms have been extended as recommended by Silvester (Fig. 50), the movement is continued forcibly until the arms actually touch the table on which the patient is placed. This causes the body to arch upward so that it rcsis mi the tabic only at the shoulders and heels; the spine is hyperextended. Withdrawal of the force lets the body recoil on the table, and collapse of the chest commences. 2. In the respiratory movement the patient's arms are pressed directly over the sternum and the costal cartilages (Fig. 51), which are forced inwards. By this method a maximum active inspiration and a maximum active expiration ace secured, and a respiratory exchange greater than by any other method, as measured in cubic centime- ters per minute, is obtained. Some have even recommended addi- tional pressure on the abdomen 4 or the addition of Howard's method" 1 to augment the effect. The danger of acapnia by over- ventilation (Haldane and Henderson) with such a procedure has been pointed out, while the hyperpnea produced may even lend to death through shock.'' The expiratory maneuver of Brosch's modi- ARTIFICIAL RESPIRATION 345 flcation of the original Silvester method is generally acknowledged as a valuable feature and is now widely used. Silvester-Howard Method. — The operator performs the maneu- Fig. 50. — First act in the Sylvester method. Fig. 51. — Second act in the Sylvester method. vers of the Silvester method, while an assistant synchronously goes through Howard's maneuver — thus effecting greater ventila- tion. 346 AFTER-TREATMENT OF SURGICAL PATIENTS In any supine posture method the position allows the patient's tongue to fall hack against the posterior pharyngeal wall, and the epiglottis to close the larynx. The tongue should therefore be se- cured. If the patient is in a supine posture, the head should hang down over the edge of the table, or the shoulders may be elevated so as to lower the head ; the head and neck are to be extended as much as possible. Howard showed that by this procedure the epi- glottis is completely removed from the glottis, and a free passage of air is allowed. Martin and Hare, however, showed that this po- sition causes the soft palate to strap itself over the root of the tongue so as to cut off the entrance of air through the mouth. They proved that if the head be extended and at the same time projected forward, the above condition is obviated, and at the same time the epiglottis is well raised from the glottis, thus permitting free breathing through both mouth and nose. 8 ' 9 Schafer's Prone-Pressure Method. — By this method the lower part of the thorax is compressed, and in addition the diaphragm forced upward by the abdominal viscera. The patient is laid in the prone position, the face turned slightly to one side, so as to leave the nose and mouth free for breathing. An assistant draws the tongue forward. The operator kneels beside or straddles the patient's thighs, facing his head, and applies his hands to the back, one on each side of the spinal column, the palms on the muscles at the small of the back, thumbs nearly touching each other, and fingers spread over the lower ribs. Keeping his arms straight, the operator with a forward swing throws the weight of his body slowly upon the patient, thus causing contraction. This movement takes two to three seconds. He then raises his body and relaxes pres- sure, allowing the thorax to expand by recoil. After two seconds the movement is repeated. The complete movement thus occupies four or five seconds, giving a rate of 12 to 15 times per minute. The method is rendered more effective if the arms are extended forward as straight as possible. 7 There is considerable controversy over the merits and faults of the various manual methods. All have been accused by the op- ponents of causing rupturing of the congested liver or fracturing the ribs, especially in old persons. These accidents are very rare and are manifestly due to improper technic. The prone posture permits mucus and saliva, which are secreted excessively in general anesthesia, to flow out of the mouth. Of the supine posture methods the Silvester method with the Brosch ex- piratory modification is most widely used. The choice of position ARTIFICIAL RESPIRATION 347 and method is evidently determined by the conditions in each case where employed during a surgical operation. Artificial Respiration with Apparatus Pulmotor. — This is an ingenious mechanical device, consisting of a tank of compressed oxygen, connected through a reducing valve with an injector to draw in air, a hose delivering the air-oxygen mix- ture to a close-fitting face mask, and an automatic mechanism to regulate expiration and inspiration. Serious faults were found by the Commission on Resuscitation; 7 among them, that any ob- struction to the flow of air will cause such a rapid succession of suction and injection as to make the apparatus inefficient and that the automatic reversal mechanism readily gets out of order. 7 The ''Pulmotor Model B" is a newer apparatus, in which the automatic feature is replaced by a hand control. Compressed air or oxygen or an electric air blower may furnish the motive power. This form of instrument is preferable to the automatic type. The latter in fact should be condemned. As to the actual amount of oxygen delivered in the air-oxygen mixture, Haidane and Henderson found it to be only 26.75 per cent, which is not much enrichment, consider- ing that pure air contains 21 per cent oxygen. The Dr. Brat apparatus is similar to the pulmotor, except that it feeds pure oxygen, and produces greater pressure and suction. It is hand regulated. Lungmotor. — This device consists of two pumps, connected by a hose to the face mask, and so arranged that the down-stroke in- jects air, while the up-stroke produces suction. An oxygen tank may be connected up and the injected air enriched with oxygen to the desired degree. Several other devices, all similar to those above described, and made on the same principle, are on the market. Objection has been offered to the suction feature of these devices by the Commission on Resuscitation 7 and others on the ground that it causes collapse of many of the alveoli, which then stick together and are not ef- fective, also that it causes collapse of some of the bronchioles, which traps a certain amount of air in a dead space, the movement of which simulates respiratory movements with an actually les- sened gaseous exchange. Meltzer's Pharyngeal Insufflation Apparatus. — 10 > " With this ap- paratus the necessary inspiratory pressure is obtained by means of a foot bellows, or from an oxygen tank or other source of constant 348 AFTER-TREATMEXT OF SURGICAL PATIENTS pressure. The air or oxygen is delivered by a hose to the pharyn- geal tube, which is so constructed as to close the entrance to the nasopharynx and thus prevent escape of air through the nose, while it permits it to enter the lower pharynx freely. A slight escape through the mouth, around the tube, is negligible but usually there is none. The pharyngeal tube also has a hole through which a stomach tube (size 33 French) may be, and preferably should be, introduced, to permit the escape of any air reaching the stomach. A respiratory valve is inserted in the connecting hose. This valve is regulated by the operator, alternately allowing an inspiratory blast and the escape of expiratory air, A large rubber bag is in- terpolated between the valve and the source of pressure. A T-tube with a clamp-screw on its free rubber end is interpolated between the respiratory valve and the pharyngeal tube; this regulates the amount of air intake. A padded wooden board is used to compress the abdomen by means of belts. This prevents the entrance of air into the stomach. It may thus he used to supplement the stomach tube, or either may be used alone, depending on circumstances. A further advantage is claimed for the board, that its use drives blood from the splanchnic area toward the heart. In applying the apparatus, the tongue is pulled ou1 by forceps, and after the pharyngeal tube has been inserted, the tongue is tied to it by means of tape. This prevents the tongue and glottis from falling back, and also keeps the tube in place. This method has been reported to be very efficient, and was rec- ommended by the Commission. Intralaryngeal Insufflation. — Among the devices for effecting in- tralaryngeal insufflation are the Fell O'Dwyer apparatus, with bel- lows; and the apparatus devised by Matas, 12 consisting of a modi- fied O'Dwyer cannula connected with a graduated, adjustable pump for injecting the air. but with no return suction. Intratracheal Insufflation of Meltzer and Auer. — Meltzer consid- ers intratracheal insufflation the most reliable method of artificial respiration: and its use has been recommended wherever possible. An endotracheal tube is introduced instead of the pharyngeal tube, otherwise the same apparatus may he used. As to the comparative efficacy of the manual and the mechanical modes of artificial respiration, the claims are somewhat conflicting. The best authorities, however, hold that in cases in which natural respiration has ceased but the heart still beats, artificial respira- tion by apparatus (pump or bellows) will maintain life more easily and much longer than employment of either of the two most widely ARTIFICIAL RESPIRATION 349 used manual methods, the Silvester and the Schafer. 13 The weak point of the compression methods is the low ventilation, which decreases as the muscles of the body lose tonus. 14 The inflation methods unquestionably produce greater ventilation. For the manual method, a noted physiologist 13 says: "I have a strong impression that during the first minute after the cessation of respiration (in anesthesia) the administration of manual arti- ficial respiration is more effective than that by means of a pump or bellows, the reason apparently being that a slight assistance is given to the heart and circulation by the manual method which is not afforded by mere changes of air pressure in the lungs. Cer- tainly both in the laboratory and operating room, the immediate application of manual artificial respiration is effective in restoring normal breathing." The objection has also been raised against in- flation methods that they may injure the lungs by the violent as- piration. 7 ' 12 Keith 15 objects that inflation is not physiologic, i. e., does not correspond to the normal mode of producing breathing. He, however, states: "My mind is open to the conviction that the an- cient method of mouth-to mouth insufflation with expiratory com- pression of the chest may not prove more effective than either Silvester or Schafer Methods." Laborde's Tongue Traction. — This procedure is a valuable agent in reestablishing respiration. In anesthetic accidents, simple trac- tion on the tongue a few times may restore breathing, acting in such cases by lifting the epiglottis and thus preventing its occlud- ing the larynx. Laborde's traction is executed thus: Grasp the tongue deeply s.o that the entire organ is acted on, draw it out forcibly and sharply, then relax suddenly and completely. Do this at a rate of about fifteen times a minute. This method acts by inducing reflex ac- tion on part of the diaphragm. Laborde traced the impulse through the glossopharyngeal and lingual nerves to the respiratory center, and thence to the phrenic and other respiratory nerves. The method is a valuable adjunct to the use of artificial respiration proper. Stimulation of the Circulation Artificial respiration acts as a circulatory stimulant by sufficient oxygenation of the blood ; the contractility and conductivity of the cardiac muscle are increased and the heart picks up. 350 AFTER-TREATMENT OF SURGICAL PATIENTS Heart Massage Indirect or Extrathoracic Massage. — This procedure is often a valuable adjunct to artificial respiration. The massage is executed by rhythmical compression of the thorax over the heart by means of the hands. With some of the manual methods of artificial res- piration heart massage may readily be incorporated into the ex- piratory maneuver, e. g.. in the Silvester-Brosch method. Mas- sage has also been done from the abdominal cavity through the diaphragm. Direct or Intrathoracic Massage. — This method is much more ef- fective, but is, of course, to be considered a last resort on account of the danger of the surgical procedure, of mechanical injury to the heart, and of the risk of infection. In anesthetic accidents the success of the method has been indifferent (Stewart). Respiratory Stimulation Sodium Cyanide. — Recently Loevenhart and associates 16 have se- cured strikingly good results in the use of sodium cyanide as a respiratory stimulant in respiratory failure due to increased in- tracranial pressure, deep chloroform and ether anesthesia, and some other conditions. The drug is administered by slow intravenous in- jection of the fiftieth normal solution (0.1 per cent). Response is quick. The injection must be properly controlled and the patient be under observation. The method is very promising. Electricity. — The use of a faradic current for resuscitation pur- poses has been shown to be useless and may even be harmful. 8 Adrenalin. — Adrenalin injected intravenously is said to be use- ful in circulatory failure. Experimentally, Crile and Dolley se- cured good results by intracarotid injection of adrenalin in saline infusion, directed toward the heart, combined with artificial respiration and indirect heart massage, in cases of complete heart failure. Crile has used the method successfully on human beings. There are others who do not approve the method. 2 Oxygen Inhalation.— Compressed oxygen is widely used as an adjuvant to the various methods of artificial respiration. Objec- tion has been raised to prolonged administration of pure oxygen. Position. — The Trendelenburg posture has been advocated except when the face is cyanosed. It has also been cautioned against in persons with large abdomens, owing to the pressure of abdominal contents on the diaphragm. Application of heat, by hot-water bot- tles and hot blankets, is useful. Friction of limbs, slapping of the ARTIFICIAL RESPIRATION 351 body or face with a towel wrung out of ice water, forcible dilata- tion of the sphincter ani, mechanical and chemical (ammonia) stimulation of mucous membranes of the nose, of the precordial or pudic regions or of the soles of the feet, are useful forms of stimu- lation and should not be neglected as adjuvants to the other meth- ods used. Full credit is due Adolph Rumreich for having abstracted all the literature to which reference is made in this chapter. Bibliography iCarrell and Guthrie: Am. Med., 1908, x. sCrile and Dolley: Jour. Exper. Med., 1906, viii; ibid., 1908, x. sStewart, Guthrie, Burns and Pike: Jour. Exper. Med., 1908, x; Am. Jour. Physiol., 1908. 4Aron, E.: Berl. kliu. Welmsehr., Feb. 8, 1915. sHerter, G.; Deutsch, med. Wchnschr., 1905. i. eEysselsteijn: Die Meth. der Iviinst Stm. Julius Springer, Berlin, 1912. "Eeport of the Committee on Besuseitation from Mine Gases, Cannon, Crile, Erlanger, Henderson and Meltzer: Tech. Paper 77, Bureau of Mines, Dept. of Interior. sHare: Keen's Surgery, 1911. v. sHare: Bull. Johns Hopkins Hosp., 1895. icMeltzer: Jour. Am. Med. Assn., 1913, lx. "Meltzer: Med. Bee., Xew York, July 7, 1917, xcii. 12 Matas, B.,: Jour. Am. Med. Assn., 1902, iii. isHenderson, Yandell: Jour. Am. Med. Assn., Julv, 1916, Ixvii. "Liljestrand : Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1913, xxvi. i5Keith: Hunterian Lectures, Lancet, London, 1909. isLoevenhart, Lorenz, Martin and Malone: Arch. Int. Med., 1918, xxi. CHAPTER XLIII POSTOPERATIVE FEEDING By J. W. Larimore, St. Louis, Mo. The problems of postoperative feeding have for the result of their solution the maintenance of body nutrition during a period of acute physiologic disturbance, and frequently, later, through a period of physiologic adjustment. It is often necessary to hold in abeyance for variable periods all energy intake and leave the body to continue on its own resources, which alone introduces all the alterations of normal metabolism incident to partial or com- plete starvation. The first problem is the early resumption of food intake. Dietet- ics of postoperative conditions is based upon the fundamental facts of nutrition in an effort to approximate or maintain full nutrition, as well as may be possible under the limitations of disturbed physi- ology. The maintenance of nutrition during a postoperative course is quite as great a gain for the patient, as has been the maintenance of adequate nutrition in those infectious fevers, where formerly medical treatment included extreme starvation. The process of re- pair and the resistance of the patient are augmented and the con- valescence and regaining of strength greatly shortened. Adequate nutrition can at no time be withheld without detriment to the body functions and in operative conditions where suspension of diet is unavoidable, the early resumption (Fig. 52) of partial or adequate nutrition is urgent, and offers the greatest aid to the return of normal physiologic adjustments and to the successful outcome of the surgical measures. Physiologic disturbances result from various fundamental causes often irrespective of operative procedures. The pathology may be such as to alter metabolism or to present mechanical difficulties to ingestion and digestion, these latter not always being entirely relieved by the operation. The postoperative feeding must neces- sarily be adjusted to these uncorrected conditions. A diabetic should not have and could not utilize the carbohydrates which are otherwise of immediate preference in postoperative feeding. Stenosis of the esophagus, of course, is not relieved by gastrostomy. The physiology is further altered by the invasion of the disease into 352 POSTOPERATIVE FEEDING 353 various organs necessary to the digestive process, or to interme- diary metabolism. These considerations influence more the charac- ter of postoperative diet than its manner or degree. Anesthesia disturbs the mechanical functions of the gastrointestinal tract and the degree of this disturbance determines the time of resuming feeding and also the amount of feeding. General anesthesia also has a definite effect upon intermediary metabolism, promoting those con- ditions which give rise to acidosis with acetonuria. or acetonemia. Local anesthesia has no great or direct effect upon the mechanics of the gastrointestinal tract. The physiologic processes are further disturbed by postoperative Fig. 52. — -A convenient scheme for early administration of fluids. complications, among which the chief are infections, acute cardiac dilatation, acute dilatation of the stomach, intestinal ileus, hemor- rhage, and shock, also pneumonia and cardiac disturbances. The nature of the operation, of course, is most important, in an- ticipating or determining the nature and degree of the dietetic problems. Minor surgery seldom necessitates any postoperative con- sideration of diet. Major surgery will vary in its influence upon nutritional factors according as it involves structures removed from the enteron, or as it may be upon organs collateral to the enteron, or upon the tract itself. 354 AFTER-TREATMENT OF SURGICAL PATIENTS The extent of the starvation period which is necessary fol- lowing- many operations is necessarily determined by the physi- ologic disturbances which have resulted and which would prohibit or limit feeding. The manner in which the patient endures this starvation period, especially if it he extended, will depend upon his preoperative nutritive condition. This often has been greatly impaired as the direct result of the pathologic and physiologic status of the disease. It is also determined by the manner of pre- operative feeding which often has been practically a longer or shorter period of partial starvation, frequently to the point of es- tablishing a marked acetonemia. Often one or several days of complete starvation have preceded the operation. Such conditions naturally lessen the facility with which the patient endures a post- operative period of complete or partial starvation. It is also proba- ble that the acidosis and the increased H-ion concentration of the blood resulting from the preoperative starvation increases the det- rimental effects <>f general anesthesia and promotes those conditions which simulate or may become actual shock. It is desirable that prior to operation the nutrition <>f the patient should receive careful attention and be raised to the highest possible level, continuing feed- ing even to a few hours prior to the operation. Other preoperative measures in management and preparation have their bearing upon postoperative feeding, especially those directed in the condition of the intestines. The colon should be empty. The manner of accom- plishing this is important. Purgatives accomplish the result by a mosl violent, unnatural action, and they Leave the intestines in a condition of marked peristaltic disturbance, and. as a collateral effect, disturb the vasomotor and other controls of the circulation of both blood and lymph. For such a result of purgation to be presenl at the time the abdomen is opened increases the tendency to shock and intestinal paresis, which may resull from trauma and from the general anesthesia. It is best that the emptying of the colon by purgation should be accomplished a few days prior to op- eration. Parallel case series have shown that purgation just prior to operation increases the ballooning of the intestines and the diffi- culty of keeping them within the abdomen at laparotomy, and also greatly increases the frequency of postoperative lnis pains and cramps. Animal experiments have shown thai gas absorption as normally occurs fails in the purged intestine. In most e;ises where the colon needs attention, immediately prior to the op- eration, a large enema is usually effectual, and is the only measure POSTOPERATIVE FEEDIXG 355 without undesirable effects at laparotomy. It is also very adequate for all other operations. Preoperative measures are, of course, not possible in emergency operations. In emergency laparotomies a large cleansing enema, (when allowable) is the most satisfactory preparation of the colon. In elective operations sufficient time should be taken (from two to seven days, or even more; to secure the best possible state of nu- trition and gastrointestinal adjustment. With pyloric stenosis a few, or. in the lesser grades, several days of careful feeding and lavage once or twice daily will accomplish a considerable improve- ment in nutrition, and a lessening of the edema and the atony of the stomach walls, which will be very satisfactory to the op- erator and will facilitate postoperative gastric functioning. These days will allow for cleansing of the gastrointestinal tract by a laxative and enema and the return of normal peristaltic stability. If constipation has been usual with the patient, the use of small enemas of magnesium sulphate, three ounces of the saturated solu- tion, will assist not only in the emptying of the colon, but will help correct also any spasticity which may be the cause of the constipa- tion, and which would, postoperatively, be a factor in gas retention. Nutrition should be brought to an adequate level, sufficient to re- lieve any acetonemia, which may have resulted from the patient's limitations of diet, self-imposed or otherwise advised. On the day prior to the operation it is desirable to force carbohydrate foods. This is an effort to hyperglycogenize the patient. I have noted in cases of rather extreme malnutrition, where a sufficient time could not be taken to correct the condition, or when the pathology obvi- ated correction, that intravenous glucose injections gave splendid results in lessening the postanesthetic gastric disturbance and the urinary acidosis. It is the aim of postoperative feeding to attain as rapidly as is safe the necessary energy-requirement for the basal metabolism of a patient under such conditions. The range of this energy require- ment will be from 1000 to 2000 calories. (By a calorie is meant the amount of heat necessary to raise one liter of water through one degree of centigrade temperature.) This will vary according to many factors: (1) age; (2) according to the nutritive condition of the patient, whether emaciated, thin, robust, or fat; (3) according to any febrile condition present ; and (4) according to the state of rest, whether sleeping, nervous, restless, etc. One effective guide to the adequacy of any diet is the acetone reaction of the urine, 356 AFTER-TREATMENT OF SURGICAL PATIENTS which will be positive when the diet is less than the starvation level. The total number of calories that may be given is, of course, not limited to the minimum energy needs. The patient should be given a very large energy supply when it becomes safe to do so, in a diet adjusted to the postoperative gastrointestinal situation and to any general condition. Ulcer of the stomach or duodenum and gastro- enterostomy should be protected from recurrence of activity if the original ulcer has been untouched, or from the development of a stoma or jejunal lesion. Ileostomy necessitates providing the op- portunity for the terminal ileum to assume the functions of the colon, and this is in large part done with dietetic measures. Such general conditions as diabetes, cardio-renal hypertension and gout must be considered in outlining the diet. The immediate postoper- ative problem is, however, to secure adequate energy intake. Fat is equivalent per gram to 9.3 calories; protein to 4.1 calories, and carbohydrate to 4.1 calories. Carbohydrate is the type of food preferable in postoperative diet. It is quickly absorbed and easily available for energy. Dextrose itself is absorbed within 30 minutes (there being no gastric motor delay) and is immediately available for energy. Protein, by a spe- cific dynamic action, raises the level of basal metabolism and in- creases the heat output of the body, and adds very considerably to the energy requirement. It is desirable only in moderate quantities. Protein is seen clinically to afford strength to a patient which can not be secured by a diet otherwise calorically adequate. This is perhaps directly associated to its specific dynamic action. Fat because of its high caloric value is of great advantage in securing high energy intake in a small bulk. It is often essential to calculate the per- centages and caloric values of the diet. For anyone who does not use such data daily, and therefore does not hold it in mind, it may be readily found in any book on general dietetics. A guess at dietetic values can easily be wrong, and Only by careful calculation can one be sure of adequate nutrition. In protracted and difficult cases, where a progressive increase in the diet is impossible, accurate calculation must be done to have any sure conception of the nutri- tional situation. Fluid is volumetrically the greatest of the body's requirements, and this is greatly increased by postoperative disturbances. Water is lost by the body, not alone by the mine, but also through the skin and lungs, and this normally amounts to from BOO to 800 c.c. in a day. The loss of water vapor through the lungs and skin during POSTOPERATIVE FEEDING 357 and after anesthesia is very greatly increased. This dehydration of the patient occurs not alone from water lost, but also because all fluid intake is stopped or limited. The loss of fluids is further aug- mented by the creation of any drainage fistula?, especially biliary. A postoperative diarrhea greatly increases the loss by preventing the body 's water economy which occurs by resorption in the cecum. Postanesthetic vomiting may account for a great loss of fluids. The measures of postoperative feeding may be divided into those directed to the immediate and acute situation, and those directed to the more remote problems. The immediate condition is in greater part the result of surgical wounds of the gastrointestinal tract and of the anesthetic. The great amount of water lost through the skin and lungs creates a greater or less degree of dehydration, which in any event it is important to quickly relieve. At times re- lief becomes urgently necessary. On the other hand, in the pres- ence of circulatory disturbances, especially in the aged, and even when general dehydration is fairly extreme, there may be such a plethora of the lesser circulation as to contraindicate the addition of fluids by any other manner than oral administration. Water may be given by proctoclysis, hypodermoclysis or even intravenously. Should it be given intravenously, it is a great advantage to give a glucose solution, and thereby add a large energy quotient. This solution may range in percentage from five to twenty and should be made with anhydrous dextrose. Two to four per cent of sodium bicarbonate may be added if desired. It is also desirable that the proctoclysis contain glucose. Three to five per cent glucose solu- tion is borne by the rectum about equally as well as tap water or saline. There is seldom any contraindication to allowing water in small amounts by mouth immediately after operation. Even with vomiting, fluid intake will often have a quieting effect, and if not, it will add greatly to the ease of vomiting, and will accomplish a spontaneous lavage of the stomach. However, unless relief is quickly gained more direct measures must be used and especially in laparot- omized cases. Gastric lavage should be used freely in the hours immediately postoperative, and is perhaps one of the most effectual measures in returning the stomach to the function where it will receive and al- low the progression of food. This is especially true after stomach operations. These stomachs may retain, even without any retching or vomiting, and with perhaps nothing more than a slight nausea, 358 AFTER-TREATMENT OF SURGICAL PATIENTS very great amounts of hyperacid secretion mixed with old blood. Such retention increases the possibility of acute dilatation. The progression in diet should be as rapid as is safe. Usually by the end of the third day all acute symptoms are past. The distention of the intestines postoperatively often gives great hindrance to in- crease in diet. Tympanitis is especially distressing. It interferes with proctoclysis and increases nausea and retching. The use of small enemas of magnesium sulphate as has been described above is very effectual in relieving the condition. When it is slight and unaccompanied by nausea and retching, the postoperative diet should not be stopped. Rather, the entrance of the food into the stomach is often a positive aid in the establishment of the normal reflexes and tonus, which will overcome the tympanitis, assist in the release of flatus, and secure the first postoperative defecation. There are those cases which upon each intake of food or fluid have an urgent desire for defecation or even intractable diarrhea. This is a disturbance in the autonomic nervous system and is controlled by liberal use of atropine to its physiologic limits. Late after operation, vomiting is at times, even when the enteron has been untouched, perniciously prolonged without discoverable cause. It is apparently intractable, and nutrition suffers greatly. When there is no other accompanying condition which contraindi- cates, feeding should be continued and forced with a selection of the simpler mobile foods and an avoidance of cellulose roughage. Such vomiting is usually on a neurotic basis. It gives rise to an acetonemia which increases all general nervous disturbances. Usu- ally by persistent feeding with consequent relief of the acetonemia and by the use of sedatives, this vomiting can be eventually con- trolled, and the patient returned to a normal diet. It is in these cases so often that rectal feeding is used. The absorption of other than the sugar content of any nutritive enemas is very doubtful. The use of other than the glucose proctoclysis in rectal feeding only clouds the estimation of the energy supply that is being secured and too often allows the assumption that greater help is being at- tained than is actually the case. The remote problems of postoperative diet are directed to those conditions which will assist in a complete cure of the patient, such as the relief of constipation after appendectomies or hemorrhoid- ectomies; the fattening cure after nephropexy; the careful pre- scription of a nephritic diet following other kidney operations; and in the presence of a biliary or pancreatic fistula, the avoidance of POSTOPERATIVE FEEDING 359 those articles or types of food, which need for their digestion and absorption the secretions which are lost to the body. The following postoperative diet, which is for a general applica- tion after laparotomies including gastroenterostomy, is very con- servative, and when used routinely has given large advantage and satisfaction. Often it may be increased more rapidly than is indi- cated. It is often considered very unpalatable by the patient, and may have to be urged as a necessary measure similar to medicines. Preparation : First Day: (Day of Opera- tion) Second Day: Postoperative Diet In addition to the preoperative diet, which should continue to and include on the evening prior to operation liberal liquid nourishment, give 3% glucose as proctoclysis, continuing from noon until morning after operation. 3% glucose as proctoclysis. Water, small sips, ad lib. Third Day : Fourth Day: X grains of Sodium Citrate in II ounces of water every 3 hours. Junket or oatmeal jelly, I ounce at a feeding, every 3 hours; to alternate with Sodium Citrate Solution. Continue 3% glucose as proctoclysis. Feed every 2 hours, alternating Junket, oatmeal jelly, or Bulgarian milk and cream (2/3 and 1/3) ; II ounces at a feeding. (One or two feedings during the night if awake.) Feed every 2 hours. Same as on third day, plus custard, blane-niange ; gelatine, served with sugar of milk and cream. One seven-minute egg. 7:00 A.M. One-seven-minute egg. 9:00 A.M. Oatmeal jelly. 11:00 A.M. Custard. 1:00 P.M. Junket, 3:00 P.M. Blanc-mange. 5 : 00 P. M. Bulgarian milk. 7:00 P.M. Gelatine. (This order may be rearranged.) Increase cpiantity to IV ounces with feedings 2% hours apart. Same articles. Junket, oatmeal jelly, custard, blanc-mange, and gelatine, to be made up with sugar of milk (no cane sugar used in list). Operations about the mouth, head, and mediastinum, even when of a minor nature, may give mechanical difficulties to feeding. This may necessitate the use of a tube for the introduction of food into Fifth, Sixth and Seventh Days: 360 AFTER-TREATMENT OF SURGICAL PATIENTS the stomach. Infections accompanying or following surgical condi- tions introduce dietetic problems, chiefly because of the effect of the resulting toxemia upon gastric secretions and motility. Carlson states that experimental infections are shown to cause complete atony and absence of gastric hunger contractures and that bacterial toxins may depress the motor mechanism of the stomach directly, lower the vagus tonus, augment inhibitory reflexes, or induce ex- cessive secretion of epinephrin. Cannon has observed that infec- tions also depress the digestive peristalsis of the stomach and in- testines in cats. In the presence of such inhibitions from toxemia the size and character of the feeding must be of the simplest kind to obviate accumulation in the stomach and its attendant results; distention, belching, nausea and vomiting, and flatulence. This toxemia may even be a basis for an acute dilatation of the stomach. In acute dilatation of the stomach following anesthesia, rest of the organ is imperative, and this will prohibit food and fluids by mouth. In all cases of persistent vicious vomiting, often with re- sulting acute dilatation, lavage is the greatest help. This should be used freely, and will give the patient more comfort and the sur- geon greater protection against postoperative gastric conditions than any other measure. In dilatation of the stomach in soldiers due to anesthesia and shock and to toxemia, I have used, with very great success, the gastroduodenal tube for constant and in- terrupted drainage. The tube is retained in the stomach and, at first, constanl drainage is maintained, allowing small amounts of water by month for lavage. When this lavage water only is re- covered and no additional quantity due to secretion, then small hourly feedings of a simple nutrient fluid may be begun, and the tube clamped. The stomach is drained prior to each feeding. Com- parison of the quantities given and recovered will indicate the de- gree of motor recovery of the stomach and determine when tube feeding and drainage may be discontinued. After shock, even water will be contraindicated. The engorgemenl which exists in all of the splanchnic, area will allow no absorption, rather we may expect a secretion of thuds due directly to the engorgement. This will also necessitate Lavage. It is doubtful whether in these cases proctoclysis is accomplished, due to a similar lack of absorption. The only routes for administering fluids in a condition of shock are subcu- taneous or intravenous. Peritonitis, when acute and general, indicates rest of the intes- POSTOPERATIVE FEEDING 361 tinal tract and the suppression of peristalsis. The general rule has been to avoid for long periods nutrition and fluid by mouth and to give nutritive enemas. The latter doubtless will create as much peristaltic unrest as will bland and nonstimulating fluids by mouth. It must be remembered that the infection itself has inhibited peri- stalsis. Often, however, associated vomiting will prevent oral feed- ing. Flatulence and fermentative processes are dangerous and the residue starches must be avoided. Nutrition becomes imperative if the patient's resistance and recuperative powers are to be supported and maintained. The surgical postoperative diet, as has been given, but with slower progression, can be used to advantage in this con- dition. An initial starvation period of 48 hours should be used, but feeding should be started early enough and in sufficient amount to prevent acetonemia, which is the first indication that nutrition is beginning to suffer. In localized, acute peritonitis the dietetic prin- ciples are the same as in general peritonitis. In chronic peritonitis, which is usually of tuberculous, origin, there is often an accompanying diarrhea, perhaps due to exudative proc- esses and perhaps to lack of absorption. Depending upon the de- gree of this disturbance, the food must be more or less residue free. In any case there must be a simple, bland diet. Hypernutrition is not contraindicatecl. Flatulence and the distention of the bowels are to be avoided. In cases of obstructive jaundice relieved with a biliary fistula, there is a large danger jof a yellow atrophy of the liver with fatal termination. The liberal use of carbohydrates is of the greatest service not alone in nourishing the patient, but in the protection of the hepatic parenchyma. The enterol digestion of carbohydrate is more complete than that of other foods where there is a partial or complete absence of bile in the intestines, and the liver is relieved of its metabolic functions, in handling fat especially, and also the protein products. The carbohydrate has been shown to have a di- rect protective action. The postoperative diet of gallstone cases should be very poor in fat, and obese patients should be urged to re- duce. The hypercholesterinemia which is present in these cases is thus corrected. CHAPTER XLIV REDUCTION OF OBESITY By Willard Bartlett and Alfred Goldman, St. Louis, Mo. The postoperative treatment of the obese is of especial interest from two standpoints: first, directly, by aiming- at the particular or- gan or region involved ; second, indirectly by building up the general condition of the patient. The treatment of obesity is of importance after abdominal operations, where an excessive panniculus and sub- peritoneal fat are prone to produce postoperative hernia. It is also of importance in that it improves the cardiovascular, the respira- tory, the digestive systems, the smooth working of which is es- sential to a good recovery. Moreover it seems a most Logical tiling to start the treatment of such a condition after a surgical operation; first, because the patient's metabolism is of oecessity much deranged, his ingestion considerably diminished, etc; second, because a rigid reduction treatment must lie carried on under careful supervision to be effective, preferably therefore in an institution. It is essential to determine when a reduction is indicated. When this is determined and the proper methods of treatment applied, then a reduction will strengthen the patient. The indications have been aptly considered in this class of cases by von Noorden and others. A high degree of obesity, 1 which may be arbitrarily taken as 70 pounds or more than the weight corresponding to a normal indi- vidual of the same height is always to be considered as an indication for reduction. In children and in the aged, one should be careful in advising treatment. A moderate degree of obesity I 40-70 pounds over weight) is an indication for reduction in the young and middle-aged, unless there is some special contraindication. In older people, as a rule, it should not be advised. A slight degree of obesity. (20-40 pounds over weighl I is not an indication for treatment, unless there is a tendency for the condi- tion to be aggravated. In such a case, reduction can be made very effective with slight restrictions. Certain special conditions call for a reduction core, even in mild cases of obesity. They are disease^ of the circulatory system, chronic 362 REDUCTION OF OBESITY 363 bronchitis, or emphysema, in which the removal of an excess weight will enlighten the burden of the various systems. In contracted kidney, reduction should be very gradual. Advanced age is a contraindication. Diabetics and gouty individuals do better when there is a certain degree of obesity. The same may be said of cases of pulmonary tuberculosis. Any rational treatment of obesity must, of course, seek to do one thing, namely, to make the expenditure of energy greater than the energy intake of food. This means that the body makes up its def- icit from its own tissues, and as is well known, will obtain this chiefly from its adipose supplies. Obesity may be due to many various causes. Before devising a plan of treatment, it is essential to obtain an accurate account of the habits of the individual, for treatment must be adapted to fit the cases. If there is an outstanding etiologic agent, this should be removed first. All dietitians consider treatment under three heads : dietetic, mechanical and medicinal. 1. Diet. — All rules in regard to dietary measures should be based on caloric feeding. The food must be weighed and measured, at least at first, and the patient must be accurately weighed at short intervals. There are a number of "systems" in vogue, the principal ones being those of Banting, Ebstein, Oertel, and von Noorden. In Banting's 2 method, sugar, fats and starches are greatly restricted; water is not reduced, and alcohol is allowed. This system with its high protein content and small amount of food in general, has been called "unphysiologic and impractical." In Ebstein 's 3 system, the proteins and carbohydrates are dimin- ished and fat is increased. Ebstein found that when fat forms a large element in the diet, a feeling of satiety is readily produced, so that the total food contains fewer calories. This does not always hold by any means, since the patient may soon cease to be affected in this manner. Oertel's 4 method is good for cases of obesity with weak hearts. Oertel allows little fat but more protein and carbohydrate than Ebstein. "Water is greatly diminished, only one pint of free water being allowed, and one pint along with the food. His diet-table follows : Carbohy- Albumia Fat drates Calories Minimum 156 25 75 1100 Maximum 170 45 120 1600 364 AFTER-TREATMENT OF SURGICAL PATIENTS The following is an illustration of Oertel's dietary: Morning: A cup of coffee or tea with a little milk about six ounces (178 c.c.) altogether; bread, three ounces (93 gm.). Noon: Three to four ounces (90 c.c. 120 c.c.) of soup; 7-8 ounces (218 gm. to 248 gm.) of roast beef, veal, game, or poultry; salad or a light vegetable; a little fish, 1 ounce (32 gm.) of bread or farinaceous pudding; 3-6 ounces (93-186 gm.) of fruit for dessert. No liquids at this meal, as a rule; but in hot weather 6 ounces (178 c.c.) of light wine may be taken. Afternoon: Six ounces (178 c.c.) of coffee or tea, with as much water. An ounce of bread. Evening: One or two soft-boiled eggs, 1 ounce (32 gm.) of bread, perhaps a small slice of cheese, a little salad, and fruit; 6 to 8 ounces (178 c.c. to 236 c.c.) of wine, with 4 or 5 ounces (120 c.c. to 148 c.c.) of water. Some 5 cases of obesity are due mainly to an excessive amount of water in the tissues. In such a case, Kanke's diet is to be recom- mended, meat, 280 gm. ; fat 100 gm. ; bread, 400 gm.; the limitation of the amount of fluid ingested, allowing only 400 c.c. more water to be taken daily in drink and food than the daily amount of urine secreted. To carry this out, the percentage of water in different forms of food must be estimated. Von Noorden's 1 dietetic measures are widely recognized and are based on scientific principles. In every case a general estimate should precede the actual reduction cure in order to determine the patient's "maintenance diet.'' Since the obese tissue does not par- ticipate in energy production one must calculate by how much the weight of a stout individual exceeds that of a normal person of the same height. The number of calories essential are obtained by mul- tiplying the body weight by the caloric value per kilo. The maintenance diet of an obese patient is then the caloric value per kilo, multiplied, not by the weight of the patient, but by that of a normal individual. Of course, there are certain errors involved, but for practical purposes this method suffices. Von Noorden 1 recognizes three degrees of reduction diet. If, for example, the maintenance diet of an individual is estimated at 2500 calories, the' three degrees of diet reduction would be: (1) four- fifths of the demand, or 2000 calories; (2) three-fifths of the de- mand, or 1500 calories; (3) two-fifths of the demand, or 1000 to 1500 calories. For Diet I, omit all visible fat, as butter, oil, meat fat; also prepare vegetables and dishes made Prom flour with little fat. REDUCTION OF OBESITY 365 This measure would cut calories down to 2000. For Diet II, besides the above, dishes from flour, stewed fruits, and milk, must be omitted. These patients should eat abundant albuminous foods, as lean meat and cheese. For Diet III, the following articles of food should comprise the diet: Coffee, tea, meat broth (fat skimmed off) with vegetables, lean meat or fish, lean cheese, abundant green vegetables and salads with little fat and oil; vinegar, lemon, pickles, tomatoes, celery, radishes, raw fruit, with small percentage of sugar (apples, peaches, strawberries, raspberries, currants, blueberries, grape-fruit, early oranges), coarse bread (bran or graham) in quantities from 40 to 70 grams, potatoes (in quantities of 80 to 150 grams), mineral waters ad libitum, one to two eggs, skimmed milk, and buttermilk. A diet of low caloric value should be made up from the foods mentioned. In analyzing this dietary further, one should consider the rela- tive amounts of fats, carbohydrates and proteins, and the question of water ingestion. Fats are very much diminished, down to 30 grams per day. Lower than this one can not go because many of the essential foods contain some fat. Carbohydrates are high in von Noorden's system. One hundred to one hundred twenty grams per day should be prescribed. Such an amount can be procured from 500 gm. potatoes, 100 gm. coarse bread, or 1000 gm. apples, etc. The reason for allowing large amounts of carbohydrate is that the body albumin is spared. Also carbohydrate food occupies a large volume and tends to be filling. It is essential that the pa- tient's sense of hunger should be satisfied, otherwise his strength and energy are diminished. An abundant amount of protein is advisable, this to be obtained from lean meat, eggs, and cheese. One should begin with 120 gm. of albumin and gradually increase to not more than 180 gm. The diet in Reduction III may then be tabulated as follows: Minimal Maximal Albumin 120 gm., 490 cal. Albumin 180 gm., 738 cal. Fat 30 gm., 280 cal. Fat 30 gm., 280 cal. Carbohydrate 100 gm., 410 cal. Carbohydrate 120 gm., 492 cal. 1182 cal. 1510 cal. The question of water ingestion is a much disputed one. Certain it is that reduction of water will reduce appetite in some cases, but in many it will not. Water restriction is advisable in circulatory 366 AFTER-TREATMENT OF SUBGICAL PATIENTS disturbances. In most eases, von Noorden permits free use of fluids in the form of plain water, alkaline waters, coffee, tea and broths. There is one very essential point which most "cures" disregard, namely, that the future mode of life of the patient must he con- sidered. It is useless to institute a cure which the patient will not continue to follow and therefore once more reestablish his obesity. On this account one should adhere as closely as possible to the ordinary mode of life of each individual and make restrictions ac- cordingly. One must also not fail to vary any routine occasionally. 2. Mechanical Treatment. — Mechanical treatment, the purpose of which is to increase oxidation, comprises (1) exercise. (2) massage, (3) hydrotherapy. (4) ''passive ergotherapy." 1. Exercise causes' direct destruction of the fatty deposits of the body. In postoperative conditions, of course, intensive exercise is impossible at first. Breathing exercises are generally permissible. Various trunk and hand movements may be tried, systematically and frequently. As soon as the patient is allowed on his feet, if there are no contraindications, walking out of doors, climbing, gym- nastics for trunk and limits, milder games. — all are invaluable in the successful treatment. The patient's cardiovascular system must always be considered in advising exercise. 2. Massage may be of value, particularly in reduction of local de- posits, as of the abdomen. A course of deep massage with Swedish movements should be tried. 3. Hydrotherapeutic 7 ' 8> 9 measures are often of great value. Sweating by means of the steam or Turkish baths, etc.. may pro- duce marked loss of weight, but as a matter of fact, the loss is chiefly of water, which is soon replaced. Sweating causes no loss of fat. In patients with circulator}' disturbances and edema, sweat- ing is recommended. When this is done in conjunction with cold bathing, however, much may lie accomplished. Following the sweating, the patient takes a cold bath or cold sponge and a cold rub. Exercise following this is very effective. This method stim- ulates the circulation and respiration and causes destruction of fat. Milder measures, as cold rain douches or cold sitz baths during the day, may be undertaken. 4. "Passivi Ergotherapy." — Recently much attention has been drawn to "passive ergotherapy" or "electrically excited muscular work." This method, as defined by Smith/ consists in an applica- tion of the faradic current by which the muscles, in groups or in entirety, are thrown into rhythmic contractions, "without dis- REDUCTION OF OBESITY 367 comfort or fatigue to the patient, without strain on the heart, and with beneficial effect on the muscles themselves." The faradic cur- rent is provided by a coarse-wound coil, capable of giving a large output at a low voltage. The electrodes are large metallic ones, the supply to each being controlled by rheostats. The method 10 is ap- plicable particularly in those cases of obesity in which muscular exercise is difficult, as in cases of very extreme obesity, of compli- cated heart affections, of foot or joint troubles. In cases of weak- ened abdominal muscles, so often coexistent with obesity, passive ergotherapy is especially indicated. The current is directed to the muscles themselves. This method of reduction protects the heart upon which voluntary muscular exercise may have a detrimental effect. 3'. Medicinal Treatment. — On the whole, the many varied mineral water cures give but temporary relief. They are therefore neither satisfactory nor successful. Thyroid extract is probably the only drug which is effective. Its use, however, should be limited to cases showing hypothyroidism. There are some patients who do not re- spond to even strict dietary measures and vigorous mechanical proc- esses, also others in whom fat is quickly regained. In them one should suspect hypothyroidism and a justified etiologic treatment may be instituted; i.e., feeding of thyroid preparations. They should not be given in those cases of obesity due to overfeeding or lack of exercise, because such treatment does not aim at removal of the real cause. The thyroid preparations should be given along with full maintenance diet and large amounts of albumin. It is best to start with small amounts and slowly increase to three to five grains three times a day. Larger quantities will produce irrita- bility of the heart. Dr. Stuart McGuire presents these instructions to patients who are subject to obesity as they leave the hospital. Your "wound requires no further attention. An abdominal binder should be used, both day and night. During the day a comfortable corset may be worn over the binder. You may safely walk at once. Start with a short walk, the distance of two or three city blocks, and increase gradually. Go slowly. At first you should be cautious even in such matters as straining at stool, getting in and out of the bath tub, and the like. Tub baths are not, however, objectionable. For three to six months be careful about getting on and off cars, lifting weights, the use of the sewing machine, athletic sports, heavy manual work, etc. Drugs such as thyroid extract, antifat cures, etc., should not be employed ex- 368 AFTER-TREATMENT OF SURGICAL PATIENTS cept under supervision of your physician. They are capable of harm unless properly controlled. The following diet is adapted to a safe reduction in weight : Take one pint of hot water slowly before rising or while dressing. At the usual breakfast hour, take a cup of tea, or coffee, without milk or sugar, a small mutton chop or beefsteak, or one egg, and one slice of toast. At 2 o'clock, eat all you desire of any one of the following meats and vege- tables, the latter cooked without meat: (a) Well-done roast beef, steak, mutton, fowl, or raw oysters. (b) Spinach, tomatoes, cabbage, turnip tops, celery, parsnips, apples, rhubarb. At 6 o'clock eat one slice of well-toasted bread and one poached or soft-boiled egg- At bedtime take one pint of water. Prevent constipation by exercise, a regular habit, and mild laxatives occasion- ally if necessary. Open air exercise, gradually begun and progressively increased, and a tran- quil mind are most important. Avoid carefully bread, beans, peas, potatoes, all sweets and pastry, and fluids with your meals. Strictly followed, this regime should reduce your weight one-half pound per day. If more is lost, let up on the diet every fifth day, and eat moderately of fruits. Full credit is due Alfred Goldman for having abstracted all the literature to which reference is made in this chapter. BibliogTaphy ivon Noorden: Disorders of Metabolism and Nutrition, i, viii, ix. sSchweniger: Sammlung Med. Abhandl., No. 4. sEbstein: Dio Heilkunde, 1902, No. 2. *Oertel: Obesity, Twentieth Century Practice of Medicine, ii. 5 Anders: Modern Medicine, Osier. eGermain : Del 'obesite. ^Winternitz : Therapieder Gegenu, 1899, p. 50. sSniith: Practitioner, 1916, xcvii, p. 264. ^Taussig: The Medical Fortnightly, St. Louis, May, 1903. icRobinson: New York Med. Jour., 1915, cii, p. 329. CHAPTER XLV ARTIFICIAL NUTRITION By Willard Bartlett and M. G. Peterman, St. Louis, Mo. Modern artificial feeding* probably began with Galen and Celsus. These men were the first to use rectal alimentation. Medicine has made considerable advance since the second century and artificial nutrition has become more and more important. The problem of artificial nutrition after certain operative procedures involves not only a question of the protein, carbohydrate, and fat requirement in the repair and up-building of tissues, but often presents a more serious and complicated phase in the administration of the body needs. The chapter on Dietetics deals with the proper foods after various operative conditions. It is the purpose of the authors to here consider the various difficulties which present themselves to the surgeon after operations which make it impossible, either tem- porarily or permanently for the patient to take food through the normal channel. It may be well to mention the normal food requirements of the average individual, and the lowest limits on which the body can carry on its functions and processes without utilizing living tissues. The average adult consumes daily about 118 gm. of protein, 500 gm. of carbohydrate, and 56 gm. of fat, a total of 3055 calories. 1 Ex- periments have shown, however, that health and strength may be maintained on a diet of 20 to 30 gm. of protein, provided the neces- sary caloric requirement is made up with carbohydrate and fat. 2 Atwater gives a standard diet for a man at rest which consists of 90 gm. of proteins with carbohydrates and fat to make 2450 calories. In prolonged feeding the inorganic salt and the vitamine require- ment must also be taken into consideration. The various methods by means of which artificial nutrition may be introduced are: per rectum; through gastrostomy or jejunostomy tubes, by subcutaneous injection, by intravenous injection, by cu- taneous application, and by intraperitoneal injection. Of these various methods but two have thus far proved satisfactory for practical application. Nutrient enemas have been and still are the most satisfactory and practical solution of the problem of artificial 369 370 AFTER-TREATMENT OF SURGICAL PATIENTS feeding. Gastrostomies and jejunostomies are becoming more popular and more satisfactory, the latter being much easier to per- form. "We shall consider the methods in their order of practica- bility. Per Rectum. — The old so-called nutrient enema consisting of milk and eggs, milk and bread, chopped beef, minced pancreas, or a combination of these foods still enjoys wide popularity in spite of its worthlessness. Modern investigation has shown that any of these food substances injected into the rectum serve little more than as irritants to the large intestine and a source of discomfort to the patient. There is little doubt that digestion and absorption continue in the large intestine. The work of Erlanger and Hewlett proved that a dog may carry on digestion and absorption and thrive with 70 to 83 f ; of his small intestine removed, provided that the diel 1"' carefully chosen. 3 Recent work, however, has shown that absorp- tion in the colon is limited to amino acids in their simplest forms and to monosaccharides, while the amount of fat absorbed may be said to be negligible. Water and alcohol are freely absorbed. The main function of the large intestine may he said to be the excretion of mineral salts ami absorption of water. Of the reported cases of successful artificial nutrition by the old undigested or insufficiently digested nutrient enema one must he somewhat skeptical. Boyd and Robertson 1 repcrl cases of seven young women fed for seven days entirely on enemata consisting of milk and eggs, dextrose, and normal saline, the whole pancreatized for twenty minutes. The cases were reported as having done well. Examination of the data, however, shows thai the nitrogen excreted in the urine Avas always greater than thai absorbed by the bowel. Also the patients con- tinued to lose weight. Edsall and Miller"' reported two cases of actual absorption of enemas of peptonized milk and eggs, bnt they give figures which show an average nitrogen loss of 11.8 to 79.9 gm. for the six day period. Carter' furnishes data on three cases of rectal feeding in a modern city hospital where nursing condi- tions were as good as can be found. In these cases the colon was cleared daily, the injections were given high up, and they were well retained. The 24-hour urine was analyzed and the results of the irrigation and all of the stools were examined. The results of the enemas were an almost complete return of the nutrient ma- terial with little or nothing absorbed. The nitrogen balance varied from -.8.81 to -.24.19 gm.. always accompanied by a steady loss of weight. Goodall 7 concludes thai the simple sugars and alcohol ARTIFICIAL NUTRITION" 371 are the only substances practical for rectal alimentation. More modern results indicate, however, that proper amino acids added to the enemas produce good results. The work of Short and Bywaters, 8 where patients with gastric ulcer were treated by cutting off all food by mouth and feeding by nutrient enemas, shows that ni- trogenous protein will be absorbed if it is properly prepared to make it available. These patients were given either normal saline or milk peptonized twenty minutes during the first four days and then changed to milk pancreatized for twenty four hours, to see if it would stop the fall in the nitrogen output. The enema was pre- pared by boiling the milk in a flask, adding two to four drams of pancreatized extract and incubating for twent t y-four hours, then boiling. Five to eight ounces were given every six hours. The rectum was washed daily, but the washings were not kept, The nitrogen in the urine was estimated by the Kjeldahl method and the ammonia nitrogen by the A. P. Opie formalin method. These cases showed that it took twenty-four hours for the urine to show a rise in the nitrogen output after thoroughly pancreatized milk was fed. This time is required when mouth feeding is resumed after the same conditions and is therefore the time necessary for the body to restore normal equilibrium. The results of the experiments, on the whole, show a satisfactory result and justify the conclusions which the author draws, i. e., the daily output of nitrogen in the patients fed with enemas of milk and eggs peptonized for 30 minutes shows that almost no nitrogenous material is absorbed ; that milk, pancreatized for twenty-four hours to allow the formation of the amino acids, furnishes food which is absorbed as demonstrated by the rise in the nitrogen output. Cornwall 9 states the modern views when he sums up the es- sential points in rectal feeding. He states that all food should be predigested; that the protein ration must be considered in the terms of amino acids and of a definite variety in particular propor- tion to favor nitrogen economy. These amino acids are found in flesh, milk, and eggs. Flesh and eggs putrefy and are therefore not advisable. Milk is protected against putrefaction by the finely mixed lactacidifiable carbohydrate. Milk is therefore the ideal food and if properly prepared furnishes, when supplemented with the sugars, a practical and satisfactory solution to the problem of nutrient enemas. Cornwall believes that by using fresh and un- boiled milk the vitamines and the enzymes are preserved. The milk should be thoroughly peptonized and pancreatized to reduce the proteins completely to amino acids. The fat must be skimmed from 372 AFTER-TREATMEXT OF SURGICAL PATIEXTS the milk, for it is not absorbed and putrefies in the intestine. To the prepared milk should be added glucose in solution. The salts contained in milk closely approximate the normal body requirements though calcium and sodium are only necessary when long-continued feeding is required. The solution prepared for the enema should always be alkaline. This avoids irritation and stimulates absorption. Also it more nearly approaches and preserves the alkalinity vital to the proper functioning of the body tissues. To these points may be added several precautions to be observed in the administration of the alimentation. The solution should not be a chemical or me- chanical irritant. It should always be alkaline and it should be given to avoid irritation. If necessary opium should be added to the enema to allay inflammation. An inflamed mucosa will not absorb properly. The rectum should always be clean. This pre- vents putrefaction and hastens absorption. The enemas should be given high up and the foot of the bed should be raised on blocks with the patient lying on the right side. This position should be maintained for an hour after injection. The amount of material given should be carefully measured. Although the enema will not usually pass the ileocecal valve, the liquid may pass up into the ileum and may even reach the stomach presenting all the complica- tions of acute dilatation. This condition is rather uncommon, but it must be borne in mind. In gastric conditions, it must not be thought that the rectal feeding gives the stomach complete rest. The injections are always followed by a reflex or psychic secretion. This secretion, though not excessive, must not be neglected in cer- tain cases. The following formula? for rectal feeding have been gathered from the literature where the records and data available have proved their merit. Dextrose 50 gm. Absolute alcohol 50 gm. Normal saline 1000 gm. This formula will furnish 555 calories of heat. 10 Larger enema in the same proportion or enemas in greater concentration are not advisable. Larger amounts are not absorbed and greater concen- trations are too irritating. The above formula may be alternated with the following : Dextrose 2 °- 50 g™- Alcohol 20-50 gm. Pancreatized milk or commercial amino acids 1000 c.c. Salt 9 S m - ARTIFICIAL NUTRITION 373 Of this preparation 250 c.c. may be given every 4 hours. It has a calorie value of 420-755 calories. Short and Bywaters used the following preparation: 8 Milk iy 2 pt.j boiled and cooled, to which was added Pancreatic fluid, % ounce. This mixture was incubated 24 hours, then there was added, Dextrose (pure), 1% ounces. Four ounces of this material may be given every four hours, or ten ounces, if retained. Cornwall gives the following excellent formulae : 9 Prescription 1. Glucose (pure) 1 oz. Strained juice of % orange. Sodium bicarbonate 30 grs. Sodium chloride 30 grs. Water q.s. ad. 10 oz. This mixture is given at 6 a.m., 12 m., 4 p.m., 10 p.m., and is al- tered with 5 oz. of skimmed milk thoroughly peptonized and pan- creatized for 24 hours, which is given at 8 a.m., 6 p.m., 12 p.m. With the above schedule a colonic irrigation of normal sodium chloride is given every second day and the glucose enema at 6 a.m. following is omitted. This prescription may be modified as follows : The quantity of glucose may be reduced to 8 oz. The amount of glucose in the glucose enema may be reduced to y 2 or y 3 oz. The amount of the glucose enema may be increased to 12 oz. or to 16 oz., with or without an increase in the percentage of glucose. One-fourth oz. of glucose may be added to each milk enema. The glucose enemas may be omitted altogether with or without the substitution of a drink enema of physiologic saline. Five gr. of calcium chloride may be added to each glucose enema. Cultures of acidophilic bacteria may be added to any of the enemas. This formula supplies daily 700 calories, 20 gm. of protein, the necessary salts and vitamines, with 50 oz. of water. Prescription 2. Glucose 1 oz. Str. juice of % orange Sodium bicarbonate 30 gr. Sodium chloride 30 gr. Water q.s. ad. 10 oz. 374 AFTER-TREATMEXT OF SURGICAL PATIENTS This preparation is given at 6 a.m., 10 a.m., 2 p.m., 6 p.m., 10 p.m., 2 A.M. The formula may be modified as follows : The same modifications may be made of this preparation as of similar glucose enemas in prescription 1. The sodium bicarbonate may be increased to 60 gr. The orange juice may be omitted. Calcium may be added. All of the above preparations should be given at 100° F. and slowly. The buttocks should be elevated and the patient should lie on the right side tor an hour after the injection. For real slow absorption the drip method may be used in administering the fluids. Gastrostomy. — Artificial introduction of food into the stomach for practical purposes probably began when Kussmaul first introduced the stomach tube in 1870. Beaumont in 1826 fed St. Martin through an artificial opening into the stomach and was probably the pioneer in this field. 11 This work, however, was more in the nature of ex- perimentation than practical feeding. Beaumont's valuable work is the foundation of our modern knowledge of the physiology of digestion. Although we can not aceepl all of his conclusions, we may gather much from his results. At the end of one experiment he slates. "This experiment shows the necessity of mastication, and demonstrates thai simple maceration at the natural temperature will not effect digestion." However, in his conclusions he states that. "The processes of mastication, insalivation, and deglutition, in an abstract point of view, do not affect the digestion of food or. in other words, when the food is introduced into the stomach directly (Fig. 53) in a finely divided stale, without these previous steps, il is as readily and as perfectly digested as when they have been taken." The experiments did no1 state whether or not the patient was aware of the fad that he was being fed. or whether he was hungry or satiated. Both of these factors have considerable bearing on the digestion of f 1 as modern investigation has shown. 12 The later and more scientific work of Pavlov throws new light on the physiology of the stomach. 13 The Russian scientist con- cludes a lecture with. "I hope you have been convinced of the great importance of the passage of food through the mouth and esophagus, or. in other words, and this, according to our former experiences, means much the same thing; of the desire for food. Without this interest, without the assistance of appetite, many ARTIFICIAL NUTRITION 375 foods which enter the stomach remain wholly imsupplied with gas- tric juice." This statement he later limits by saying, "It is there- fore quite possible that in the case of some dogs, and at a certain stage of hunger, the touching of the mucous membrane with any Fig. S3. — The introduction of liquid food, directly into the stomach. object at hand, its mechanical irritation, its distention by the food- mass may give the impulse which excites appetite ; and when the appetite is awakened the juice flows." (Fig. 54.) Matas had kept a man in good health for fifteen years when we saw him, by the process here shown. 376 AFTER-TREATMENT OF SURGICAL PATIENTS For practical purposes we may assume that the stomach will digest almost any of the digestible foods which can be introduced through a tube. In other words, the diet in feeding gastrostomy cases is determined by the condition of the stomach. The sooner after opera- rig. 54. — The patient first ensalivates his food and then sends it indirectly into his own stomach, which gives the best possible results. tion the patient is supplied with nutrition and fluids, and the sooner normal peristalsis and the digestive action set in, the better the prognosis. Two excellent diets for gastroenterostomy or gastros- tomy cases are given, viz.: ARTIFICIAL NUTRITION 377 Finney's Diet First day. First 12 hrs., nothing by mouth, nutrient enemas every four hours, alternating with continuous salt solution by the drip method. Second 12 hrs., water in 4 c.c. doses by mouth. (By mouth or tube.) Second day. — Increase water gradually up to 30 c.c. every 2 hrs. Third day. — Water 30 c.c, alternating with albumin, 4 c.c, gradually increase quantities of each until, Eighth day. — Any liquid, 60 c.c every 2 hrs. Ninth day. — Any liquid, 90 c.c every 2 hrs. Tenth day. — Any liquid, 120 c.c every 2 hrs., discontinue rectal feeding. Eleventh day. — One soft boiled egg in addition to any liquid. Twelfth day. — Two soft boiled eggs in addition to any liquid. Thirteenth day and Fourteenth day. — Soft diet. Fifteenth day. — Very restricted diet, light. Sixteenth and Seventeeth days. — Eestricted light diet. Eighteenth day. — Any digestible solid food. After the eighteenth day the following diet list may be gradually followed and should be continued for at least four or five months: SOUPS. Any light soup. MEATS. Any easily digested meats as brains, sweetbreads, beef, mutton, lamb, poultry (minced and taken either broiled or boiled). FISH. Mainly the white variety, mackerel, bass as well as oysters (boiled or broiled). EGGS. In any form except fried. FATTY foods, as cream, butter, olive oil. VEGETABLES. The easily digestible forms, best taken mashed or strained as asparagus, spinach, peas, beans, potatoes, carrots, farinaceous foods, any cereals, stale bread. DESSERTS. Any of the light puddings. FRUITS, mainly stewed. DRINKS. Milks, buttermilk, cocoa, carbonated mineral water, and plain water. The following must be avoided: Rich soups, pork, fried foods, veal, stews, hashes, corned meats, twice cooked meats, potted meat, liver, kidney, duck, sau- sage, crabs, sardines, lobsters, preserved fish, salted or smoked fish, salmon, cauli- flower, radishes, celery, cabbage, cucumbers, sweet potatoes, tomatoes, beets, corn, salad, bananas, melons, berries, pineapple, hot bread or cakes, nuts, candies, pies, pastry, preserves, cheese, strong tea or coffee, alcoholic stimulants. Leube's Diet, as Modified by Lockwood On the second or third day, 2 oz. hourly of artificial Vichy, alternating with 2 oz. of milk fully peptonized for two hours. Each day the milk is increased 1-2 oz. until 8 oz. are taken every two hours and the Vichy increased 1 oz. each day until 4 oz. are taken every two hours. Thus fluids are given every hour, either Vichy, or the peptonized milk. At the end of a week or ten days there may be added junket, fine cereal, milk toast, and sometimes a soft-boiled egg. During the third week, creamed fish (fresh or halibut), mashed potatoes, cream of wheat, or hominy, spaghetti, puree of vegetables, and creamed soups. Farinaceous desserts such as farina, tapioca, cornstarch, blanc mange, and custard. Avoid alcoholic beverages for many months, but after the second week, weak tea, coffee, or cocoa, or a little milk and coffee, if it agrees, may be taken. The beverages should be weak and discontinued if they cause irritation. Both of the above diets advise that no food be given for 12 hours to 24 hours after operation. More recent work, however. 378 AFTER-TREATMENT OF SURGICAL PATIENTS indicates that if feeding is begun immediately after operation, the results are much better. When the opening is completed the feed- ing is begun and 200 to 250 mils of whiskey, coffee, or other stim- ulant is poured down the tube. The fluid should be 1<>.V F.. and may be given by the drip method. After the operation, Andresen ad- vises feeding certain definite amounts at definite intervals. He gives 200 mils of peptonized milk, 15 gm. of dextrose, and 8 mils of whiskey at 2 hr. intervals. This diet furnishes 2500 calories and may be altered according to conditions. Jejunostomy. — Much has been written on gastrostomy, no doubt because it is theoretically the ideal procedure to supply food at the highest possible point in the digestive tube. In practice it has worked out so that we have never made a single gastrostomy, but many jejunostomies. The stomach lias always been found shrunk and retracted, but the intestine vastly easier to handle. These have always been desolate subjects, hence it has seemed expedient to choose the method which mosl easily solved the surgical problem in hand. The postoperative feeding is exactly the same, no matter which route for the introduction of food is chosen. Intravenous.— The intravenous method of feeding is attended with danger and great care should be exercised it its use. For immediate results intravenous injections are of considerable value. The two formulae following are taken from Carter's Nutrition and Clinical Dietetics. I )c\t rose 50 gm. Sodium chloride '.» gm. Adrenaline ehloride (1-1000 sol) 10 gtt. Ai|ua destillata q. s. ad. 1000 c.c. Filter and boil and give intravenously b. i. d. For children: Dextrose 55 gm. Potassium chloride .2 gm. I lalcium chloride .'2 gm. Sodium earbonate .1 gm. Aqua destillata q. s. ad. 1000 c.c. Filter, boil and give intravenously b. i.d. The above formulae should be given in apparatuses which may be carefully regulated as to the flow. The fluid should be given very slowly to prevent excretion by the kidneys. The excellent work of Woodyatt 24 throws new light on the in- travenous injection of glucose. This work proves withoul doubl that a man of 70 kg. resting in bed may receive and utilize 63 gm. ARTIFICIAL NUTRITION 379 of glucose by vein per hour without glueosuria. This means a caloric value of 6,048 calories ! Thus we may inject an enormous caloric diet which will be readily utilized and give immediate results. Woodyatt mentions two precautions to be observed in the injection of glucose, i.e. — " — too great dehydration on the one hand, and heart failure from imposing too much mechanical work on the other. These can both be avoided by knowing the number of grams of glucose which enter the body hourly, what volume of water is moved by such a rate of sugar injection." In using the injection of glucose for artificial nutrition the Woodyatt apparatus is advisable. This description of the mechan- ism is taken from the author's article which appeared in the Journal of the American Medical Association, December, 1915. "The machine consists of a glass syringe barrel with a metal piston provided with a piston ring (record syringe), the barrel being fixed while the piston is actuated by a piston rod from an eccentric on a power shaft. The latter is driven by an electric motor through a worm and gear which reduces the speed of the motor and increases the power correspondingly. On the nozzle of the syringe there is a two-way all-metal valve of special design which is turned automatically by a cam shaft and alternately permits an influx or outflow of fluid to or from the pump barrel. The rate at which the machine delivers fluid is controlled in three ways: first by the size of the barrel, which is interchangeable so that any capacity can be used from .5 c.c. to 10 c.c; second by a device which regulates the stroke of the piston to any desired length from a millimeter up, and, third, by a rheostat with Avhich the motor speed can be controlled delicately while running so that the pump makes any desired strokes per minute between 15 and 60. "The machine is intentionally provided with a surplus of power. It is heavily built and of a high grade of workmanship. It pumps precisely and relentlessly anything from water to an 80% glucose syrup, at any rate from 10 c.c. to 5 liters hourly, overcoming with negligible variations in speed any obstructions which may occur in the tubing or the intravenous cannula or needle. All parts which come into contact with the fluid to be injected are detachable and sterilizable." Subcutaneous. — There is little to be found in the literature on successful results in administering nutrition via the subcutaneous method. This is rather a dangerous procedure and should not be resorted to until the other methods are unavailable. Among the 380 AFTER-TREATMENT OF SURGICAL PATIENTS more or less successful experiments may be mentioned the follow- ing: Kreng 16 in 1876 stated that he successfully nourished a patient for 20 days on subcutaneous injections of olive oil, but he gives no figures or data as to the weight or strength of the patient during and after the feeding. Whittaker" in 1877 quoted a case of a man nourished for 6 days with subcutaneous injections of milk, beef extract, and cod liver oil. In report, however, he gives no data as to the body weight, the amount of food, or the excretion. In- dividuals may survive long periods and show little evidence of malnutrition. Unless the nitrogen output is measured, it is im- possible to determine the exact condition of the patient. Eichorn ls in 1881 published a report of feeding cow's milk, Sander's peptone, and egg albumin. lie states that egg albumin injected subeu- taneously produces abscess, and thai cow's milk is only slowly ab- sorbed, but that there is no reaction from the injection of 20 gm. of peptone. Eichorn concludes that peptone may be used to ad- vantage. His work, too, lacks the necessary data to determine its worth. Leube 19 in 1895 injected sugar subcutaneously and deter- mined that if a few c.c. were injected at a time 15 to 20 g.m. might be injected daily. lie used a 20 per cent solution of glucose. This method is only an aid to lie used in conjunction with other means. Perhaps with an apparatus similar to the Woodyatt intravenous contrivance whereby glucose could be injected slowly and at a definite rate, the subcutaneous route may offer more successful re- sults. Barker 20 in 1905 stated that the glucose should be in 5 per cent solution in normal saline and reported several eases of arti- ficial nutrition by this method. Henderson and Crofutt 21 in the same year found that oil injected subcutaneously was absorbed too slowly to be of value in nutrition. Subcutaneous feeding may be best summed up with the original experiments of Carter. 22 A set of six experiments was carried out on a number of dogs. The animals were first placed on the normal laboratory diet and kept on this until there was no change in weight. All excreta was saved, the dogs were weighed daily, and they were carefully watched for clinical symptoms. Experiment 1. Somatose and glucose were injected in normal saline. The first injection caused a severe reaction of toxemia. The dogs had a high temperature, marked trembling, and weak- ness. Later the toxemia became less marked, but the temperature rose, the weakness increased, and the urine showed hyaline and ARTIFICIAL NUTRITION 381 granular casts, albumin, peptones, and sugar, and a severe edemr. followed. Experiment 2. The alkali albuminate of meat was injected. This was followed by a bloody diarrhea, vomiting, renal irritation, and local necrosis at the point of injection. Experiment 3. Milk peptone with the cream removed, digested 3 hours with the dried extract of pancreatic gland and dilute sodium carbonate was sterilized by boiling. This preparation was fed to a pregnant dog. The injections were followed by only moderate symptoms of toxemia but there was a continual loss of weight. In a few days the dog delivered pups but only one lived. The mother was unable to nourish the pup and both died shortly. Experiment 4. The milk preparation in Exp. 1, was fed to a normal dog, and toxemia followed. Experiment 5. Skimmed milk was peptonized 1% hours and was first fed by mouth until the dog became accustomed to the diet. Then the subcutaneous feeding was begun and the mouth feeding was gradually stopped. Toxemia followed shortly and death re- sulted in 3 days. Experiment 6. The same milk preparation was fed but the in- jections were begun with .098 gm. per kilo. This experiment was followed by little reaction and the results were good. Carter summarizes his experiments by stating that : Skimmed milk, peptonized for 1% hrs. may be fatal when injected subcu- taneously and that hypodermic injections of meat peptones and alkali albuminate are not feasible because of their great toxicity and the tendency to local necrosis. He feels, however, that meeting the full nitrogen requirement is possible by the injection of skimmed milk, peptonized 1% hours and given in gradually increasing doses. The great toxicity of hypodermic injections of protein makes sub- cutaneous feeding rather a questionable procedure to be resorted to only in emergency. The use of aseptic serum or ascitic fluid, up to 400 c.c. daily is the preferable protein to inject for maintaining in part, the nitrogen balance. In hypodermic injections it must be remembered that slow injection is necessary for complete absorption. If the fluid is injected rapidly it may be, for the most part, ex- creted by the kidneys. Intraperitoneal. — This method of artificial feeding has not been of practical use. Few experiments are found in the literature and nothing of practical value is reported. The injection of a foreign substance into the peritoneal cavity is too serious an undertaking to :"J^2 AFTER-TREATMENT OF SURGICAL PATIEXTS allow of feeding by this method. Serum and glucose have been introduced intraperitoneally. but the results have not warranted consideration of this method. There are few eases where the afore- mentioned methods will not be found feasible and their use is far less hazardous. Cutaneous Application. — This method of feeding by inunction is applicable only to infant-. Cod liver oil rubbed into the skin in the axilla? and the groins is absorbed to some extent but only a small part of the required intake may be supplied in this manner. Full credit is due M. G. Peterman for having abstracted all the literature To which reference is made in this chapter. Bibliography iVoit : Physiologie des Stoffwechsels. -siven: Skandinavische Archive fur Physiol _ •Erlanger and Hewlett: Am. Jour. Physiol.. 1902. •*Boyd and Eobertson: Scottish Med. and Surg. Jour.. 1906. sEdsall and Miller: Wisconsin Med. .lour., 1903. eCarter: Arch. Int. Med., 19 - TOoodall: Boston Med. and Surg. Jour., elxx. No. 2. -short and Bywaters: Brit. Med. Jour.. June. 1913. wall: Jour. Am. Med. Assn., May 18, 1918. loCarter: Nutrition and Clinical Dietetics, 1917. Philadelphia. Lea ^- Febiger. "Beaumont: Physiology of Digestion, I s 17. isHowell: Textbook of Physiology, 1918, Philadelphia, W. B. Saunders Co. "Pavlov: Work of the Digestive Glands, 1902, Philadelphia. J. B. Lippincott Co. "Einhorn: Med. Bee, New York. .Tun./ 16, 1917. isAndresen: Ann. Surg., May. 1918. - Ki>ng: New York Med. Jour.. March, 1876. iTWhittaker: Am. Jour. Med. Sc., April. 1877. isEichorn: Wien. klin. Wchnschr., 1881. Leube: Verhandl. Congress Innere Medecine, Weisbaden, 1895, xiii. - Barker: Am. Med.. 1905, xiv. "Henderson and Crofutt: Am. Jour. Physiol., 1905, xiv. ^Carter: Arch.. Int. Med., April, 1905. - Finney: Am. Jour. Med. Sc, 1915, el, No. 4. 2«Woodyatt, et al : Jour. Am. Med. Assn., December, 1915. CHAPTER XL VI CARE OF THE BOWELS AFTER OPERATION OTHER THAN GASTROINTESTINAL By Willard Bartlett, St, Louis, Mo. The subject of pseudoileus has been adequately treated, it is hoped, in the chapter on ileus; hence no attention will here be paid to distention, gas pains, etc. We must divide the surgical convalesence very distinctly into two periods so far as reference to this subject is concerned. The earlier of these has to do with the time that the patient is in bed on a restricted diet, and in other respects is leading an abnormal exist- ence. The second period may be defined as that which begins when the patient gets out of bed and resumes to a certain extent the tenor of his customary existence, though somewhat modified it may be to suit hospital conditions. During this early period the care of the bowels is not infrequently left to the patient's own discretion in all but the best conducted hospitals, strange as this statement seems. Only one grade better is the plan, which many readers will recognize at a glance, of leav- ing the whole matter to the judgment of a more or less experienced nurse, and while it can not be said that the care of the bowels is often one of the vital factors in the convalescence, still it is impor- tant enough, especially if diarrhea be present, for the operator or at least his house surgeon to have full control of it, and surely no cathartic should be given in a hospital without an order emanating from a medical source. It is impossible to formulate any general rule governing this sub- ject, and here, as in many other departments of postoperative treat- ment, one must individualize. This is true with reference not only to the individual needs of patients, but it will be readily admitted that various surgical procedures entail widely differing treatments of the intestinal canal. So it comes about that the best type of hospital interne will await indications before proceeding in the in- dividual case. This is particularly true of the early convalescent period, since during this time one can readily imagine a state of depletion existing in many a patient which would render any ex- 383 384 AFTER-TREATMENT OF SURGICAL PATIENTS hausting procedure, such as vigorous catharsis ma}' be, highly inad- visable. So little food is ingested during the few days which suc- ceed a major surgical operation that the need of catharsis on this ground is customarily exaggerated, I am sure. Of course, we will presuppose the patient has been subjected to the ordinary prepara- tory measures. On the other hand, one can imagine the subject to have been brought to the table in an emergency, and then post- operative bowel movement no doubt becomes more urgent than would otherwise be the case, though here again one must not fail to individualize. The procedure is, unfortunately, not often thus. Every operator will remember frequently having been waylaid in the corridor by a solicitous relative who states that the sufferer's bowels have not moved for so and so many days, or the nurse will ask whether she may not, on general principles, give a dose of castor oil, or the patient, who has no local or general complaint pointing to the bowel, will want to know what our hospital rule is with regard to cathartics. The line of least resistance is for the medical attendant to tell the nurse to give the patient a cathartic, leaving the choice to her, or if he is not quite so careless, he will suggest an enema without any further consideration of the in- dividual's needs. Of course there do arise general evidences of the need of a bowel movement. They are not easy to put into words, but may be stated in general as abdominal discomfort, tenesmus, lack of appetite, rise of temperature, and a general ill feeling which the patient is unable to more accurately define. Where the symptoms are distinctly local, no matter what their nature, a digital or even possibly a proc- toscopic rectal examination is to be made in every instance, some- thing which under the circumstances is, I am convinced, rare out- side of the leading hospitals. One who does this for the first time will be surprised to note the frequency of fecal impaction, a strictly local affair, which can be best remedied by local mechanical meas- ures, and for which no doubt a cathartic is very frequently care- lessly given. In order to establish the need for bowel movement, one who is inclined to individualize will be interested when confronted by the man who has several watery stools a day when he is in perfect health, as well as by the woman who for years has gone about her normal pursuits with never more than one movement a week. That the needs of the two differ greatly goes without saying, and this is no less true after a surgical operation than before. It is com- CAEE OF THE BOWELS 385 nionly stated, and with a certain degree of truth in many instances, that a patient's bowels are not likely to move while he is in bed. However, I have been considerably more sanguine about this mat- ter since being recently called to treat a patient who had not been off his back for fifteen years, and who, according to his own state- ment as well as that of his attendant, had not missed a normal daily bowel movement in all those fifteen years. A few experiences of this sort makes one less likely to indulge in generalities, and incline him rather to the line of individual reasoning. Of course this does not mean that nearly every patient confined to bed will go without help as far as the bowels are concerned. However, it does indicate that the needs of each and every one are entitled to a special con- sideration. To be perfectly fair, I will state a circumstance in marked contrast to that just related. The high temperature of 107° was noted in a young lady who did not seem to be very ill. She stated that her bowels had not moved for a week, and that under similar circumstances she had been affected in this way on other occasions. A cathartic was given, and we were all astounded, after her bowels moved in an hour or two, to find that her temperature had returned to the normal. Nothing further developed in expla- nation of the phenomenon; hence one is forced to the conclusion that there must have been the relation of cause and effect between con- stipation and fever on the one hand, as well as between cathartic and result on the other hand. One is not to be unreasonable on this point and urge that no re- gard is due the lower digestive tract of the patient confined to bed, but on the other hand there are weighty enough reasons for seeing to it that the bowels do move after operation when occasion re- quires. Xot only are the indefinite general symptoms above outlined to be relieved, but it is distinctly a physician's duty to see that a difficult movement is made easy, for the very same reason that he will endeavor to spare the patient a violent effort of any other kind. There is perhaps nothing worse for a convalescent patient than a great increase of intraabdominal tension, especially should this be continued for any length of time. One has but to keep in mind the pain in the wound which is occasioned in this way, to say noth- ing of the fact that cerebral apoplexy occurs frequently in elderly individuals at stool. Pulmonary embolism is distinctly favored by any increase in intraabdominal tension, provided, of course, that there be thrombosed veins in any part of the abdomen from which a fragment can be torn loose. Local evidences of undue strain of 386 AFTER-TREATMENT OF SURGICAL PATIENTS this particular kind consist in the appearance of blood in the stool, the formation of hemorrhoids, and not infrequently the appearance of prolapse in varied degrees. The duration of these manifestations will depend upon whether or not the causal condition is transient or permanent. Granted, now. that the need for bowel movement has been estab- lished. Ave take up in general the question of how this shall be brought about. As is perfectly Avell known, most cathartics ex- aggerate the muscular activity of the entire intestinal tract. On the other hand, x-ray studies have demonstrated that the food is in a few bonis carried into the colon, much of it into the lower end of that viscus. — this, of course, in the absence of mechanical obstruc- tion. Does it not, then, seem logical to attack the lower, rather than the upper end of the bowel under such circumstances? This would seem so. and for a still further patent reason to one who has been operated upon and who has bad experience with a large dose of castor oil before really recovering from the nausea, depression and pain attendant upon a major surgical procedure. I do not know of any way in which one can detract more from the psychic and physical comfort of an individual, sick or well, than by giving him a large dose of the nauseating oil. which is so universally em- ployed under circumstances now discussed. Hence, are we not at least justified in seriously considering the matter, especially in view of the x-ray knowledge referred to above? There are prophylactic measures which in many individuals with special predilections render the use of any remedial measures un- necessary. There are those in whom a cup of coffee or a cigar will invariably cause a movement of the bowels soon after they are enjoyed. Others find that they become constipated only when de- prived of beer or some of the other malted drinks, while the em- ployment of fruit juices is universally valued. One can hardly think of a pal ienl who is given anything at all in the mouth who can not tolerate the three classes of fluid just mentioned. Suppose, now. that prophylactic measures have not availed, may we not, before attacking the intestinal tract directly, with reason have recourse to the various nonmedical procedures which under the conditions of normal life are of value in accentuating the intestinal functioning ability? I refer here to massage of the abdomen, di- rected particularly to the colon and applied, of course, in the line of peristalsis. This can be quite conveniently done by the patient himself, if not too ill and provided there is not a wound of the ah- CARE OF THE BOWELS 387 dominal wall, by running a heavy ball about over the anterior ab- dominal wall while lying on the back. Many individuals are not hindered by reason of their malady from going farther than this and indulging in quite a variety of light gymnastics while in the recumbent or semiprone position. Suppose that none of the measures detailed up to this point have been of any avail and there are cogent reasons why the bowels should be caused to move. Knowing that practically all of the food has reached the colon, I have not in recent years used a general cathartic, unless for some very especial reason which lack of space here forbids, but have resorted uniformly to enemas, and must say that the results have in general been much more satisfactory than was the case in my earlier experience of another kind. But before taking up the various forms of enema in detail, we must proceed to disabuse ourselves of the idea that there is any difference between a low and a high enema. The painstaking nurse will ask, as soon as an enema is ordered, whether or not the operator wishes it given high or low. Xo such distinction, however, can be made at the present date by those who are familiar with Soper 's x-ray work now universally accepted which shows that a tube passed into the rec- tum merely curls up if any attempt is made to introduce a length of it greater than that of the ampula. There are fluid substances without number which may be employed in the form of an enema. It has been the writer's practice in recent years, at the suggestion of Dr. Soper of St. Louis, to use in an adult 3 ounces of a saturated solution of magnesium sulphate, because this is the one chemical substance harmless in nature which relaxes the musculature of the sigmoid and thus most readily lets the intestinal contents out. Soper believes that contracture in this limited portion is the prin- cipal feature which we have to combat in postoperative lower in- testinal spasticity. Some patients are quite readily affected by mere injection of a moderate amount of warm water, while in others soap suds very readily produce the same results. Often a few ounces of some cheap oil, like cottonseed oil, is very pleasant and effectual, and I have often found that a teaspoonful of alum dis- solved in a pint of water will bring about very marked peristalsis, although it is quite probable that this may seriously damage the mucous membrane of the bowel. Hence, I have not used it in recent years. Where there is any objection to a large quantity of fluid, it is my practice to make use of an ounce or even two ounces of un- diluted glycerine. This is almost sure to start peristalsis, although this has sometimes been exaggerated and rather painful in nature. 388 AFTER-TREATMENT OF SURGICAL PATIENTS Of course, an enema of whatever nature is most transient in its effect. Hence it may often be well to accompany its use by the ad- ministration of simple mineral oil, which, by lubricating the lining of the bowel (this being nonabsorbable), tends to maintain in- testinal motor function after the effect of the enema has worn off. Patients vary greatly in the effect of mineral oil. One may begin with a half ounce administered four times a day. and decrease or increase as the individual need indicates. I have seen many pa- tients in whom four ounces a day were required, and others who could get along with half an ounce or an ounce equally well. Certain cautions may be well observed by the individual who has never had experience with mineral oil. It is a most elusive fluid and can not be very accurately controlled by every one. It is not wise to pass gas with impunity after taking it, unless one happens to be so situated that a flood of oil does not matter particularly. Many a patienl has thought flatus to be escaping and later found his clothing saturated with oil. or discovered that he was actually sitting or lying in a pool of it. It awakens no peristalsis, and in consequence gives no warning of its impending escape. Mineral oil is most heartily and unreservedly recommended by me. It is the only substance of medicinal or semimedicinal nature which I give by mouth as routine as an aid to intestinal motor function. I have not seen any difficulty where properly used, al- though I am willing to admit that some others consider it to pos- sess only a moderate value. So much for the early period of a patient's convalescence, when he is probably in the recumbent position and relatively quiet in bed. If the bowels are to move at all. we will have had in this period io resorl in many instances to some artificial aid. But let us now suppose the individual to be up. and the second period of his recovery to be commenced. It seems now nothing less than a mistake, to put it mildly, for the surgeon to indulge in a regime of cathartics which may lay the foundation for future chronic constipation. The upright posi- tion, especially at stool, will now be of inestimable help to the patient. Furthermore, he should be encouraged to resume the habit of a lifetime with reference to going to siool at a certain hour, and as a matter of course the character and quantity of food most calculated to favor normal bowel activity can now be better indulged in than A\as the case when in bed. As he begins lo ex- ercise, lie will also find without perhaps recognizing it. that the CARE OF THE BOWELS 389 use of voluntary muscle tissue exerts a directly stimulating in- fluence upon the unstriped musculature of the intestinal tract. Diarrhea. — As has been shown in preceding paragraphs, consti- pation may play a subordinate role in the convalescence of a surgical patient. On the other hand, diarrhea may be the leading symptom of some pathologic condition which terminates fatally. Hence the extreme importance of considering this phase of the sub- ject along with the other. It is wholly illogical to talk about treat- ing diarrhea when it appears as a postoperative manifestation. One must diagnose the cause, a matter frequently as difficult as the treatment is easy, provided accurate indications can once be es- tablished. There are here so many possibilities, as stated by the gastroenterologists, that the natural limitations of such a chapter forbid us even mentioning all of them. AYe will, however, take up in some detail the four varieties of diarrhea which are most fre- quently observed after a surgical operation. Nervous. — Nervous diarrhea may appear after an operation as well as before it in the neurotic type of individual, who will admit having been subject to it. The nervous upset caused by the opera- tive procedure, as veil as the circumstances antedating and follow- ing it, are surely enough to bring on one of these explosions so characteristic of a certain type of individual. The remedy is the same as that employed at other times. It consists first of all in an exercise of will power and self-control on the part of the in- dividual, aided by the use of sedatives and more liberal feeding than would be employed in patients of any other type suffering from hyperperistalsis. Fermentive. — Fermentive diarrhea is not common among patients who are carefully fed as a part of the postoperative convalescence. However, when it does occur, it should not be difficult to diagnose, and is best treated by large, warm enemas given slowly to the patient in such a position that the water may find its way up into the colon and wash out any decomposing material which has not already been spontaneously ejected. If the paroxysms of pain be very violent and the circumstances of the case permit, a long-con- tinued, warm, relaxing tub bath is of great value. Opium sup- positories of 1, 2, or 3 grains may be needed to secure rest and comfort. Such an upset is to be followed by starvation within the limits of such a patient to endure, and when feeding is recommenced the carbohydrates should be given distinct preference, since they, as a matter of course, do not decompose with the same virulent ef- fect as do the albuminous substances. 390 AFTER-TREATMENT OF SURGICAL PATIENTS Stercoral. — Stercoral diarrhea from the mechanical irritation of the colonic mucosa is dependent upon the presence of hardened feces, eoproliths, or foreign bodies. The diagnosis is here made by digital proctoscopic or x-ray examination, and the remedy con- sists, as a matter of course, in the removal of the offending sub- stance. This in one instance has necessitated, in my own hands, the opening of the sigmoid after laparotomy, and the removal of an enormous fecal stone. In another I was obliged to correct the posi- tion of a heavy uterus which dropped back upon the rectum and rapidly reproduced the same condition repeatedly in that viscus. It never recurred after the uterus was definitely out of the way. Septic. — Septic diarrhea is a distressing symptom of a grave surgical complication. It appears in such a variety of surgical con- ditions and is of such comparative frequency as to deserve much more extended mention than is here possible". It will usually be recognized by the fact that it accompanies other symptoms of a septic nature, and will of course be treated ao1 only symptomatically by the use of opium derivatives to the extent needed for its con- trol, but the original focus, if it can be discovered, must of course not be neglected. For the direct control of septic diarrhea I have been in the habit of using 1 or sometimes 2 drams of paregoric immediately following every bowel movemenl in excess of one in twenty-four hours. Where this has been objectionable to the pa- tient. I have used suppositories containing 1 or 2 grains of pow- dered opium immediately after every movement in excess of one in twenty-four hours. It does not seem reasonable to lay down any oilier tixed rule for the administration of opium products than the one just referred to. since the frequency of the bowel movements varies so greatly in the different individuals that no other procedure has been found to suit the requirements of all cases. Dr. Stuart McGuire presents these instruct ions to every patient suffering from constipation when lie leaves the hospital: In general the diet should be coarse and bulky, containing especially the fibrous parts of \ egetables. On arising drink cue in- two glasses of hot or cold water. Breakfast: Fruit, raw or cooked, except bananas; oatmeal; cream; corn bread, Graham bread, or bran biscuits; plenty of butter; eggs, except hard boiled; molasses or honey; coffee. Milk affects individuals differently; your own ex- perience must guide you in the use of tliis article. in a.m., drink two glasses of water. CARE OF THE BOWELS 391 Dinner: Soup; fish, oysters; meats; chicken or turkey; any vegetables, but especially coarse vegetables, such as string beans, spinach, cauliflower, celery, lettuce, cucumbers, tomatoes, asparagus, salads with oil dressings; corn bread or Graham bread; butter, fruits; and desserts with or without cream. 4 p. M. } drink two glasses of water. Supper: Breads of the kind indicated; butter; chicken; oysters; fish; eggs; molasses or honey; vegetable salads, desserts with or without cream; coffee. On retiring, eat dried figs, prunes or dates and drink one glass of water. II. EXERCISE A moderate amount of out-door exercise should be regularly taken, but not carried to the extent of profuse perspiration. III. LAXATIVES Consult your doctor. Xo one laxative will prove efficient indefinitely. All lose their effect and have to be changed. When it is necessary to use any, the best are compound licorice powder, eascara, senna, and mineral oil. Glycerin suppositories and soap suds enemas also have their place. IV. HABIT It is far better to regulate the bowels by food, water and exercise than with medicine. But it is better to use laxatives or enemas than to fall into the habit of constipation. Have a regular time to go to the closet, and acquire the habit of having an action at this time. The habit is not formed quickly; it may tak< months. But once formed, it will greatly improve your health. CHAPTER XL VII TREATMENT OF POSTOPERATIVE RETENTION OF URINE AND CYSTITIS By John R. Caulk and Harry (i. Greditzer, St. Louis. Mo. Retention of urine, following surgical operations, occurs with a variable frequency, depending in a measure upon the nature and site of the operation, the anesthetic used, the temperament of the individual and coexisting pathologic conditions other than those to which the surgery was directed. Though it is not a common post- operative attendanl to the genera] run of surgical cases, it happens frequently enough to promote a thorough understanding of its cause, and particularly of its treatment, since if improperly handled such serious consequences may ensue. Postoperative retention occurs more frequently after rectal, perineal and gynecologic surgery. It lias been shown that catheterization is necessary in from 4 to L8 per cenl of the cases following labor, and as high as 23 to *-2.~> per cent following major gynecologic surgery. The percentage is made high by the interposition operation for prolapse and extensive operations for cancer of the uterus. The large majority of hemorrhoid operations require catheterization. The more frequenl operations in general surgery, such as gall blad- der, appendix, and hernia operations are attended usually with a very small percentage of postoperative retentions, such retentions often being due to a complicating stricture, prostate or dormanl tabes. A considerable number of individuals have what might be termed temporary retention, these usually void spontaneously and do not require catheterization. Taussig showed thai in the normal postoperative cases following gynecologic operations spontaneous urination occurred on an average of twelve hours. However, quite a number of the patients went from 16 to 33 hours. Effects of Anesthesia. — It has been pretty definitely established thai patients operated on under local or spinal anesthesia empty their bladders a1 a shorter interval and are less apt to have re- tention than patients who have been subjected to a profound general narcosis. Furthermore, the length and depth of the anesthesia seems to be a factor. It has also been observed that patients who RETENTION OF URINE AND CYSTITIS 393 have required large doses of morphia and sedatives are somewhat more prone to retentions. Neurotic individuals are more prone to postoperative retentions than are the phlegmatic ones. The cause of the retentions is usually put down as a reflex, and often this is the case, yet there are many patients who suffer postoperative reten- tion who are included in this category, who in reality have an ex- plosion of some organic central nervous system disease, or me- chanical obstruction at the neck of the bladder. Such cases, if not transitory, should be cystoscopically investigated for such complica- tions. Treatment. — The average patient will void in from 8 to 12 hours after operation. Should they not void at the end of 12 hours, measures must be instituted for the relief of retention, especially if the patient shows symptoms of a full bladder, either subjec- tively or by objective findings, namely, the bladder dullness above the pubis. Should the patient be comfortable and show no signs of retention, he may be given a longer period. In the latter case he may be allowed to go either until he has a desire to urinate and can not or until the bladder seems distended. They must not be al- lowed to go so long as to produce marked overdistension of the bladder, with deleterious effects on its wall, or suppression of renal function. Should a patient begin to void in small amounts and continue to do so, one should be alert to the fact that a full bladder is frequently behind such a performance. The methods of treating postoperative retention of urine are numerous. In the transitory and evanescent type, most any one of the simple measures will usually suffice, whereas in the protracted retentions a catheter will usually be required. Simple measures which are most currently utilized, are the employment of hot appli- cations, such as hot water bags, hot stupes to the suprapubic region, hot enemas, and turpentine enemas about a dram to a quart ; chang- ing the patient's position, such as propping him up in bed, and even if the case permits, allowing him to stand. This latter meas- ure when permissible, will often suffice to relieve a stubborn re- tention. Massage of the suprapubic region, as advocated by some is not very successful and often contraindicated. Pituitrin has been used in recent years with varying success. Ebeler found it extremely effective, as did Jaschke, but other observers have met with considerable failure. The introduction of drugs or air has been advocated by some. Braasch in 1903 proposed introduc- tion of 20 per cent boro-glycerin with the hopes of stimulating bladder contractions. Waldstein used soap glycerin bougies, and 394 AFTER-TREATMEXT OF SURGICAL PATIENTS Taussig proposed the intravesical insertion of air. Glycerin and its derivatives have been effective in numerous cases; but as they are irritants, they are liable to harm the already indis- posed bladder mucosa and lend to cystitis. I can see no excuse for any of these methods if a catheterization can be properly done. Should these measures prove ineffective, catheterization is the next resort, and here a word of warning nerds to be issued. Under such circumstances catheterization must be done extremely carefully be- cause the soil is fertile for bacterial growth. Since there is retention and usually bladder wall trauma with interference to the circula- tory and nervous mechanism, catheterization should be executed tinder the strictest asepsis, as infection is likely to occur. When properly done, such an infection should be extremely rare. Catheterization of the Male. — Catheterization of the male from a urological standpoint is seldom properly done by the average in- terne in the hospital. Great care is taken in the scrubbing of the hands, the wearing of gloves, and the adornment of the patient with sterile towels, and equal rare is taken in the sterilization of the catheter, but the more important, and indeed the one important feature of catheterization passes neglected, namely, the thorough cleansing of the meatus and anterior urethra by swabbing and lavage to eliminate the bacterial flora from this region, which though not pathologic in their normal habitat, may be extremely so when put into the deep urethra and bladder. This one point of cleansing the anterior urethra should be more thoroughly taught. The choice of catheter depends in a greal measure on the individual operator. As a general rule T should say thai a woven silk gum coude catheter is far preferable to any other instrument. It is usually easier to pass, and gentleness is the keynote in catheteriza- tion. It is certainly less liable to become contaminated during manipulation than a soft rubber catheter, and the silver catheter is seldom the instrument for a novice who usually has to do the catheterization. In passing a catheter the inexperienced often becomes alarmed at the normal spastic contraction of the ex- ternal sphincter. "When one readies this region with the tip of the catheter, firm pressure should be made and not a to and fro fishing motion as is so frequently done. The spasmodic contraction of the sphincter will shortly be broken by firm pressure. II is ex- tremely essential not to intlict trauma, as this is the one im- portant factor in the production of infection. Should the retention be due to a latent stricture, as is very often the case, urination may RETENTION OF URINE AND CYSTITIS 395 be produced by moderate dilatation with nlifornis and followers, or soft woven bougies. Stricture is occasionally mistaken for spas- modic contracture of the external sphincter or obstruction at the neck, and unnecessary trauma made by repeated attempts at the passage of the catheter. This mistake should not be made if one will gauge the distance from the meatus, as most of the impas- sable strictures that offer such confusion are located at the bulbo- membranous junction well in front of the bladder neck, and usually at a distance of about six inches. Should the retention be due to a prostatic hypertrophy which has suddenly become engorged fol- lowing operation, a woven silk gum coude catheter is the in- strument of choice. If this will not pass, one will usually succeed with either a bicoude or silver prostatic catheter. In the female catheterization is more simple, and should be at- tended with far less trauma. As females are usually catheterized by the nurse, every hospital should give thorough instructions in the routine catheterization to the nurses. Here again it is extremely important to thoroughly cleanse the meatus and the surrounding lips. The choice of catheter lies between the female silver catheter with a rubber connecting piece, and a woven catheter. Glass cathe- ters which are so frequently used are extremely dangerous. I have seen within the last few years quite a number of instances of glass catheters having been broken in the bladder. A soft rubber catheter is more difficult to pass, and it is extremely difficult to prevent con- tamination of its distal end. Here again gentleness is paramount. After catheterizing the patient, whether male or female, the blad- der should be thoroughly washed with an antiseptic solution, and a small amount of the solution allowed to remain in the bladder ; or it should be instilled with 25 per cent argyrol, or 1 per cent silver nitrate. This administration of an antiseptic we believe is ex- tremely important and is almost an insurance against infection if the rest of the procedure is properly executed. In a urological office or clinic, patients may be catheterized for weeks or months without the slightest sign of infection. Very frequently one catheterization is all that the average post- operative case will require. There are some, however, who demand repeated catheterization before normal urination is established. In such instances nitrate of silver may provoke evacuation. Should retention be at all protracted, some mechanical or neurological ob- struction must be looked for, and this corrected by proper measures. In case catheterization is impossible, and this should be extremely 396 AFTER-TREATAIEXT OF SURGICAL PATIENTS rare, suprapubic puncture may be done. Suprapubic puncture is clone much more frequently than is necessary. Even in cases of retention from pronounced grades of prostatic obstruction there is not one case in a hundred that can not be catheterized. As a matter of fact I have never seen a case that required suprapubic puncture or cystotomy unless it were for ruptured urethra or im- passable stricture and. of course, the former would have no bearing on postoperative retention. Treatment of Postoperative Cystitis. — In this brief discussion on the treatment of postoperative cystitis there will be no attempt to give a detailed description of the exact etiologic factors, the paths of infection, or the various pathologic changes. "We shall concern ourselves entirely with the ordinary type of acute inflam- mation which occasionally develops during the convalescence of a surgical patient. The three factors in the production of cystitis are retention, trauma, and bacteria. Various grades of retention are extremely frequent, both in the male and the female. There is an entire lack of appreciation of this fad with reference to the female. So many women have small amounts of urine retention in the bladder from various causes. This retention is often exaggerated and sometimes made complete after the administration of an anesthetic or op- erative manipulations in the vicinity of the bladder. Trauma of the bladder wall, particularly in pelvic operations is very frequent in- deed, much more so than is usually thought. If one cystoscopes a bladder following some of the simplest pelvic operations, there will be observed a diffuse, extensive submucous hemorrhage throughout the base and posterior wall of the bladder. It is easy to see how this. by lowering the resistance of the bladder wall and interfering with the mechanical emptying capacity, could, in association with re- tention, play a responsible part in the production of bladder in- fection. The third factor, the active factor in bladder inflamma- tion, is the presence of bacteria. We know that bacteria are con- stantly being excreted through healthy kidneys and pass out into the urine. In a normal untraumatized, unobstructed bladder they make their exit without molest, but with such an attractive medium as stagnant urine they find a fertile field for growth. This, of course, is not the only method of entrance for bacteria into the stagnant bladder, as they frequently enter through the lymphatics, either from the bowel, or from the pelvis, for instance in pelvic inflammatory disease, or possihly they may ascend through the RETENTION OF URINE AND CYSTITIS 397 urethra or through the blood stream, so that a bladder inflammation may easily develop without the entrance into the bladder of a catheter. However, with catheterization there are practically al- Avays inserted numerous organisms. It has been shown that under the strictest asepsis innumerable bacteria are introduced into the bladder through instrumentation. In the normal bladder this is without untoward effects. The lighting up of an old chronic infection of the kidney, such as pyelitis, pyelonephritis, or a recrudescence of chronic bladder in- fections, may be responsible for cystitis following operation. There are to be differentiated from a true cystitis two somewhat frequent complications which may occur postoperatively. Trigoni- tis or trigonal hyperemia in women, and prostatic and posterior urethral inflammation and irritability in the male quite frequently produce symptoms which are identical to those caused by cystitis. A catheterized specimen of urine will serve to differentiate the two, as in the latter the urine is clear and uninfected. Another symptom complex which may occasionally puzzle the attendant until urine has been obtained is the occasional frequent, painful urination, which is seen with a bladder which does not empty itself. This is quite common in women past middle life. Just recently we saw a patient who was supposed to have a cystitis from her symptoms. She was passing urine very frequently and suffering excessive pain. A catheter relieved a two quart retention of urine and the patient's symptoms immediately subsided. This suggests a very careful suprapubic percussion and a urinalysis. SymptGms. — A cystitis will usually make its appearance within the first week of the postoperative course, generally the third day. There is noticed an increased frequency and burning on urination, often terminal pain with a sense of dissatisfaction after the act of urination, and the desire to make another attempt. Often a suprapubic pain and a sense of pressure, or bearing down pain in the lower abdomen, occasional low backache, also occasional hema- turia, which in the acute cases is usually terminal, are present. With such symptoms one may be quite assured that cystitis has developed, even though catheterization has not been done. A catheter speci- men of urine should be carefully examined, one will usually find pus and bacteria, and usually the colon bacillus. There is seldom fever in an acute cystitis unless there is some coexisting lesion either in the urethra or kidney, so that if a patient with these symp- 398 AFTER-TREATMENT OF SURGICAL PATIENTS loins has fever one should certainly susped a renal infection. The urine is usually acid as a result of a colon bacillus infection. Occa- sionally it is alkaline due to the proteus group, the micrococcus urea or the staphylococcus. Treatment. — As a preface to our remarks on the treatment of acute eystitis it may he stated that almost invariably a frank cystitis un- der appropriate treatment will be promptly relieved within a -week or ten days. This may be stated as a golden rule. Should it not respond one must direct attention to some other cause, such as an associated vesical, prostatic and seminal vesicle lesion or an in- flammatory kidney. This must be borne in mind as so many in- dividuals are treated for weeks, indeed months, without improve- ment to their bladder condition, while its running-mate infection, either above or below is progressing to unnecessary, and often damaging developments. The treatment of cystitis may be classified as follows: Prophylactic I Hygienic Medical Dietetic General Therapeutic Local Removal of Cause Surgical Curettage Suprapubic < 'y st ostomy Perineal Vesicovaginal fistula Concerning prophylaxis, mosl has been said under the paragraph devoted to urinary retention. The important things to observe are care during surgical manipulation to prevent injury to the bladder wall, and in the case of retention following operation, gentle, care- ful cleanly catheterization followed by the administration of an antiseptic into the bladder, and vigilance to protect the bladder from overdistension in an individual who is voiding, and the general administration of copious amounts of water, urinary antiseptics, and careful attention to the bowels. Should a cystiiis develop, medical treatment, either general or local, usually suffices to promptly cure the postoperative type, and it is seldom that one sees a case neces- sitating surgical interference, and then only in cases of complicated cystitis, that is one in association with stone, tumor, diverticulum, or some other abnormality. Medical Treatment. — During the acute symptoms patients should he kept quiet, instructed to drink freely of water, at least a glass or more an hour, in order to make the urine bland. Alkaline RETEXTIOX OF URINE AND CYSTITIS 399 waters are given by some, but plenty of good hydrant water is suffi- cient. Patients should be kept on light, nutritious and substantial food, avoid all condiments, and should not be allowed alcohol in any form. Mild laxatives such as cascara, phenolphthalein or small doses of saline in the morning, are essential. Local heat either through hot compresses. hot-water bag. or the electric pad. to the suprapubic region are often helpful. Hot rectal, or vaginal douches are also extremely soothing. The medical applications are given for a twofold purpose: to relieve the distressing symptoms and to combat the infection. For relief of the pain and tenesmus, ad- ministration of alkalies is often exceedingly beneficial. Bicarbonate of soda. 10 to 30 gr. three times a day. in case of an acid urine, is helpful, as it lessens acidity, produces a mild diuresis, and has a slight antiseptic property. It also possesses the advantage of not disturbing digestion. The alkalies used most frequently are potas- sium citrate, potassium acetate, and liquor potassse. Combinations of these drugs which are more or less standard are the following: R Pot. acetate Tinet. hyoscyam aa oz. 1 "Water q.s. oz. 6 M. Sig. Two teasjjoonsful in a little water after meals. IJ Liquor potassse oz. 2 Ext. hyoseyam gr. x Tinet. opii eamph. oz. 1 Syr. acacise oz. 2 Water q.s. oz. 6 M. Sig. One tablespoon in glass of water after meals. For tenesmus and extreme pain, anodynes are often necessary. A most satisfactory one is a suppository containing % gr. pow- dered opium. 1 ± gr. extract of belladonna, or a similar combination containing double strength. The bromides are often beneficial. Triple bromides, ammonium, sodium and potassium prepared in an effervescent wafer, is a very satisfactory remedy. Occasionally if the symptoms are hyperacute, morphine and codeine may be recpiired. To combat the infection, internal antiseptics, coupled with local applications to the bladder are necessary. The most efficacious internal antiseptic is urotropin for an acid cystitis. It is often equally efficacious in alkaline cystitis if the urine can be rendered acid by the administration of an acid-producing drug. Other antiseptics in common use are salol. benzoic acid, acid sodium phosphate, helmitol, hetralin. borovertin, cystogen. and certain of 400 AFTER-TREATMENT OF SURGICAL PATIENTS the balsamics, particularly sandalwood oil. In gonorrheal cystitis the balsamics are more applicable. In staphylococcus and strep- tococcus infectious, urotropiu is preferable in conjunction "with benzoic acid or acid sodium phosphate. Acid sodium phosphate is unquestionably the most valuable drug for acidifying the urine. Urotropin should be given in doses from 30 to 60 grains a day, preferably after meals and at bedtime in conjunction with 20 gr. of acid sodium phosphate. Various other drugs, such as hetralin. borovertin. eystogen, uraseptin, methylene blue and others have been extolled as having superior qualities, but none possess the efficacious effect of the substantial urotropin. Of the balsamics. which, as has been said, are particularly effective in gonorrheal cystitis, the oil of sandalwood stands preeminent. It should be given in 10 minim doses, three times a day after meals and at bedtime. Numerous preparations of sandalwood are on the market, namely, gonosan, arrhovin, santyl and arrhoel. The allied drugs are supposed to be free from production of disagreeable gastric symptoms. We believe, however, that there is very little difference in this respect. Demulcents arc not as frequently used today as formerly. Such drugs as buchu, uva ursi, triticum repens. flaxseed lea and corn silk, while soothing, are seldom used in urology today. Their popularity was gained by their somewhat quieting effect in acute and chronic cystitis lasting over long periods, in uninvestigated cases of urinary infections. Local Treatment. — Many cases of acute cystitis without retention may be cured by hygienic and dietetic means, and internal medica- tion. The majority, however, arc hastened in their cure by local applications to the bladder itself. In the acute bladder infections, instillations are preferable. After catheterizing the patient, in- stillation of 2.") per cent argyrol to the empty bladder is most trust- worthy. Even though argyrol is supposed to have very little anti- septic quality, it is remarkable how quickly it will clear up an acutely inflamed bladder. Protargol, 1 to 2 per cent is used by Mune. but it is often badly borne on account of its irritating quality. Nitrate of silver is seldom tolerated in the acute bladder, but it is the master of all in chronic infections. It is surprising how quickly relief may be obtained by a few instillations of argyrol. and as has been previously stated, the average cystitis will clear up within a week or ten days. Irrigations are not desirable in acute bladder inflammation, as they disturb the bladder rest by distention and are EETENTION OF URINE AND CYSTITIS 401 not as efficacious. In the subacute or more chronic cases irriga- tions of potassium permanganate 1 to 6 to 8,000, boric acid 2 to 4 per cent and bichloride, 1 to 50,000, silver nitrate, 1 to 5,000, and hot saline solution are most beneficial. In case of alkaline cystitis which is a very stubborn, intractable and painful type of bladder inflammation, the problem consists in rendering the urine acid in order that the alkaline producing or- ganisms may not live. Various acid irrigations have been given, but usually without effect. The most helpful, and at times almost magic treatment for such conditions is the intravesical injection of Bulgara bacillus. Make an emulsion of 4 to 6 tablets, which are prepared by various drug houses, and inject through a catheter into the empty bladder and have it retained. This should be repeated twice daily until the urine is rendered acid. If the cystitis is not complicated by a kidney lesion, the cure will be prompt. Even in cases of incrustation, we have seen a rapid solu- tion of the incrusted material within forty-eight hours, and a prompt restoration of normal bladder function in a very short period. In case the kidney should be involved, the administration of acid sodium phosphate in conjunction with the Bulgara bacillus to the bladder will be necessary. If a cystitis is protracted and has not abated within two weeks, one is certainly dealing with a complicated lesion, either a kidney lesion, some associated bladder phenomena, such as stone, tumor, diverticulum, bladder neck obstruction, either mechanical or neu- rologic, or one of the many types of chronic cystitis, namely, the hemorrhagic, ulcerative, vegetative, or bullous type. The treatment of these will depend on thorough cystoscopic investigation and study, and has no bearing on the postoperative treatment commonly termed. Therefore the surgical treatment of cystitis need not be considered in this discussion. CHAPTER XLVIII THE TREATMENT OF WOUNDS ]\y Willard Bartlett, St. Louis. Mo. Historical Considerations. — The healing of wounds, naturally, forms the oldest chapter in the history of surgery. Marchand 1 is authority for the statement that Hippocrates, more than two thousand years ago, recognized two varieties of wound healing, one with the format inn of pus, and the other without it. Celsus realized thai wound fluids were derived from the blood, while the influence of Galen was so marked upon the development of this subject, that it persists to the present day. He knew, for instance, that certain wounds heal without the loss of substance, whereas others take the contrary course, thus laying the foundation for the use of the terms, "first and second intention." His treatise, Ars Medica, contains a number of principles to which we adhere today. His influence is distinctly the most important one that has come down to us. from the remote past, and was about all that it furnished up to the discovery of the circulation, the invention of the microscope, and the inception of experimental study. The Middle Ages produced practically nothing of value on wound healing, so the second period of development, which has lasted to the present time, may be said to have commenced with Schwann's discovery of the cell, which was developed by Yirchow in L855, in his aphorism "Omnis cellula e cellula." A natural enlargement of the idea came down through the discoveries of Pasteur, which were applied to practical surgery by Lister, and marked the beginning of the antiseptic era. which was later to develop into our present aseptic regime. Principles Which Underlie Wound Healing. — The study of the subject may be classified in many ways. Perhaps as good as any. for general purposes, is a division of wounds into ihosc uniting by "first intention." thai is, without loss of substance, and those which unite indirectly after loss of substance has been compensated by granulation tissue which has changed into scar, this last procedure being known as "healing by second intention.'' ft can be definitely and clearly stated that there is no such thing as absolutely perfect asepsis. It is said that positive culture's of in- 102 TREATMENT OF WOUNDS 403 fective bacteria can be obtained in over 50 per cent of fresh surgical wounds, and in fact, it is safe to assume, at least, that no wound is ever made and closed without a germ getting into it, but for practical purposes; the tissues themselves take care of a reasonable number, in consequence of which, closed wounds usually heal with- out pus formation. It is quite a different matter with wounds which heal by second intention. These latter invariably become infected, and it is important that proper means for the drainage of their products be furnished, if the patient is to be spared the toxic effects of bacterial growth. Bier 2 was the first to grasp the importance of furthering the ef- forts of nature towards healing wounds in her own way, as shown by the invention of his hyperemia treatment. He noted, very early, that cyanotic lungs are rarely tuberculous, and rightly concluded that some of the substances in the dammed back blood, act as germ destroyers. He applied this deduction to wound treatment, in- tensifying redness, heat, and swelling, by constriction or cupping, "passive or active hyperemia." with the happiest results. One can gain a clearer and more comprehensive idea of the mechanics which aid repair, by reading John Hilton's 3 little book on "Rest and Pain." This admirable dissertation was written a long time ago. but will well repay a careful perusal, so long as men continue to practice surgery. The direction of an incision in certain parts of the body, has very much to do with the nutrition of the wound edges. A fairly high percentage of tissue loss has followed almost every method of flap making, which contemplates complete closure after radical breast operations, although in our own experience, we have had uniformly satisfactory results, since using a transverse elliptical incision, pro- posed by Stewart. 4 This example can be multiplied almost in- definitely; no one. for instance, would consider making a crescentic scalp flap, with the base upward, and other illustrations of this rule or precept will no doubt present themselves to the reader's mind. Wounds located in regions particularly well supplied with blood and lymph, heal much faster than those so placed as to receive a minimum amount of these vital fluids. Thus, it is a matter of common observation, that tissues of the face, for instance, heal much quicker than do those in other parts of the body. For the same reason, the skin more quickly repairs than do the deeper tissues, as exemplified by fat, muscle, fascia and bone. 404 AFTER-TREATMENT OF SURGICAL PATIENTS The extent of the cut also is a factor in wound healing, which can not be overlooked. After long incisions, the greater surface exposed to infection, and the impossibility of perfect immobilization, are some of the causes for the slow reparative processes frequently seen in such instances. The importance of this observation is well borne out by the be- havior of long wounds in the aged. In them, tissue repair is much slower than in the young, and failure to remember this has often resulted in long drawn out convalescence, due to the slow healing of a needlessly long incision. In view of the fact that these pa- tients should lie restricted as little as possible after an operation, careful attention to this detail will not only result in better wound repair, but also, now and then, be the means of saving a life. The importance of having no tension on wound edges can scarcely be overemphasized; the mere fact (in the event this is not properly attended to) that the blood supply will lie cut off and sloughing result, or stitches cut through, and wounds come open, is certainly more than sufficient cause to commend a most careful observance of this importanl matter. Incidentally, it should be mentioned that there musl be no pressure by bandages or dressings on the Haps, else nutritional changes will ensue. Among the general considerations to be observed, are ventilation, which not only make; the sick-room habitable, but also directly con- tributes to the patient's increase in tone, which, as a matter of course, must underlie every healing process. The effecl of general conditions on local processes, was strikingly illustrated to us re- cently. An anemic girl had experienced a thyroidectomy, and the skin wound stubbornly refused to heal, for many weeks. She was put to bed in the hospital, and absolutely nothing done but to feed her up, and keep the granulations clean. Almost immediately a marked improvement was observed, and in a few days the skin edges had correctly approximated themselves. We now and then see a Large wound which has opened up spon- taneously, although there is no sign of infection, and while it looks clean, yet no evidence of repair is apparent. This can practically always be attributed to the influence of one of the dyscrasias which prevent local reparative activity. Weather and temperaturi are said to exert a very marked in- fluence on wound healing, the hot. dry seasons and climates seem- ing to favor it. while those in which moisture predominates, ap- parently have the opposite effect. TREATMENT OP WOUNDS 405 Phagocytosis apparently is a matter of great importance in the healing of infected wounds. It has been determined by Steuber, 5 that cholesterin decreases this activity, while lecithin completely stops it. He states that a bedside determination of these two blood constituents is, therefore, of prognostic value. Preexisting sepsis is a matter of great importance in this con- nection. On one occasion, we were compelled to open the abdomen of a patient who had just recovered from a severe influenza, with most disastrous consequences as far as wound healing was con- cerned. An operation performed during the incubation period of any of the exanthemata is extremely unfortunate. In the experience of the author this influence was observed in two cases of scarlet fever, one case of measles and one case of variola. In each instance the wound became infected, in spite of every precaution. Surgical pro- cedures undertaken in the presence of such diseases, carry with them the risk that dire consequences may follow, so far as the severed tissues are concerned. Laboratory experimentation shows that pus infections of the skin, within an appreciable distance of the region to be operated, make it impossible to cleanse such regions sufficiently to prevent the growth of cultures. Therefore, patients with a localized staphy- lococcus infection, much more a generalized infection, or an ex- tensive dermatitis of infectious nature, can hardly be prepared for operation with any assurance that infection will not be disseminated. Chronic diseases, such as tuberculosis, diabetes, arteriosclerosis, and syphilis, are particularly apt to cause delay in wound healing. We have seen this repeatedly in patients with marked hardening of the arteries, but after heavy doses of potassium iodide, the wounds in almost every instance rapidly closed. In none of these cases were we able to find any other explanation for the tissue inactivity. In patients suffering from syphilis, breaking down of any wound may occur. In large clinics, where the lowest class of patients are operated, mercury is given as a routine measure to prevent this so far as possible. Recently, a patient with a perfect history and negative physical examination was operated for hernia. The wound refused to heal, though there was no infection or any reason why it should be obstinate. The blood revealed a four- plus Wassermann. The patient was now put on antisyphilitic treatment, which resulted in the defect healing as though by magic. The very obese, or those of generally lowered resistance, due to 406 AFTER-TREATMENT OF SURGICAL PATIENTS varying causes, present difficulties in wound repair, while the poor results obtained in the cachexia of extensive carcinoma are well known. Germ carriers are naturally not good subjects, a matter which needs no further elucidation. Among the more uncommon causes of faulty wound healing, is in- fection with the diphtheria organism, as reported by Zeullig. 6 A special consideration must be given wounds of the mucous membranes. As a matter of course, none of them can be regarded Fig. 55.-- A convenient wire basket containing the necessary materials foi dressing wounds. Used at Mayo Clinic. as clean, hence they musl be protected as far as possible. This will be taken up later in connection with the special regions involved. Early Treatment of Aseptic or Closed Wounds. — After a surgical wound has been sewed up. we musl see t«> it that it remains sealed against the entrance of germs, and is protected from every me- chanical insult, until the reparative process is well under way. The form of dressing will be dictated by the region involved, as well as by a consideration of the wound discharges. In the vicinity of external orifices, heavy sterile vaseline, or a sealed dressing (col- li, dion. varnish, paraffine, etc.,) is admirable as a protection againsl TREATMENT OF WOUNDS 407 the possible ingress of the various secretions and excretions. In other parts of the body, the expected discharge of blood, serum, or lymph, from a clean wound, would naturally presuppose the im- mediate application of a sterile, voluminous, absorbent dressing. \Vhen shall the dressing on a sterile wound be changed? This is a question which is difficult to answer in a general way, since individual wounds, as a matter of course, make individual re- Fig. 56. — Large basket containing materials used in treatment of wounds. Fig. 57. — A water bottle which may be maintained at any temperature by means of a stream of water passing through it. quirements. It may, however, be stated for most patients, that an inspection of the dressing, or the patient's sensations of discomfort, or a glance at the temperature chart, or all three of these combined, will very readily settle the matter, (Figs. 55, 56 and 57.) Where no drain has been left in, and there is no cosmetic reason for the early removal of sutures, where the patient is comfortable and there is no marked rise in temperature or pulse, it is common in our 408 AFTER-TREATMENT OF SURGICAL PATIENTS practice to alloAV the original dressing- to remain in place about one week. When shall a drain lie removed after septic operations? Gener- ally speaking, there is no reactionary hemorrhage after twenty-four hours, hence, a drain which is expected to conduct away blood can usually be removed at the expiration of this period, ('lean wounds must often be drained for lymphorrhagia niter the dissec- tion of the inguinal, cervical, and other similar regions, but these drains must usually be left in place for several days, and be re- moved when the dressings no longer become soaked. Fig. 5S- — Stitch pulled up and cut through portion that was buried in skin. Scars upon the face and neck arc. as a mailer of course, and if at all possible, to be avoided. In order that this "consummation, so devoutly to be wished" may be attained, it is necessary to pay attention to a number of details, among which may be mentioned the early removal of stitches, say in one or two days, if a deeper layer has been firmly sutured. This early removal of the stitches invariably prevents the unsightly si itch cross-marks which one so frequently sees on scars not so happily Healed. In other parts of the body, Ave allow the skin stitches to remain about a week (Figs. 58-61.) Agglutination transpires within twenty-four hours, and after a week's time, considerable fibrous union is noted. TREATMENT OF WOUNDS 409 "Through-and-through" stitches are removed in ten, twelve, or fourteen days, according to whether the patient is quiet, provided they do not cut and become too painful; this latter contingency is however, unlikely to occur if the stitches have been run through thin rubber tubing or been tied over other material, which protects the skin. Patients are, almost without exception, nervous and apprehensive of suture removal. In order to avoid, or indeed, eliminate this un- necessary strain as much as possible, we have often found it ex- pedient to inform the individual that our intention is to remove the Fig. 59. — Dividing and removing superficial stitches. sutures the following day, and thereupon, to proceed immediately to that very step. In this way he is spared hours of uneasy and unhappy imaginings. Severe pain may some times be lessened by counterpressure on the skin while pulling upon the stitches. If liquid fat, lymph or blood serum collects in a wound that has been tightly sewed up. it is advisable to spread the edges a short distance by thrusting forceps into the cavity and opening the jaws, after which, a strip of rubber dam is to be inserted. A few hours of this treatment will usually be found to be all that is neces- sary, and the drains may then be removed. 410 AFTER-TREATMEXT OF SURGICAL PATIENTS Stitch infections are painful, as a rule. They may be recognized by a circumscribed redness around the stitches, and naturally, they demand immediate removal of sutures, after which, they will usu- ally heal spontaneously; although sometimes they may demand dila- tation, and the insertion of rubber drains, when abscesses have formed. Early Treatment of Infected or Open Wounds. — Too much can not be said regarding the importance of asepsis when employed to prevent us engrafting tetanus or other infections into already sup- ture. purating wounds. The treatment of infected wounds resolves it- self into a comparison between forms of drainage as against an- tisepsis, which latter is certain to cause coagulation of the ex- cretions. We consider the drainage of any open wound to be the matter of major importance, while the chemical destruction of bacteria, as formerly practiced, was nol only of doubtful value, but indeed, harmful, since drainage was impaired. The use of hypertonic solutions of various sorts has been found to promote drainage, while in my own experience, glycerin (hygro- TREATMENT OF WOUNDS 411 scopic) (Figs. 62 and 63) has besn the most efficient agent of this kind I have ever used. In closed dressings it depletes tissues rapidly, and gives" immediate relief from pain. It is universal in its applica- tion, and although the cheaper grades contain sulphuric acid, and hence, are highly irritating, yet this may be readily ascertained and easily avoided. An excellent vet (Figs. 64-68) dressing is glycerin, peroxide of hydrogen, and distilled water, equal parts. We have used this for many years, especially where dirty wounds are to be Fig. 61. — Cleaning the wound after stitches have been removed. cleaned up rapidly. An admirable dressing for painful granulating surfaces, is Una's Mixture, which is made after the following formula : Amyluni and. Talcum, each 100 grams Glycerin 40 grams Liq. Plumbi subacetate, dilute, 200 grams This is to be thoroughly shaken and poured on cotton to be covered with gutta percha, and changed every few hours. It gives a most delightful sensation of relief and cooling. 412 AFTER-TREATMEXT OF SURGICAL PATIENTS utely inflamed scrotum and : ich glycerin rack is about to be applied. Fig. 63. — Same scrotum and penis after twenty-four hours' application of glycerin pack. TREATMENT OF WOUNDS 413 There can be no set rule for the frequency of changing wet ab- sorbent dressings. This must occur as often as they become satu- rated or foul. Ways of keeping dressings in place will be discussed under "Bandaging," and in other places in this book, but I shall mention just a few special devices here. Dressings for breast wounds may be attached to underwear. This applies to a less extent to other portions of the trunk, where gauze and cotton are not easily kept in place, and when patients experience, more or less, the dis- comfort caused by the slipping of the bandage. Adhesive plaster Fig. 64. — First step in making cotton pledgets. (Fig. 69) has been found very satisfactory for this purpose, as it holds the dressings immobile, neither is it necessarily removed at each dressing. The plaster should be cut in the middle and folded back when the dressing is changed, and adjoining ends be refastened with tape or safety pins (Figs. 70 and 71). In order that the adhesion may be perfect, all surfaces to which adhesive plaster is applied should be shaved and rendered absolutely dry, or hairy parts may be conveniently treated with a depilatory, the chief ingredient of which is calcium sulphide dissolved in water. Fenestrated adhesive plaster, which allows the escape of perspiration, is to be recom- 414 AFTER-TREATMENT OF SURGICAL PATIENTS mended in that it is more comfortable to the patient and less likely to cause itching and dermatitis. Fig. 65. — Second step in making cotton pledgets. Fig. 66. — Third step in making cotton pledgets. A sterilizing agenl long Lauded by German authors, is balsam of Peru. This is injected into wound cavities and applied on wound TREATMENT OF WOUNDS 415 surfaces. Blumberg 7 conducted a series of the most thorough and exhaustive experiments in the use of this agent, and found it a most valuable one in the successful handling of fresh, primary, dirty wounds, as well as in cases where granulations were present. Fig. 67. — Small covered basins fo mg antiseptic unions. Used at Mayo Clinic. Fig. 68. — Washing lip of alcohol bottle before pouring the liquid on a cotton Dakin's Fluid, a product of the present great war, is the sensa- tion of modern times, so far as wounds are concerned. Dr. C. L. Gibson 8 returned from France, early in the Fall of 1916, and told us that the minority of the surgeons then working in France were 416 AFTER-TREATMENT OF SURGICAL PATIENTS enthusiastic over Dakin's fluid, while the majority thought un- favorably of it. Surgeons of the laboratory type claim wonderful results for it, while the eminent clinician in America will have none of it. It seems that Carrel, who gives extensive personal care to many little details of treatment, uses the fluid with the highest measure of success, while Du Page, who has eighl hundred beds at Le Pan, is equally successful, for the reason that he carefully follows the Carrel regime. With Hie exception of Dr. Henry Lyle, of New York, no one else seems to have followed out Carrel's technie in the entirely, and this accounts, in Dr. Gibson's opinion, for the Fig. 69. — Use of ordinary adhesive for holding dressings in place. fact that the fluid lias not been more widely used with success. Gibson saw Carrel] do the first dressings in a number of cases, where an infected compound fracture had been treated with Dakin's fluid, and then sewed up tightly. In not one instance was there a disturbance of wound healing. He also saw Dn Page dress eighty compound fractures in four hours, without a drop of pus being apparent, many of these having been first treated with Dakin's fluid, before the wounds were sewed up. In Hie early days of Dakin's fluid, flic solution was not properly made, and proved to lie too highly caustic, hence, it has been altered, the composition now being as follows, according to the so-called technie of Dr. Daufresne : TREATMENT OF WOUNDS 417 The solution of sodium hypochlorite for surgical use must be free of caustic alkali; it must only contain 0.45% to 0.50% of hypochlorite. Under 0.45% it is not active enough and above 0.50% it is irritant. Fig. 70. — Attaching gauze tapes to adhesive. Fig. 71. — Gauze tapes tied so that adhesive does not have to be pulled off skin when changing dressings. With chloride of lime (bleaching powder) having 25% of active chlorine, the quantities of necessary substances to prepare 10 liters of solution, are the following: Chloride of lime (bleaching powder) 25% of CI. act. 200 gr. Sodium carbonate, dry, (soda of Solway) 100 gr. Sodium bicarbonate 80 gr. 418 AFTER-TREATMENT OF SURGICAL PATIENTS Put into a 12 liter flask the two hundred grams of chlorine of lime and five liters of ordinary water, shake vigorously for a few minutes, and leave in contact for sis to twelve hours: one night for example. At the same time dissolve in five liters of cold, ordinary water, the car- bonate and bicarbonate of soda. After leaving from six to twelve hours, pour the salt solution in the flask containing the macerated chloride of lime, shake vigorously for a few minutes, and leave to allow the calcium carbonate to be precipitated. In about one- half hour, siphon the liquid and filter with a double paper to obtain a good clear liquid, which should always be kept in a dark place. Titration of Chloride of Lime (Bleaching Powder). — Because of the varia- tion of the products now obtained in the market, it is necessary to determine the quantity of active chlorine contained in the chloride of lime which is to be used. This is in order to employ an exact calculated quantity according to its concentration. The test is made in the following manner: Take from the different parts of the jar a small quantity of bleaching powder to have a medium sample; weigh 29 grams of it, mix as well as possible in a liter of water and leave in contact a few hours. Measure 1" c.e. of tin- clear fluid and add 20 c.c. of a 10% solution of iodide potass - c.c. of acetic acid or hydrochloric acid. then put, drop by drop, into the mixture a decinormal solution of sodium hy- posulphite - 18 until decoloration. The number of cubic centimeters of hyposulphite employed, multiplied by 1,775, will give the weight A" of active chlorine contained in LOO g - of chloride of lime. The test must be made every time a new product is received. When the re- sult obtained will differ more or less than 25%, it will be necessary to reduce or enlarge the proportion of the three ] inducts contained in the preparation. This - ined by multiplying each of the three numbersj - 100. mi, by the factor 42.1. in which X. represents the weight of the active chlorine percentage of chloride of lime. Titration of Dakin Solution. — Measure 1" c.c. of the solution, add 20 c.c. of potassium iodide 1 10, 2 c.c. of acetic acid and, drop by drop, a decinormal solution of sodium hyposulphite until decoloration. The number of cubic eentimel - • 1 multiplied by 0.03725 will give the weight of hypochlorite of soda contained in 100 c.c. of the solution. Never heat the solution and if in a case of urgency one is obliged to re- sort to trituration of chloride of lime in a mortar, only employ water, never salt solution. Test of the Alkalinity of Dakin Solution. — To easily differentiate the solu- tion obtained by this process from the commercial hypochlorites, pour into a about 2o c.c. of the solution and drop on the surface of the liquid a few centigrams of phenolphthaleine in The correel solution does not give any coloration while Labarraque's so- lution and Eau de Javel will give an intense red color which shows in the last two solutions existence of free caustic alkali. Ill the treatment of a wound, a great deal depends upon the fluid reaching every little cavity, hence, four rubber tubes are con- nected to a glass apparatus Fig. 72 . These are closed at the outer TREATMENT OF WOUNDS 419 ends, and perforated with many small openings, so the fluid in- jected through them is widely diffused. The surface of the wound is kept damp but not flooded. Irritation of the surrounding skin is pre- vented by the liberal use of vaseline on a cloth. The reservoir is held one meter above the wound, and frequently, six to ten of the glass connecting rods, previously mentioned, each equipped with four rubber tubes, are employed in a large defect, A very small dressing is used, just a layer or two of gauze, on which the glass connecting rods lie. This dressing is changed every day. and if all the pockets are reached, germs rapidly disappear from the wound. Matter which is obtained as a fresh smear, is taken and examined daily; in ten days or two weeks, the wound becomes V .,-;..: '■•% WfW n n~fl B^L ^ £H m ^fi JL* Ms W ' v J w Fig. 72. — The Carrel-Dakin glass distributor. sterile ; when it remains sterile for about six days, the edges are trimmed with a scissors and the whole tightly sewed up. Surfaces are prepared for skin grafting in the same way, and Gibson reports astonishing successes for it. He saw some such areas dressed four days after the grafting on granulations, and they were perfectly dry. It may be added that Carrel considers the method complicated, at the present time, and is trying to produce a much simpler one. Dr. Lyle, 9 who has just returned from the front in France says: "The Carrel method of disinfecting wounds is based on the follow- ing conception : To render an infected wound sterile, it is neces- 420 AFTER-TREATMEXT OF SURGICAL PATIENTS sary to employ a suitable antiseptic in such a manner that the chosen antiseptic comes in contact with every portion of the wound, that the antiseptic is maintained in a suitable concentration through- out the entire wound, and that this constant strength is maintained for a prolonged period. If these conditions are fulfilled, every wound will show its response to the treatment by the diminution and disappearance of its microorganisms. The chemical destruc- tion of the microorganism of a wound depends on the difference of resistance existing between the tissues involved, and the bac- teria present on their surfaces." He summarizes his conclusions on this subject as follows: "The future course of the wound is directly dependent on the thorough- ness of the first surgical act. This should be carried out under the strictest aseptic precautions and at the earliest possible moment. It consists of a thorough, methodical, mechanical disinfection of the wound with the extraction of all shell fragments, particles of cloth- ing, dirt, etc. "The Carrel method is not a continuous irrigation. It is not de- pendent on the miraculous power of an antiseptic, or on any one feature of the method, but on the combination of the whole. It is a method of sterilizing wounds by mechanically delivering an an- tiseptic of definite chemical concentration to every portion of a surgically prepared wound and insuring its constant contact for a prolonged period. The progress of the sterilization is rigorously controlled by the microscope. Gentleness, thoroughness, and at- tention to detail are essential for success. I firmly believe that the adoption of this method is destined to save many lives, to re- duce the gravity of the mutilations, and allow the rapid return to the front of many men who would otherwise be lost to the service of their country." In a recent personal communication. Dr. \Y. C!. Fralick writes us: "The great impetus which has been given to the use of the Drs. Carrel and Dakin Hypochlorite in surgery, through widely published reports, would seem to warrant our giving to the pro- fession the most intimate knowledge we have of their chemistry and bactericidal effects, together with technical reasons for fl preference of a particular hypochlorite, for clinical use. My re- search work with the halogen compounds extends over a period of more than 15 years, and deals with methods of preparation, their chemistry and bactericidal action, together with their surgical ap- plication on deep and superficial wounds, intraperitoneally and in- TREATMENT OF WOUNDS 421 travenously; also their action and dissolving power on infected blood clots and necrotic tissue." Hypo chlorous acid, as a medium for wound treatment has received wide commendation; among others, Dalton 10 reports a series of fifty-seven cases, thus treated. The results obtained were uni- formly excellent. Fraser 11 tells us that the solution has been used with inestimable benefit in gas gangrene, and in compound frac- tures, complicated by infection. Again the Medical Research Com- mittee 12 of the Royal College of Surgery of Edinburgh, advocates the application of eusol, and praises its use in wounds which have become septic after certain operations, and considers that it has been proved nontoxic and nonirritating. as well as an efficient an- tiseptic. The specific use of antiseptics is well brought out by Oehsner 13 when he writes that he believes our physicochemical experiments. biochemical studies, bacteriologic investigation and clinical experi- ence are corroborative, and justify the following conclusions, viz : that osmosis is a purely chemical process; that boric acid, when ap- plied to the surface of the body in a saturated aqueous solution, is absorbed in appreciable quantities by a process of osmosis similar to the process studied in the chemical laboratory ; that, when used in cases of septic infection, it is most potent in reducing the viru- lence of certain pathologic bacteria; but. that in order to be ef- fective, it must be applied in saturated solution, and finally, that when applied as above directed, in the early stages of septic infec- tion, most eases will make a complete recovery without incision, without the loss of any member, and without permanent impairment of function. He also states that he has come to the point where he looks upon this dressing as almost specific in streptococcus, Staphylococcus albus and citreous infections of the skin and cellular tissue, as well as in pemphigus, and that in order not to be disappointed in our use of boric acid wet dressings, it is important that we make a diagnosis as to the nature of the infection. As a rule this can be done easily, at least one can practically always say whether a case is one of malignant edema, tuberculosis, or impetigo contagiosa, and it is only in these three infections that boric acid is contra- indicated. Beck seems to have injected bismuth paste with good results (Fig. 73). 422 AFTER-TREATMEXT OF SURGICAL PATIENTS One of the most important recent innovations is well described by Dyes, who, in discussing the treatment of infected wounds says: Heat and moisture are essentially necessary for the growth and de- velopment of pathogenic bacteria, consequently tissue destruction is greater in moist, than dry gangrene. He calls attention to the fact that the Indians preserved their meats by placing the carcasses high above the ground and exposed to the air and sunlight. He also comments upon Ihe fact that domestic animals rarely have suppurating wounds, and that these wounds are kept open and clean by constant licking. In conclusion, he remarks upon the success- I he injection of Beck's bismuth paste. t'nl treatmenl of burns by the open method, and mentions the remarka- ble results attained by Rollier by this mode of procedure in surgical tuberculous affections. The method pursued by Dyes is as follows: The patient is put to bed. A cradle (Figs. 7-4 and 75) is placed over the affected part, over which a mosquito netting is placed as a protection againsl Hies and flying crusts. In some instances, a small electric fan is turned on the lesion, and kepi going for from fifteen minutes to half an hour, four or five times a day. Only an occasional raising of the crusts, to allow the escape of serum or the irrigation of a stubborn area for a time, is permitted. An inert TREATMENT OF WOUNDS 423 Fig. ;i.— a under which a large surface may be kept exposed. Fig. 75. — A small shield for exposing a small area. 424 AFTER-TREATMENT OF SURGICAL PATIENTS desiccating powder is used at times, and in ambulatory cases, wounds are protected by a wire screen held on by adhesive plaster. I have made extensive use of the method, and found it em- inently satisfactory. The patient is comfortable, the surrounding skin stays healthy, much money is saved, as no dressing need be bought, and all in all. it has answered every requirement very well. I combined it with Crile's 15 electric light treatment and found the combination particularly applicable to the treatment of suppurating abdominal lesions, such as those of the appendix. Caput in 1914 first discovered that electric light would take the place of the sun- light in the healing of wounds. In fact, analysis shows the two rays to be similar. At the present time I am treating two fecal Fig. 76. — An automatic glass rubber cupping device. fistulas in this manner. The patient is Ear more comfortable, and indeed much better off than with voluminous dressings soaked with feces. The entire abdomen is covered by a cradle which supports the light and at the same time holds the bed clothes at a distance. In smaller wounds, I use an ordinary wire gauze strainer from a hardware store, as a protection, and am careful to see that there is an electric lighl near by. or that sunshine falls on them from a near-by window. There arc certain infected wounds which are best treated by suction cupping. This will he found to relieve edema; it remove's secretions, eases pain, and in general, facilitates rapid repair. Fur- TREATMENT OP WOUNDS 425 uncles (boils) form excellent examples of this class of wounds. In a case which could not be aborted, but has had to be operated upon, if sufficient time has elapsed before the incision is made, the necrotic center of the lesion can be lifted out at once ; but if it is not loose, gentle suction (Figs. 76 and 77) should be employed every hour or so, the wound being merely covered by a vaccination Fig. 77. — A positive suction cupping device. shield and exposed to the rays of an incandescent bulb, placed so close to it as to produce an agreeable degree of warmth. A fifteen watt lamp gives a delightful sense of warmth, as the recent experience of the author has demonstrated, while the or- dinary green metal household shade protects surrounding parts from heat and light. In a short time the necrotic, center can be sucked out in toto, after which the defect rapidly granulates up, 42G AFTER-TREATMEXT OF SURGICAL PATIENTS and no further treatment is needed than the occasional cleansing with alcohol to prevent the reinfection of the surrounding skin openings, and the protection of the wound with a vaccination shield. Suppose The lesion is on the hack of the neck, and any form of circular bandage be worn. Painful pressure and distressing massage of the Lesion are unavoidable every time the head is turned. The patient endeavors, by using all of the neck muscles, to hold the field at rest, and very soon excessive local fatigue added, makes his lot still more unhappy. It may be further said that any form of venicnt way of storing sterile gauze packing in glass talus. dressing makes a pus poultice, and accounts in a greal measure for the reinfect ions and for neighboring si adary furuncles; on the other hand, the growth of bacteria is hindered by the drying up of excretions from a wound exposed to the air. This treatment may lie carried out by any intelligent member of a family or office force, which brings it veil within the range of possibility for many men. withoul upsetting the ordinary routine of life. If carried mil faithfully, with regard (<>v every detail, it robs this distressing malady of its mosl serious features. Tin' sorl TREATMENT OF WOUNDS 427 of "stock" affected by horsemen and golfers, can readily be worn over the vaccination shield, and the patient be rendered somewhat uncomfortable, though much more presentable, than is the case when an otherwise well-groomed man with a stiff neck, goes about minus collar and tie, with a surgical bandage where they should be. The suction rapidly reduces the edema in adjacent muscles, with the consequent early disappearance of the stiff neck so charac- teristic of the condition. Generally speaking, the irrigation of infected wounds has almost passed out of use. I vividly recall a case of axillary abscess, many years ago, which was treated by daily irrigation. The tem- perature rose to 104° within an hour after each treatment. The treatment was discontinued, but left a memory, never to be for- Fig. '9. — Granulations covered with gutta percha which protects them from gauze dressings which would otherwise adhere. gotten. Mention of daily gauze packing (Fig. 78) of defects is made, only to be condemned. It is not only highly painful, but at the same time, gauze retains the secretions and becomes foul. "Where gauze (Fig. 79) must come in contact with granulations at all, it is perhaps well to consider Fisher's 16 suggestion that plain surgical gauze is unsatisfactory, where it adheres to granulating wounds, a disadvantage which is less troublesome if narrow mesh gauze is used. Xo particular advantage attaches itself to medicated gauze. (Figs. 80 and 81.) He considers that he secured the best results from the use of gauze impregnated with paraffme treated in the following manner : eight parts of paraffme mixed with two parts of white petrolatum and lanolin boiled for ten minutes. 428 AFTER-TREATMENT OF SURGICAL PATIENTS Drainage is "well employed in the removal of lymph, liquid fat, blood or pus. The length of the period over which it is to be con- tinued must be determined in each individual case. As to drainage material, I shall preface this subject by the brief warning, that this never should be gauze, as it does not drain. Neither do I advise glass tubes, as I have seen these break in the wound. A rubber tube (Fig. 82), if used, should be split the entire length, in order that fluid may run into it at any point, and the tube itself be withdrawn more easily, than one with holes, into which granula- tions have grown. A folded rubber dam makes an excellent drain, in that it causes no pressure, which is likely to result in decubitus. All drains should be sutured to the edge of the skin, or otherwise prevented from slipping into a cavity and being lost. Fig. 80. — The insertion of stitches which are intended to hold gauze packing in place. The drain opening should, of course, be placed at the most dependent site. It is well to remember that the posture of the pa- tient can be altered to influence this. For instance, we frequently keep a patient on his face to facilitate abdominal drainage. Chaput, 17 for some time, has discarded tubular drainage, in path- ologic cavities and replaces them by filiform drains. These con- sist of threads of varied caliber. The drainage is capillary and he considers this form of material much heller than tubes, and says further, that they permit a more rapid recovery with an insig- nificant cicatrization. T distinctly favor through-and through drainage where it is possible to secure counter openings. The ends TREATMENT OF WOUNDS 429 of the drain are fastened together, and hence, do not slip out, thereby insuring greater comfort for the patient. Isuardi 18 would shatter time tried tradition, in opposing the employment of drainage in the treatment of septic wounds. Of two hundred wounds treated by him in the Reserve Hospital of Vercelli, thirty-two were very grave and septic, most of them being fracture wounds. He is of the opinion that drainage and incisions disturb the progress of the reparatory process, and that drains, whether gauze, rubber, or glass, are foreign bodies, which irritate the tis- Fig. 81. — The gauze packing held in place by tied suture ends. sues, and give a harboring stronghold and breeding place to mi- crobes. Isuardi must at least be mentioned for the sake of com- pleteness. Three pregnant statements regarding fixation were made recently by von Eiselsberg, 19 in connection with the treatment of emergency wounds. They relate to: (a) Fixation of bacteria surrounding the wound, and the protec- tive bandages. 430 AFTER-TREATMENT OF SURGICAL PATIENTS (b) Fixation of broken limbs through plaster casts, and (c) Fixation of the patient on his bed. We must emphasize the advantages of titration and suspension as applied to the extremities. They favor circulation, and hence minimize edema, relieve pain, and altogether hasten repair. It will be found advisable to splint an extremity on which there is an infected wound. The patient should remain as quiet as pos- sible, since motion favors spreading of infection through the lymphatics, causes pain and delays healing. The dressing can be changed through a fenestrum (Fig. 83) in the cast. The splint is especially advantageous when combined with elevation or suspen- sion. The constant exposure of granulations to a blast of dry air, preferably warm, is said by Bergeat 20 to hasten drying up, and the Fig. S2. — Split rubber tube drain as used at the Mayo Clinic. whole healing process; it should be applied for five or ten minutes at a time. In this connection a hot air chamber is highly recom- mended for decreasing edema, and promoting shrinking of the swol- len region; ii will also be conducive to the comfort of the patient and assisl repair through improving the circulatory conditions. Close attention musl be paid that granulations art not lorn, or caused to bleed by changing of gauze, and especial care should be given that this does not occur at the edge of the skin. It is wise to use a protection of gutta percha (Fig. 70); this renders the dressing painless and is favorable to rapid epidermization. Time is saved in the healing of large defects, after the wound is cleaned up and granulations are healthy, by drawing tht shin edges to- TREATMENT OF WOUXDS 431 gether, and adhesive plaster will be found most convenient in this connection. Strips are to be placed a short distance apart, to al- low the escape of wound fluids. Very often the patient complains of the offensive odor of the dressing. The sprinkling of two or three drops of formalin upon the bandage is a suggestion which, if carried out. will be found most efficient in overcoming this annoying detail. In wounds com- municating with the mouth, a packing of gauze soaked in comp. tr. of benzoin, which may remain in several days, will completely dis- pose of the characteristic odor, and a little alcohol, sprinkled upon the bed clothes, not far from the patient's face, is an effective help in disguising disagreeable smells. It is vastly more difficult to lay down rules concerning the chang- ing of dressings on infected, than on clean wounds. Briefly, we may Fig. S3.— Fenestrum in a plaster cast as used at the Mayo Clinic. say that every instance is a law unto itself, and the amount and character of the excretions, the saturation of the dressings and its odor, the sensations of the patient, as well as the temperature chart, must govern the surgeon. Foreign Substances.— It is a well-known fact that the healing process in wounds is delayed by the presence of foreign substances, an example of which is seen when we strangulate a mass of tissues with a ligature. Among the many illustrations of this truth, which present themselves to mind, is a case in which a bone fragment in an infected wound causes a discharging sinus; the wound remains open, refusing to heal, until the removal of the fragment, after which it readily responds to treatment. In another instance, a 432 AFTER-TREATMENT OF SURGICAL PATIENTS particle of clothing, carried in by a projectile, had much the same effect. Very frequently small gauze pads have been left in wounds, causing infection and sinus formation, which necessitates removal. Infected nonabsorbable ligatures act similarly, and we may men- tion that drain tubes, which are not fastened, and through careless handling, slip in. frequently make operative removal necessary. Some Remote Consequences of Wounds. — One of the most com- mon consequences is a painful scar. as. for instance, after burns, Fig. 84. — Injecting local anesthetic under skin of thigh previous to cutting grafts. when very frequently the nerve endings arc caught. If the scar is near a joint, limitation of its movements, and consequent pain is present. Radical breasl operations are a very usual cause for ihi* distressing limitation at the shoulder joint. The best prophylaxis is early movement. Scars are very frequently most disadvantageous about the hands and fingers, in that the resulting limitation of mo- tion impairs the usefulness of the member, which in many cases, decreases tin 1 earning capacity of the patient. It sometimes occurs TREATMENT OF WOUNDS 433 that a large nerve is caught in a scar. This is most common after fracture. Very recently I released the ulnar nerve, just above the elbow, and made a fat sheath for it. Cancer sometimes forms in a scar; it is usually in an old one, and is most frequently met with in elderly people. Quite lately I amputated the foot of an elderly gentleman, for cancer under the heel, which appeared in the scar of a burn, received thirteen years previously. At the present writing, I have under treatment, an Fig. 85. — Cutting the grafts with a razor. old lady with an extensive cancer in the scar of a varicose ulcer, just above the inner aspect of the ankle joint. Late Treatment of Wounds. — In the late treatment of wounds, I have found skin grafting (Figs. 84-93) to be of the greatest value in hastening the repair of extensive granulating surfaces, and am in favor of covering the defect completely. Sprengre 21 ad- vises dividing the wound by two or more skin-naps, transversely across — one from each side, and meeting in the center, if necessary. 434 AFTER-TREATMENT OF SURGICAL PATIENTS TREATMENT OF WOUNDS 435 This makes at least two new wound edges, in addition to those already existing, from which skin formation is hastened in a truly surprising way (Fig. 94). It is advisable to wait until all sloughs are cleaned off, and granulations are healthy. Ugly disfiguring scars should he excised and the defect resutured, although I am of the opinion that keloid is best treated by radium or x-ray. Depressed scars are greatly improved in appearance by a hori- zontal subcutaneous division, and the insertion of fat transplants. I have in several instances rebuilt a complete breast in this manner, after the removal of all but the skin, for benis'n tumor. Fig. 88. — Grafts in place on a varicose ulcer of the ankle. Fig. S9. — Cross layers of gutta percha, which fix grafts and their backing in place. Transplantation of cartilage successfully corrects a depressed scar over ridge-like eminences. I have under treatment, as this is written, a boy with a depressed incisional scar across the bridge of his nose, which will be treated by subcutaneous elevation, and in- sertion of a thin section from a costal cartilage. The transplantation of bone (Fig. 95) is almost too common at the present day, to merit more than a passing mention, nevertheless, it is possibly not so often done for cosmetic purposes, as is perhaps indicated. "We formerly -waited to get a clean field, but Law 2 ' 2 has apparently secured as effective results in infected areas as well. Autotransplantation of bone, following the removal for carcinoma 436 AFTER-TREATMENT OP SURGICAL PATIENTS Fig. 90. — Gauze and adhesive which covers grafts and gutta percha. Fig. 91. — Ordinary gauze bandage which covers gauze and adhesive left on forty-eight hours. TREATMENT OF WOUNDS 437 Fig. 92. — Removing gutta percha after grafts have remained in place forty-eight hours. Fig. 93. — Open air treatment of grafts after first forty-eight hours' compression. 438 AFTER-TREATMENT OF SURGICAL PATIENTS of that part of the mandible which forms the chin base, was re- cently accomplished by M^eKittrick. The region in which the grafl was placed was infected and necessarily remained this way through- out the time the wound was healing. The ultimate outcome resulted in perfect restoration of the parts. It is hardly necessary to mention that all grafts, no matter what tissue is involved, must he taken from the body of the same in- dividual, since autografts alone can be depended upon to remain viable. i -kin. *W Pis- It is unfortunate thai lids important subjed must be treated in a fragmentary way. A large monograph would be required if every detail of it were to be exhaustively considered. Bibliography iMarchand, V. : Der Process clei Wundheilung, Stuttgart, verl. v. F. Enke, 1901. -'Bier: Byperaemie als Heilmittel, F. I . W. Vogel, Leipzig, 1903. Hilton, John: Rest and Pain, NTew York, l s 7'.'. Maemillaii Ann. Surg., 1915, Ixii. TREATMENT OF WOUNDS 439 sSteuber: Miinehen. med. Wchnsehr., 1913, xx, 1111. eZeuling: Beitr. z. klin. Chir., 1913, lxxii, 3. rBlumberg: Inaug-Diss., Berlin, Sept., 1912. sGibson, C. L. : Personal communication. £>Lyle: Jour. Am. Med. Assn., Jan., 1917, p. 107. loDalton, F. J. A.: Brit. Med. Jour., 1916, i, 126. iiFraser, J.: Edinburgh Med. Jour., 1916, xvi, 127. 12 Medieal Beseareh Com. : Lancet, London, 1916, cxc, 356. isOchsner, E. H. : Tr. So. Surg. Assn., 1916. "Dves, F. G. : Jour. Am. Med. Assn., May, 1915. i-5Crile: Surg., Gynec. and Obst., Oct., 1916. isFisher, H. E. : Jour. Am. Med. Assn., 1916, Ixvi, 939. iTChaput, H. : Bull. Soe. de Chir., 1916, xlii, 163. islsuardi: Gior. d. v. accad di med di Torino, 1915, lxviii, 439. isvon Eiselsberg: Wien. klin. Wchnsehr., 1913, Xo. 23. 20Bergeat: Miinehen. med. Wchnsehr., 1913, xxy, 1377. siSprengre : Deutseh. Gesellsch. f. Chir., 1901. 22Law. A. A. : Autografts in Infected Fields. The following authorities were also consulted : Bell, John: Discourse on the Nature and Cure of Wounds, Walpole, X. H., 1807, Thomas & Thomas & Justin Hinds, i. Cheyne, W. W. : The Treatment of Wounds, Ulcers, and Abscesses, Philadelphia, 1895, Lea Bros. & Co. Cheyne and Burghard: A Manual of Surgical Treatment, London and Bombay, 1904, Longmans, Greene & Co., part I. Gamgee, S. : On the Treatment of Wounds and Fractures, Philadelphia, 1883, P. Blakiston's Son & Co. Hunter, John: A Treatise on the Blood, Inflammation, and Gun-Shot Wounds, Philadelphia, 1S23, James Webster. Pilcher, L. S. : Treatment of Wounds, New York. 1S83, Wm. Wood & Co. CHAPTER XL IX BANDAGIN* ! By 0. F. McKittrick, St. Louis. Mo. Bandages play an important role in the care of the postoperative patient. Their use is not so extensive in this day of open wound treatment as formerly, but they are still found indispensable in holding various regional "wound dressings, supporting splints, im- mobilizing points, applying pressure for arrest of hemorrhage, Bier's hyperemia, compression of varicosities, and many other con- ditions "which arise in the daily routine nursing of the surgical pa- tient. The most common materials utilized for this purpose are usually bleached or unbleached muslin, crinolin, or this latter dress lining to which sonic hardening substance has been added as plaster of Paris. The elastic bandage also has a wide range of usefulness. Ordinary band towels are employed with greal effectiveness by some surgeons. These came into use through Mayo's descrip- tion of the handkerchief bandage, and -was first introduced in our work by Vilray P. Blair. Bandages are classified as simple or compound. In the former the materia] is in one piece, as exemplified by the ordinary roller bandage. In the hitler two or more pieces of material are used, these being cui to suit the individual portion of the body to be covered. The crinolin or plaster of Paris bandages are usually referred to as immobilizing bandages, while the rubber bandage is considered a pressurt bandage. In order to adequately describe the method of applying the bandage, the free end is called the initial extremity and the closed end is known as the terminal extremity, the portion between these points is designated as the body. The surfaces may be conveniently designated as inner and outer, re- spectively. In describing the towel bandage, the first fold made preliminary to applying it is called the initial fold, while the sides, ends, and corners of the towel retain their original names. Roller muslin bandages are most conveniently supplied in rolls of five to ten yards long and are the full width of the muslin. This is usually 36 to 42 inches. The width of the bandage itself 440 BANDAGING 441 (1 to 6 inches) is regulated by cutting them off the main roll as shown in Fig. 96. In case it becomes necessary to roll a bandage, machines especially manufactured for this purpose may be em- ployed, either the whole width of the muslin is encased in the roll or the width of the bandage alone. In most instances, however, these conveniences are not within reach, and the bandage is rolled by hand. In order to do this several folds are made into a small uniform roll. This is now grasped by the thumb and middle finger of the right hand and revolved in the left hand so as to force each revolution to add material to the roll from the strip of muslin Fig. 96. — Method of cutting a roll of muslin into bandages, devised by Pattingson of the Mayo Clinic. A. Muslin, 36 inches wide, 10 yards long, being tightly rolled over a yard stick which is pulled out at the end of the roll in order to show. b. Finished roll, yard stick partly withdrawn. C. Finished rolls ready to cut into bandages. D. Cutting the bandages into desired widths in a miter box. This box is made of pine. The top and ends are left open, and the sides are sawed so as to permit the use of the Christy knife. The bottom is divided into equal parts which are fastened with hinges. Four foot pieces support the whole. These are so arranged that the bottom of the box is beveled. This, together with the three-cornered pieces of wood placed on each side at the top and bottom inside the box, holds the bandages absolutely tight as pressure is placed on them during the cutting. The instrument for this purpose is an ordinary Christy (bread) knife. .E. End of box showing the bandage held securely by the four three-cornered pine strips within the box. Note the beveled bottom of the box. This permits pressure as desired during the cutting process. F. Bandage box open with cut bandages ready for removal. G. The finished bandages. which is drawn through the forefinger and middle finger of the left hand as shown in Fig. 97. The roll can then be wound as tightly as desired through the tension exerted by the fingers of the left hand. Before a bandage is applied, the parts to be covered are thor- oughly cleansed with water, alcohol, and then dusted with talcum powder. If a wound is to be covered, it is covered first with gauze and cotton batting or sheet wadding. It is also to be observed that 442 AFTER-TREATMENT OF SURGICAL PATIENTS bony prominences are to be treated likewise, and occasionally it is desirable to have all the parts protected with this material. No two skin surfaces are to be allowed to come in contact, cotton or sheet wadding being intervened. In applying the roller bandage, the body is contained in the right hand, the initial extremity held in place by the left, and the bandage rolled away from the operator. In this way the inner surface becomes the center. Wrinkles in the cloth are to be avoided. The edges of the exposed strips of bandage are turned in "while they are being applied, and a firm smooth application of the band- Fig. 97. — Rolling a bandage by hand. Fig. 98. — Bandage age, which is do1 too tight, is the objed to be attained. The ex- tremities are wrapped from the distal end towards the body of the patient, always bearing in mind the danger of ischemia with gangrene from too great or uneven pressure. The terminal ex- tremity is nicely folded to a point and fastened with adhesive or a safety pin. In removing the bandage it may be cut with bandage scissors Pig. M s or unwrapped. The folds are kepi massed together, which facilitates the transfer of the unwrapped bandage from one hand to the other. A concrete description of the various kinds of bandages em- ployed is not indicated in a work of this kind, but rather in one in minor surgery. Still there are a few points which should be dis- cussed and to these, onlv, will attention be directed. BANDAGING 443 Head Bandages. — In placing the frontooccipital bandage the ini- tial extremity of a roller two inches wide is held beneath the oc- cipital protuberance and the body is then carried around the right side of the head across the forehead and then around the left side of the head to the starting point. The turns are repeated, each time a part of the preceding turn being left uncovered. The exposed edges are turned in as shown in Fig. 99 and the terminal extremity fastened at the side with adhesive. In covering either of the parietal regions alone the bandage is fixed as in the bandage above, one or two turns being made so as to more firmly secure it ; then beginning at the occipital protu- berance the body is passed obliquely over the parietal eminence to the forehead, where it is held with the finger directly above the eyebrow. From here it is doubled back and continued to the oc- Fig. 99. — A head roller bandage. cipital protuberance below the first strip of bandage, part of its external surface being left exposed. The bandage is now brought back to the region of the eyebrow ; this time, however, the body passes above the first layer. The body is continued back and forth in the manner described until the region is covered. Then the bandage is secured by another turn or two around the head as in the beginning. All edges are turned under as the folds are placed. The terminal extremity is fastened at the side with a strip of adhesive. A recurrent bandage is commonly employed to cover the entire vertex. The initial extremity of a roller two inches wide and six yards long is fastened by the frontooccipital turns as de- scribed above, then beginning at the forehead the bandage is doubled on itself and brought directly over the head to just under the occipital protuberance, making a right angle with the first turns. 444 AFTER-TREATMENT OF SURGICAL PATIENTS From here it returns to the forehead only to be taken back to the point beneath the protuberance. This is continued, each turn cov- ering the lower portion of that gone before, until the vertex is completely lost to view. The ends of the folds are then secured by several frontooccipital folds and the terminal extremity having been nicely brought to a point, is held in place with adhesive. In the hands of some, as mentioned above, it is much easier to use an ordinary towel in bandaging this region of the body. A Fig. 100. — A towel folded for bandaging. Fig. 101. — First step of applying towel bandage to head. towel, preferably Kix'24 inches, and one that has been washed frequently and is therefore soft and easily handled, is folded as in Fig. 100. For the adult head, unless, of course, too much dress- ing has been already placed, this size towel, folded, will be found most satisfactory. After folding the towel, the center of the largest surface shown in the figure is placed directly on the back of the head, the region of the initial fold passing under the BANDAGING 445 occipital protuberance. The ends are then brought across the sides of the head above the ears, and fastened at the root of the nose as in Fig. 101. Here it can be made as tight as desired by simply pulling the two extremes of the initial fold and then pinning them in place. The corners of the towel now protrude as seen in Fig. 101, one having been simply tucked under the other. The opposite corner is at once brought over firmly and smoothly and fastened as in Fig. 102. If it is unnecessary to include the eye (or eyes), the initial fold of the towel is simply brought further down on the side of the head, above the ears and fastened over the bridge of the nose. In this case the completing folds will be shorter than the preceding band- Fig. 102. — The completed head bandage, Fig. 103. — The completed head bandage, eye eyes and ears (if desired) included. (^r eyes) excluded. age and will terminate as in Fig. 103, the same tucking process hav- ing been carried out as in Fig. 102. In bandaging a stump the recurrent roller bandage (Fig. 104) may be applied. It is placed, in the main, as a recurrent bandage of the head, and need not be further described. A towel is easily utilized here. One about the same as that in Fig. 100 is folded as there depicted and the initial fold is fastened around the extremity just above the stump. The corners are then tucked in and pinned as in Fig. 101. It is further secured by adding strips of adhesive plaster. The size of the towel depends on the size of the stump and the amount of dressings. If such bandages are applied properly, they will stay on in- definitely, and will not become roughened and disarranged so 446 AFTER-TREATMENT OF SURGICAL PATIENTS quickly as the roller bandage. In unruly patients or the delirious, it may become necessary to attach muslin straps behind the ears and on the lower edge of the towel so that they can be tied under the chin in order to insure against the slipping of the bandage. When one eye alone is to be included in the head bandage the bandage is folded as in Fig. 105, and applied as in Fig. 101, except that the side of the head and the adjacent eye are covered by the initial fold of the towel. The corners are tucked in as was done in Fig. 102. The final appearance of the bandage is shown in this figure. More extensive covering of the head, i. e., one which includes the cheek as well as the eye. usually requires a larger towel. A size 16x28 inches is very desirable. 11 is folded as in Fig. 105. One cornei- is twisted preparatory to placing under the chin, as in Fig. 106. The initial fold of the towel is now adjusted around the neck and then pinned to the twisted corner. This gives the left Fig. 1114. — A roller bandage applied tn an amputation stump (arm). Fig. 105.— Method of folding towel for band- aging face. side, the one requiring the bandage in the first place, more towel than the right, as depicted in the figure. The latter is first brought over the right side of the head and cranium, and being tucked in firmly, is at once covered by the former so as to make a smooth, even covering, the bandage being finished as in Fig. 107. The extent of the face covered on the right side is regulated by folding the towel to the desired extent. In bandaging the left side of the face and head, the towel shown in Fig. 105 is folded so as to present a right twisted corner instead id' the left, and the folds made accordingly. The posterior aspect of the bandage shown in Pig. ins appears in Fig. L09. BANDAGING 447 Other bandages of the head including portions beside the cranium and excluding the towel coverings, are explained in text books on Minor Surgery. One of these which proves at times a valuable dressing is the Barton bandage or some modification of it. In placing this bandage the initial extremity of a bandage, two inches wide and six yards long, is held at the center of the vertex, and the body carried over the left parietal bone, under the oc- cipital protuberance and then over the right parietal bone to the point of starting. From here it passes over the left temporal bone in front of the ear, along the side of the face to the chin, under this, then up the right side of the face and head to the starting point again. The body of the bandage is now carried over the left parietal bone again to the point under the occipital pro- tuberance where it is extended around the right base of the skull Fig. 107. — Final step for bandage of face Fig. 106. — First step of face bandage. and eye. along the right inferior maxilla and then around the left base of the skull to just below the occipital protuberance where it then follows the former strip of bandage to the center of the vertex. The process is repeated several times until the desired number of turns are made. This bandage is frequently modified by adding a frontooccipital turn before any of the turns "are repeated. When this has been accomplished the turns are followed out in the order named above until the bandage is completed, the intersections being secured by means of adhesive or safety pins, care having been taken that all edges were turned under during the application. For the many other bandages of the head the reader is referred to text books on Minor Surgery. 448 AFTER-TREATMENT OF SURGICAL PATIENTS Neck Bandages. — One of the simplest bandages of the neck is that shown in Fig. 110. It consists simply in a strip of gauze covering the dressing over the wound and fastened in place by two strips of adhesive. This is a particularly useful dressing for goiter patients, since it does not necessarily encase the whole neck. It was first brought to my attention at the Mayo Clinic. Another simple dressing of the neck is that shown in Fig. 111. A roll of gauze 15 x 15 mesh to the inch is placed over the lesion on the neck, which in this case, is high up, reaching nearly to the lobe of the ear. In order to force the dressing to cover the lesion without resorting to a head bandage, a piece of cardboard or several layers Fig. 108. — Final step in hood bandage for sidi s '>t' face ami head. Fig. 109. — Posterior appearance of hood bandage. of paper are eiil ;is in the figure and incorporated in the dressing. The idea was originated and carried out by Frelich at the Mayo Clinic. An ordinary unfolded towel may lie utilized as a neck bandage. It is placed around the neck and over the wound dressings without any preliminary folding and pinned as in Fig. 112. The small towel as shown in Fig. 100 fulfills this requirement very well. This neck covering can also he used as the upper part of a breast bandage. A towel long enough to reach around the patient is folded at the sides and then passed around the chest and pinned as in Fig. 114. The posterior aspect of the combined bandage is shown in Fig. 113. Probably a more secure bandage and one meeting the same demands is that shown in Pig. 108. A towel just large enough to fit the patient comfortably is folded in its Longest dimensions (Fig. 115). The initial fold is placed directly around the neck and BANDAGING 449 held in position with a safety pin. The ends of the towel as shown by the borders in Fig. 108 are then brought around the shoulder under the arm pits and pinned at the back. In order to force the bandage to remain snugly fit in front and also keep the sides of the towel in place, one or more safety pins are placed as shown. This chest bandage is used in connection with the head band- age as shown in the illustrations, but it is a useful bandage ap- plied without any complicating head dressings, and, as a matter of fact, is far more frequently employed separately. Fig. 110. — A simple dressing with gauze support for goiters. In bandaging the chest alone, a simple towel folded as in Fig. 115 is taken by its farthest corners and brought around the body, the initial fold of the towel reaching the lowest point on the chest, while the ends encircle the arms as in Fig. 116, and are pinned at the back as shown in Fig. 117. The pin in front (Fig. 116) merely holds the two sides of the towel in close approximation. Such a 450 AFTER-TREATMEXT OF SURGICAL PATIENTS bandage gives freedom to the arms, is easily applied and is com- fortable. Bandaging the shoulder and axilla is carried out by taking the towel (Fig. 115) by its extreme corners and placing it on the shoul- der to be covered, the initial fold being brought nearest the base of the neck. It is now passed around the body to the opposite axilla and pinned at a point just past that region of the body. The initial fold being placed highest on the body, the sides pass around the patient at the lowest extent of the bandage, the ends of the towel Fig. 111. — A high neck bandage held up by cardboard inserts. being fixed around the arm and pinned at the axilla to be band- aged (Figs. 118 and 119). (In this case it is the right.) A gauze fold may be placed over the opposite shoulder to hold the bandage more securely. Fig. 120 shows a bandage being forced to fit by drawing the initial fold taut and pinning it on top of the shoulder. Bandages more extensive than those in Figs. 108 and 109 are required following radical breast operations. Usually the first bandage applied is one which includes the arm for the first night. A small towel unfolded, is laid over the shoulder so that its ends BANDAGING 451 extend beneath a larger towel which covers the whole of the arm (Fig. 120). The breast wound protected with gauze and a sufficient amount of cotton being placed under the arm, this extremity is brought over onto the chest and the end of the towel pinned to its fellow of the opposite side. The front of the bandage is made straight at the points of contact by tucking in the lowest part of the end of the towel (Fig. 120). Safety pins are put at desira- ble points, one supporting the hand in its present position. Fig. 121 shows the posterior aspect of this bandage. The pins are hold- ing in position the towel which was placed over the uppermost part of the shoulder. Fig. 113. Fig. 112. Fig. 114. Fig. 112 — A simple neck towel bandage. Fig. 113. — Neck and breast bandage as viewed from behind. Fig. 114. — A combination neck and breast towei bandage. A bandage which only partially limits the arm is used by some at this early stage. In these cases the shoulder bandage as shown in Fig. 118 is put on at the close of the operation and the circular towel brought around the arm as in Fig. 120, but not to the extent of including the forearm. The two surfaces are pinned on the inner aspect of the arm as they meet here, after encircling it, and the end now passing on meets its fellow of the opposite side and the two are pinned in the long axis of the body. The arm is partially re- stricted further by placing a wide strip of gauze around the wrist and pinning this to the towel around the chest. The following day, when all bleeding has stopped, and it is desired to release the arm from the bandage, which was put on the 452 AFTER-TREATMEXT OF SURGICAL PATIENTS patient while still on the operating table, this is removed with- out disturbing the dressings and a shoulder bandage as depicted in Fig. 118 is placed on the patient, the towel being forced to fit, if necessary, by pinning it just above the shoulder. A large unfolded towel is now brought directly around the body close up under the axilla (Fig. 122) and pinned in front parallel with the long axis of the body, even if it is necessary to tuck in the lower part of the end of the towel to accomplish this end. The shoulder towel bandage, and the circular towel bandage are further fastened by means of safety pins as shown in Fig. 123. Further restraint being unnecessary the gauze cuff (Fig. 124) is left off the wrist. A double-breasted bandage is made by simply adding another Fig. 115 — The towel folded as vised in chest handages. Fig. 116.— A towel chest handagc. Fig. 117.— Posterior view of chest bandage. towel to the left shoulder as in Fig. 125. or else placing a left shoulder bandage as in Fig. 118. If it is necessary to have the arm secured, methods resorted to in Figs. 120 or 121 are easily carried out. Instances requiring still more fixation, as after operations for fractured clavicle, etc., where the towel bandage would be applied by unskilled hands, ii may be safer to use the well-known Velpeau. BANDAGING 453 The skin is first thoroughly cleansed and powdered with talcum, suitable padding placed in the axilla and the other portions of the body to be covered are protected with sheet wadding. The arm is acutely flexed (Fig. 126) and brought across the chest so that the palm surface of the hand of the affected side rests on the opposite Fig. US. — Towel chest shoulder bandage held in place by strip of gauze. Fig. 119, -Chest shoulder bandage as shown from behind. Fig. 120. — Chest towel bandage with arm included. Fig. 121. — Fig. 120 as viewed from behind. shoulder close to the base of the neck. Two or more bandages 2% inches wide will be required. The initial end of a roller is held over the body of the scapula of the sound side. The body of the bandage is now carried over the unsound shoulder at its outer part and down along the lateral surface of the arm (Fig. 127), under the elbow and then across the body to the axilla of the opposite 454 AFTER-TREATMENT OF SURGICAL PATIENTS side to the beginning point. This turn is repeated once or twice in order to thoroughly anchor the bandage. Starting again at the scapular region, the bandage is brought directly around the body Fig. 122.— A double towel bandage for chest Fig. 123. — Second step of chest shoulder and shoulder. bandage. Fig. 124. — Arm held in position by ac- cessory fold of bandage pinned to lower edge. Fig. 125. — Beginning step in shoulder breast bandage. across the point of the elbow, across the axilla of the sound side and back again to the place of starting. The bandage is now carried over the unsound shoulder, covering the inner two-thirds of the BAXDAGIXG 455 strip which has gone before, passes behind the elbow and follows the course of the first strips, care being taken to cover the upper Fig. 126. — First stage of Velpeau. Fig. 127. — Second stage of Velpeau. Fig. 12S. — Third stage of Velpeau. Fig. 129. — Fourth stage of Velpeau. two-thirds of these as the bandage crosses the back to its starting point over the scapula. The process is now repeated until the arm 456 AFTER-TREATMENT OP SURGICAL PATIENTS is bound securely and all surfaces covered, the bandage traveling from without inwards across the shoulder, and upwards across the arm and chest (Figs. 128 and 129). The terminal extremity is fastened with adhesive where it ends. Other strips of adhesive are used at points which are in danger of slipping. Fig. 130. — A convenient towel sling for arm. Pig. 131. — Gauze sling fur arm. Fig. 132. -Gauze sling supporting wrist of ; encased in plaster of Paris dressing. Bandages of the upper extremity may be composed of the regular roller or common towel. In utilizing the former the spica of the shoulder, the figure of eight a1 the elbow or the spiral reverse for the whole arm is usually employed. BANDAGING 457 Description of these is superfluous. The same, however, can be accomplished by the towel, this folded and applied as shown in Fig. 130, which depicts the method of bandaging- the lower ex- tremity is also used here. The extent of the surface to be covered regulates the size of the towel and the length of the initial fold. A larger surface requires a larger towel, and the length of the bandage determines the amount of towel turned under. Figs. 131 Fig. 133. — The sling run through a rubber tube to protect the neck from pressure. Forearm is drawn too low in the figure. and 132 depict a good gauze bandage for the shoulder and arm (Mayo Clinic), while Fig. 133 shows how the neck can be protected from pressure. In placing a towel bandage of the hand, the towel should be about 16 x 20 inches and folded as in Fig. 134. The initial fold is brought around the wrist and secured with a safety pin. Then 458 AFTER-TREATMENT OP SURGICAL PATIENTS the side of the towel is brought under the thumb and the edges tucked nicely over the dorsal surface of the hand (Fig. 135) the towel then read}' to complete the final folds is straightened out as in Fig. 135. This is now simply wound around the hand and pinned Fig. 134. — A towel folded for purpose of bandaging hand. First step. Fig. 135. — Second step in towel bandage of hand. Fi£C. 136. — Final step of towel bandage of hand. Palmer aspect. Fig. 137. — Final step of towel bandage of hand. Dorsal aspect. as in Fig. 136, which shows the dorsal surface, Avhile Fig. 137 shows the palmar surface. The whole procedure resolves itself into start ing with the right sized towel with some of its parts folded on the BANDAGING 459 bias. The rest is a matter of individual folding of the towel so as to make a neat appearance. Bandaging the fingers is best done with the roller bandage, the description of which is found in books on this subject. Abdominal bandaging is accomplished by the abdominal dressing and binders described elsewhere in this book. Fig. 138.— First step of towel bandage of Fig. 139.— Second step of towel bandage of th 'gh- thigh. ud thigh. Bandages of the lower extremities are usually composed of the roller as for the arm. Here too the spica of the groin, knee, ankle, and foot or the spiral reverse of the whole lower limb need not be described. Towels taking the place of these bandages are shown in the accompanying figures. Fig. 138 shows a towel folded pre- 460 AFTER-TREATMENT OP SURGICAL PATIENTS paratory to covering the thigh. The initial fold is first anchored around the thigh by means of a safety pin and then the rest of the towel is simply folded around, drawn firmly and finally completed as in Fig. 139. A roll of gauze or folded towel fixed around the waist supports the upper corner of the towel by means of a pin. For more extensive covering of the limb a larger towel is secured and the initial fold is made much shorter than in Fig. 138. In this instance it is first placed just above the ankle, the towel now is simply drawn around the limb and pinned as in Fig. 140. A band Fig. 141. — First step of towel bandage of foot and ankle. Fig. 142. -Second step of towel bandage of foot and ankle. Fig. 143 — Third step of towel bandage of Fig. 144. — Final step of towel bandage of foot and ankle. foot and ankle. of gauze pinned to the waist hand keeps it firm along the course of the extremity. In bandaging the foot the towel which is best used is much smaller than the one employed on the limb above. It is folded as in Fig. 141, when the foot is placed onto it, the corner nearest the heel is brought up around the plantar surface of the foot. The end of the towel is now pulled tightly over the dorsal surface and tucked in on the inner side (Fig. 142) the other end of the towel is folded over the toes as in Fig. 143, the final appearance of the bandage being something like that in Fig. 144. Pins are placed at convenient BANDAGING 461 points and any tucking of the towel necessary to make a firmer as well as a neater appearance to the dressing. T-bandages are very useful. They are either single (Fig. 145,) or double (Fig. 146), and are used mostly for holding perineal dressings in place. The single T-bandage is composed of two strips of unbleached muslin hemmed and sewed together in the form of the letter "T." The top strip should be about 4x38 inches, the other strip 3 x 16 to 20 inches. The double T-bandage is made the same way, the part employed to pass around the body has the same dimensions but the part which passes over the perineum is divided in the middle (Fig. 146). This piece is the same length as in the single " T " but is an inch or more wider. A T -binder of the chest is a very handy contrivance at times. It is composed of a bandage about twelve inches in width and long Fig. 1*5. — Single T-bandage. Fig. 146. — Double-tailed T-bandage. enough to pass around an adult's body. The strip is fastened to its upper edge so as to pass over the shoulder. Another strip passing over the opposite shoulder is sometimes used. The strips are pinned in front, so also is the binder, all slack being taken out by mean of pins. Suspensory bandages are extremely necessary after operations involving the testes or any part of the anatomy near this region as well as the groin. For the first few days ordinary adhesive plaster strapped to the sides of the thighs and passing directly under the testes may be used. Cotton is placed directly under the testes so as to avoid possible irritation and give a still better support. (Fig. 62.) 462 AFTER-TREATMENT OF SURGICAL PATIENTS Aii ordinary piece of gauze brought around the testes and held with adhesive alone makes a quite efficient suspensory so long as the patient remains in lied. Adhesive placed directly on the scrotum and then fastened to the abdominal wall is sometimes employed. The scrotum, unless shaved, will give more or less pain due to the hair which will be pulled by the adhesive. It holds the scrotum well up and prevents edema, but on account of the fault mentioned is not a comfortable suspensory. By far the best apparatus for this purpose is one consisting of a web body which supports the testes and at the same time is itself held in place by a small waist band and perineal straps. This suspensory is besl used late in the course of the recovery sii a better fit can be obtained at this time as the edema will have disappeared from the scrotum and unnecessary irritation and pres- sure from the straps are avoided at a time when the tissues are most susceptible to injury. The surgeon should (il these suspen- sories, as one too tight will cause trauma and swelling, while one too large is of little value. The most important immobilizing dressing is the plaster of Paris bandage. Fixation bandages have been in use many centuries, a mixture of other material, such as chalk, mussel shells, albumen, oil, hemp, etc., having been utilized in their manufacture. It was not until the middle of the nineteenth century however, that the plaster of Paris bandage, which now holds the Eoremosl place in this kind id' dressings, came into common use. The bandage, as ordinarily employed, is bought ready made from the stores, and so often does not fulfill the expectations of the operator. This is due to many causes. In the first place, it may con- tain too much calcium carbonate, which prevents complete harden- ing of the plaster, when mixed with water. The plaster may have absorbed too much water, due to exposure to the atmosphere, or in drying out such plaster, it may have become too hot. and thereby rendered it almosl useless, since it then takes up water poorly. The plaster may have been shaken from the meshes of the crinolin by too severe handling in shipping, etc. The most satisfactory bandage is one made of crinolin (25x25 meshes to the inch and the best grade of dental impression plaster, smoothly and uniformly filling the meshes throughout the band- age. Such bandages are conveniently made by buying crinolin by the bolt. Each bolt contains twelve yards, folded in half-yard lengths. The boll is cut at the sixth fold, which exactly divides BANDAGING 463 it, leaving therefore six yards to the piece. Each piece of crinolin is now rolled on a yard stick (Fig. 96, page 441), and put away for a week or more until the former creases have disappeared from it; at the end of this time the roll is placed into a miter box, and cut with a Christy knife, into widths the size of the required band- age. The miter box (Fig. 96), as employed by Pattingson, who prepares all the bandages used at the Mayo Clinic, is beveled at the bottom, so that pressure from the top forces absolute fixa- tion of the crinolin, during the cutting, which naturally insures a more uniform roll. As employed at this clinic, the rolls are 4 and 6 inches, respectively, though any size roll may be cut. Fig. 147. — Pattingson's plaster bandage rolling machine used at Mayo Clinic. (Viewed from the side.) Fig. 148. — Pattingson's plaster bandage rolling machine used at Mayo Clinic, (Viewed from above.) The crinolin roll is first "squared" at the end, then as the band- ages are cut, the frayed edges are carefully freed of the threads, which immediately form the side of the bandage. This precaution prevents the hands of the operator becoming entangled in a useless mass of threads, as he attempts to apply the dressing. The plaster of Paris is next added to the bandage. This can be done either by hand, or by using some instrument especially made for this purpose. O-ne of the best which I have had occasion to observe is that employed by Pattingson (Figs. 147 and 148). He does not permit us to give this instrument in detail, but in the main it consists of a rectangular tin-lined wooden box, so arranged 464 AFTER-TRKATMKXT OF SURGICAL PATIENTS that the crinolin is drawn from a spindle at one end of the box, through the plaster to the spindle at the other end. The proper proportion of plaster deposit is automatically regulated by a sliding gate in the middle of the box, -which is accurately set and held in place by a side pin so that it arranges that the meshes are exactly and uniformly filled with the plaster. A metal weight at- tached to a curved tin which supports the roll forces the bandage to be rolled at the proper tightness This latter is very important, since a bandage too tightly rolled does not absorb the water readily, and one too loosely rolled does not retain the plaster. A small metal pan. which catches the excess of plaster as the bandage revolves, is retained at the end of the box. The spindles are so arranged that by moving a special board, any sized bandage can be rolled. Fig. 149. — Pattii plaster of Paris bandages in tissue paper 1. r>andap:c placed to the right of tin- middle of the tissue paper. 2. Beginning the roll. 3. Turning in tin- side. 4. Showing in detail method of turning in the side. : * Ad\ an< ed in the side. Almost completed — crumpling in the end. 7. Compli ' When the bandage is completed, it is removed, and rolled firmly backward and forward under the edge of the hand, which doubly insures uniform distribution of the plaster. The terminal extremity of the bandage, having been encased in the plaster, is pinned to the body of the bandage. When bandages are rolled by hand, the crinolin bandage is dragged over a heap id' plaster of Paris as wide or wider than the width of it and as the roll of the plaster bandage is begun, plaster BANDAGING 465 is sprinkled on the upper, exposed portion of the crinolin, in order to equally thoroughly impregnate it as the lower side is already well covered by its contact with the plaster lying under it. The roll is made loose and even, the process being best carried out on some hard surface at the foot of the heap of plaster. In order to prevent the bandage from absorbing moisture from the atmosphere, and thereby rendering it useless, Pattingson rolls Fig. ISO. — A device for immersing plaster of Paris bandages. the bandage in a good grade of tissue paper as in Fig. 149. The paper which surrounds the bandage is so arranged that only one end remains open, to be closed later, by a twist of the paper. The completed bandage then is placed in a tin box in a dry place and kept in readiness for immediate use. 4fi6 AFTER-TREATMENT OF SURGICAL PATIENTS The paper is held in place by a small rubber band around the roll. The wrapped bandages are now stored in tightly covered tin boxes, located in some dry place, where they are kept ready for use. As soon as they are required, the number necessary for completing the dressing is brought out, and placed near the bucket of water in which they are to be immersed. In wetting the bandage, preparatory to its immediate use, we do not remove the paper, but tear away the ends, so as to allow free access of water and at the same time allow no plaster to es- cape. The bandage is immersed slowly, and is then held beneath the surface until all bubbles have ceased to appear, and the original hard roll is soft and pliable. It is now taken from the liquid, and Fig. 151. A device for expressing water from plaster of Paris bandages. the excess gently squeezed out, by compressing with a hand holding each end of the bandage. The paper is at once removed, and the bandage is then ready for use. Henderson, at the Mayo Clinic employs a readymade wire stage (Fig. 150) supported by a long rod which he uses to immerse his bandages. This is a convenient contrivance, when a large amount of such work is required, bu1 ordinarily the hand alone is sufficient for this purpose, or a potato-masher may be employed as is done at Rochester (Fig. 151). Regardless of the method, however, immersion should be so timed BANDAGING 467 that a bandage is kept ready for instant use, so as not to delay the operator. The water which is usually employed is warm, and without the addition of salt, alum, sugar, etc. In cheaper grades of plaster, such chemical adjuvants are found useful in bringing about quicker setting, but with the high grade dental impression plaster, this is unnecessary. When the floor, table, and surroundings, have been adequately protected by newspapers, the patient is placed in position, the skin powdered, and the tricot applied. . After the bony prominences have been protected with heavy felt or cotton, the plaster is then applied. Care must be taken not to use too much padding, as this, at times, interferes with the firm support of the bandage. Unfortunately, this dressing is most often required in patients who are bedridden. It is always a matter of more or less im- Fig. 152. — A convenient box for supporting patient during application of plaster cast. portance, as to what method is best pursued in getting the patient in position for the application of this important dressing. In cases requiring a spica of the thigh, including a dressing also for the body and limb, I have found the following procedure a very good one : the patient is taken from his bed and wheeled to the operating room, where he is placed upon the operating table. When proper precautions have been taken so that he does not become chilled, he is brought well down, so that his lower limbs extend off the table, and are supported by an assistant. A homemade plaster box 468 AFTER-TREATMENT OF SURGICAL PATIENTS is placed under the body. Further support than this is deemed su- perfluous. The plaster box. which is the secret of good support in such eases, and one which we employ, was devised by Blair. It is simply l : ig 153. — Apply tricot and felt as preliminaries to plaster cast. Fig. 154. — Applying plaster cast with reinforcement of iron strips. a wooden box made of timber V/ 2 inches thick. It is 24 inches long, 20 inches wide, contains no sides or lop. but the end pieces are 8 inches high. On the surface of the end pieces, and near the center, BANDAGING 469 are located two iron supports for the two iron strips (Fig. 152) which bear the weight of the patient. The iron strips are 2 inches wide, % inch thick, and are malleable, so that they can be bent to fit the curve of the patient's back. The box as usually employed is shown in Fig. 154 though in some cases it can be turned over as in Fig. 153 and a metal support given the hips. I have found this last method not nearly so efficient as using the box alone. In cases requiring a cast of the leg only, this may be supported by strips of muslin bandaging, which are attached to iron piping, located directly over this bed and patient. It is held in place by two wooden supports, strapped to the bed. When the cast has been made, the muslin is cut, and the defect closed by a few turns of the bandage. This method is very efficacious in handling large patients, when one is short of help. It is not so convenient when the hip and body are to be encased in the cast. However, with the plaster box placed under the patient, this procedure could be carried out, even in bed, though not nearly so efficiently as when the patient is taken to the operating table. The skin, previously thoroughly cleaned, is now sprinkled with talcum powder, and then covered with seamless tricot hose. This elastic material can be secured in any width desired, and can be stretched to snugly fit any portion of the body. When it is neces- sary to cut the tricot here and there, to perfect the fit. the several parts are held with adhesive. Heavy felt is now placed across the abdomen at the highest point reached by the plaster, and another, extending over the anterior superior spines of the ilii. Others are placed over the trochanters, the knee, around the heel and ball of the foot, as in Fig. 153. Directly under the top in front a pillow, roll or other filling may be used to prevent too tight application of the bandage in this region, which would embarrass respiration, and cause gastric discomfort. The pillow roll is removed at the close of the procedure. The operators are protected with gown and rubber gloves. The plaster bandage, as described above, is taken and rolled firmly, but not tightly, over the areas to be c-OA T ered. The bandage is not al- lowed to wrinkle, and each layer is so placed that it lies flat, Ee- versing the bandage is unnecessary. The plaster is kept smooth by frequent rolling with the hand throughout its application. In ap- plying the bandage as shown in Fig. 155, it will be necessary to give the same amount of weight to the hip opposite to that covered with the bandage, or else the patient will slip off the box. This is accomplished by holding it down with the hand and at the same 470 AFTER-TREATMENT OF SURGICAL PATIENTS time the limb is held parallel with the affected one which is ab- ducted and slightly bent, depending on the condition for which operation was performed. As the application of the bandage proceeds, supports are placed at the sites most likely to break with muscular movements. This 1 55. — Usi the healthy thigh. Fig. 156. — Removing iron supports from the plaster hox. is accomplished by means of heavy wire, wood, or iron strips, bent to suit the individual u 1. In addition, further support by fold- ing the bandage on itself, ;is in Pig. 154 and then placing it at tin 1 desired points, is very efficacious. Pig. L54 shows a strip already in BANDAGING 471 place posteriorly, in addition to the iron strip and another fold of plaster being prepared for use elsewhere. As the bandage nears completion, the tricot, which is purposely left long, (Fig. 153) is turned back over the plaster and secured by additional folds (Fig. 155). The completed bandage is light, well supported with strips of bandage and iron bars, also the skin protected along all edges Fig. 157. — A fenestrum for dressing the wound. by layers of felt or cotton, which is covered with tricot, as shown in Fig. 155. The trimming of the bandage takes place on the table while the plaster is drying and is still soft, and before the tricot is turned over the edges. Otherwise this procedure is post- poned until the patient is off the operating table, and the cast is dry: then upon wetting the part to be trimmed with plain warm 472 AFTER-TREAT.UEXT OF SURGICAL PATIENTS water or water in which a little acid (acetic) has been added, the cast can be easily cut with a sharp knife. The tricot is then pulled over the cut edges and fastened with adhesive, running length- wise with the turns of bandage. The iron bars of the plaster box which supported the patient on the table are removed as shown in Fig. 156 just as soon as the cast becomes hard enough to keep from breaking when these are taken out. Fenestra, as shown in Fig. 157, are made after the east becomes hardened. The plaster cut from these areas is strapped with ad- hesive, and held in place. Casts cut to relieve tension, are also strapped with adhesive plaster to hold the parts together. In applying the initial layers of a plaster of Paris bandage, the same rules as regards any bandage (concerning the prevention of esehemia, venous stasis, etc. I must be observed. In addition, the pressure from this unyielding covering is apt to produce necrosis, gangrene, etc.. so that the bony prominences can hardly be too critically watched. Any pain complained of must be carefully looked into, and extra fenestra cut if necessary to relieve the pres- sure and pain. Neither the toes nor the lingers should be incased in such bandages, and when an extremity is so fixed, most careful attention must be given these digits, as cyanosis and coolness are the first indications of the bandage being too tight. The position which the patient will maintain in the cast is assumed at the be- ginning of the application, and he is held in place by competent assistants. Failure to rigidly enforce this rule often causes the bandage to be applied incorrectly, which is followed by breaks and discomfiture to the patient, necessitating a reapplication of the dressing. A description of the various kinds of plaster bandages, and the indications for their use, is no1 deemed proper in a work of this kind, but I should like to call attention to the low hip immobilizing* cast, which is sometimes employed in old people. A high dressing tightly binding them around the upper abdomen can not. at times, be tolerated, and in such cases it is necessary not only for the comfort of the patient, but also for his actual safety, that such means of treatment are not insisted upon. In these cases, where such measures are necessary, a low cast is applied, one which extends to just below the umbilicus, and above the knee. The casl is made as described above, but is firmly supported by one wire around the waist, and outer side of the leg. and one wire, bent so BAXDAGIXG 473 as to follow the curve, at the lower portion of the cast, and extend- ing on the inner side of the thigh. The wire is incased in the folds of plaster so as to avoid injuring the patient or pushing through the bandage on the outside. Another bandage is that employed by Henderson for immobilizing Fig. 158. — A plaster cast split for temporary removal. the arm and shoulder after transplantation of bone for ununited fractures of the arm. The cast is applied before the operation, with the patient in the standing posture, which insures its perfect fit and avoids the usual dangers attendant upon such dressings. The bandage is shown in Fig. 158. A temporary dressing is put on the arm to be operated, the same size that is to be used following the 474 AFTER-TREATMENT OF SURGICAL PATIENTS operation. The cast is made over all, and is allowed to stay in place until it hardens. Then the plaster is v\-et along the line of in- cision, and the cast cut through, dividing it into two equal halves, and is removed, as shown in Fig. 158. A fenestrum is cut over the operation site and held in place by adhesive. Immediately after the operation, and as soon as the wound is dressed, the two halves of this cast are placed around the patient, and held together with strips of adhesive, as in Pig. 158. Such a dressing permits the pa- tient to be up and around very soon after the operation, without the slightest danger of displacing any bony fragments from move- ments of the arm. The dressing is light, durable, and covers a small portion of The chest only, which prevents any interference with respiratory movements. The fenestrum permits change of dressing whenever desired. If. for any reason, discharge issues from the wound em- braced in the cast, the edges of the fenestra are covered with col- lodion, which prevents moistening, and therefore softening of the cast, which would soon defeat the purpose for which it was orig- inally intended. The drying of the cast is accomplished by simply keeping it uncovered. As soon as the patient returns from the operating room. measures are taken to carry out this procedure. If it does not then dry fast, an electric fan is turned on it. or hot bags of salt placed around it. which drives away the moisture. In removing the cast, the patient need not leave his bed; this is protected by rubber sheeting, and the floor with papers. Along the line of incision, cotton strips, soaked in plain hot water, or hoi water to which vinegar has 1 n added are applied, and as soon as there is a line of softening, the casl is divided along its course with a sharp knife, particular care being exercised that the patient is not injured by the knife. The underlying tricot, cotton, etc., arc cut with a pair of bandage scissors, as shown in Pig. 98. Bibliography Sister Constance: St. Anthony's Hospital, St. Louis, Personal communication. Pattingson: Personal communication. Blair, A*. P.: Personal communication. Henderson : Personal communication. Henderson: Ann. Surg., April, lOlfi. Ware: Plaster of Paris and How to Use It. 1906. Fowler: The Operating Room and the Patient, 1913. CHAPTER L THE ABDOMINAL BINDER By 0. F. McKittrick, St. Louis, Mo. The role which abdominal supports play in the surgical con- valescent has always been an uncertain one. The tendency among most operators is to discard them altogether, a practice which can never meet with universal approval, since there are certain classes of patients whose physical needs demand their use. Like all ques- tions involving human infirmities, one rule will not apply to every individual, and the indiscriminate application of an unyielding idea, renders it unsafe. However, it is generally observed that the first few days' treatment of the incised abdominal wall is approx- imately the same among the majority of operators, and the va- riance of opinion concerning this subject is. in the main, directed toward the later protection to be given it. Immediately following the completion of the sewing necessary to close the abdominal wound, gauze (20x20 mesh to the inch) is placed over it, either flat or fluffed, the amount to be determined according to whether or not the wound is drained. A layer of cotton batting, or a pad made of cotton batting, and covered with gauze, is placed over the flat gauze, which covers the wound ; the pad is now strapped with 2 inch adhesive, and the patient placed in bed. This dressing is popular in many of the large clinics. The adhesive, however, gives considerable support, if used in 4 inch strips, and applied well around the body on both sides. There is some danger of such binders coming off. thereby exposing the wound to infec- tion; otherwise they are inexpensive, easy of application, do not restrict respiration, or any of the body movements, and being light and cool, are especially comfortable in summer. It has long been a practice in hospitals throughout the country, however, to apply a cotton domestic binder, as in Fig. 159 in ad- dition to the previously mentioned dressing, and in many cases, the dressing without the adhesive straps. The binder is first pinned tightly up the front, and the slack at the sides is then taken up by using the pins, as in the illustration. I feel that, in many cases at least, such extra precautions could be easily dispensed with, especially in those cases which do not fall into the class 475 476 AFTER-TREATMENT OP SURGICAL PATIENTS of individuals to be suggested as favorable candidates for such treatment. The support which the additional covering adds to the properly applied adhesive, is not sufficient, so long as the patient remains in bed, to warrant the unnecessary discomfort which it sometimes entails. Some hospitals employ perineal straps to pre- vent the binder from slipping upward, and thus exposing the wound; these straps at times give no end of annoyance. In clean wounds, the dressings are not disturbed, except to make sure the wound is healing normally, until the stitches are to be removed. In drained wounds other measures must be employed, in order to allow frequent dressings. In such cases the usual dressings are employed, but the adhesive is drawn tightly over the pad by means of gauze strings, and tied. The adhesive is then placed well under the back, usually three strips three inches wide, and so arranged as to pull evenly with the strip on the opposite Fig. 159. — The ordinary immediate abdominal binder pinned on in the operating room. side. In placing the gauze string, care is taken that the strip is made long enough to come up well over the dressing, and in line with the one on the opposite side. The two parts of the adhesive are stuck together, so thai the free end extends below the lower por- tion of the pad. which prevents its sticking to the dressing. The wound with such a covering can be dressed frequently without dis- turbing the patient, and at the same time, gives good support to the abdominal wall. The abdomen receives no further protection, so lonij- as the stitches are in place, and the patient remains in bed. As soon as the stitches are removed, usually within ten days, in wounds healing by first intention, more attention must be accorded the abdominal wall. This, however, is not urgent until the patient is allowed to sit up. Crossen 1 as a matter of routine, applies boric acid powder to the wound and then, having placed a Hat piece of gauze over it, he THE ABDOMINAL BINDER 477 applies an adhesive binder to the lower abdomen, which gives ample support to the healing wall. The strips of adhesive which form the support are two inches wide and are smoothly applied with moderate tension, from below extending upward. This maneuver prevents unnecessary wrinkles in the binder, and tends to push the abdominal contents upward. Such a procedure takes all strain from the abdominal wound and insures against its rupture, either in whole or in part, during any sudden increase in intraabdominal pressure. Over the adhesive is placed a pad of cotton batting ; this in turn is held with the binder. The adhesive support is worn for about one month, a straight front corset having, in the meantime, been adjusted over the dressing, worn during the daytime, and re- moved at night. If, for any reason, the wound is to be inspected, the portion covering it can be removed, and the abdomen re- strapped. The rules which we observe in applying an adhesive support are those outlined by Soper 2 in the use of his abdominal support for gastroptosis. These, in the main, imply that the first strips applied, i.e., the "X" strips, are first anchored to the dorsal vertebra, and then directed so as to follow the lower margin of the ribs. The patient, being in the sitting posture when this maneuver is accom- plished, now lies flat on the back. The abdominal contents are pushed up, and the strips continued across the abdomen, one at a time, to be attached at the sides in the region of the inguinal liga- ments. The cross strips are now placed, beginning at the anterior superior spines of the ilii. In patients whose operations did not re- quire an abdominal incision, i.e., those in whom all work was ac- complished through the vagina, the Soper support, which is a modi- fication of that devised by Eose, can be worn without the additional coverings as employed in laparotomies. Such a support is not bur- densome to the patient, and it does not interfere with the routine habits of life. If the skin becomes irritated, the dressing is removed with a little benzine and after a few days is reapplied. Except the dressing and possibly the additional binder, no further abdominal support is required during the two or three w^eeks the normal individual is recuperating from the operation. As for the general use of abdominal binders, Mills 3 says there is no particular indication for them, but when they are brought into service they should be used selectively, for instance, in people with lax abdominal walls, due to great loss of weight, frequent child bearing, large abdominal tumors, such as the fibromata, multilocular 478 AFTER-TREATMENT OF SURGICAL PATIENTS cysts, etc., and especially in patients with very much fat or pen- dulous abdomens. Occupations such as laborers who do heavy lifting or those who lead sedentary lives may require the utilization of abdominal binders. Static conditions play a part in deciding when to use the abdom- inal support. Patients with round shoulders always have poorly developed abdominal Avails, since the entire burden of standing is thrown upon the muscles of the back; the abdominal muscles being so little used, accounts for the lack of development of the abdominal wall. The type of the individual must be considered. Those generally debilitated, or who are naturally of poor physique, especially re- quire this treatment. Such patients lack general tone, and as a result there is a state of generally diminished tone in the abdominal muscles. Many women of frail asthenic physique have naturally a low di- gestive plane, and in such the viscera are abnormally low. How- ever, the low position of the viscera per se in individuals not en- titled to such visceral topography, is an indication for the binder. Patients with the " enteroptotic habitus" of Mills are frequently operated upon. But there are other cases of gastroptosis or gen- eral visceral ptosis that are also seen here, and in such patients, especially, must attention be given to the artificial support of the abdomen. Normally, their peritoneal attachments of the viscera are slack, the organs being kept in position by the positive intra- abdominal pressure. This is maintained by the tonus of the ab- dominal and pelvic musculature. Any decrease in tone in these muscles produces a weakness which permits an increase in the ab- dominal cavity, and causes a decrease in the intraabdominal pres- sure, with a resulting pull on the peritoneal attachments followed by a fall of the viscera. Hertz 4 states that a decrease in the bulk of the abdominal contents, such as a diminution in the normal intra- abdominal fat, will also bring about the same result as the decrease in muscular tone, and general laxity of the muscles. At any rate. the conditions usually go hand in hand, and as Mills has said, the accumulation of a desirable amount of intraabdominal fat is greatly to be desired in these cases, where marked loss in nutrition as a result of the surgical condition is present. The character of the wound is vitally important in deciding upon the use of a support. The muscle splitting incision of McBurney. very rarely requires support. Usually such wounds are covered THE ABDOMINAL BINDER 479 with a collodion dressing, or supported with adhesive strips, and the patient allowed up in two or three days. The anatomic relations are not disturbed, and consequently there is very little danger of hernia. The rectus incisions when properly performed, require very little more attention than the McBurney incision. Incision through the linaa alba, below the umbilicus requires greater support than the muscle incisions above. Here the pressure exerted on the abdominal wall is greater, and the wound does not receive the benefit of any muscular support. Wounds, however, made above the umbilicus, whether within this region or through the abdominal muscles, rarely require any support at all. Fig. 160. — An ordinary straight corset. Front view. (Courtesy Just-Us Corset Co., St. Eouis.) Fig. 161. — Ordinary straight corset, view. Back- Wounds which have been drained, and therefore heal by second intention, require longer and more intelligent care, than those which heal by first intention. Just how long binders should be worn in such cases depends entirely upon the type of individual, the length of time in bed, and the nature and size of the defect. In no instance does a wound demand a longer time than six months after the skin has closed over it to heal soundly. Binders should not be worn 480 AFTER-TREATMENT OF SURGICAL PATIENTS longer than this period, except, possibly in the very obese. In such cases, some sort of abdominal support will be necessary to be worn throughout the life of the patient. Cases properly handled surgically as to direction of incision, ac- curate dissection, with perfect approximation, and cleanliness usually need no artificial support. No binder should take the place of a well-developed abdominal wall, but is applied to relieve the tension present on the wound. This tends not only to prevent a wide, thin scar, but also to some extenl prevents hernia. It is usually worn, in those cases which need it, until the wound has thoroughly healed. This is ordinarily about four weeks, but Longer periods of time are sometimes required depending, of course, upon the nature of the case. But in no instance should il be worn longer than six months, except in the condition as noted in the foregoing. Abdominal binders acl as splints to the musculature, and too long continuance will produce atrophy from disuse. How- ever, within the Limits of time suggested, the support, that is. the weight of the viscera being Lifted from the abdominal wall, allows the overstretched muscles to regain their tone, and the comfort secured from such devices allows the patient many times to eat more without fear of dis- comfort, and take more exercise. This not only tends to overcome the sluggish- ness of the intestines, hut also 1o increase the amount of intraab- dominal fat. The binder is hut a makeshift, in that it protects, and by protect- ing renders possible an opportunity for the development of the ab- dominal Avail, through exercises. These are begun just as soon as the wound is thoroughly healed. The abdominal exercises are first started moderately, allowing Hie patient to raise her body from the Hat position to the sitting posture without raising the heels from the floor. This is impossible for some patients to accomplish at first, but after many trials, these same persons carry out the pro- Fig. 162. Tin- athlc lie web coi set. Side view. THE ABDOMINAL BINDER 481 cedure with ease. It should, never be persisted in sufficiently to tire the patient ; however, the feat can be performed several times a day, each day increasing the number of times the process is repeated. Further abdominal exercises should be followed out as suggested by Posse, 5 but for the first six months the abdomen should be pro- tected during the exercise, by some abdominal pad or adhesive binder. Many contrivances have been presented for use as late abdominal supports. I have found very little use for any of them. The most Fig. 163. — The athletic web corset, view. Front Fig. 164. — The athletic web corset laced. Front view. important feature to be observed in selecting a support, is that it applies itself to the lowest segment of the abdomen, and in so doing, fits closely to the inguinal ligaments, as near as possible to the symphysis pubis, and does not quite reach to the umbilicus. The abdominal contents are thereby pushed upwards, backwards, and inwards, which alone efficiently relieves the muscular strain. The apparatus should be as plain as possible, inexpensive, and at no time cause any discomfort to the patient. 482 AFTER-TREATMENT OP SURGICAL PATIENTS In my experience I have found no support to surpass the ad- hesive strips further reinforced by the straight front corset (Figs. 160 and 161), when the patient is out in the world again, and per- forming the duties of life. Some patients find great comfort in the athletic corset, which is composed mostly of rubber web (Figs. 162 and 163). Such corsets can be worn indefinitely, without any injury to the abdominal wound, so long as the lower abdomen is pushed up while the corset is being laced from the bottom, and the ab- dominal exercises kept up. For cases with pendulous abdomens, the very obese, or the visceroptotic, I have found that best results can be obtained by having the patient fitted with a corset most suited to her build and size. In such corsets some insert a rubber web support, which is attached to the corset. The added elastic support fulfills every requirement, and yet the patient is not con- scious of the necessity of wearing an abdominal binder for her condition. The belt is so adjusted that it unhooks as does the corset, and very little trouble is thereby entailed. This insures its more frequent use by the patient. At night no support is worn, the corset being utilized during the time the patient is on her feet only. In men, the adhesive support of Soper has proved amply suffi- cient. All cases requiring the use of abdominal supports should see the surgeon occasionally, to make sure that the supports are carrying out the purpose for which they were intended. Bibliography iCrossen: Operative Gynecology, St. Louis, L915, C. V. Mosby Co., p. 602. sSoper: Jour. Mo. State Med. Assn., January, L912. sMills, R. Walter: Personal communication. *Hertz: Pract. Enclyp. Med. Treat,, Till."), 323. sPosse: Special Kinesiology of Educational Gymnastics, p. 168. CHAPTER LI EXERCISE AND MASSAGE By F. H. Ewerhardt, St. Louis, Mo. In the consideration of the after-treatment of operative cases it seems timely to incorporate in the plan physical measures, which, if properly applied, will stimulate repaired processes. Such agencies as massage, remedial exercises and hydrotherapy will here receive thought and attention. These measures have, until lately, received very little consideration at the hands of the medical profession; little or no thought was given them by the medical school curriculum. Consequently most surgeons have but a passing knowledge of its technic, physiologic effect or therapeutic applica- tion. Scientific research and clinical experience have, however, placed it on a rational basis. Massage has gained recognition as a result of the labors of Lucas Championneire of France, who was the first to champion massage and manipulation in the treatment of fractures; Sir Wm. Bennett of England, Mezter of Amsterdam, Zabludowski of Berlin, Peter H. Ling of Sweden and later Graham, Weir Mitchel and W. K. Mitchel, Jacob Bolin, Kellogg and others of America. Among the pioneers in modern hydrotherapy the fore- most was Winternitz of Germany who was followed by Brandt, Ziemssen, Schott and Fleury in Europe, and Kellogg, Pope, Pratt, Baruch and others in America. In the field of medical gymnastics we turn first to Sweden, where Peter H. Ling founded his well- known system of Swedish gymnastics. Others to follow him were Enebuske, Nissen, Wiede, Kleen, Jahn and Kellgreen of Europe and Nils Posse, Jacob Bolin, McKenzie, Bucholz and others in the United States. Due to the labors of these men physical therapy has been incorporated in the medical curriculum of all the im- portant European universities and is practiced extensively in most of the large hospitals in the United States. This work has received a tremendous impetus during the past great war and is being employed intensively in German, English and French convalescent hospitals. It is not the purpose _at this time to go into a comprehensive description of massage, exercise and baths, but rather to present an outline of those measures in a brief fashion, and yet embrace the salient elements in a manner 483 484 AFTER-TREATMENT OF SURGICAL PATIENTS which may be of best service to the busy surgeon. The mode of presentation will embrace the technic, the physical effect, and the indications. Massage General Discussion. — The question who should apply massage is, of course, a very pertinent one. Theoretically this should be the physician himself. His technical knowledge of anatomy and physi- ology coupled with the intimate understanding of the patient's physical condition and idiosyncrasies places him in a most favorable position for the performance of this work. Practically, however, this is not true because of the time-consuming element involved. Neither the general practitioner nor the specialist finds it a judicious division of labor to devote a great part of his time to massage and other forms of physical therapy, and it is well for the future of these measures that it is so, for otherwise it would not have reached its present high development. Massage, for instance, covers such a big field that men and women spend months of training in theory and practice in order that they may reach a degree of perfection commensurate with medical requirements. They are required to master to a fair degree a knowledge of physiology and anatomy and in addition possess a fair understanding of the pathology of dis- eases. The physician's part in the matter of massage is to possess a good working knowledge of its technic and its therapeutic ap- plication. It would be wise for him to have in addition a fair degree of skill so that he himself could, if necessary, perform the work, particularly in localized areas, when the labor involved would cover only a short period of time. In order to meet these indications, namely, to give the busy surgeon an opportunity of be- coming acquainted with this subjecl and be able to intelligently prescribe and perform the work himself if necessary, a brief de- scription devoid of exhausting details and repetitions follows: Fundamentally, success following massage depends largely upon proper technic based on a knowledge of anatomy and physiology. A few general remarks, however, relating in some way or other to the subject are perhaps not amiss. Apparently trifling elements are oftentimes of sufficient importance to make or mar the success of the whole. Preferably the operator should be of genial and sympathetic disposition, yet firm in the correct performance of his work. He should exercise cleanliness with respect to himself as well as to the material with which he works. The surroundings should be quiet and inviting. It is quite discomforting to be mas- EXERCISE AND MASSAGE 485 saged by an unkempt individual in an untidy, dark room. The operator, if not a doctor, should be extremely careful in discussing the patient's condition, treatment or prognosis. Patients are fre- quently prone to question the operator along these lines, which often- times results in embarrassing situations. The operator must ever remember his relation to the doctor; viz., to adhere closely to in- structions, avoid discussing the treatment with the patient, and never offer advice. Authorities agree that barring certain conditions, massage should be performed on the bare skin. Bucholz of the Massachusetts General Hospital makes this exception: "In cases of a septic hand where some granulations or superficial sinuses still exist, and where delay until these openings are all healed would cause adhesions and scars to become still firmer and stronger, kneading and friction may be done with benefit through a sterile sponge." Or, he adds, "in the case of a sprained ankle strapped with adhesive plaster." It is always essential to keep in mind the healthy condition of the skin. If the stroking movements are to predominate, some lubricating material should be employed to prevent irritation of the hair follicles. For this purpose any of the following may be used: Cold cream, white vaseline, cottonseed, olive, cocoanut or mineral oil; or cocoa butter. If, however, deep kneading or fric- tion is primarily indicated, a too thorough lubrication of the skin would interfere with the proper performances of the movements. The operator will then find it very difficult to properly grasp the deeper structures. In these cases common talcum powder had bet- ter be used or nothing at all. Again, parts that need to be mas- saged more than two or three times should not be shaved. If there is an abundance of hair, the parts should be well lubricated and, following the massage, well washed with alcohol. Patients with skin diseases or fever should not be massaged. Fleshy, aged, or emaciated persons should receive only gentle treat- ments. In these cases the tissues are easily bruised. In acute in- flammation, acute constitutional diseases and cancers, massage should not be given. Physiologic Effect. — In the after-treatment of operative cases, massage may be used as an aid to Nature's way of bringing to the body cells nutrition and removing effete matter. Activity is the fundamental basis of all life, and equally important to the various structural units comprising the human body, the cell, tissues, and organs. In normal life the body cells are sufficiently nourished by fact of a constant supply of rich blood being brought to the parts, 486 AFTER-TREATMENT OF SURGICAL PATIENTS while the products of catabolism are washed away, the factors chiefly concerned in this procedure being the expulsive force of the heart, the elasticity of the arterial walls, alternate compression and relaxation of the muscles, faseire and joints, and the thoracic suction force produced by the negative atmospheric pressure in the thorax. Following an operation all of these factors may be, while in all cases some of them will be, affected. Depending upon the degree of immobility required of the patient, a greater or less degree of assistance is taken from the heart in its effort in main- taining proper circulation. The lymph flow too, as Starling has pointed out, is entirely arrested during rest. The effect of this is reflected unfavorably on the general bodily condition. To replace this loss is one of the chief functions of massage and exercise. If there is no acute inflammatory process, cancer or fever present, these measures are indicated in order to improve the general well- being of the patient. Massage is particularly in place in muscular and nervous exhaustion. It feeds muscle and nerve without fati- guing them ; active exercise on the other hand, feeds, but at the ex- pense of nerve force. Therefore at the earlier convalescent stage general massage may be employed. As soon as the condition of the patient permits, mild passive and later mild active exercise are useful, at first in a lying position and later graduating to a sitting, and finally to a standing position. The effect of massage and exercise on the digestive organs re- flects itself by way of the improved circulation, particularly by removing visceral congestion and through reflex influence upon the glands of the stomach and the intestines. Furthermore the in- testinal mass may be caused to move along the colon by means of mechanical manipulation, and by increased peristalsis stimula- tion. Finally the general increase in nutrition creates a demand for an additional supply of nutriment which nature manifests by an in- creased improvement in appetite. In discussing elimination, it seems pertinent to mention the favorable effects of massage on the liver and kidneys. The skin also is made to functionate with in- creased vigor. This is effected by a direct stimulation of the sweal glands and reflexly by its influence upon the circulatory system, thus furnishing the skin with an increased supply of blood. Mas- sage manifests itself upon the nervous system in a variety of ways, but no attempt will be made at this time to enter into these various channels. For our purpose, mention will be made only of its stimulative and sedative effect. For the former, vigorous friction and percussion movements are used, for the latter, slow and gentle EXERCISE AND MASSAGE 487 stroking or kneading. Frequently bedridden patients are restless both day and night. For these cases a short stimulating massage in the morning and a sedative treatment in the evening would be an excellent procedure. A properly performed sedative treatment is usually followed by a peaceful repose and a satisfied feeling of well-being. Frequently patients fall asleep during its administra- tion. Massage improves the nutrition of muscles. Physiology teaches us that a muscle which is inactive is also poorly nourished, and we know that an inactive, poorly nourished muscle soon enters upon a condition of atrophy. Furthermore we have learned that it is best for a healthy muscle to functionate regularly to its com- plete extent. If this process is interfered with for too long a time, the muscle will shorten by adapting itself to its new mode of requirement. Massage and exercise would do much to prevent these untoward effects. The effect of massage upon the red and white blood cells and hemoglobin is interesting. J. K. Mitchell of Philadelphia in his observations of thirty-five persons suffering from various types of anemia, some slight, others severe; some from toxic causes, others malnutrition and some from hemorrhage, noted that massage pro- duces a general increase in the number of red blood cells and in about half the cases an addition in the hemoglobin. This result has since been frequently verified. The increase manifests itself one- half to one hour following the treatment and continues for several hours. While both white and red cells are found in large numbers, the whites show a relatively greater increase. Massage does not manufacture blood cells or hemoglobin, but merely puts into circu- lation those that have remained dormant in the system, particularly in the liver and spleen. Technic. — The proper technic of massage depends primarily upon a knowledge of normal and pathologic anatomy and the correct per- formance of the various movements. These are not difficult to learn, but the finer movements, the delicacy of touch, and a high degree of skill can only be acquired through actual experience. The simplest classification divides massage into four groups. We shall use the French terms because they are so universally employed. Effleurage. — Bffleurage consists of a stroking motion with the pal- mar surface of the fingers or of the whole hand. It has for its main object the emptying of the venous and lymph glands, the resultant suction force bringing more blood to the tissue. The movements should, therefore, follow the outlines of the muscles, beginning with 4- AFTER-TREATMEXT OF SURGICAL PATIENTS Fig. 165. — E^eurage, foot held firm with operator's left hand, firm stroking towards toes right hand \ Fig. 166. — Diamond effeurage. Beginning at the coccyx apply pressure on both sides of the spine upward to the 7th cervical, effleurage by placing palm of hands on back, apply firm stroking motion downward to pelvis. a gentle pressure a1 the insertion, increasing to its maximum in- tensity at the belly of the muscle and concluding with decreased pressure a1 the origin. The effort, where possible, should be made to surround the muscle with the whole hand, applying a grasping EXERCISE AND MASSAGE 489 Fig. 167. — Draining the jugular veins Fig. 168. — Alternate wringing of the flexor muscles. Hold leg in position with right hand, wring the muscle with the left. motion. On the trunk or upper thigh where this can not be done, direct pressure against the more solid and deeper tissues should be made. Effleurage should form the beginning and ending of every treatment and may be injected at any other time. It is particularly 490 AFTER-TREATMEXT OF SURGICAL PATIENTS useful for the removal of exudations following fractures and joint disturbances. If instead of the above-described stimulating move- 1 ' Fig. 169. — Kneading of the patella Log in a flexed position. Both hands cover the patella. Knead outward and upward. Fig. 1~0. — Alternate kneading of the flexors of the thigh, beginning at the upper part and working toward the knee. ment. a sedative effed is desired, the stroking should be very gentle with the tips .»(' the fingers barely touching the skin in a centrifugal direction. It is 1 liis form of massage which is not uncommonly EXERCISE AXD MASSAGE 491 followed by a restful sleep. It is indicated in cases of restlessness, certain forms of headaches, neuralgia and neurasthenic pains fFies' 165 and 166.) Petrissage.— By this term is meant deep or superficial kneading Fig. 171.— Pulling and pushing of the flexors and extensors of the Fig. 172.— Thumbs kneading the anterior muscles of the leg. of the muscles together with grasping, pinching, rolling, pressing and stretching of the underlying tissues. One hand may grasp as much tissue as possible, lifting or squeezing it, repeating this 492 AFTER-TREATMENT OF SURGICAL PATIENTS manipulation until the entire muscle group is covered. Or one hand may alternate with the other; or again, one hand may work on the anterior while the other on the posterior part of the limb. Again Fig 173. — Anterior frictional kneading of the thigh alternate up and down. l"ig. 174. — Fist kneading of the small intestines. Place fists one inch above and to the side of the umbilicus, alternate knead down to one inch below the umbilicus. the tissues may be caught between the thenar eminence of both thumbs and rolled againsl themselves or against the underlying tissues. Another type of petrissage consists in supporting a Limb with one hand and grasping the fleshy portion with the other, push- EXERCISE AND MASSAGE 493 Fig. 175. — Circular muscular kneading of the thigh, beginning at the upper part and work- ing toward the knee, place the hands firmly on either side of the thigh and roll the muscle around the bone. Fig. 176. — Breaking up adhesions. Place one hand on the side of the scar and hold in position. The other hand is placed on the opposite side and rolls or pulls the tissues against the counterpressure. 494 AFTER-TREATMENT OF SURGICAL PATIENTS ing and pulling it in the direction of the long axis. This procedure is especially useful in muscular spasm and the stretching of con- tracted tissues. Petrissage is a decidedly stimulating measure acting on all the vital functions. It brings about circulatory changes, improves muscle tone, serving very much as an active exercise. (Figs. 167-175.) Friction. — This term does not signify merely rubbing over the skin which is a motion akin to gentle stroking, but instead consists of a series of rotary motions executed by the tips of one or more fingers, the thumb resting quite firmly on the skin and moving it over the underlying tissues. It is especially useful in loosening adherent tissue and therefore is employed a great deal in the treat- Fig 1"~. — Cupping. ment of abnormal joint and scar conditions. It also tends to relieve local congestion by lending aid in the forward movement of the venous and lymph currents. I Pig. 176.) Tapotement of Percussion, consists of a series of blows delivered with a flexible wrist to avoid bruising of the tissues. Various methods of percussion are employed : (a) Clapping is performed with the palmar surface of the hand so shaped as to form a cup. The hands are alternately brought EXERCISE AND MASSAGE 495 down producing a resounding effect. This serves as a stimulant to the skin (Fig. 177). (b) Hacking is applied with the ulnar surface of the hand, the fingers being held rigid and close together or relaxed and separated. This is applied particular^ to large masses of muscles and along nerve trunks (Fig. 178). (c) Slapping is performed with the flat of the hand. This excites the peripheral nerve endings. (d) Tapping is a measure executed with the tips of the fingers. It is used chiefly along nerve trunks, whenever the bone lies close to the skin or in scalp treatment. Fig. 178.— Hacking Vibration Vibration may be transmitted to the body in a variety of ways all tending to produce either locally or generally a more or less rapid, to and fro motion of the tissues. Manually it may be performed by pressing one or more finger tips firmly against the part to be treated and executing rhythmic movements at the rate of from eight to ten times per second. The act may be localized or it may follow 496 AFTER-TREATMENT OF SURGICAL PATIENTS the course of a nerve trunk. This method, however, is very tiring on the operator and can be sustained for a short period only, for which reason various types of apparatus have been invented, some of "which are very good. Portable Apparatus. — The more general way of performing vibra- tion is by means of an electrically propelled apparatus which im- parts to the tissues a rapid rotary or lateral motion ranging in velocity from 1000 to 6000 per minute and even more. A variety of applicators are used in connection with the machines. Stationary Apparatus. — The most popular of this form of ap- paratus is the vibratory chair, so constructed that the whole body, or parts thereof, if desired, may be treated at the same time. The oscillatory movements may be regulated as to speed and length of movement. There are various modifications of this type. Shaking and Kneading- Appliances. — The use of this type, as well as the chair just described, is almost entirely limited to institutional use. Their action approaches more nearly a mechanical massage than vibration. The trunk shaker is an apparatus which has at- tached to it an eccentrically revolving wheel. The patient stand- ing in an upright position allows his body to rest against a belt attached to the wheel. The resultant action is a violent shaking of the body. The mechanical horse acts by bouncing the riding individual at a regulated speed and distance. The kneading table acts by means of four to six uprights which project through an opening in a table and operate on the ab- domen of the patient lying prone. Here too the speed and distance of movements are adjustable. Physiologic Effect. — The particular effect of vibration is general stimulation, causing rapid but small muscular contractions. At first the superficial blood vessels are contracted then dilated. If applied along a nerve trunk a diminished sensibility may be brought about, for which reason this method is sometimes used in connec- tion with the treatment of neuritis and neuralgia. Applied to the heart the pulse may be caused to beat slower but stronger. It has been used successfully in relieving muscular spasm, a fact first noted by Charcot who used vibration in the treatment of paralysis agitans. The shaking and kneading movements are Used principally in cases of obesity and constipation. EXERCISE AXD MASSAGE 497 Exercise Today exercise is regarded by the laity as well as by the pro- fession as a synonym of health. Xo one agency in the whole category of the laws of personal hygiene has received such impetus as has that of exercise. Young,, middle age. and old of both sexes indulge in it as never before. Public schools, colleges and even municipalities recognize its value and spend much money in its promotion. It seems therefore reasonable for the medical profes- sion to consider this agency from the standpoint of therapeutics and add it to the present established methods of postoperative treatment. To gain a clearer understanding of its therapeutic value we classify exercise into various forms. We speak of an active exercise as one which follows an effort of the will. It is voluntary on the part of the individual and may be executed with or without assistance. A passive exercise is performed by an operator, or apparatus, on a patient without the latter 's assistance or resistance and has no connection with the will of the patient. Resistive exercises are performed by the patient, the operator resisting the active muscle becoming shorter. This is spoken of as positive concentric in action. Or the operator performs the move- ment while the patient resists, in which case the active muscle be- comes longer, negative, or excentric in action. This latter form for instance, is used in cases where the muscles are still too weak to use concentrically. Movements of skill are primarily active exercises involving the coordination of the nervous and muscular systems. It means edu- cating the muscle to perform an act with the least expenditure of nerve energy and requires strict and concentrated attention. As examples may be cited the swinging of Indian clubs, fancy skating, walking a railroad track, or it may be of a more violent form like foil fencing, tumbling or tennis playing. "When such an exercise is first begun, fatigue quickly sets in, because an unnecessary num- ber of motor nerve impulses are being sent from the brain, not only to the muscles involved in the correct performance of the act, but to other groups as well, including often its antagonistic fellows. Furthermore a failure to send inhibitory impulses to the antagonistic group increases the disturbance of the normal neuromuscular mechanism so that there occurs a more or less irregular and hap- hazard contraction and relaxation of muscles producing an awk- ward exercise, not at all that which the individual had willed to do. 498 AFTER-TREATMENT OP SURGICAL PATIENTS The muscles soon tire and refuse to respond to the will because of the exhausted condition of the motor cells. Nerve cells fatigue quicker than the muscle cells which they innervate. Obviously, ex- ercises involving such close attention are not indicated in persons already suffering from nerve exhaustion. For these patients pas- sive motion, joint movements, and massage serve the purpose very much better, for here muscles are fed with new blood without brain expenditure. These latter measures, however, should be replaced as soon as the patient's condition warrants it, by mild active ex- ercise, because the general physical effect of the latter is of greater value as a general body building measure than massage or passive exercise. Neither should exercise folloAving a command, like march- ing tactics, or a new wand or dumb-bell drill be given in these cases because of the concentrated attention necessary. This is a valid reason why mentally tired school children and business men prefer playing games to formal gymnastics. Because of the great mental activity involved in this class of exercise they are termed edu- cational. Oftentimes repetition of these intricate movements finally results in their performance with an increasingly less ex- penditure of nerve force because of properly directed stimulating and inhibitory impulses, and therefore are less fatiguing. They then become less educational in character and no longer stimulate the element of discipline. Applied therapeutically, an accomplished tennis player, following an illness, can more quickly resume his game with profit than the individual who is just learning to play. Contrariwise exercises of effort involving decided mental action may be properly given to persons of sedentary habits, not of a too active brain, to whom active exercise is a drag even when in the best of health. Exercises of effort vary from a single act like lifting a heavy weight to a simple exercise frequently and quickly repeated, like jumping a rope, racing, and games of like nature. In a violent form of effort practically every muscle group in the body is involved even to the facial group. This has been so interestingly described by McKenzie of the University of Pennsylvania. Witness the drawn face of an athlete at the finish of a race. This form of exercise demands a great deal of nerve expenditure and should not be given in cases where it seems desirable to conserve nerve force. In this case we place most of our modern athletic performances like sprints, hurdles, the long runs, pole vaults and jumps; basket, hand, and foot ball. These exercises, however, are classified as acts of effort only so long as attempts at maximum intensity are made. If, for instance, a given run be covered at a minimum rate of speed, it EXERCISE AND MASSAGE 499 becomes an exercise of mild or severe endurance, depending upon the distance run. The physiologic effect is decidedly different from that following an exercise of effort. Thus while a distance of several hundred yards run slowly would become an act of endurance and an excellent prescription for a boy with a so-called weak heart, it is decidedly contraindicatecl if the distance were run at maxi- mum speed and thereby became an exercise of supreme effort. Be- cause of a failure to appreciate these conditions many a young man has been denied mild athletic exercise by his doctor, which might have been of help to him. It is exercise of mild endurance which may be of particular helpfulness to physicians. They involve acts demanding a minimum expenditure of nerve force. Included in this class we place hiking, rowing, a mild game of tennis of not too keen competition, golf and noncompetitive swimming. Ex- ercises of this type are very beneficial for strengthening the heart and general body building. Mild exercises of strength constitute another form of activity well suited for the convalescent, for they require little skill and may be indulged in while the patient is yet in bed. Some effort at attention is necessary, but the essential requirement is to attempt as complete a contraction as possible. It is this type of exercise which increases the bulk of the muscle and is therefore used for general developmental purposes. Appropriate movements at the earlier stage might consist of arm and leg movements in the various directions, executed as either voluntary, active or resistive. Physiologic Effect of Exercise. — No part of the body is more pro- foundly affected by exercise than the great mass of voluntary mus- cle. The effect is directed in a line of increased bulk and in an increase of strength and endurance, the former, however, not de- veloping in direct ratio with the latter. One may, for instance, exercise the biceps until its maximum girth is attained, after which no amount of additional exercise will increase the circumference of the upper arm. The endurance and strength of it may, however, keep on growing towards a greater maximum. This is explained by the fact that active exercise will not oinV strengthen the mus- cles, per se, but also the nerve force causing its contraction. In others words, active exercise prompted by the individual himself is a force, and the only force, which causes an increased power and efficiency of the neuro-muscular apparatus, involving as it does for its execution the functioning of nerve cells situated in the seat of higher consciousness, the motor areas and elsewhere, the central nervous system, as also the muscle tissue itself. This is not 500 AFTER-TREATMENT OF SURGICAL PATIENTS true with respect to passive movement or massage. It is for this reason that we aim to treat paralytics by means of active exercise as soon as this may be permitted. Through the muscular system, exercise powerfully affects other vital activities. The circulation is hastened and the lymph is pro- pelled along its channels. Breathing becomes deeper and fuller, aiding thereby the return circulation, increasing the carbon diox- ide output and the oxygen intake. The effect of exercise on the heart has long been misunderstood. McKenzie of Philadelphia has gathered data which seems to disprove the generally accepted thought that athletics are harmful to the college student. To be sure if untrained individuals with weak hearts are subjected to violent exercise the inevitable harm will follow On the other hand observation and experience and research seem to give an abundance of conclusive evidence to the effect that athletics prac- ticed under safeguarded conditions may be an excellent heart strengthening agent. The pulse rate and blood pressure rise quite decidedly and the heart increases in size but these return to normal in a surprisingly short space of time. Tins is even true with re- spect to the more violent forms of exercise like rowing, wrestling, marathon running, heavy lifting, and mountain climbing. The criterion as to whether the heart is capable of performing a given amount of work is found in the fact that following muscular ex- ercise there will be a definite rise in the pulse rate and blood pres- sure and that these will return to the normal at the expiration of a given period, depending upon the amount of work done. In one of the British hospitals a covenienl test is employed to determine the heart efficiency. A soldier is required to raise his body weight twenty feet in not longer than 30 seconds, e. g., running up a flight of stairs. He is considered as having a "good reaction" if his pulse and respiratory rate and Mood pressure return to normal at the end of three minutes. General Outline of Exercise Treatment for the More Common In- dications. — Select at first a mild grade of movements and graduate to the more severe type. Exercise preferably twice a day and con- tinue to a mild degree of fatigue, then stop. If physical conditions permit, it is well to follow the exercise with a mild tonic hydriatic procedure and a general massage once a day. I. For relaxal abdominal muscles common with enteroptosis, con- stipation (except spaslic type), puerperium, faulty posture, con- valescence, etc.: EXERCISE AND MASSAGE 501 Lying position arms at side. 1. Head raising with rotation. 2. Trunk raising, chest leading shoulders back, with exhalation. Raise from 1 to 6 inches. 3. Leg raising first one then the other. 6 inches. 4. Same with knees flexed, later with resistance. 5. Knees flexed, abduction and adduction, later with resistance. 6. Bring flexed knees towards chest slowly, exhaling to prevent undue intraabdominal pressure. 7. Bring one flexed knee toward shoulder of opposite side. 8. Retract abdominal muscles as much as possible with deep chest raising and inhalation. 9. Keeping shoulders down roll legs and hips to opposite side. Later with knees flexed, then legs extended upward. 10. With hands on hips raise trunk to sitting position. Later hands on neck or arms extended upward. 11. See exercises on Hernia. 12. If used for enteroptosis. it is well to raise foot end of table 12 to 15 inches. Sitting position on straight chair with feet resting on floor. 13'. Alternate knee raising; later both. 14. Knee raising with abduction and adduction ; later with both, and then with resistance. 15. Knee raising with alternate extension. 16. Extended leg raising with abduction and adduction. Sitting on stool. 17. With legs fixed, or supported by nurse, incline trunk back- ward. Hands on hips, on neck or extended upward. 18. Same position as 17 with trunk circumduction. 19. Same as above with trunk twisting. Hanging position. 20. From mild type of knee flexion to knee extension with ab- duction and adduction. II. Exercise to improve posture. It is very important that all standing exercises should have as a starting position a correct posture. Caution not to exaggerate. A good standing posture is one in which the body weight is so balanced that no undue strain is placed on any muscle group or pelvic ligaments ; the important pivotal points of the body, the ankle, knee, hip, are practically in a straight line, with the body weight transferred largely forward on the forepart of the foot ; the chest is held high, the abdominal con- 502 AFTER-TREATMEXT OF SURGICAL PATIENTS tour almost flat ; the physiologic spinal curves slightly dorso-con- vexed and lumbar-concaved; the pelvis inclined forward about 60° from the horizontal. In such an attitude the gluteal prominence and the dorsoconvexity are in the same perpendicular which line falls approximately two inches back of the heel. To maintain this attitude it is necessary to have a normal skeleton and a healthy and well-trained neuromuscular system. Conditions which influence this posture abnormally are: fa) a change in the bony architecture (b) weak, atrophied or stretched muscles and ligaments (c) disturbance of part of the nervous system. It is further influenced by incorrect shoes and bad-fitting corsets. Treatment consists in: (a) Removal of the cause i. e.. bony defects, poor shoes or corsets, conditions maintaining poor posture. (b) Strengthening of musculature. (c) Training a proper balance sense. For this purpose we em- ploy general massage, exercise and hydrotherapy. The patient is given a treatment in exercise and posture which is followed by any of the tonic hydriatic procedures. Preferably we use the Scotch jet douche because of its powerful tonic effects on the whole body. Massage may follow in selected cases. Exercise. Active exercises only should be employed. Generally speaking the patient should be encouraged to engage in all of the common out-of-door games. Indoor exercises should aim especially towards developing the scapula' retractors, the stretching of soft contractures of the anterior shoulder girdle, the strengthening of the abdominal group, to hold the chest high and learn correct breathing. If apparatus is available, a good part of the work should consist of stretching and hanging exercises, also balancing exercises of various types. The day's order should, of course, include ab- dominal exercises, examples of which are described elsewhere. For chest, back and general development, the following may serve as a guide. (a) Arms, chest and had: exercises. 21. Arms extended sideward. Touch shoulders with finger tips. extend the arms forcibly side and upwards, always behind the body line. 22. Elbows sideward, shoulder high, thumbs touching chest, palms down. Fling anus forcibly backward with palms facing up- wards. EXERCISE AND MASSAGE 503 23. Arms extended sideward. Lower, cross in front, continue to full extension over head. Reverse direction. Keep hips back and weight well on ball of feet. 24. Arms extended sideward. Make circle two feet diameter, reverse. Emphasize backward motion and keep arms behind body line. 25. C4rasp hands behind body. Raise the stretched arms backward and upward with head bending backward. (&) Leg exercises, standing position. Leg and arm exercises should alternate with trunk movements. 26. Hands on hips. Alternately raise extended leg forward, side- ward and backward. 27. Bring left heel towards right hip. Reverse. 28. See flat foot exercises. 29. Hands on hips. Deep knee bending with knees directed out- ward and heels raised ; trunk erect. 30. Alternate toe and heel raising. 31. Standing on one foot perform various movements with the other. (c) Trunk exercises, standing position. 32. Trunk bending with back held straight, hands on hips, then on neck, elbows back, then extended over head. 33. Same as 32 trunk bending sideward. 34. Hands on hips, trunk circumduction. 35. Hands extended sideward, feet together, twist trunk right and left as far as possible without moving feet. 36. Hands on hips, twist hips to the right, the head to the left as far as possible. Alternate. 37. Trunk bending forward touching floor with finger tips. (cZ) Abdominal exercises, see Exercise 1. (e) Breathing exercises. Breathing exercises produce certain definite physiologic effects upon the body. They may be prac- ticed in almost any position and during any part of the wakeful period and without preliminary preparations. They are therefore of great value to us in cases of bedridden patients. Primarily we use deep breathing as a means for strengthening the respiratory muscles, thus helping to keep the chest up and improving faulty posture. It promotes a more complete aeration of the lungs by putting into action certain portions of lung tissue which would otherwise remain more or less quiescent. It very definitely aids the return venous circulation by its suction action 504 AFTER-TREATMEXT OF SURGICAL PATIENTS on the large veins. Deep breathing' exercises promote a greater mobility of the chest vail. We recognize two distinct types of breathing, the thoracic or costal and the abdominal or diaphrag- matic; the former is practiced almost to the exclusion of the latter wherever the waist line is constricted, either by corset or belt. It seems best, however, that both be developed and used. There are three kinds of deep breathing; voluntary, against re- sistance and forced breathing. The first form is self-explanatory. The second type may be produced by blowing through a thin tube, into a respirometer, musical instruments, etc. This form is particularly useful in the treatment of asthma, emphysema, and postoperative contractures or scars. Forced breathing is the result of running, jumping and other forms of violent exercise. Although deep breathing may be practiced in any position, the lying supine and standing positions are best suited because of a greater freedom of restriction than is the case in sitting position. Examples of breathing exercises: 38. May be practiced in combination with arm, leg or trunk move- ments, but more particularly with first named type. 39. In bed with arm raising, later against resistance. 40. "While walking. Ten or twenty deep breaths several times each clay. 41. Standing with hands against abdomen and inhale deeply; ex- hale forcibly by drawing in abdominal wall. 42. Same position as 40 but using thorax only. 4:!. Arms forward upward raising with heels raising and deep inhalation. Stretch as high as possible. Lower arms and exhale slowly. 44. Same as 42 except exhale with rapid chest slapping from above downward. Special Exercises for Strengthening the Heart. — The value of se- lect ive bodily exercise and certain kinds of baths in the treatment of dilatation and other functional disturbances of the heart has long ago been established. Very serious organic changes in the heart and vascular system are not suitable for physical treatment. Muscular exercise was first prescribed for "symptoms of breath- lessness and debility of the heart" by Sir \Vm. Stokes as early as 1854. Since then it has had its advocates among the medical pro- fession to this day. As a result, a number of systems were evolved all based on the same type of exercise, viz., mild effort and en- durance, but the methods differed somewhat. Today there are two EXERCISE AND MASSAGE 505 systems practiced, the Oertel system of graduated. Mil climbing and the brothers Schott system of graduated resistive exercises. Only the latter is practiced in America, and then almost always in con- nection with effervescent baths. The plan has had the endorsement of some of the most prominent physicians of England and America. In this list we find the names of Sir Brunton, Sir Broadbent, Sir Stewart, Satterthwaite and others of England, and Anders, Bab- cock, Billings, Osier, Osborne, Tyson and Ellsworth Smith of America. In the first stages of functional disturbance Dock of St. Louis prescribes mild tonic hydriatic procedures and general mas- sage. He reports marked success in cases of auricular fibrillation. Dr. Theodore Schott defines the essential characteristics of the plan as given below. For details the reader is referred to his book. Summary of important regulations governing the passive re- sistance exercises. "1. Passive resistance-movements include abducation, adduction, flexion, extension and rotation in a vertical, horizontal or lateral direction. "2. These movements should so alternate that new groups of muscles are continuously made to act in sequence thus avoiding fatigue. "3. The resistance should be made by the operator as slowly and gently as possible, but with as much firmness and muscular power as the patient's physical condition will warrant. "4. The operator should never grasp the patient's limb tightly, but should oppose its movements by firm eounterpressure against the advancing side, thus retarding the movement, but always per- mitting the patient to retain the 'balance of power.' "5. The operator should change his resistance whenever the di- rection of the physical force is changed. "6. To gain a well-balanced and uniform effect these exercises should always be bilateral. "7. The operator should closely watch the patient's breathing and circulation and at the slightest sign of embarrassment should stop the exercises. The patient should never be allowed to hold his breath while exercising. "8. A pause of one or two minutes should be allowed between each exercise in order to avoid any fatigue. The patient may sit down during the pause, especially during the latter half of the seance. 506 AFTER-TREATMEXT OF SURGICAL PATIENTS "9. The length of time devoted to each seance should be about a half-hour. At the end of that period it will frequently be found that the number of heart beats has been reduced from 10 to 15 per minute and that the area of cardiac dullness has been made to eon- tract an inch, more or less. "10. After the seance is finished the patient should rest quietly on a couch for at least 15 minutes." The following series of exercise constitute what is known as group one. Additions of the same type of exercises are made until the number reaches fifteen in group four. 1. Raise the arms slowly outward from the side until on a level with the shoulder. After a pause slowly lower to position. 2. Extend one leg as far as possible sideways from the body, the patient steadying himself by holding on to a chair. Same with the other leg. 3'. Extend arms in front of body to a level with shoulders, and then put down. 4. One leg is raised with the knee straight forward as far as possible, then brought back. Repeat with the other leg. 5. With fists supinated, the arms are extended outward and next inward at the level of the shoulders. G. Raise each knee as far as possible to the body and then extend leg. 7. With lists pronated extend arms as in Exercise 5. 8. Each leg is bent backward from the knees and then straight- ened. Hernia. — The best security against hernia is a Avell-developed muscular abdominal wall. By its contractions it aids powerfully in keeping the abdominal contents in their proper place. A weak- ness of this defensive wall plus sudden or continuous strain pro- duces an increased intraabdominal pressure which may result in an adbominal hernia. In cases of muscular atony following lessened activity, especially with localized deposits of fat; or women with general muscular weakness induced by prolonged illness, pro- phylactic measures of massage or exercise may well be instituted. Or, if acquired, these same measures will, with the wearing of a truss, in selected cases, brine about complete recovery. Further- more, following operative procedure, these measures can help much to hasten recovery and prevent a recurrence. In dealing with an abdominal recti diastasis, the aim should be towards improving the two recti muscles. Massage and simple leg EXERCISE AND MASSAGE 507 raising with patient in supine position, will accomplish this. The exercise is to be done 15 to 20 times three times daily, with ex- halation during contraction. In acquired inguinal hernia the desideratum is to strengthen the two abdominal oblique and transversalis muscles. Also, as Me- Kenzie puts it, "To cultivate alertness, control, and self-conscious- ness in these muscles, thus causing them to respond instantly and automatically to any sudden strain that may be thrown upon them.*' This, he says can best be done by exercise of twisting and bending of the trunk and by forced breathing, raising the chest high, thus drawing up the abdominal contents and relieving downward pres- sure. "In the movements of straight flexion of the trunk the rectus muscle only is employed at the beginning and the relaxed oblique muscles are distended, forming two distinct pouches or weakened areas over the lower abdomen, and by the time they con- tract in self-protection the mischief may have been done." A caution which must be observed is to support the dilated ring with (a) the finger, (b) a proper fitting truss. Also to always avoid sudden and severe strain with holding of breath, and long standing position. With such precautions patients may be allowed almost all kinds of nonviolent games, like tennis, golf, bowling, dancing, swimming and canoeing. Contraindicated are football, the weight events, field competition, and .jumping. Bicycling is cham- pioned by Lucas Championniere. "Working with Dr. Seaver, at Yale, the writer has witnessed his patients performing all the or- dinary gymnastic "stunts" which college students like to indulge in with no untoward results. His percentage of cures of acquired hernia by means of exercise and massage was well over the seventy per cent mark. AlcKenzie prescribes a more conservative method of gymnastics as follows: Exercise 1: Patient lying on back. Place one hand across ab- domen, the other protecting the ring. Inhale deeply. Exhale by pressing the abdominal wall until voluntary contraction has been acquired, when this movement can be done without placing the hands over the abdomen. Exercise 2: Patient lying on back, one hand across the abdomen, the other protecting the ring. Inhale and exhale without drawing in the abdomen. In this way, control of the abdominal wall is obtained, while the hernia is protected by placing the fingers over the external ring. In most patients it is possible to teach them in 508 AFTER-TREATMEXT OF SURGICAL PATIENTS one or two seances how to find the external ring and how to protect it in the various exercises. Exercise 3 : Patient lying on hack, right hand behind the neck, the left hand covering the external ring. Eaise the head and shoul- der, twisting in the opposite direction from the hernia to the right. In this way the oblique muscles of the affected side are put into strong contraction, but if the movement be symmetric, the rectus alone will receive the strain. Exercise 4: Patient lying 1 on back, external ring protected. Without bending the knees raise body from the lying to the sitting position, with the shoulders twisted so that the shoulder of the affected side is forward. Exercise 5: Massage, consisting of circular kneading movement. beginning at the external abdominal ring and passing upward and outward to the anterior superior spine. Flat Feet. — When we recall the physiologic fact that prolonged rest causes muscular weakness and that muscular weakness is the primary cause of fiat feet, we find justification in discussing exer- therapy at this time. Flat feet may be caused by paralysis or trauma, but in the great majority of cases it is the result of a disturbance of the soft tissue mechanism of the foot in consequence of a variety of causes tending towards a weakening of the sup- porting longitudinal arch of the foot. Prominent among these are wasting diseases, especially of an infectious nature; lack of muscu- lar development or lack of exercise; faulty walking or standing; and ill fitting and incorred s ; Many gynecologists are awake to the debilitating effect of the the puerperium on the general musculature. What is true of the puerperium is equally true of typhoid fever and other conditions which compel patients to a long siege of muscular inactivity. A good surgeon will look further than the immediate repair of an injury, and will consider the future welfare of his patient. The modern obstetrician, for instance, considers the future of his pa- tient with reference to bodily outline and poise as well as health. and begins muscle training for feet and posture at the earliest pos- sible date following confinement. Grossman and Gellhorn have pointed this out with special reference to the feet. Therefore, in the after-treatment of patients long bedridden, it would seem wise to institute simple measures which would tend to save the patient future suffering. Exercise and proper massage, particularly knead- ing and friction of the feet are indicated. EXERCISE AND MASSAGE 509 The problems associated with the question of flat feet are many and find discussion elsewhere in this volume. The treatment in all cases, however, aims at the restoration of the architecture of the foot and the muscles and ligaments holding it in position. In so far as the latter is concerned, physical therapy may play a most important part in the treatment. All cases should first be thoroughly heated to promote the circula- tion and make the massage, which is to follow, more effective. This heating may be done by means of the hot foot bath (100° to 105°) for 15 minutes, or by a gas or electric light heated appara- tus. The peronei spasm and pain may be relieved by the above men- tioned heating process or by hot fomentations applied twice a day. The foot should next be forcibly adducted, inverted and dorsoflexed which may be done by the operator or by the patient himself using his knees as a fulcrum. Massage, particularly kneading and per- cussion, will frequently relieve spasm; when this method fails, however, forcible stretching under an anesthetic must be resorted to. The circulation will be improved by the preliminary heating and massage and may be further enhanced by the Scotch douche ap- plied twice daily. Hot, 105° to 110°, for two minutes; cold for one- half minute. Exercise. — Passive movements should only be used to secure free mobility and should involve all possible motions of a normal joint. Resistive exercises may be done in all directions save eversion and abduction, which is true also of active movements. "We see no valid reason why these should ever be used at all. It is neverthe- less frequently prescribed in the exercise of complete circumduc- tion. Eversion and abduction tend to aggravate the condi- tion of fallen arch and also bring into strong contraction the powerful peroneus, a muscle which is generally found spastic and overworked in these foot affections. We must guard against the tendency of overdevelopment of this muscle as compared with its antagonistic group, the adductors. We are also of the opinion, which is shared by others, that excessive heel raising, particularly in the more advanced type of flat foot is harmful because of the additional strain which this exercise places on the already stretched plantar ligament. It will also, in the standing position, bring into powerful contraction the peroneus longus which we believe not to be desirable. 510 AFTER-TREATMEXT OF SURGICAL PATIEXTS We use the following series of exercise in the Mechano Therapy Department of the "Washington University Medical School. 1. Resistive movements in direction of adduction, inversion and toe reflexion. 2. Standing position with feet crossed close together and paral- lel with each other. Exercise, alternately raise right, then left foot Fig. 179. — Illustrating flat foot exercise No. 3. Starting position. Dorsoflexion. Fig. 180. -Second position exercise No. 3. Complete extension avoiding abduction of foot. Fig. 181. — Extreme inversion, then bringing foot back to starting position (Fig. 179), re- taining during the movement inversion of foot and flexion of toes. off floor one inch and hold this position for one minute. Each foot five times. 3. Sitting on chair with knees crossed or legs extended place foot in (a) extreme dorsoflexion, using this as a starting position; EXERCISE AND MASSAGE 511 (b) foot extension with strong effort at toe flexion; (c) return to starting position (a) with extreme inversion of foot. (Figs. 179, 180 and 181.) 4. "The forefoot is placed upon the end of a towel, and in adducting, the toes are to grasp the towel, pulling it toward the inside. By repeating these motions a number of times the whole length of the towel is moved under the foot, the knee and heel being at the same time not removed from the spot. In placing weights of increasing size on the outer end of the towel the resistance can be increased to any amount desired. After this exercise has been thoroughly practiced in sitting without weight-bearing it should be taken up in standing." — Bucholz. 5. In selected cases, we add balancing exercises, dancing and games. These exercises should be practiced until fatigue sets in and re- peated two or three times a day. Joint Disturbances. — Sprains and Dislocations. — The part which exercise or massage plays in the treatment of sprains is, in many ways, identical with that of a reduced dislocation. In cases of rup- ture of the muscular attachments or ligaments about a joint, there follows more or less swelling, pain and limitation of motion. If seen soon after the accident the application of proper pressure bandages will do much to promote the absorption of the existing effusion and also act as a splint to support the injured parts. To further promote this absorption, deep stroking massage in the di- rection of the venous flow will be found very helpful. This is also true of deep and rapid vibration, either manually or by means of a vibrating machine, if applied directty over the seat of localized swelling. After a time passive and active exercises are indicated, provided the injured soft part can be held in close apposition by a splint bandage. The beneficial effect of massage and exercise will be to reduce the swelling by hastening the venous flow, thus causing a rapid absorption of the effusion and to that extent the prevention of fibrous adhesions. Motion to an injured joint is contraindicated where separation of the injured parts can not be prevented by bandages, thus neces- sitating total immobilization. This does not apply, however, to healthy distal joints of the same limb where motion should be encouraged, thus preventing the organization of the hematoma and other exudations into fibrous adhesions. There will also be present muscle spasms with pain, and possibly retraction of mus- cles together causing joint stiffness. There may come a time when 512 AFTER-TREATMENT OF SURGICAL PATIENTS adhesions will have to be broken down and there seems to be a right and a wrong time for doing this. At the beginning the new tissue is rich in new blood vessels which are readily torn by move- ments, causing more bleeding, more effusion and more adhesions. At this stage passive motion should not be given. Active exercise, however, is indicated to the point of producing pain. This apparent confliction can be explained by the fact that active exercise is under control of the will of the patient while passive motion is not. It is quite unlikely that the patient will carry the motion beyond the point producing pain, and therefore the chance of tearing the Fig. 1S2. — Passive stretching of the arm and shoulder with scapular fixation. Breaking ad- hesions in case of Sub-Deltoid Bursitis. newly formed tissue is very small. Passive motion, on the other hand, mighl be carried beyond this point. We thus have a phys- iologic index guiding us in the proper dosage of motion in these conditions. Massage above the seat of injury and repeated hot and cold douches should not be neglected. It is unwise to Avail too long before prescribing motion. Prolonged immobilization causes the cicatrix to become firm and stiff, so much so that very frequently they can only be broken under EXERCISE AND MASSAGE 513 a general anesthesia. If this should become necessary, then mas- sage and active exercise should be encouraged. The exercise should include all possible motions of the joint. In breaking down adhesions manually we choose the period im- mediately following the acute stage, when swelling and pain have entirely disappeared. We then employ complete passive motion in all directions daily, preceded by preliminary heating and followed by stimulating massage above and below the seat of injury. If no ad- ditional tenderness develops, more motion is applied and deep fric- tional massage is added to the treatment. (Fig. 182.) Early Functional Treatment of Fractures. — This method of treat- ing fractures was first practiced by Lucas Championniere of France, and Bennett of England, and has found a large number of adherents. It is founded on the principle that restoration of function is equally desirable with that of bony union and should therefore receive equal attention in the treatment prescribed. It is an unfortunate fact that a very large percentage of fractures, especially near joints, are finally left with badly restricted joint function and pain, almost always due to prolonged immobilization. The surgeon in each case treated the condition entirely from the viewpoint of attaining bony union, leaving the question of function solely to chance. Some one has said that it is far better to have a poor union with a good joint function, than a perfect union with impaired function, and that in a great number of Colles' fractiires far greater damage has been done the patient by the treatment than by the injury itself. In all cases the desideratum should be a good union and fully restored function. Advocates of the early functional treatment believe that by proper splinting and proper manipulations this can be accomplished in a far greater number of cases than without the manipulations. The fact that muscles and joints may be moved with- out injury to the opposing fragments has long been overlooked by many, and the fact that in delayed union very slight motion of the fragments has proved to be beneficial must also be new to them. Yet this is claimed by many surgeons today. If a fracture occurs near or into a joint the problems involved are (a) the possible organization of extravasated fluid into fibrous adhesions causing limitation of motion; (b) the passive venous con- gestion retarding absorption and repair processes ; (c) muscle spasm and pain interfering with the aim to hold the fragments in close apposition, besides causing great discomfort to the patient; (d) retraction of muscles leading frequently to contractures. A stiff joint may follow a fracture of the middle third of a long bone as 514 AFTER-TREATMENT OF SURGICAL PATIENTS illustrated by a case reported by Bennett. "Fracture of both bones three inches above the ankle two months previous to present ob- servation. Fragments firmly united, good position, no motion be- yond a little 'springing' in the ankle joint could be produced. P.M. showed: (a) Ant. Tibialis was firmly adherent to the bone, (b) The muscle structures at posterior aspect of fracture had to be torn and were matted to the bone by cicatricial tissue, involving the Post. Tib. nerve, (c) After each structure had been dissected off the bone the ankle joint could be freshly moved." Eeasons for massage and exercise in fracture treatment are : (a) Movements of tendons through the area of swelling would prevent matting of these sofl tissues. (b) The increased arterial blood flow would displace the venous congestion, hasten absorption of extravasated fluid and promote repair processes of bone and ligaments. (c) Exercise would tend to maintain endurance and power of muscles and prevent retraction. (d) Pain and spasm would be materially reduced by massage aiding thereby bony consolidation and improving the general wel- fare of the patient. (e) The joint would be kept supple and retain its normal mo- bility. (f) Patient's period of incapacitation would be materially re- duced. Caution must be exercised in applying this treatment. There can be no question that harm may be done by the improper use of massage and exercise. We must always remember the advantages gained by primary union. We are told that scars, the result of early union, are firmer, less painful and Less liable to disease than scars of delayed union. Our treatment, therefore, aims to keep the torn ends of ligaments and tendons together and yet encourage those things which will promote repair processes and retain normal function. Massage and exercise, we believe, are therefore indicated in such cases where adhesive and other bandages and splints will prevent the separation of the torn ends. To illustrate our thought: A sprain of the ankle tearing the external lateral ligament. Apply pressure bandage over seat of swelling and begin stroking mas- sage over injury. Next day, if greater part of swelling has sub- sided use alternate ho1 and cold foot baths each four times, to promote circulation. Continue massage above seat of injury and firmly strap foot in eversion. Passive motion to all toes. After three to four days, add flexion and extension of foot. If bandage is properly applied this motion need not interfere with the torn EXERCISE AND MASSAGE 515 ends. If on the other hand, there exists with this condition a frac- ture, then the question of motion depends on the possibility of suffi- ciently supporting the fragments to allow ankle motion. Massage and exercise of toes should, however, he encouraged. (Fig. 183.) Paralysis. — (I) Anterior Poliomyelitis. — It is the practically un- divided opinion of the men who have studied this disease that absolute rest is essential during the first stage, that is, until all tenderness has disappeared. Massage, exercise or electricity tend only to further irritate the diseased nerve roots. During the second stage these measures constitute the most important phase of the active treatment; the passive are equally important, aiming to pre- vent deformities by means of braces. The first consideration is to plan all active treatment with a view of getting the patient on his feet as soon as possible, not for one minute, however, losing Fig. 1S3. — Thumb kneading and draining of a Colles' fracture. sight of the fact that the kind and dosage of exercise employed is highly essential. Much harm has been done the patient in the past by overstimulating and overexercising the weak and atrophied muscles. Each individual or group of muscles, if possible, should first be carefully examined and tested as to strength and capacity. Then daily exercise, approaching the active type, should be pre- scribed. Active because it is essential to develop the neuromuscular system and not merely a muscle. For this reason passive exercise and movements by various types of apparatus are much less effec- tive as a whole, stimulating nutrition of the muscle but not voli- tional movements. At first it may be necessary to perform the movements passively, but every means should be used to stimulate and encourage the patient to help the movements by concentrating his attention on it. Each movement should be carried out to its 516 AFTF.R-TREATMKXT OF SURGICAL PATIENTS physiologic limit. As soon as the patient is able to perform 1he movement actively or partly so, passive movements should cease, but the active movements must be assisted by the nurse, so as to avoid overtiring the muscle, until the patient can perform the ex- ercise without assistance. As soon as this can be done with ease, then resistance may be offered on the part of the nurse. Great care must be used not to work the muscle beyond the point of mild fatigue. To recapitulate, the aim should be (a) to have the patient perform active exercise, (b) to get it to walk as soon as possible, and (c) to avoid, by all means, overexercising. The nutrition of the muscle can be greatly benefited by daily mild massage, heating by means of a dry air or electric light heat- ing apparatus and the alternate hot and cold baths to the affected limbs. Lovett and Martin point out the importance of professional su- pervision of the exercise treatment. They found "that the chance of improvement in affected but not totally paralyzed muscles under expert treatment by muscle training was about 6:1; under super- vised home exercise 3.5:1; under home exercises without su- pervision 2.8:1. Untreated muscles showed an improvement ratio 1.9:1." We can at this time do no better than refer the reader to the chapter on muscle training by Lovett. II. Other Form.-: of Flaccid Paralysis. — The particular indications are as follows: (a) To maintain and improve the nutrition of the muscle. This is accomplished by means of radiant heat, deep kneading and stroking massage, and tonic hydriatic procedures. (b) Prevent contractures by means of proper braces, shoes, and daily stretching. (c) Measures which will stimulate the general nervous system, for which purpose Ave use the hacking and percussion movements of tapotement and vibration; also the Scotch spinal douche. (d) Restore the continuity of the impaired motor and sensory paths. This can only be brought about by voluntary exercises which are directed by the will of the patient. Massage, electricity, passive motion or motion caused by a mechanical apparatus can not in our opinion perform this function. In order to achieve the best results, various methods may be employed, which, because of their varying character, tend to stimulate a better cooperation of patient and nurse. This procedure applies of course only to cases of partial paralysis. EXERCISE AND MASSAGE 517 1. The patient is induced to imitate the movements of the opera- tor, choosing at first the easier arm or leg movements and ad- vancing to the finer finger or toe movements. This may frequently be done in connection with simple finger plays and games. 2. Exercises following definite commands. Besides their physi- ologic effect they are of a decided educational value which has a direct bearing on the complete restoration of the neuromuscular complex. They awaken "numerous sensory and motor perceptions, clear cut and well defined regarding distance, direction, weight, force, resistance and effort which might otherwise remain dim and vague." 3. Stimulating initiative by means of various games and plays particularly, if conditions allow it, in company with other children. In a gymnasium class, drills, marching and dancing are excellent. The balance board and wall ladders are very useful apparatus if available. It is a good plan to have both limbs, the sound and paralyzed work together, e.g., with wands, hoops, basket ball, etc., or let the sound limb perform first, the other following. An un- limited fund of patience must be at the command of the operator who conducts the work, for very frequently weeks and weeks go by without any sign of improved function. The patient too gets restless and impatient and his efforts become rather feeble, but, unless the nerve is entirely destroyed, oftentimes repeated volun- tary exercises, even if weak, will definitely aid in repairing the damaged motor tract and restoring motion. 727. Sjjasfic Type (a). — Here also the essential factor in the plan of treatment is voluntary active exercise, particularly that type involv- ing the element of skill. The plan noted above may well be followed in these cases. In addition there is the problem of spasticity which is present so frequently in a most distressing fashion. The measures which may be tried for the relief of this condition are sedative massage, like slow deep kneading or vibration, either locally by means of a portable apparatus or generally by using the vibratory chair. AVe have found this latter to be of real comfort in all of our spastic cases. Other useful measures are radiant dry heat, hot fomentations or neutral baths for an hour or more at 95°. IV. Paralysis Agitans (&). — The prognosis is, as much as we know today, almost hopeless. Attention should be directed toward mak- ing the patient comfortable. In the line of physical measures we have tried massage, exercise, neutral baths and vibration with vary- ing results. We have found, for instance, that the vibratory chair has given the patient comfort when all other measures failed and 518 AFTER-TREATMENT OF SURGICAL PATIENTS we also found that local vibration increased the tremor of another patient to an alarming extent. We have achieved our best results with a sedative massage followed by a neutral douche. The type of massage we use is the slow, deep, long kneading motion cen- tripetally applied, avoiding very carefully any stimulating reac- tion. Bibliography Bennett: Massage in Fractures, Lancet, London, Feb., 1898, p. 361. Bolin: Gymnastic Problems, New York, F. A. stokes & Co. Bowin and MeKenzie: Applied Ajiatomy and Kinesiology, Philadelphia, Lea and Febiger. B'ucholz: Therapeutic Exercise and Massage, Philadelphia, Lea and Febiger. Cohen: Physiologic Therapeutics, Philadelphia, P. Blakiston's Son & Co. Cryiax: The El-em ats of Kellgren's Manual Treatment, New York, Wm. Wood & Co. Ewerhardt: Gymnastics in Relation to Crippled Children, Am. Physical Educa- tion Rev., Nov., 1914. Frenkel: Tabetic Ataxia. Philadelphia, P. Blakiston's Son & Co. Graham: Massage, Philadelphia, J. B. Lippincotl Co. Jones: Injuries to Joints, New York, Oxford University Press. Kellogg: The Art of Massage, Battle Creek, Mich., Modern Medicine Publishing Co. Lovett: Treatment of Infantile Paralysis, Philadelphia, P. Blakiston's Son & Co. Lovetl and Martin: Certain Aspects of Infantile Paralysis, Jour. Am. Med. Assn., 1916, p. 729. MeKenzie: Exercise in Education and Medicine, Philadelphia, W. B. Saunders Co. Nanerede: Principles of Surgery, Philadelphia, W. B. Saunders Co. Nissen: Practical Massage and Corrective Exercise, Philadelphia, F. A. Davis Co. O'Reilley: Unpublished paper on flal feet. Starling: On the Physiological factors Involved in the Causation of Dropsy, Lancet, London. May 9, L896. Wide: Medical and Orthopedic Gymnastics, New York, Funk & Wagnalls Co. Heart Affections in Soldiers, Brit. Med. Jour., Sept. 1916, p. Ms. On Repair of Fractures, Interstate Med. .loin.. L909, No. L6, p. 63. CHAPTER LII HYDROTHERAPY By F. H. Ewerhardt, St. Louis, Mo. Water owes its value as a therapeutic agent chiefly to its power to (a) absorb and communicate heat; (b) the facility in which it may be changed from a solid to a liquid to a gaseous state; (c) its property as a solvent agent, and (d) its adaptability to various methods of application. "We speak of the action of cold upon the human bod}' as being a depressant, all the vital functions being lessened in their degree of activity. If, however, this application is a short one, it is fol- lowed by a reaction which is tonic or stimulating in nature. The explanation of this phenomenon is found in the fact that the body recognizes cold as a depressing agent and attempts to meet the emergency by quickly producing more heat, the thermic reaction; this manifests itself by causing a rush of blood to the periphery, the circulatory reaction, which in turn is followed by a tingling of the nerves, the nervous reaction. Together they are spoken of as the tonic reaction following an application of cold to the body. If this reaction does not manifest itself in its various phases the cold bath must be modified to a lower degree of intensity or dis- continued. There are various agencies which may be employed before the bath which will aid the bringing about of a reaction the most essential being warmth of body. In fact cold should never be applied to the whole body when the skin is cold. This warmth of body may be secured by clothing or covering, hot water, dry heat, exercise, friction, hot drinks or hot enema. During the bath fric- tion and slapping may be employed while following the bath any of the measures used before the bath are indicated. Cold baths are contraindicated in old age, infancy, extreme ex- haustion, either muscular or nervous ; in obesity with severe anemia, cold or clammy skin or extreme aversion to cold baths. A short application of heat is another stimulating agent, but its reaction is atonic in nature. Prolonged heating measures are de- pressing, leaving the individual in a relaxed, atonic, languid state of feeling. To recapitulate : the application of cold, short, is stimu- 519 520 AFTER-TREATMENT OP SURGICAL PATIENTS lating, reaction is tonic; heat, short, is stimulating, reaction atonic; cold or heat prolonged are depressing. In introducing cold tonic baths care must be exercised in begin- ning with a mild form and graduating to the more severe ones, e. g., (1) cold mitten friction, (2) wet sheet rub, (3) salt glow, (4) shallow bath, (5) cold douche, and (6) Scotch douche (see page 531). Reflex Effects Every portion of skin surface is in special reflex relations with some internal organ or vascular area. The vessels may be caused to contract or dilate according as the application is hot or cold, short and intense or long and moderate. As examples may be cited the following, practiced by Abbott, Kellogg, Winternitz and others: Special Reflex of Prolonged Cold. — 1. Cold applied over the trunk of an artery causes contraction of the artery and of its distal branches. Example: ice-bags applied over the carotid arteries de- crease the blood going to the brain and head generally. Such an application is called a proximal application. 2. Prolonged immersion of the hands in cold water causes con- traction of the vessels of the brain and nasal mucous membrane. 3. Prolonged cold to the upper dorsal region causes contraction of the vessels of the nasal mucous membrane. 4. An ice-bag applied to the precordia slows the heart rate, in- creases its force, and raises arterial blood pressure. 5. An ice-bag applied over the thyroid gland (in parenchymatous goiter), decreases its vascularity and lessens its glandular activity. 6. An ice-bag to the epigastrium or mid-dorsal region causes con- traction of the vessels of the stomach, and lessens gastric secre- tion while the application continues. 7. Long cold applications to the face, forehead, scalp and back of the neck cause contraction of the blood vessels of the brain. 8. Ice-bags applied to the sides of the neck just below the angle of the jaw contract the blood vessels of the pharynx. Special Reflex Effect of Short Cold. — Short cold applications to a reflex area produce tonic and stimulating effects in the deep part by virtue of the reaction which soon follows: 1. Short cold applications to the face and head stimulate mental activity. 2. A short cold application to the chest, as a cold rub, friction, or cold douche, at first increase the respiration rate. Soon it re- sults in deeper respiration with a spmewhal slowed rate. HYDROTHERAPY 521 3. A cold douche to the precordia or slapping the chest with a cold towel, increases both the heart rate and force. After the cessation of the application, the rate decreases while the force re- mains increased. 4. Short very cold applications to the abdomen, hands, or feet cause contraction of the muscles of the bladder, bowels and uterus. 5. A short very cold douche to the liver causes dilatation of its vessels, and increase its glandular activity. 6. The reaction from a moderately prolonged cold application to the epigastrium causes increased gastric secretion. Special Reflex Effects of Hot Applications. — 1. A very much pro- longed hot application to a reflex area produces passive dilatation of the blood vessels of the related organ. 2. Long hot applications to the precordia and to many other parts increase the heart rate, decrease its force, and lower the blood pressure. 3. Hot, moist applications to the chest facilitate respiration and expectoration. 4. Prolonged hot applications to the abdomen lessen peristalsis. 5. Prolonged hot applications to the pelvis, as a fomentation, pack, or sitz bath, relax the muscles of the bladder, rectum, and uterus, dilate their blood vessels, and increase the menstrual flow. 6. A large hot application to the trunk, as a hot trunk pack in biliary or renal colic, relaxes the muscles of the bile-ducts, gall- bladder, or ureters, and aids in relieving the pain due to spasm of these muscles. Hydrostatic Effects. — Prolonged application of heat covering a large area causes the peripheral circulation to dilate; if cold is sub- stituted the blood vessels will contract and drive the blood into the internal organs. This interchange of flow is termed depletion and the means of producing it derivation and is used primarily to re- duce congestion of areas and organs. While reflex effects are pro- duced through nerve action, depletion is primarily mechanical and although both effects are produced by the same application, one of these will, by its greater intensity, soon overbalance the other. There are definite laws which govern this balance which Abbott defines as follows : "The first relates to the size of the area treated; the second, to the intensity of the application ; the third, to the location of the area." "1. Size of Area. — (a) When an application covers a small area, as an ice-bag or a jet douche, the effect is chiefly reflex, and is concentrated upon the internal organ in reflex relation with the 522 AFTER-TREATMENT OF SURGICAL PATIENTS surface treated. These applications are so small that the circulatory effect in driving blood from the skin will be slight. The resulting hydrostatic effect, therefore, being very slight and spreading out over all the rest of the body, will be of no importance. "(b) With all the large applications the mechanical or hydro- static effect soon overbalances and wipes out the reflex effect. This is true of hot leg-baths, hot packs, full tub baths, etc. "2. Intensity of Application. — When small applications are of great intensity (very cold or very hot or with strong percussion), the tendency is also to produce a decided reflex with but little mechanical effect upon the blood current. "3. Locution of Area. — An application made over the heart al- ways produces a reflex effect, no hydrostatic effect being perceptible. The same is true of an application to the head, the reflex effect nearly always being greater than the hydrostatic effect. On the contrary, applications to the feet or legs practically always pro- duce hydrostatic effects unless the applications cover a very small area. This implies thai certain areas give reflex effects chiefly, while with certain other areas the mechanical effect predominates. " A-> illustrative of therapeutic applications may be mentioned: 1. The brain. Blood may be withdrawn from the brain by ap- plication of heat to the feet. Legs, or the entire lower limbs; also to the spine and entire surface of the trunk. 2. Lungs. It is necessary to use applications to large areas, since the lungs contain much blood when congested. These areas are the feet and legs, and the entire skin surface of the trunk and hips. In pleurisy it is best to use a fomentation directly over the affected area. 3. Pelvic organs. Then- are two principal areas used: First, the entire skin surface of the hips and lower abdomen, as by a hot sitz bath or hot hip pack. Second, the lower limbs, as by a hoi leg- bath. P>oth areas may be treated by the hot hip and leg pack. 4. Kidneys. Where there is much congestion in the kidneys, it is necessary to use hot applications to the entire surface of the body, the head, of course, being excluded. Less intense congestion may be treated by large fomentations to the back or by the trunk- pack. .">. 'Idle middle ear. The whole side of the head and face di- verting blood from the internal carotid and internal maxillary. If the hot compress extends below the jaw. the common carotid will be dilated. An ice-bag below the jaw with the fomentation in- creases the effect by contracting the carotid. HYDROTHERAPY 523 It is possible and frequently advisable to combine reflex with the derivative action. Thus: To relieve a congested uterus apply ice-bags over lower abdomen which refLexly contracts the blood vessels of the uterus ; a hot hip and leg pack drawing blood to the legs. (The pack covers the ice-bag). Eenal congestion. Ice-bags over lower sternum with hot fomen- tations to loins. Gastric congestion. Ice-bag over stomach, hot fomentations to dorsal region of back. Visceral congestion. Hot-water bag to abdomen to divert blood from viscera to cutaneous veins. Cold compress to back which at first causes contraction of the small vessels then dilatation due to reaction. Technic 1. Fomentation. — Fomentation is applied preferably by means of a piece of old blanket about a foot and a half square, which, after being saturated with boiling water, must be thoroughly wrung out by means of a wringer so that every possible drop of water is squeezed out. This is an important element of technic for if any water remains we are liable to scald the patient. Little fear of a burn need be entertained if the part has been well rubbed with an oleate and all the hot water has been carefully squeezed from the piece of blanket. The nurse takes the hot moist piece of blanket, lays it beside the patient, opens the blanket covering, then places the fomentation upon the affected part. It must be quickly ad- justed to the part, the blanket closed, and all air excluded by draw- ing the blanket cover tightly over the fomentation, and especially close at the ends. The patient will likely complain of the intense heat, but must be encouraged to bear it, as this will disappear as soon as the tissues relax. If the heat can not be endured, the nurse may "ease" matters a little by lifting the fomentation from the surface for a few seconds, without greatly loosening the blanket cover, and again dropping it in place. The fomentation may remain in place for five to ten minutes, and may be immediately repeated, or again as soon as the physician deems wise. If it is immediately repeated the parts must be kept covered by the blanket cover, and the process gone through with as little loss of time as possible. Two pieces of blanket will be found useful on such occasions, the nurse preparing the second one while the other is in place being thus enabled to make the exchange with great rapidity, a feature 524 AFTER-TREATMEXT OF SURGICAL PATIENTS much to be desired. The beneficial effect of the fomentation can be decidedly enhanced by terminating the treatment with a brief cold application not to exceed a minute. The part is then dried, rubbed briefly with the dry hand and protected from the air. Effect. — The fomentation is used to relieve pain, produce deri- vation, as a preparation for cold treatment, and for stimulating or sedative effects, according to the temperature and mode of applica- tion. Its first effect is that of a vital stimulant; unless followed by a cold application the reaction is atonic. A brief application is stimulating; prolonged applications are sedative or depressing. For sedative effects the heat should be moderate and the application more prolonged before renewal. These points should be observed in ap- plying fomentations to the spine for insomnia. 2. Heating Compresses. — A heating compress is a cold compress so covered thai warming up soon occurs. The effect is. therefore, that of a mild application of moist heat. A heating pack or compress consists of an application to the body of three or four thicknesses of gauze or one of linen or cotton cloth wrung from cold Avater and so perfectly covered with dry flannel or mackintosh and flannel as to prevent the circulation of air and cause an accumulation of body heat. In case warming does not occur promptly, it should be aided by hot-water bottles or radiant heat. It is usually left in place for several hours be- tween other treatments, or overnight. If left on overnight it should be dry by morning unless an impervious covering, such as a mackin- tosh or oiled silk, is used. On removal of the compress, the part should be rubbed with cold water. If the pack dries out before being removed, it will have a mild derivative and sedative effect. If the coverings prevent drying, the result will be that of a stronger derivative because of the local sweating. It also causes relaxation of the muscles and vasodilata- tion of the vessels in immediate or reflex relation with the surface treated. 3. Ice Pack.- -An ice pack is used where a Large, continuous, and very cold application is desired. Spread cracked ice over a thick Turkish towel, folding one end and the edges over this so as to retain the ice. Apply next to the skin or over a single layer of flannel. This may be used over the heart, also over a consolidated Lung area in pneumonia. In the hitler case, it should never be ap- plied until after the hot packs have warmed the body sufficiently to prevent chilling. It should occasionally be interrupted by ap- HYDROTHERAPY 525 plying a fomentation. This helps to preserve the desired reflex effect. Snow may be used in place of the pounded ice. In applying an ice pack to a joint, first wrap the part in flannel so as to prevent actual freezing, then pack the snow or pounded ice closely against the flannel, forming a layer about one inch thick, retaining it in place by a larger flannel cloth wrapped about all and pinned to- gether. Ice packs should be interrupted often enough to prevent freez- ing, and either the part rubbed with snow or a fomentation ap- plied to renew local reaction. 4. Cold Wet Pack. — Requisites. — One or two blankets; a linen or cotton sheet ; four small towels and a hot- water bag. Technic. — The patient in wrapper sits in a convenient chair with feet in the bath of warm water and with a cold compress on the head. The attendant then wrings out the sheet from the water in the bucket and spreads it smoothly over the bed, so as to reach near the foot. The patient then quickly drops all clothing and lies on the wet sheet with arms extended. The attendant, standing on the right side, promptly draws the overhanding left side of the sheet across the body, smoothing it between the lower limbs and along the right side. The arms are then lowered to the sides and the remaining free portion of the sheet is drawn over the body and smoothly adjusted over the lower limbs, covering in both arms. The feet are left uncovered by the sheet, but the hot water bag, covered with a towel is placed at the soles. The underlying blanket is adjusted in a manner similar to the sheet, except that it is not tucked between lower limbs, and the surplus at the feet is folded under them. The blanket should be closely adjusted at the neck so as to exclude all air. Another blanket, folded in several thicknesses, is then placed over the entire body from the neck down and tucked snugly in at the sides. A fresh turban of ice- water is adjusted to be changed every five minutes as it warms. It is found in many cases that if the wet sheet is allowed to extend beyond the feet and is then placed over the feet without the use of the hot-water bag, the reaction in the feet is slow and correspondingly unsatisfactory. There is no advantage in covering in the feet with the cold wet sheet, and the use of the hot-water bag favors the action of the pack. 5. The Hot Wet Pack. — This is applied in three principal ways, viz., by means of a sheet wrung out of hot water; by means of a blanket wrung out of hot water; and by means of both. In many 526 AFTER-TREATMENT OF SURGICAL PATIENTS cast's especially in treating children, 1 lie first method suffices, and it avoids the necessity of dealing with wet blankets. Requisites. — These arc the same as for the cold wel pack, except that a bucket of hot water should be provided. The bed is pro- tected as previously described and on it two blankets are spread. Technic: This is practically the same as the cold wet pack. 6. Hip or Sitz Bath. — Requisites. — Blanket, towels, sitz bath suf- ficiently filled with water of the desired temperature to cover the patient's hips, a foot bath at a temperature of from 105 to 110° F., except in the very hot sitz bath, when the foot bath should be at least 2 or 3 degrees warmer than the sitz bath, a basin of ice water for compresses for the face and neck if for the hot sitz bath. Technic. — A blanket is placed about the patient, being pinned at the back of the neck; the patient is seated in the bath, the feet placed in the foot bath. The upper edge of the blanket is brought up around the patient's shoulders and over the edge of the tub. the lower edge covers the foot tub. A folded towel should be placed at the back and also at the front of the tub under the patient's knees to protect the patient from contact with tin 1 tub. Avoid pressure on popliteal space. Cold Sitz Bath. — Temperature 75 to 55 F., the temperature may be higher when the patienl enters the bath and rapidly decreased to the desired degree. Temperature of the foot bath, 105 to 110° F. Duration. — One to eighl minutes. Technic- The patient sits in the tub with the feet in the foot tub, the edges of the blanket are separated and placed over the patient's shoulders; water is dipped from the tub and friction ap- plied to the back, patient giving friction to the abdomen. Friction is applied throughout the bath and may be given with the wet hand or with bath mitts. Effects. — A short cold sitz bath of I to 4 minutes' duration, greatly stimulates the pelvic circulation and tones up the musculature of the bowels, bladder, and uterus. The lower the temperature, and the more vigorous the friction, the more intensified are the effects. Indications. — Constipation, subinvolution, atony of the bladder. Cold sitz baths may be used to stimulate the liver by increasing the portal circulation. Modified 'temperatures may be used in treating children for nocturnal enuresis. Contraindications. Acute inflammation of the pelvic or abdom- inal viscera, acute pulmonary congestion, and painful affections of the bladder and genital organs. HYDROTHERAPY 527 Prolonged Cold Sitz Bath. — Temperature. — 85 to 75° F. May be begun at a higher temperature and decreased. Duration. — Fifteen to forty minutes. No friction is applied. If there is a chilling sensation, a fomentation may be applied to the spine. Effects. — The pelvic vessels and walls of the uterus become ex- tremely contracted. 7. Salt Glow. — Prepare about two pounds of coarse salt and wet with cold water. The treatment should be given in a "wet room" or in a bath-tub. The patient stands in a tub of hot water. While standing at the side of the patient begin with the arm. Wet the entire skin surface of the shoulder, arm, and hand with hot water from the foot tub. This is clone by clipping the water with the hands. Next apply the wet salt, spreading it evenly over the skin ; now with one hand on each side of the arm, rub vigorously with to-and-fro movements, until the skin is in a glow. Stepping behind the patient to the opposite side, proceed in the same manner with the other arm. Retain the last position to treat the front and back of the trunk. With one hand in front and one behind, wet the skin surface with hot water from the foot tub. Now spread the salt as before, and rub the entire skin surface of the chest, abdomen, shoulders, back, and buttocks. Stepping behind the patient, with one hand under each arm, continue rubbing with the salt, treating the sides of the chest, abdomen and hips. Next proceed with the legs in like manner. For each limb have the patient put one foot on a low stool so as to bring the thigh about horizontal. Wet with water as before and rub the thigh, leg, and foot with the wet salt. Finish the treatment by thoroughly washing off the salt and dry the patient. If for any reason the patient ought not to stand so long, he may be seated on a low stool while the salt glow is given. Proceed as follows : The patient sits on a stool with the feet in hot water. Beginning with the feet and legs, apply the water and then the salt, rubbing briskly with short strokes, the hands being on either side of the part treated. Next treat each arm separately; then the chest, abdomen, and back should be rubbed with the wet salt, the attendant standing at the side of the patient with one hand rubbing the chest and the other rubbing the back. The pa- tient should stand while the buttocks and thighs are treated. Wash off the salt and dry. The salt glow is a vigorous circulatory stimulant. Since no great amount of cold water is applied to the body, it does not require as great reactive ability as the wet sheet rub or cold douche. 528 AFTER-TREATMENT OF SURGICAL PATIEXTS x . Nauheim Baths. — The Nauheim bath, also known as the Sehott, carbonic acid, carbonic dioxide or effervescing bath, was originally administered in Bad-Nauheim near Frankfort, Germany, from their natural springs. In the last decade or so, however, the hath has been prepared artificially in this country by adding the most im- portant constituents of the true Nauheim water to the ordinary full bath. There are three methods in general usage, which are employed in this country at the present time, differing', however, one from another only in the manner of producing the carbon dioxide. The chemicals necessary arc sodium chloride, calcium chloride hydrochloric acid and sodium bicarbonate. The hydrochloric acid may be replaced by acid sodium sulphate. Essentials. — Full bath at the proper temperature (98° to 90° F.), sheet to cover tub, air cushion, large turkish sheet, towels, cold turban, required chemicals, bath thermometer. Technic. — The patient should rest one hour before the bath, then have his blood pressure, pulse, respiration recorded. "When ready he should be assisted into the bath in order to avoid any unnecessary exertion. Inhalation of the carbon dioxide should be avoided by spreading a sheel over the tub and well around the neck of the pa- tient. Watch the patient closely, and should he become cyanosed, unduly excited, pulse weak or irregular, terminate the bath im- mediately. Help the patient out of the tub. and at once cover him with a warm turkish towelling blanket and put him to bed. Chill- ing must be avoided, if necessary by aid of hot-water bottles to feet. After an hour's rest again lake blood pressure, pulse, and respiration. Baths should not be given more often than five times a week, allowing two days of rest. In very weak cases only every other day. On alternate days it is a wise plan to give the Sehott heart movements. A series of baths usually consists of 18-20 or 24 to be repeated after an interval of four to six months. Indications. — In valvular insufficiency and stenosis, auricular fibril- lation, cardiac dilatation and neuroses, Height's disease, chronic articular rheumatism, gout and obesity, neurasthenia, hysteria, rachitis, anemia, nephritis, chlorosis and locomotor ataxia. Contraindications. — Acute inflammatory diseases and in acute en- docarditis, in extreme arteriosclerosis, aneurysm, and in angina pectoris. Thysiologic Effects.— The physiologic effects are stimulation of the vasomotor apparatus due to the carbonic acid gas and the salts in solution, principally the sodium and calcium chloride. The HYDROTHERAPY 529 cutaneous circulation is dilated, drawing the blood from the con- gested viscera, relieving thereby the labor of the heart. The pulse rate is markedly reduced, but it becomes stronger and fuller. The left ventricle is able to produce a more complete contraction. The blood pressure at first rises from 5 to 10 mm. but invariably drops that much from the starting point. This has been our ex- perience in almost all of our cases complicated by hypertension. The area of dullness in cases of dilatation is often very markedly reduced. Stimulation to the skin increases its activity, thereby lessening the labor of the kidneys. Methods. — (a) Generating the C0 2 by means of bicarbonate of soda and hydrochloric acid. After the temperature of the water has been properly regulated, the necessary salts, sodium chloride, calcium chloride, and sodium bicarbonate are added. It is well to strain the sodium chloride through a cheese cloth in order to remove the impurities which are usually present. Next add a strong solution of hydrochloric acid equal in quantity to the sodium bi- carbonate used, by pouring it direct^ on the surface of the water from a small mouthed bottle, distributing it well over the entire surface without agitating the water. The layer of C0 2 which forms on the surface, should be dispersed by means of a towel. (b) The Triton Company of New York (Schieffelin & Co.) has put a very convenient method for the preparation of an artificial Nauheim bath upon the market, which has been used successfully. (c) By means of an apparatus carbonic acid liquid gas may be used instead of the bicarbonate of soda and HC1. The principle is that of forcing the gas through several pieces of rattan 3 feet long by y 2 inch in diameter beveled down from one end to a flat point. The gas is then emitted from the cut ends of tubules or pores along its entire length in the shape of very minute globules which quickly adhere to and cover the skin surface of the patient. By means of a gauge the amount of gas can be absolutely measured and controlled, thus insuring any strength of saturation one may want. When this method is used, sodium chloride, 5 pounds to 40 gallons of water is first dissolved in the water. The amount is gradually increased. Authorities use various formulas of salts, temperature of water and duration of bath. We append herewith the one we use at the Hydrotherapeutic Department, Barnes Hospital, but wish to add that we do not adhere absolutely to it, changing it as the conditions of the patient may demand. The course of twenty baths extends 530 AFTER-TREATMENT OF SURGICAL PATIENTS over a period of four weeks, treatment being given daily except Wednesdays and Sundays. NaCl CaCJ n a Bicarb . 11C1 Duration Temp. Lst wk. 4 lbs. (i oz. oz. n oz. 5 to 7 min. 97 to 9-j degrees 2nd " 5 ' ' 8 " 8 " 8 " 8 to 11 " 94 to 92 3rd i i i; •• in " In ■• 10 " 12 to 13 " 91 to 90 " 4th i c 7 " 12 '• 12 " 12 " 14 to 15 " 89 to 88 " Graduated Tonic Cold Applications 1. Cold Mitten Friction. — Cold mitten friction is the mildest general treatment, and can be employed to advantage even in the treatment of feeble, bedridden patients. The water is best ap- plied with a wet bath mitten. One part of the body after another should be rubbed, first with cold water 50° to 75° F., and then with a rough towel. If the circulation is poor, alcohol may be added to the water. The skin of the part treated should become red and warm. The intensity of the local reaction furnishes a guide to the selection of the proper tonic measure. If a good reaction is ob- tained with the ablution, stronger measures may be used, of which the douches have the greatest range of usefulness. 2. The Wet Sheet, or Sheet Bath. — This important measure re- quires very little apparatus. The best time for its application is late in the afternoon or toward night. The requisites are a pail or large basin of water at 65 P., a foot tub with water at 100° p., ice-water ; two face towels ; a bath towel; a bed with an extra blanket at hand, and protection for the floor. Put the sheet into the water, letting the corners hang out. The patient, dressed only in one garment, stands in the fool tub containing the warm water. One face towel is then dipped in ice water, wrung out, and wrapped about the head like a turban. The nurse then places a pail of cold water with the sheet behind the patient, and. while standing in front seizes the vet sheet by two corners and throws it around the patient, without any attempl to wring ou1 the sheet. A rough, smart rapid rub applies il everywhere. This process should occupy about two minutes. Then drop the sheet and wrap in the dry blanket, and put the patient to bed. Lower the temperature of the water 1 degree each day until 55 P. be reached. This is the quickest and simplest method of applying the drip sheet, and may be modified or extended by slapping the surface occasionally with the hand or a we1 towel, this increasing the mechanical irritation of the skin. In addition, a basin of water 10° P. colder than the water used for the sheet should be provided, HYDROTHERAPY 531 from which water is poured over the head and shoulders two or three times at short intervals, being alternated with slapping and friction for from five to ten minutes. In any given case the physi- cian may judge whether to commence moderately or with the full technic. The general effect is moderately tonic, with the abstraction of considerable heat. 3. Shallow Bath. — Prepare bath at temperature of 75° to 65° F., four to six inches deep. Feet should be warm before entering the bath. The pateint sits in the bath and applies friction to the chest. ^T ~ « -- '-: Fig. 184. — Showing apparatus controlling jet douche, needle douche, shower douche, and Scotch douche, and manner of application. Temperature and pressure of water under instant control. abdomen, arms and legs, the operator applying the same to the back. Cold water is dipped from the tub and dashed over the pa- tient's shoulders and back and friction continued. The patient lies in the tub giving friction to the chest and abdomen while the opera- tor applies friction to the extremities. Duration. — Two to four minutes. 4. Cold Douche. — This is a single stream of water under pressure coming from a nozzle of % or % inch in diameter at a distance of 532 AFTER-TREATMENT OF SURGICAL PATIENTS 10 to 15 feel from the patient. The temperature may be regulated by valves which govern the mixing chamber in the control table, and may be graduated from a warm stream down to the coldest water supplied. It is a powerful stimulant and useful for its tonic effect after the hot-air hath and circular douche. (Fig. 184.) It is contraindicated in asthma, as paroxysms of asthmatic breath- ing may he induced. The sudden contraction of the pulmonary vessels restricts the area of blood subjected to oxidation in the lungs, tin- carbonic acid is not properly eliminated, and a sense of suffocation ensues. This is corrected as reaction occurs, and the secondary effects are powerful, tissue change being highly stimu- lated. Fatigue gives place to renewed energy, especially if the cold applications be preceded by heat and followed by vigorous rubbing. 5. Alternating Hot and Cold Douches. — This form of douche, for some unknown reason called the Scotch douche, produces distinctly exciting effects. It is not applicable to the head or the anterior chest, but may be applied to the spine and posterior thorax and sides; to the abdomen and to the lower extremities. With tem- peratures alternating between 105° and 70° F., or possibly a few degrees higher and lower, g I results are obtained; in robusl patients the extremes may reach 110 : and oo F. or lower. The Electric Cabinet Bath Compared with Russian or Turkish baths the electric lighl cabinet bath offers many advantages, (a) 11 combines both light and heat. Lighl is used because of its property of being able to penetrate soft tissue and thus exert a definite influence on the body cells in that way. (b) Because the patient is more definitely under the control of the nurse, which is very important in advanced cardio- renal cases where elimination is so desirable, (c) The heart action is easily controlled by cold applications to the head, (d) The blood can be further diverted from the head by means of a hot foot bath given at the same time, (e) Perspiration can be Induced in from five to ten minutes with a temperature of less than 125°. (f) It can be so readily used for the purpose of heating the body prepara- tory to giving a hydriatic treatment, (g) Can be installed at a relatively small expense in home or institution. (Fig. 185.) The stimulating and tonic effects of radiant Light and heat upon the general metabolism are dm' to several specific actions or effects in- duced on the tissues in the circulating fluids of the body and are defined bv Snow as follows: HYDROTHERAPY coo "I. The actions on the blood. (1) The oxidizing influences of radiant light and heat favor to a remarkable degree active tissue metabolism. (2) The oxygen-carrying function of the blood is en- riched by an increased percentage of hemoglobin due to the direct action of light rays, and (3), the lymphatics are rendered more ac- tive in eliminating waste products and toxins by the sweat glands and other emunctories of the body. "II. The superficial end organs are stimulated to a greater ac- tivity with an increased tissue change, both anabolic and catabolic. "III. The deep spinal centers are reflexly stimulated to greater reflex activity by the intense effects of the applications of radiant Fig. 185. — Illustrating electric light cabinet bath. light and heat to the peripheral neurons, thereby arousing greater general activity of the vital centers, particularly the perspiratory, cardiac, and excretory centers. "IV. The general diffusion of heat which takes place by con- vection from the blood heated at the periphery, promotes general tissue oxidation and elimination throughout the organism. "V. The actinic and thermic action of the radiant light and heat upon the germs in local areas of infection, causes inhibition of ac- tivity and destruction of the germs by the phagocytes thereby re- 534 AFTER-TREATMENT OF SURGICAL PATIENTS lieving the tissues generally from the toxic materials otherwise thrown out. "VI. The induction of superficial hyperemia, local or general, promotes nutrition in the tissues hy an increase of nutritious pabulum distributed through the tissues, as well as an increase in the number of nature's scavengers, the phagocytes, where hy- peremia exists, thereby increasing the general tissue resistance, as well as awakening a greater metabolic activity. "VII. The stimulation of increased elimination through the sweat glands and other emunctories, induces the removal from the system of the poisonous toxins which vitiate the general system and cause general impairment of metabolism." Bibliography The following publications were freely consulted I'm material, as well as for confirmation or otherwise of cur own experience. Pope: Practical Hydrotherapy, Chicago Medical Book Co. Kellogg: Rational Hydrotherapy, Philadelphia, F. A. Davis Co. Abbott: Hydrotherapy, Loma Linda, Cal., College Press. Barush: Hydrotherapy, New York, Win. W I & Co. Hinsdale: Hydrotherapy, Philadelphia, W. B. Saunders Co. Sehott: Treatments of Chronic Diseases of the Heart. Philadelphia, P. Blakis ton 's Son & Co. Snow: Radiant Light and Heat and Convective Heat, Xeu York, Scientific Author Hub. Co. CHAPTER LIII POSTOPERATIVE TREATMENT BY RADIUM AND THE ROENTGEN RAYS IN MALIGNANCY By Russell H. Boggs, Pittsburgh, Pa. Discussion of the value of radium and the roentgen rays in malignancy necessitates dealing with the various types and stages, and the citation of results produced by each agent alone, as well as when used as a supplementary treatment to surgery. In cer- tain locations and stages of malignancy, anteoperative or preliminary treatment is undoubtedly advisable. In advanced growths in the mouth or throat, and in advanced carcinoma elsewhere, the results obtained both by radium and the roentgen rays, have given them a place as a routine method alone ; for instance, in the treatment of se- lected cases of epithelioma. Postoperative treatment by these agents, therefore, can not be satisfactorily discussed without considering, separately, their positive values when used apart from surgery, and citation of cures by the rays alone will only emphasize their value in treatment of postoperative cases. Before any one can use radium and the roentgen rays intelligently, it is not only necessary to study the properties of radioactive sub- stances, but also their physiologic actions on both normal and dis- eased tissues. Interest from the beginning centered around the action which the rays had upon malignant cells, and as a result of detailed studies by many investigators, the treatment of malignancy by radiotherapy has been placed upon a rational basis. Investigators have shown that the rays given off both by the radium and x-ray tube act primarily on the nuclei of the cells and inhibit their power of proliferation before the function of the cell is impaired. Embryonic cells and those which are undergoing ac- tive proliferation are the most susceptible. It has been shown that malignant growths are retarded by radiation and become less malig- nant, although they may not have diminished in size or disappeared. By further increasing the quantity of radiation, the injury becomes more pronounced, and the cells are completely destroyed, the rays acting differently on the various types of cells, destroying one kind of tissue and leaving the other adjacent tissues intact or so slightly injured that they will completely recover. 535 536 AFTER-TREATMENT OF SURGICAL PATIENTS The therapeutic action of the rays on a new growth consists, not only in the destruction of the tumor cells, but also in the change produced in the blood vessels. The endothelial cells of the intima degenerate, the lumen of the vessels retract, finally being obliterated, and consequently the tumor cells can not obtain the nourishment needed for their maintenance of life and for their proliferation. It may be of interest to call attention to some of the reasons bet- ter results were not obtained in the early days of radiotherapy, even by those who were good clinicians and pathologists. Eadia- tions from radium are of a complex character as regards penetra- tion, and it is necessary for some of the rays to be absorbed before reaction takes place. Kays of low penetrability are the most active physiologically. Often rays of too low or too high penetration were employed; if too low, only the surface of the lesion is treated while if too high, energy is wasted and the best form of radiation is de- feated. Rays given off radium are known as alpha, beta, and gamma. Many did not know, in the early days, whether the gamma or beta ray predominated. The therapeutic value of radium can not be thoroughly under- stood if it has not been studied with a sufficiently complete and varied range of filtration. 11 is also necessary to know how to cut off the low rays, which are not wanted for the lesions under treat- ment, and to know the method of avoiding the deleterious effects of these rays, as well as to understand the secondary radiations set up by the various filters employed. In the beginning no one was familiar with filtration and secondary radiation. They did not know whether they were treating the patient with beta or gamma rays. Good results were accomplished only after this was known as well as the limitations of radium. Radium, I believe, when properly applied, is the most efficient form of radiation we have, today, for a depth of from two to three centimeters, but large areas can not be treated with it. and when it is necessary to ray the adjacent glands it should be supplemented by the roentgen rays. Modern radiation means the use of radium and the roentgen rays with the improved technic, using the Coolidge x-ray tube. The treatment of malignancy demands specialized study. Every physician or surgeon who treats malignancy should know its various forms and stages, and also know what has been accomplished by radium, roentgen rays, surgery and any other method by which results have been obtained. Carcinoma of the Breast. — Treatment of carcinoma of the breast by roentgen rays has been carried out by many during the past 15 RADIUM AND ROENTGEN RAYS IN MALIGNANCY 537 or 16 years, and is today a recognized method in the treatment of postoperative cases, recurrent and metastatic, primary inoperable and primary cases which do not permit operation. For a long time it was taught and accepted as indisputable that the only proper and scientific method was the radical operation, which meant the surgical extirpation of the growth even in the hopeless stages ; but today it must be recognized that surgery, taught so long as the only method, is really only part of the treatment. Though operation still holds first place in the early cases, even at this stage it should be supplemented by roentgen therapy. This sentiment is spreading among some of the leading surgeons, who in the past did the most radical operations for cancer of the breast at any stage, their ad- vanced views springing mainly from comprehensive experience with a great number of cases traced carefully to their end results. Roent- gen therapy is taking the place of the ultra-radical operation, such as removal of the supraclavicular glands, or the clavicle. It is our duty as roentgenologists to teach the profession the in- dications for roentgen therapy and that postoperative treatment is just as important as asepsis before and during the operation. While statistics are of little value, it can be safely stated that proper postroentgen treatment will prevent from 25 to 50 per cent of re- currences even in the early cases, because cancer cells can be de- stroyed at a greater depth and distance from the original growth. If the surgeons can cure 40 per cent of cases in a certain class, why not make it 90 per cent or more? It will be a big task to demonstrate this fact to surgeons, inasmuch as many of their cases will receive inefficient therapy in the hospital by a nonmedical tech- nician, and if results are not obtained, they will relieve themselves of the responsibility by saying the rays were at fault. Then, too, it is feared that too much therapeutic work is undertaken in a half- hearted manner, even by many who can do exceptionally good roent- genograph^ work. Surgeons long ago agreed that too many un- qualified physicians operate. Since they know that proficiency is necessary in operation, they should realize that just as much care and skill is required in giving therapy. Treatment of carcinoma of the breast by roentgen rays has, com- paratively speaking, passed through the same stages as surgery. The early stage might be compared with surgical treatment of a quarter of a century ago when they only amputated the breast. Our technic in the beginning was very crude ; we neither used filters nor had a standard dose, and we omitted important chains of lymphatics where metastases frequently occurred. Indeed, it is 538 AFTER-TREATMENT OP" SURGICAL PATIENTS quite remarkable that a creditable number of good results were obtained when one considers the inefficient equipment and faulty teehnic employed. Today many have standardized their dosage and with the Coolidge tube, arc able to give uniform treatment, but the amount of radiation which should be given has not been determined in a uniform manner by the roentgenologists. This is, of course, a diffi- cult task, each case being an individual study; nevertheless, it is time more attention be given to the postoperative treatment of car- cinoma of the breast, in order to standardize, as far as possible, a teehnic for the different types and stages of the disease, just as surgeons have standardized operation. Take a given case; let us decide what amount of radiation should be given immediately after the operation, how extensive it should be. when and how often it should be repeated. All roentgenologists agree that each case should have a full physiologic dose, or all that the skin Avill stand, not only to the anterior chest Avail, but to every chain of lymphatics draining the breast, as well as to the opposite side of the body. The location and stage of the tumor; the kind of operation performed, and the physica] condition of the patient must be considered carefully in determining treatment. The writer believes two to three times the usual dose of radiation can be safely given in the supraclavicular region, in places where there is no sear and where the cutaneous circulation has not been interfered with by the operation. A study of the supply of the lymphatics and the manner in which they metastasize should be made by every one treating carcinoma of the breast. This will never be done by the nonmedical technician. In fact, too little attention everywhere has been given to the supply of the lymphatics, their depth and extent, and the besl manner of thoroughly radiating each chain. Raying the lymphatics sufficiently to proper depth and coextensive with metastases is indeed no easy task. It requires as much care and judgmenl as the most careful dissection. Efficienl radiation makes operation more radical, increases the percentage of cures in early as well as in more advanced cases, and delays recurrence in all cases. A visii to our besl hospitals shows that a very small percentage of carcinomas operated upon receive proper roentgen treatment. Who is at fault .' Both the surgeons and the roentgenologists. Many surgeons refer for postradiation only cases which are really con- sidered inoperable and then often qoI until a recurrence has taken place. Still they would like to make the operation more radical. RADIUM AND ROENTGEN RAYS IN MALIGNANCY 539 Do they not know that this can be accomplished by the roentgen rays? Many cases have been treated as a placebo, rather than a real effort to effect a cure. Often these patients would be given a few treatments within a week or ten clays after the operation with no further radiation. This was called postradiation, and from this slipshod method the physicians and surgeons drew their conclu- sions as to the value of the roentgen rays. Had they taken no more pains with the operation, surgery would long ago have been aban- doned. If we as roentgenologists are going to treat cancer of the breast, we must be familiar with the different forms and stages, so that our opinion will be worth something in deciding the best method or methods of treatment. We should know whether or not operation is indicated, as well as what can be accomplished with the roentgen rays. We must be consultants, rather than merely technicians as some have been in the past. It has been pointed out by competent surgeons, when an opera- tion was performed before a diagnosis could be made clinically without a microscope, that 80 per cent of the cases could be cured. Deaver and McFarland in their recent book, ''The Breast, Its Anomalies, Its Diseases, and Their Treatment," make the following statement: "'It has been stated that 80 per cent of patients in whom the disease is confined to the breast, as proved by both macroscopic and microscopic examinations of the tissues adjacent to this organ are permanently cured of their disease by the radical operation. There- fore, a patient presenting a small movable mass localized to the breast, can be assured that four out of five cases of a similar nature are cured by operation. When axillary lymph nodes are palpably enlarged as the result of metastases, the chances of operative cure are at once diminished to one in five." The authors further say that, "in the opinion of many surgeons, involvement of the supracla- vicular glands is a contraindication against operation." The absence of palpable enlargement does not always mean an absence of carcinomatous involvement. Halsted found that, not- withstanding the present clay extensive operation, death from me- tastases occurs in 23.4 per cent cases, and even in cases with mi- croscopically negative axilla. A few years ago scarcely any of the physicians or surgeons realized the importance of this ; and even today there are some who are operating on late or advanced cases, expecting the same results that the leading authorities obtained in early cases. Retraction of the nipple, axillary and supraclavicular 540 AFTER-TREATMENT OF SURGICAL PATIENTS involvement are late symptoms from a prognostic standpoint. Phy- sicians who talk about favorable eases for operation when the nipple is retracted, as "well as when the axillary and supraclavicular in- volvement is present, should read Deaver's book quoted above; in fact, any one treating cancer of the breast, who reads this book carefully, would not be so radical from a surgical standpoint, and would appreciate more the value of the roentgen rays. Deaver questions whether as much palliation is received from op- erative as from nonoperative methods, and expresses his general dissatisfaction with operations of a palliative nature in the treat- ment of carcinoma of the breast: since, in certain cases the disease has been excited to greater activity by an incomplete operation, and the life of the patient considerably shortened. In this connec- tion he mentions the unreserved statement of Bloodgood. that "in- complete operation hastens death." He further states that since l v !'7 such extraordinary advances have been made in roentgen- therapy that remove most of the indications for the ultraradical operative procedures, which have practically no curative value, and a primary mortality of at least 25 per cent. Since Deaver's care- fully prepared volume is a resume of the entire medical literature and of world-wide clinics, and since he has included a valuable chapter of roentgentherapy of Pfahler's, it deserves more than pass- ing notice. For my part, I am well convinced, from the cases I have seen during the past fifteen or sixteen years, that an incomplete opera- tion should never be performed, not even for palliation. It is just as accessary that as complete a study of lymphatics of the breast, Ihe frequency and extent of their metastases should be made by the roentgenologisl as by the surgeon. The lymphatic supply of the breast is greater than that of almost any organ of the body, so that metastases even of the abdominal organs occur more frequently than is generally realized. In the past many have given a few treatments over the line of incision, axilla and supraclavicular areas. Such treatment is very incomplete, since it omits those lymphatics which frequently metastasize; namely, suprascapular, anterior pec- toral of the opposite side, internal mammary, subscapular, para- vertebral, xiphoid and inguinal group. A study of bone metastases makes us realize how extensively the lymphatics become involved. It is known that metastases may occur in distant glands at a very early stage of the disease. While the axillary glands are the most frequently involved (indeed so frequently involved that the mi- croscopic freedom at the time of operation is the exceptional) in RADIUM AND ROENTGEN RAYS IN MALIGNANCY 541 some cases they are free when there is involvement of the ab- dominal or other internal viscera. The value of palpable glands is overestimated. The lymphatics in the axilla may become en- larged by previous infections of the arm or breast. Therefore, it requires judgment, and in some cases microscopic examinations, be- fore the cause of enlargement can be positively determined. Me- tastasis, too, varies with the different types of tumor and occurs earlier in the young and fat patients, owing to the greater richness of the lymphatic supply. Efficient roentgen treatment must take care of these variations. It is generally conceded that the smaller the caliber of the lymphatics, as well as the greater the degree of senile atrophy, the greater the tendency to oppose cancer dissemination. If the roent- gen rays did nothing more to adjacent lymphatics than produce a sclerosis, the treatment would still be indicated for retarding the disease. The frequent involvement of one breast to the other, is due to the distribution of the lymphatics of the chest wall. Autopsy has shown that the liver metastasizes more frequently than any of the internal organs and in many cases becomes involved in com- paratively early stages. According to Handley, the frequent involvement of the liver is attributed to the cancerous dissemination along the deep lymphatics of the fascia of the thoracic wall to the epigastrium and to the umbilicus, whence these cells follow the subserous lymphatics to become deposited either on the surface of the liver, or, are conveyed along the lymphatics of the falciform ligament to the portal glands. If Handley 's deductions are correct, we should never omit heavy treatment over the epigastric region. The next in frequency are the lungs and pleura, which are supposed to become involved through the intercostal or supraclavicular lymphatics. A study of autopsies shows that almost any organ of the body may metastasize from cancer of the breast, and however much confined to the superficial tissues this dissemination may seem to be, no one can absolutely foretell how far the so-called "microscopic growing edge" of cancer may extend. Bone metastasis increases with the proximity of the primary growth, the clavicle and distal extremities rarely being involved. Many consider a three-year limit a cure of cancer of the breast, but we can not be sure recurrence will not take place later. Barker has stated that 30 per cent of the cases that are clinically cured at the end of three years later die of cancer of the breast. Since operation has about reached its limit and since ultraradical opera- 542 AFTER-TREATMENT OP SURGICAL PATIENTS lions are not practical until some better form of treatment is dis- covered, the splendid results achieved from radiation furnish more than sni'iieieiil reasons for giving every ease id' carcinoma of the breast postroentgen treatment. This should be done even if the tumor is only as large as a filbert, because even in such cases, there may be early and fatal metastases. Handley says the pelvic viscera are involved in 8.6 per cent of Hie early cases in young patients, and in only 4.8 per cent of the late i-iim's of older patients. While roentgen rays find their most useful field in postoperative therapy, it is difficult to convince either the patient or the average physician or surgeon of this fact, because they can not see that any- thing has been accomplished. It is the teachers of surgery first of all whom we mint convince, because today they have come to realize that the most radical operation, even in the early cases, does not always reach the cancel' growing edge. Man\- roentgenologists have adopted Hie following, or its equiva- lent, as a standard dose, or the amount which cadi area id' the skin will tolerate safely using a Coolidge tube and a modern transformer, tube distance s inches, filtering the rays with 4 millimeters of aluminum, with a f) inch parallel spark gap, 25 milliampere minutes are given. With mosl transformers this dose will measure 20X Koenig-Gauss modified Kienbock scale. Mosl of us would like to give more radical Ireatment in order to produce better end results, and every one has been looking for some means by which the skin will tolerate larger doses safely. I give larger doses than this over the supraclavicular area as soon as possible, because this is a place often involved, and the surgeon seldom advises opening this chain. because when involved, many have learned it is really inoperable. 1'nless the roentgenologist has witnessed the operation, he should always obtain a careful report from the surgeon as to the location of the growth in the breast, as well as the extent of the disease and type of tumor. Then the amount of treatment, as well as the most important regions to treat can be determined. We all know that not only the axilla and opposite side, but also the glands in the pelvis, should receive postradiation if the best results are to be obtained, but this is not always practical; first, because the patients will not consent to such a lengthy course of treatment, and secondly, because the number of square inches that can be radiated is limited when a full dose is given more than once. Xone are able to tell in the individual cases what chain or chains of lymphatics have metastasized. If the growth is small and situated to the inner edge of the breast, it would probably be more important to ray the RADIUM AND ROENTGEN RAYS IN MALIGNANCY 543 opposite breast, opposite axillary, supraclavicular and suprascapu- lar areas, than the axilla of the affected side, on account of the loca- tion of the lymphatics which drain the sternal side of the breast. The inner side is rarely involved as compared with the axillary. All ray both the axilla, supraclavicular and suprascapular areas, as well as the anterior chest wall and many ray the opposite side, but as before stated, since the viscera, particularly the liver, medias- tinum, lungs and pleura so frequently metastasize, treatment should be directed to these organs as well. This is the least that should receive postroentgen therapy, and is never wide or extensive enough in advanced or recurrent cases. An examination at autopsy of the lymphatics which metastasize will convince one of this fact. What we are looking for, therefore, is the best method of raying the widest area with the least effect on the skin, and the least loss of radiant energy. I have adopted the following method, and the experience gained from treatment of recurrences has made me in- crease the areas from time to time : 1. In order to prevent recurrence in the wound, and destroy any foci in lymphatics of the anterior chest wall leading up to the inner clavicular area, three to four areas of anterior chest wall receive treatment, the last being directed downwards towards the liver. Then the liver area is given one anteriorly, one laterally and one posteriorly. With this amount of treatment, the scar is nearly all removed and a recurrence in the area is rare in comparison with the number of recurrences in cases not treated by radiation. 2. The axilla receives from three to four doses and is cross-tired as much as possible. One area below the axilla can be covered by one treatment laterally. The supraclavicular glands are usually involved from the axillary. 3'. The supraclavicular region is divided into four areas : one directed obliquely inwards including the lower cervical glands, one downward through the shoulder area towards the axilla, one ob- liquely downward and backward through the clavicle, and one ob- liquely forward from the posterior surface. 4. The suprascapular area much more frequently metastasizes than the subscapular. Each should receive a full dose on the af- fected side, while on the opposite side the subscapular area might be omitted in early cases. 5. The mediastinum should receive one or two treatments from the posterior to an area between the spine and scapula of the opposite side directed towards the affected breast region. 544 AFTER-TREATMENT OF SURGICAL PATIENTS 6. The opposite side is rayed according to indications and never receives less than from 4 to 8 treatments during the course. 7. The epigastric region must never be omitted, as this is one of the avenues by which the liver and pelvic viscera metastasize. The interval between the first and second course of treatments is four weeks. However, in most cases the supraclavicular glands are rayed again in two weeks instead of four. In treating the areas mentioned the rays must be so directed that the deep glands in the axilla, under the clavicle in the me- diastinum, those leading to the liver, and all the viscera which metastasize, will receive a full roentgen dose. This means that cross-firing must be employed, so that the deep glands will be given from 3 to 7 times the amount that is given to any skin area. If we give 20X Koenig-Gauss modified Kienbock scale dose, at the surface, in order that the tissues at a depth of 2 inches receive 20X, suffi- cient ports of entry must be employed to make up for the amount of intensity of the lighl which is lost by distance and by absorption by the tissues. If the glands to be rayed are four inches from the skin, more cross-firing or more ports of entry must be used than if the glands are only two inches Prom the skin. Experiments have shown, if the glands to be treated are below the surface, that the intensity diminishes from 100 to 15; that is. about one seventh of that at the surface. I am certain that the majority of those treating carcinoma of the breasl by the roentgen rays employ too few ports of entry and. consequently, the deep tissues receive only a frac- tional dose. This failure to employ deep therapy is responsible for many recurrences. For the past five or six years, I have considered anteoperative roentgen therapy a very important and useful field in early, as well as in advanced, carcinoma of the breast, but only comparatively few cases have been referred, as surgeons do not want the opera- tion to be delayed for three or four weeks. Tt is a demonstrated fact that in lymphatics where the vessels are of a small size, car- cinomatous cells do not disseminate nearly so readily as where they are of a larger size. It lias been proved thai after roentgen therapy, the lymphatics undergo a sclerosis, thus reducing the size of both the lymph nodes and vessels, which in turn reduces the danger of metastases. A cancerous mass after being rayed changes in type, becoming more scirrhous and is rendered much less malignant. Carcinomatous tumors in the breasl which have been growing very rapidly will be checked and reduced in size within a very short time after full doses of radiation. It has RADIUM AND ROENTGEN RAYS IN MALIGNANCY 545 been suggested that some of the patients are rendered "immune" to the growth of carcinoma for some time after such treatment. However, no one can prove at present whether there is really any immunity, or whether the checking of the growth and improvement in the general health of the patient are due entirely to histologic changes in the tissues. Observers agree that the type of tumor changes and that the danger of metastases is reduced by such treat- ment. Anteoperative treatment will often render a more advanced case inoperable, and, if deep metastases have not already taken place, more permanent cures can be obtained surgically. As I have before mentioned, metastases will not occur so readily if the caliber of the Emphatic vessels has been reduced by treatment. However, if the liver or any other of the internal viscera have metastasized before the treatment is given, the cure by operation would be only an apparent cure. But the operation would not hasten metastases as it would without anteoperative treatment. Postoperative roent- gen treatment can not take the place of anteoperative treatment as many think. I have a few cases apparently well after three to five years, which verifies this fact. We all know much palliation, and many times a temporary cure, can be produced in inoperable and recurrent cases. A study of the lymphatic supply of the breast and the extensive metastases, usually visceral, which have already taken place, explains why the results are often only temporary, or from one to three or more years. Carcinoma of the Uterus. — The value of radium is being recog- nized at present by most of the gynecologists in the treatment of carcinoma of the cervix, at least in certain stages. Since the pathologist, surgeons, and radiotherapeutists are working together and making a careful study of not only the local growth but the metastases as well, more rapid progress will be made. Radium is being employed today in hopeless, inoperable, borderline, and in early, as well as in postoperative cases. The local effects of radium in hopeless carcinoma are very strik- ing; the bleeding diminishes and disappears, and the offensive dis- charge is checked and becomes odorless. The local condition changes in character; usually within two to four weeks after the first treatment has been given the cancerous mass begins to contract and shrink and continues to diminish in size. This is more marked in some cases than in others, the growth having entirely disappeared within two months. The treatment should be repeated, but the time and dose must be decided upon by existing conditions. When 546 AFTER-TREATMENT OF SURGICAL PATIENTS the pain and offensive discharge disappear, the patient's general health improves rapidly. This even occurs in some patients who are in a toxic condition and have been taking morphine; the pain is relieved and no medical ion is necessary. In some cases an in- crease in weight is observed and the patients are restored to per- fect health. Many observers have agreed that the carcinoma in these hope- less cases disappears locally, and the patient is locally or clinically cured in from one-fourth to one-third of the cases, but when there are extensive metastases, the treatment is only palliative. In many of these cases hepatic metastases have taken place before they were referred for treatment. Often deep metastases can not be determined by physical signs. Nevertheless, the palliation is more satisfactory, and possibly adds from four to six times to the life of the patient. as compared to any other palliative measure, and even hopeless cases have remained well more than three years; hut space does not permit giving any statistics. In conversation, one of the leading gynecologists of the country said that a vast majority of the cases of carcinoma of the cervix that consulted him were inoperable, and then he considered either removal or cautery only as a palliative measure, and that the pal- liation A\as of very short duration in most cases. He further stated that he had seen cases of the same class, Avhere radium was applied either as an adjunct or alone, and that the local disease had entirely disappeared in some instances, and that a few remained free from symptoms from one to three years. Frank, in an article published in the Journal of C In operable cases it should in- variably he tried, for apparent cures have occurred in some markedly advanced cases, and in those cases that are ultimately cured, there is nevertheless a decided amelioration of symptoms — in many in- stances, the offensive discharge and hemorrhage completely dis- appear. (4) A serious disadvantage in the use of radium is that il occasionally produces ;i widespread necrosis, leaving vesical and rectal fistula* in the wake of its destructive action. This, however, usually occurs only in advanced cases of carcinoma, and need not. therefore, deter us from the use of the remedy."' Local injury to the patient will seldom occur, it seems, if the proper amount and kind of filtration is used and if the dosage is adapted to the individual patient. We know thai tissue will stand large doses of radium, if not too often repeated, leaving no scar or adhesions. Radiation carried to the extent of severe injury of normal tissue may defeat its own ends. The tissues can he more severely inflamed and yet make a complete recovery by radium sooner than by any form of roentgen therapy. RADIUM AND ROENTGEN RAYS IN MALIGNANCY 549 Clark's remarks could be applied to carcinoma of the rectum, bladder, and prostate. Operate on every operable case, radiate all cases after operation. Some surgeons advise against operating on borderline cases because usually they can be clinically cured by radium. All advise radiating advanced cases, for an occasional cure will be obtained, and some can be made operable. Radium supplemented by roentgen therapy in far advanced cases will give great palliation, but a cure will not be effected. Some of these cases are clinically cured in that all visible signs of the disease will disappear, but the patient will later succumb to deep metas- tases. The amount of radium element, the screening, the distance from the growth, the time of exposure and the nature of the tissues to be acted upon must be carefully considered when deciding upon the dosage. The law of reaction is the governing factor in its use, and success can only be attained when the radiotherapeutist is familiar with his agent, and knows the exact pathology and extent of the disease. He must also know the limitations of radium, and not promise a cure when nothing but palliation may be expected. There is a difference of opinion in regard to the technic of ap- plying radium in uterine, rectal, and vesical carcinomata. Kelly, Koenig, and others advise the use of large quantities of radium, while others advocate the use of smaller quantities, applied for a longer period. All have generally agreed that less than 50 mil- ligrams of the element should not be employed in uterine carcinoma, as stimulation of the growth instead of destruction might occur. Pinch, of the London Radium Institute, where large cpiantities of radium are advisable, prefers to use from 50 to 100 milligrams. Burma and many others have come to the same conclusion. What final dosage will be decided upon to produce the best results remains to be seen, but in reA T iewing the literature, it appears that many have decided upon doses from 2000 to 4000 milligram hours, to be given within the first week or ten days. The dosage must always be decided upon for each individual ease. Some give this amount at one seance, while others divide it up into six or eight. The results seem to be about the same, but the condition of the patient possibly should determine what course to pursue. If used continually until a full dose is given, it is advisable to remove the radium and give a cleansing douche. The treatment is repeated in three or four weeks, according to the indications. There is also some difference of opinion in regard to screening, but all agree that at least 2 millimeters of lead or its ecpiivalent of 550 AFTER-TREATMENT OF SURGICAL PATIENTS brass or bronze is necessary. The latter is being prepared by many, as it is claimed that bronze gives off less secondary radiation. The metallic tube is covered with sufficient rubber, gauze or other sub- stance to cut off the undesirable secondary radiation. One mil- limeter of pure rubber, covered by gauze and a finger cot. answers this purpose. The distance of the radium from the growth is only the thickness of the filter, but this must be taken into consideration when de- ciding upon the length of exposure, as well as the amount of radium element. During the past year some of those purchasing radium have visited me and they seemed to think all they had to do was to insert the radium. They" were unfamiliar with a radium or roentgen reaction on the surface of the skin or mucous membrane, to say nothing of the deeper reaction. They would start in about the same way as a gynecologist would without knowing the princi- ples of aseptic surgery, expecting to learn by sacrificing his patients. Roentgenologists who have had experience in therapy are much 1 tet- ter qualified. I can not too strongly advocate that radium be supplemented by the roentgen rays, feeling sure that smaller quantities applied locally with proper'roentgen therapy from without are equal, if not su- perior, to any quantity of radium ever used up to the present time so far as the end results are concerned. Kelly uses radium at a distance of two to five inches from the surface in large quantities from without, in the same way as many are using roentgen therapy from a Coolidge tube. Whether bis results are equal or superior remains to be seen. As lighl decreases inversely with the square of the distance, the tissue would be rayed more uniformly x\ it li the source of energy a1 s or in inches than at 2 or 5 inches. Besides, greater areas can be treated. Although the better method of treat- ment still remains to be determined, most of us who have treated a number of cases of fibroids will expeel more from the combination of radium and the roentgen rays than from radium alone, or when treated by any other method. As before stated, this is the method which is carried out in European clinics, and many of us have wit- nessed their results. Carcinoma of the Rectum.- -Results obtained by the use of radium in carcinoma of the rectum vary greatly, and can not be compared with the results obtained in the treatmenl of carcinoma of the uterus. Fficienl amounl of radium therapy is given, a proctitis generally oceiii's. which is very troublesome unless a colostomy has 1 a per- formed. .Most of those using radium in the treatmenl of carcinoma RADIUM AND ROENTGEN RAYS IN MALIGNANCY 551 of the rectum advocate colostomy before beginning, or within one week after the first radium treatment, This prevents the feces from aggravating the radium reaction, and avoids the tenesmus which always occurs if a full radium treatment is given. "Where colostomy has been performed and larger doses of radium have been em- ployed, a few inoperable cases of carcinoma of the rectum have been apparently or temporarily cured. If the patient will not con- sent to having a colostomy performed, palliation can often be ob- tained by the use of radium; that is, the growth will be inhibited or reduced in size, which will temporarily relieve the threatened obstruction. Pain is also relieved, either entirely or partially, but it must be remembered that unless a" colostomy is performed, tenes- mus might occur if large doses of radium are employed. Of how much value radium is in the treatment of carcinoma of the rectum as a postoperative procedure, other than that which follows colos- tomy, is difficult to determine. The symposium on "Cancer of Certain Pelvic Organs," read -be- fore the Massachusetts Medical Society,- June 9, 1915, from a clinical standpoint, should be studied by every one interested in the treatment of malignancy. This symposium emphasizes the im- portance of more radical operations than have beenlieretofore per- formed for carcinoma of the pelvic organs, or else it suggests the addition of radium and the x-ray or some unknown treatment be- fore it can be said we are able to cure a majority of cases which can be diagnosed clinically. The surgeons who took part in this symposium were not only of the highest rank, but each had spe- cialized and directed his attention to only one of the pelvic organs. In this symposium Dr. Daniel Fiske gave the statistics of the Harrison-Cripps cases to show how absurd it is to talk about car- cinoma of the rectum as a benign condition. The statistics are as follows: He saw 445 patients and operated upon 107; of these 107 cases, 17 per cent died from the effects of the operation, and 40 were alive five years after the operation ; that is, 9 per cent of the total number seen. It would be fair to assume that not more than 5 per cent would be alive at the end of ten years. In this symposium Dr. Arthur L. Chute states: "The story of carcinoma of the bladder is most discouraging when we consider the small number of cures that we effect by means of operation. Just enough cases remain well after operation to allow us to say that cancer of the bladder is not absolutely hopeless and to spur us to renewed effort in the hope that when we have a clearer un- derstanding of the condition, our results will be better," 552 AFTER-TREATMENT OF SURGICAL PATIENTS If it were possible to make an early diagnosis when only the mucous layer of the bladder is involved it would seem possible that such conditions could be promptly healed by radium. A few good results have been reported, but unfortunately these cases are usu- ally diagnosed late, and it is more difficult to apply radium to the bladder than to almost any other organ in the body. The danger of setting up an obstinate cystitis is always to be remembered. From studying the lymphatic supply of the pelvic organs, it is readily seen how difficult, if not impossible, it is to remove the adjacent glands involved at the time of operation, no difference how radically it is performed. It is usually impossible to remove all the glands affected. The question, when operating, is if the glands are affected where are we going to stop? Young, in discussing the uses of radium in the treatment of cancel- of the prostate and bladder, stnt.es that, while it is not his intention to speak of the ultimate results, il can safely he stated that truly astonishing results have been obtained in some cases; namely, disappearance of obstruction, shrinkage and great soften- ing of certain cancers of the prostate, and extensive retrogressive changes in inoperable cancers of the bladder. The methods devised by Young offer a new fertile field of therapeutics in a class of nrologic cases which heretofore have been almost beyond relief. While we do not as yet know all the possibilities of cure, we do know that much relief can he afforded. Epithelioma. — The term "epithelioma" is not altogether clear in the minds of the profession. It is unsatisfactory and is applied to all epithelial growths, semi-malignanl or malignant, regardb - oi the degree or situation. This has accounted for a diversified opinion in regard to many innocent Looking lesions which in time will show a malignant and destructive character. Education alone will teach the value of early recognition when the treatment is easy by one application of radium. .Many patients villi lesions of this type come late after they have been treated by superficial caustics and are in a hopeless condition. Ii is to he remembered that true epithelioma has certain pathologic characteristics, it is a purpose- less proliferation of cells, extending beyond normal limits and in- vading adjacent tissues, especially the lymphatics, with slight in- flammatory changes. Most text hooks have classified epithelioma under three varieties,- superficial, deep and papillary, hut it means nothing to the average student and lie leaves college with a vague idea of epithelioma, except complete excision, and does noi recog- nize t he early lesions. RADIUM AND ROENTGEN RAYS IN MALIGNANCY 553 It is astonishing how common epithelioma is and how many cases are seen in the large clinics who have never consulted a physician and the disease is so far advanced that they are incurable. Epi- thelioma, at least in the early stages, does not seem to cause any alarm among the inhabitants of a community or even among the family physicians. The disease comes on so slowly that often no one takes any notice of it until the lesion is far advanced. After the age of thirty-five, all persistent lesions which are constantly inflamed and scaly or show any degenerative changes should re- ceive attention. The prophylactic treatment is by far the most important and necessitates not only the education of the medical profession but also of the laity of the necessity of the complete removal of all excrescences, such as warts or degenerated moles ; the removal or correction of any irritation to the skin or mucous membrane; the proper treatment of cracked lip, persistent spots of eczema and leucoplakia. Precancerous changes should receive more attention by the physician. He should hold himself responsi- ble for any of his patients becoming incurable, especially if the epithelioma has been of long duration. Present day results in the treatment of epithelioma are much more effective than in the early days of radiotherapy. In the past, whether using radium or the roentgen rays in the treatment of epithelioma, there have been the two methods; namely, the fractional dose and the massive or intensive. In the early days of radio- therapy, on account of burns, it was not uncommon to give very small and divided closes covering a long time, even for the treatment of small epitheliomata. Those of us who are familiar with past results will remember that a percentage of cases was permanently cured and some cases were improved up to a certain point and then, after remaining quiescent for a period, began to take on malignant tendencies again, and that some advanced cases were unaffected by the mild treatment. It has been proved that the long radiation, and often repeated mild exposures, are an ineffective method using any form of radiation. The dose may be divided into a few strong treatments, but not into an unlimited number of mild exposures. It is a fact that from the beginning of radiotherapy, the best re- sults were obtained by those who gave strong treatments, and relatively few in number. When treatment is given by a method which produces no visible reaction by an operator who is afraid to give the full dose promptly and continued for months, such treatment will often leave the tissue degenerated instead of leaving a soft, smooth, and pliable scar. When such is produced by fault}" 554 AFTER-TREATMENT OF SURGICAL PATIENTS technic this degenerated tissue must be removed surgically and a healthy flap turned in as advised by Porter in treatment of chronic roentgen ulcers on the hands of some of the operators. Further treatment with radiation will bring only disappointment and lessen the chances of a cure. Often a surgeon is not dealing with a malignant condition and if so it is usually of a low degree. It is often difficult to convince the consulting surgeon of this fact. Epithelioma is carcinoma of the skin and the successful method of treatment involves the complete destruction of all carcinomatous tissue. It has required clinical experience and judgment to know when this has been accomplished. So you can readily see the operator faces ;i serious problem in deciding Hie proper form of radiation and dosage for each case. The operator having a case referred, must determine the type of the epithelioma, its situation, extent, the danger of metastases and the form of radiation which is the most effective before he is able to give a prognosis. Unless lie has had a clinical experience as veil as being able to produce the desired reaction at the proper depth, he is unable to determine whether it is a ease which can be cured by radium alone, whether other adjunct measures are necessary or whether radium should be used as an adjunct to some other form of treatment. We have four classes of epithelioma in regard to method of treat- ment : first, the lesion which can be cured by one application of radium with the proper dosage; second, the lesion which is so situated that glandular involvement is likely to lake place or has already occurred and the roentgen rays should be employed as an adjunct to treat the adjacent glands; third, those cases in which the local application of radium supplemented by the roentgen rays will only act as a palliative measure, and fourth, those cases in which excision is justified to be followed by radiotherapy. A marked reaction by radium heals up more promptly than a re- action of the same degree by the roentgen rays. This is a valuable point in deciding which form of radiation to use in certain cases. There have been many methods of treating epithelioma ranging from the internal administration of arsenic to radical surgical removal. It is a well-known fact that superficial caustics have been applied to cases which simply increased the blood supply and stimulated the growth. All irritating procedures which are inert are to be condemned as I hey arc worse than no treatment at all. as before stated partial removal is always contraindicated. This fact was realized by the older physicians and was one of the reasons RADIUM AND ROENTGEN RAYS IN MALIGNANCY 555 many of them still advise their patients to leave an innocent looking lesion alone until it bothers them. The results by radium and the roentgen rays are changing the views of many of these few physi- cians. At the present time, among many of the best physicians, there is a strong tendency to condemn the use of some of the older and inadequate measures which have kept the patient from seek- ing early treatment. The principal cause of failure might be attributed as much to an inaccurate technic in the use of the method employed as to the patient going late, with a large amount of glandular involvement. Until lately the value of a legitimate, con- servative and nonsurgical method of treatment in most cases has never been strongly advocated. As a result of the tremendous strides made in radiotherapy, practically all the late surgical au- thorities today recognize its value as a legitimate method of treat- ment. They agreed that radium has clinically demonstrated its power of changing and destroying cancer cells more or less per- manently with the least possible inconvenience and deformity and the best possible end results. The excision of an epithelioma is justified only in cases which demand the removal of the contiguous lymphatic glands at the same time. Except for cases of this sort, excision, in my opinion, is not the most efficient method of treatment. Excision neces- sitates a sacrifice of a large amount of healthy tissue. With the most radical operation there is apt to be left outlying malignant cells. Therefore, recurrences are common after excision. The improvement in surgical technic and the recognition of careful handling of both healthy and diseased tissue, as well as the wide extirpation of tissue involved, has lessened the number of recur- rences. But no difference how wide the removal, as before stated, it is not wide enough, and frecpiently there is a recurrence in the scar. It is to be remembered that recurrences after removal are regularly more malignant, more rapid in progress, more prone to metastases than the original lesion. Most surgeons realize that an incomplete operation is as powerless for palliation as it is for a cure. Partial operations are therefore contraindicated in any form of epithelioma the same as any form of malignanc}*. Radium and the roentgen rays, I believe should always be con- sidered first in treatment of epithelioma, because, when properly applied, practically all epitheliomatous tissue can be made to dis- appear, and there are fewer recurrences than by any other method. It is a perfectly legitimate method of treatment in proper hands 556 AFTER-TREATMENT OF SURGICAL PATIENTS but is a method liable to abuse it' it is not restricted to its proper field. Epithelioma of certain locations, on account (if special features, warrants brief separate 'description. This is on account of the nature of the tissues as well as the lymphatic supply. The virulence of an epithelioma increases or decreases proportionately with its richness or poverty of the lymphatic supply. In o-ivinp- a prognosis of an epithelioma, besides location, the several factors to be con- sidered are in the variety, extent, duration and rapidity of the process. In ;ill instances, the earlier the treatment is instituted the less chance is there of a recurrence. In many superficial forms. flu' disease if neglected is slow in its progress, but eventually it will become dangerous to life if left untreated. In the earliest stages when the disease is limited on the face and of the superficial type, treatment is almost invariably successful and permanently so. Even when moderately advanced, the results are usually favorable. The same may be said of the deep seated and papillomatous forms, if not of too lon<> duration, but in these cases glandular involvement occurs early. Cases in which marked destruction has already taken place and in which there is considerable infiltration of the sur- rounding tissues, and of long duration, the prognosis as to a per- manent cure is not so favorable, and particularly so if the glands are invaded. Rodent ulcer is very amenable to treatment early. bu1 when allowed to have full sway and cover a large area, it is of a serious nature because this type of epithelioma seldom in- vades the glands but destroys everything in iis way. Epithelioma of the upper part of the face, unless it has involved cartilage, or bone, is more amenable to treatment than in any other location. In the early cases one application of radium would usu- ally effect a cure. Radium is one of the most effective agents in the treatment of epithelioma of i lie eyelids. It can be brought in eon- tact with the lesion and there is little or no danger to the eye; and if the cartilage is not invaded, it requires only a small amount of radium to effect a cure. If caustics have been employed, the cartilage is usually involved, and it is much more resistant to treat- ment and recurrences are more likely. The cosmetic results are superior to any other agenl unless it is the x-ray. Frequently when treating an extensive lesion you will expect that, if the lesion is healed, a large amount of deformity will resull and to your sur- prise there is scarcely any deformity excepl the removal of the eye lashes. The reason for this is that the resulting scar is smooth. RADIUM AND ROEXTGEX RAYS IN MALIGNANCY 00/ pliable, and not thick and elevated like that following caustics or even a cutting operation. Epithelioma of the nose and ear is easily cured if the cartilage is not invaded, but if invaded it is very resistant. The ear is par- ticularly so, and, if the greater part of it has been removed by pastes or caustics, the glands are usually invaded and you have a very difficult if not a hopeless case to treat. Epithelioma of the lover lip, however innocent in appearance, often shows a degree of malignancy that is not usual in other situa- tions. It seems to be rather a regional than a local lesion. The lymphatics which drain it are early invaded and the results in the past from a surgical standpoint have been far from satisfactory. However, until recently the routine treatment has been early surgical removal of the ulcer and lymphatics. Until the introduction of radium and the roentgen rays there was no alternative treatment. Severe caustics would occasionally destroy the growth, but the resulting scar was large and retracted, and the percentage of re- currences was very high. Even after operation the results of re- currences were so frequent as to lead the more careful surgeons to refer these cases for postradiotherapy. Today it is an open ques- tion whether the general practitioner is justified in referring these cases for radiotherapy. In deciding these questions let us consider the results which have been accomplished in the past by surgery alone. Murphy has shown us that in early surgical removal even when radically performed, a recurrence takes place in over 50 per cent of the cases where there are no palpable glands at the time of operation, and in over 75 per cent when there is any glandular involvement whatever. I believe better results can be obtained by radiotherapy. There are a num- ber of radiotherapeutists who have had sufficient experience in epithelioma of the lower lip, and whose results justify them in con- sidering radiation a perfectly legitimate method of treatment. How- ever, the cases should be selected and treated by an experienced radiotherapeutist. Too much caution can not be directed against inefficient work which is being done by those who have just bought apparatus and have received instructions from manufacturers. Guided by these experiences, I believe that radiotherapy, by the means of radium and the modern roentgen tube, at present consti- tutes the best routine treatment of epithelioma of the lower lip. both at early and late stages. Experience leads me to a firm con- viction that whatever position you may take today you will ul- timately agree with this conclusion. There has been much hag-- 558 AFTER-TREATMENT OF SURGICAL PATIENTS gling surgery of lip cancers and it is hoped thai this chapter may not encourage haggling radiotherapy in the same field. The in- experienced, with recklessness, founded on ignorance, may burn a case; lmt he is scarcely more dangerous than the slightly ex- perienced and overcautious radiotherapeutist giving insufficient dosage which may stimulate a growth to activity. Epithelioma of the back of the hand usually responds to treat- ment, but the progress is not so favorable as with the ordinary face cases because the axillary glands are often early invaded. There- fore small lesions should have prompt and thorough treatment. Xo one realizes this better than the roentgenologists who have had keratosis on their hands. Some authorities state that progress in epithelioma in this situation is slow and there is less liability of grave ulceration than epithelioma in other situations. This lias not been my experience entirely. They have usually been slow in progress, but the lymphatic glands were all invaded in the few ses that 1 have seen at the time they were referred. Epithelioma of the genitals is always a serious matter, although with the proper treatment in the beginning the results are often successful. Left untreated until far advanced, palliation is all that can be expected from any form of treatment. Paget's disease or eczematous epitheliomatosis of the nipple is classified by most dermatologists under epithelioma or carcinoma of the skin. It is like superficial epithelioma, the onset is slow and the condition suggests an eczematous involvement of the areola of the nipple. The process begins with a moderate inflammation ex- hibited as redness and scaling involving the nipple areola. Later the surface is intensely red and granulating, exuding a copiously clear, viscid secretion and producing subjective sensations of heat and burning with intense or moderate itching. "When the disease progresses, cancerous infiltration of the breast is usually recognized and is one in which the malignancy is usually of a high degree. In the Tear's Progress Medicirn Surgery, 1015. Murphy called at- tention to Paget's disease and stated that when very little peri- mammillary irritation was present there was a mortality of over 00 per cent of the cases even when submitted to surgical op- eration. The reason for this is that the patients are usually first treated for eczema and are not given proper treatment until the disease is advanced. They try almost everything and yet from the very first it was cancer. Pagel 's disease is always malignant and should be called Paget's cancer. RADIUM AND ROENTGEN RAYS IN MALIGNANCY 559 Paget 's disease when seen early I believe, can be as successfully treated with radium applied locally, supplemented with a thorough course of roentgen radiation to the surrounding breast and adjacent lymphatics, as by operation. I have treated a few cases and whether it was my good luck or whether the cases were referred sooner than those which were operated upon, my results have been very grati- fying. This corresponds with the experience of many others. Be- sides the patients will submit to radiation long before they will to operation. One case was treated eight years ago and the patient has never had any recurrence up to the present time. If these cases were referred early when there was only the eczematous con- dition present and treated thoroughly, the results would be rather uniformly successful. It is to be remembered in all cases there is no attempt at repair, and when abandoned to its course, the ul- timate result is a profound ulceration with the destructive effects most noticeable in the region of primary invasion, the entire breast becoming cancerous and invading the lymphatics. Paget 's disease occasionally affects other parts of the body such as the scrotum, penis, buttocks, vulva and perineum, as well as other parts of the body. In the extramammary cases it is agreed by most observers that radium and x-ray give the best results. It is to be remem- bered that local treatment suggested for eczema has no effect on this condition. While it has been shown that all cases of epithelioma, when taken early, can be successfully treated and cures effected by radio- therapy, it should be borne in mind, on the other hand, that when cases have been operated upon for any reasons whatsoever, the op- erations should be supplemented with and followed by treatment with roentgen rays in order to obtain the best end results. Cancer of the Mouth and Throat. — In the treatment of malignancy of the mouth and throat with radium, results have been obtained in a sufficient number of cases to entitle its use to consideration in every case, whether alone in small lesions, as an anteoperative procedure, or as a palliative method in hopelessly inoperable cases. And since even the smallest lesions are very prone to recur locally, and the adjacent glands are so early invaded, radiotherapy should follow surgical removal of even the smallest growth. In all examinations of the mouth and throat, precancerous lesions such as leucoplakia, should always be looked for and treated promptly. Many of the earlier epitheliomata, before they have invaded the deeper tissues, will respond to one application of radium. It is al- ways advisable to have a consultation with an experienced laryn- 560 AFTER-TREATMENT OF SURGICAL PATIENTS gologisl before applying radium, and the gravity of innocent-look- ing lesions must no1 be overlooked or treated by inert methods. It is to be remembered that the persistent lesions in the mouth and throat are nearly always malignant or luetic. Superficial cautery seldom removes a malignant lesion and nearly always hastens metastases. "Whatever method is selected it must he done thoroughly. It is sad to state that so many cases are referred after superficial cautery has been employed and the groAvth has not only been aggravated, but deep metastases have taken place. Many physicians, not realiz- ing the malignancy of these lesions, will often first try cauterization or -dine inert mouth wash, allowing the disease to become far ad- vanced before they refer their patients to a laryngologist or for radium treatment. There is no place where it is more important to have early and proper treatment than in the mouth and throat. The selection of the method depends not only upon the location and extent of the lesion, hut also on the experience of the operator or the radiotherapeutist. The brilliant results obtained have in- duced some laryngologists to consider radium as primary treatment. But if good results from this treatment do not follow in a reasonable length of time, then the advisablity of coagulation or operation must he considered. Roentgenization of the lymphatic glands should always supple- ment radium therapy. The object of roentgen therapy is to control and destroy metastases in the adjacent lymphatics. The glands should he treated by roentgen therapy in the early cases because mi one is ever able to tell how early the glands are invaded. Ex- perience should have taughl this to every surgeon and laryngologist as well as to every radiotherapeutist. With the roentgen rays. •■ areas can he treated, and it is more practical than radium. when treating the entire cervical chain of glands. But. inside the mouth, the results of the roentgen rays can not he compared with those of radium, since the latter has the advantage of coming in ch.se contact with the disease. Then. ton. we are able to give a much heavier dose hy radium, even producing a caustic reaction which will heal in from '2 to 4 weeks, whereas, if this dosage were given with a Coolidge tube of the ordinary type or even with the one which has been suggested for cavities, the caustic reaction would not heal for months, or probably never. A slough mighl he the result. In some cases ii is advisable to follow radium treatment by electric coagulation. The advantages of electric coagulation are: the de- RADIUM AND ROENTGEN RAYS IN MALIGNANCY 561 struction of tissue without opening; the blood ■ and lymph vessels, and the prevention of dissemination which might occur with a cut- ting operation. The large amount of tissue which can be destroyed by electric coagulation "without hemorrhage, is an item of great im- portance, which compels serious consideration by those who have treated many malignant cases. However, a preliminary applica- tion of radium in advanced cases is always of great service, as we have no other agent which destroys cancer cells to the same extent, and at the same time sterilizes the tissues. In some cases after radium has been pushed almost to the caustic stage, it is advisable to remove the growth surgically. I have seen a few hopeless cases, where results have been obtained by this method, which would otherwise have been impossible. This is more often true where the malignant growth starts in the tonsil than the buccal mucous membrane. The best method to use is that by which all the cancer cells can be eradicated, leaving as little scar con- traction and deformity as possible, because a recurrence in the scar frequently takes place, especially if it is contracted and irritated by movement. Therefore, by whatever method the disease is eradicated, unless the resulting sear is healthy, pliable and free from contraction, it should be removed surgically. Sarcoma in the nasopharynx is much more amenable to radium treatment than carcinoma. Sarcoma, even in cases where half the throat is filled with the growth, will frequently disappear in from four to six weeks after radium treatment. One such patient whom I treated with radium has remained well two and one-half years. This is really remarkable because his throat was almost filled with a mass and he could scarcely swallow or speak above a whisper. I had another patient in whom the sarcoma started in the tonsil; three operations had been performed, and within five weeks after the last operation, there was a recurrent mass which filled two- thirds of the throat. Within six weeks after radium treatment, the growth had entirely disappeared. Did space permit, quite a number of similar cases could be reported. While, as before stated, carcinoma of the mouth and throat is not so amenable to radium as is sarcoma, still some results have been obtained. For the sake of description superficial lesions may be called epitheliomata, and those which have invaded the deeper tis- sues carcinoma. If ulceration is confined to the superficial layers of the buccal mucous membrane and has not spread to the teeth, one application of radium will frequently heal the lesion. But if the ulceration has to any extent invaded the muscle tissue, it is 562 AFTER-TREATMENT OF SURGICAL PATIENTS very resistant to radium treatment. Such eases should be given sufficient radiation to produce a marked reaction. This will usually disappear in from 2 to 4 weeks when electric coagulation should be employed rather Hum a repetition of radium. This will usually heal promptly leaving very little scarring, and no contraction of the surrounding 1 issues. If the gums are involved, the teeth seem to act as an irritant, and the cancerous process spreads readily, but if they are extracted, it seems to only aggravate the condition. What has just been stated in regard to the buccal mucous mem- brane, will apply to the tongue, except that the muscle tissues are earlier infiltrated and the glands are earlier invaded. Carcinoma of the tonsil and nasopharynx is seldom seen until glandular involvement has taken place, therefore, the results ob- tained by radium in this location, must, as a rule, be considered from a palliative standpoint. It is advisable to o'ive sufficient radium to produce a marked reaction. This checks the growth and ster- ilizes the surrounding 1 issues, and may make the case operable By combining radium with operation, some cases have been at least clinically cured, where only palliation could have been produced by radiation alone, and where operation by itself would have only made the condition worse, because the disease could have been but partially removed. I am convinced that if radium were employed as a routine pro- cedure, in early cases often no other treatment would he neces- sary, and in advanced cases when followed by coagulation or op- eration, better end results could be obtained. I also believe more can be accomplished by raying the adjacent lymphatics, than by removing them surgically, because if the glands are palpable, op- eration seems to hasten, rather than to retard the malignant process, since it is very seldom that all the cancerous cells can be removed. Sarcoma. — Sarcomata do well under treatment of both radium and the roentgen rays, if treated before dissemination into any of the internal viscera has taken place. The best results are in lymphosarcoma, where the results seem to be just as good when treated by radiotherapy alone, as when the growth is removed surgically followed by the roentgen rays. Sarcomata in other lo- cations should be removed surgically, followed by radiotherapy. It has been suggested that borderline cases should have anteoperative radiotherapy. Under radiation Large tumor masses gradually di- minish in size, smaller glands disappear, while secondary glands also clear up. The round cell variety seem to be the type of growth most easily influenced by radial ion, while the spindle variety is not so RADIUM AND ROENTGEN" RAYS IN MALIGNANCY 563 readily dealt with, probably because it is a more active type of growth. There is a tendency for sarcomata to recur within a year or so, and often in the deeper parts, particularly in the lung's and me- diastinum. It has been long realized that nearly all sarcomata recur within six months to two years after operation. Therefore, after a sarcomatous growth has been removed surgically, the patient should be irradiated over the whole area as soon as possible after the operation. It is of extreme importance that it should be car- ried out thoroughly. The difficulty lies in the fact that unless great care is exercised to irradiate the whole area thoroughly, experience has shown that recurrence often takes place in areas which have escaped treatment. The whole area to be treated should be mapped out, and central points selected which will get the maximum dose. The results of prophylactic treatment are encouraging, the patients are less pained, the movements of the parts are facilitated, and the scar is less, and more pliable after radiotherapy. That recurrence may be prevented in a certain number of cases is well established, especially in view of what we know occurs when early recurrences are treated. It is logical to assume that remnants of the disease left in the wound or adjacent tissue will disappear in the reparative changes set up in the surrounding tissues by radium or the roent- gen rays. Sarcomata will frequently recur after operation under mild treatment, but will disappear under intensive radiation. ( '! r APTER LIV REAMPUTATIONS By Willard Bartlett and Walter S. Priest. St. Louis The recent war has made necessary a much greater percentage of reamputations than is found in average civil practice. In con- sequence a number of contributions to the subject have appeared in the literature within the past Pour years. The complications and conditions arising after a primary ampu- tation which require a secondary, or reamputation, can be deter- mined for any individual case by the attending surgeon. Reampu- tation is necessary and intended from the outset where conditions attending the primary operation arc such as to necessitate the "guil- lotine" or "flush" method of amputation introduced by Fitz- maurice-Kelly. 3 Such conditions are occasionally met with in civil practice, but are frequent in military surgery where the presence of gas gangrene makes such a procedure necessary to life saving. Another condition, seen frequently in military practice, where re- amputation is employed, is the so-called "trench fool" in which simple trimming away of necrotic tissue is done until healing is established.- Such a course is justifiable inasmuch as such lesions often recover to a surprising extent, and save tissue that would have been thoughl necessary to remove earlier. In the end. though, sucdi stumps are either had functionally or do not heal completely, hence the necessity for a selected, formal reamputation. Whenever possible, reamputation should be avoided by careful primary amputation with proper after-treatment, as reamputation is accompanied by considerable shortening of the stum]) with the possibility of greatly lessened function, and entails no little hard- ship on the patient. Merely sawing off a few centimeters of bone at the secondary operations docs nol constitute a satisfactory re- amputation. It is necessary to conduct the secondary amputation along some of the approved lines for primary amputations or some modification thereof. 3 There are some general considerations to be taken into account in planning a reamputation. 4 The skin flaps need not be long. About the foot. ;i Svme operation gives a stump adapted to a mechanical ankle and is end bearing. The site of election in the 56 4 REAMPUTATIONS 565 leg is the middle third and in this region the osteoplastic method of Bier is strongly recommended as productive of the best results. Unless the distance from the posterior surface of the thigh to the end of the finished leg stump is at least five or six centimeters, a below-knee artificial limb can not be used, and amputation should be done above the femoral condyles. Every inch of the thigh until the upper third is reached is valuable, and unless the end of the stump is at least two and a half inches below the lesser trochanter, a thigh bucket can not be worn, and operation through the neck of the femur, or at the junction of the shaft with the greater trochanter with intention of using a hip bucket, should be done. In the upper extremities all fingers possible should be saved. To within three inches of the olecranon process all of the forearm is valuable. Above this it is best to do a supracondylar humeral op- eration. All of the humerus is valuable and the shoulder joint is useless unless one and a half inches of the humerus below the an- terior axillary fold are saved. As soon as possible following operation the stump should- have massage, passive motion, and gradually increasing end pressure by means of roller bandages after the method of Hirsch. 5 Psychically painful stumps have been observed due to the depressed mental at- titude of the patient, 6 cheerfulness and optimism on the part of the surgeon as to the eventual usefulness and painlessness of the stump as well as careful attention to provide cheerful surroundings dur- ing convalescence often make much for success. In cases where it is known from the outset that reamputation is to be done, the skin should be kept from retracting by strips of adhesive and weights ar- ranged so as to apply gentle traction at all times. Osteoplastic Reamputation. — As the art of surgery advances, more responsibility is placed on the surgeon in securing good amputation stumps. For some time an effort has been made to perfect stumps of the lower extremities with respect to end bearing, in addition to making them capable of supporting the weight of the body through an artificial limb applied by means of a cuff or bucket laced around the stump. The obstacle to the successful application of a pros- thesis which depends solely on the fit of the cuff is readily seen when one considers the atrophy which the soft tissues are certain to un- dergo. AVhile such an artificial limb usually serves its function well when first applied, the gradual decrease in diameter of the stump makes necessary a constant readjustment and padding of the bucket to make it fit snugly enough, and eventually a good fit may be impossible. In order to make possible the placing of some 566 AFTER-TREATMENT OF SURGICAL PATIENTS of this strain on the end of the stump, i. e., to make the stump end capable of bearing weight, various procedures have been devised. It has long been recognized that the heel is nature's example of a properly constructed, -weight bearing stump. Therefore, ef- forts should be made to approximate the conditions found there as nearly ;is possible. To accomplish this Bier devised the osteoplastic method of amputation. His work began in 1891, thirty-seven years after Pirogoff introduced the subject. Bier's 7 first contribution to the subject appeared in 1802, but the type of "peg-leg" for which Ibis operation was devised is now seldom seen. His next contribu- Fig 186. — The direction of skin incisi lion, the one with which we are concerned, appeared in L897 8 and dealt with amputations in the middle and upper thirds <>!' the leg. The technie as modified by Kocher 9 and Storp 10 is ns follows: an anteriomedial elliptical skin incision, the lowesl point corresponding to the inner surface of tin' tibia, is made and carried down to the muscles and periosteum (Fig. L86). At the level of the apex of the flap the periosteum is divided transversely across the medial surface of the tibia and reflected upward sufficiently to permil ;i small wedge of thickness not quite extending to the marrow cavity, to be removed from the bone thus laid bare (Fig. 187). The skin REAMPUTATIONS 567 is retracted along the tibial margins and a rectangular flap of periosteum marked off by longitudinal incisions directed proximally along the tibial borders (Fig. 188). By means of a Gigli saw in- troduced into the wedge previously made, a rectangular bone flap, corresponding to the periosteal flap already outlined, is reflected by sawing parallel to the inner margin of the tibia. The normal continuity of skin, fascia, periosteum and bone is disturbed as lit- tle as possible. When the desired length of bone flap is thus sawed, it is severed at its base by manipulating the saw in a vertical di- rection a few times, then breaking it across with an elevator, great Fig. 187. — Incision through skin, deep fascia and periosteum. care being taken not to injure the periosteum. The periosteum is then stripped up about a centimeter further in order to provide an ample periosteal hinge for the bone flap. Thus, we have an an- terior flap consisting of skin, fascia, periosteum, and bone. The muscles are now divided at the proper level parallel to the skin in- cision, and the tibia divided at the level where periosteum leaves bone. The fibula is divided at a somewhat higher level and is not covered by a bone flap. The bone flap is now sutured over the end of the tibia by means of its periosteal covering (Fig. 189); the vessels secured and ligated; the nerves divided as high as pos- 568 AFTER-TREATMENT OF SURGICAL PATIENTS sible; the muscles sutured; then the fascia and finally the skin, leaving a posterior sear extending about half way around the stump. It is well to place the three layers of sutures so that they are no1 directly superimposed upon each other, otherwise a hard, deep, contractile scar will result. After the soft tissues over the end of the stump have undergone fibrous union, a well-formed stump (Fig. 190) capable of supporting the body weight or a part of it should result. Other osteoplastic amputation procedures described 11 are: Ssa- Fig. 188. Periosteum and bone flap elevated. banajeff's femorotibial amputation, through the femoral condyles in which a bone flap from the upper anterior portion of the tibia is used; the Stokes-Gritti supra-condyloid operation on the femur in which the anterior half of the Longitudinally divided patella with its superior tendinous attachment intact is used as the bone Hap. Chappie 12 speaks highly of this operation in a recenl publication and offers a modification which he claims overcomes the failures of the operation which have caused it to lose favor. To these failures he ascribes i he upward pull of the quadriceps extensor tendon and also the mechanical devices used to keep the patellar flap in place. He does away with both these features by freeing REAilPUTATIOXS 569 the flap from all tendinous attachments and fixing it in place by periosteal suturing. While the above operations were designed originally for primary amputations, they are equally applicable to reamputations in cor- responding regions. Osteoplastic reamputations can likewise be carried out on the thigh with the prospect of equally good results so far as end bear- Fig. 189. — Bone flap sutured in place after complete division of all structures at a high level. ing is concerned. Modifications of Bier's technic should be used. Other Methods of Reamputation. — Chappie 13 of the British Army who had a large series of cases requiring reamputation following guillotine amputations done at the front where conditions were far from ideal and where amputations in a great many cases were emergency operations in the truest sense of the word, sets forth 570 AFTER-TREATMENT OF SURGICAL PATIENTS some factors of value in treating such cases. It must be remem- bered the patients were in a bad condition generally when received and their stumps presented conical granulating and suppurating ends from which the skin and soft tissues had retracted leaving various lengths of exposed bone, often sequestrated. Not only were such stumps seen following the guillotine amputation, but it was not uncommon for patients to present themselves with stumps made by one of the regular flap methods in which the flaps had broken down and retracted, leaving a similar condition. In brief, the technic outlined by Chappie as described by Neve 14 is as follows: (1) Curette granulating surfaces, paying particular Fig. 190. The stump with flaps sutured. attention to any pockets. (2) Expose the bone through a Longi- tudinal incision on the outer surfaces of the stump. (3') Feel peri- osteum back without using longitudinal incisions. (4) Cut the bone a1 the lowest possible level with a Gigli saw. (5) Trim away any soft tissues injured in sawing, free the skin from soft tissues and trim ragged edges, avoiding injury to subcutaneous fat. (6) Attend to hemostasis. (7) Introduce a purse string suture into the periosteum infolding it as a cuff over the end of the bone, thus preventing the formation of painful spurs. Suture muscles. In- REAMPUTATIONS 571 troduce tension sutures "staple-wise" from one to one and a half inches from the skin edge and tie while skin flaps are held se- curely in position. Suture the skin edges. Drain with rubber tubes at each end of the incision. The button sutures which form the essential part of this technic are composed of heavy silk threaded through oval buttons of vulcanite. If these are not at hand, India rubber tubing may be used. The theory on which the importance of these sutures de- pends is that "tension and not pus is the enemy of union" and that even if the skin sutures break down and suppuration occurs, a sort of secondary union will take place because the tension sutures hold the skin edges closely enough together so that when suppuration ceases, the epithelium bridges the narrow gap without difficulty. If suppuration is excessive, drains may be inserted between the skin stitches. These stitches do not serve to hold the skin edges together especially, but prevent bulging of the sub- cutaneous tissues. Advantages claimed for this technic are: less loss of stump, long skin flaps are not recpiired; muscle and tendon ends are kept to- gether over the end of the bone which ultimately undergo fibrous union and furnish greater motive power to the stump, the muscles do not retract up the bone; hematomata are prevented; the vascularity following the primary operation is used to combat sup- puration and shorten convalescence. Flapless Method of Reamputation. — This method is described by Handley. 10 Two parallel incisions are made on the lateral surface of the stump at the desired level of bone division, and about one third the circumference of the femur apart. A curved forceps is introduced into one incision and worked around the bone until it grasps the end of a Gigli saw introduced in the other. It is then withdrawn, bringing the end of the saw out through the first incision. The saw may be protected by tubular guards. The direction of the saw cut is always from the main arterial trunks so there is little if any danger of injuring them. After the bone is sawed through, an assistant grasps the end of bone protruding from the end of the stump with lion- jaw clamps and exerts traction, while the operator detaches the muscles with the aid of a periosteal ele- vator. Any necrotic or calcified tissue is trimmed away from the end of the stump, and after attending to hemostasis, the skin edges are sutured and drained. Maryland 10 uses a chain saw instead of the Gigli in doing Hand- ley's operation, and also makes lateral incisions three to four inches 572 AFTER-TREATMENT OF SURGICAL PATIENTS long extending to the bone. A silk ligature is used to guide the saw. Carbolic oil dropped on the chain is used to prevent necrosis of the bone. By this method and its modification, there is a minimum exposure of fresh surface to infection in septic stumps and max- imum conservation of tissue. Apparent Lengthening of an Arm Stump. — In arm cases where it is not possible to leave a stump of sufficient length to provide for the attachment, of a mechanical arm. Smith 17 has devised a method of apparently lengthening the stump. The operation con- sists in making an inverted horseshoe incision into the axilla, the ends of the incision being well within the borders of the axillary space. The insertions of the pectoralis major and latissimus dorsi arc divided to about one-half their length distally, the arm being held in the abducted position meanwhile. The divided portions of these muscles are then sutured high up into the axilla and the in- cision (dosed with the arm still in the abducted position; the line of incision changing from a "U" to a "Y." In the case reported the length of the stump was increased, functionally, from three- fourths to two inches and allowed the successful application of a prosthesis controlled by the stump. Kineplastic Reamputations. — In suitable cases, reamputations of the upper extremities offer a fertile field for the application of the principles of kineplasty, or cineplasty, as it is sometimes called, in order to obtain the maximum function of the stum]). In 1896, Vanghetti, although qo1 a practicing physician, became interested in the possibility of usini;' 1he contractile power of mus- cles and tendons of amputation stumps to activate the mechanism of a mechanical prosthesis. His report of experimental work on animals was published in L899 1S and the following year Cici first applied in a practical way the principles set forth, using them in an arm amputation. Later in the same year Codivilla demonstrated the applicability of the method to amputations of the lower ex- trem.i1 ies. The idea, although described in some of the works on surgery published after thai time, was not used to any great extent until the recent war furnished such a quantity of material concentrated in favorable institutions under conditions permitting a careful study of its merits. Gaudiani 19 in this country and Putti of Bologna and others have recently urged a wider employment id' this method in reconstructive work and in reamputations as well as in primary amputations. Putti, in an address before the British Royal So- ciety,-" urged that, where time and other conditions do not permit REAMPUTATIONS 573 of such a procedure at the primary amputation, the surgeon should operate in such a way as to make the future application of kine- plastic principles possible. To this end. as much osseous and con- tractile tissue as possible should be saved; the muscles and tendons being kept from retracting. Besides providing for the transmission of motion from the stump to the prosthesis, a simpler and firmer means of attachment of such an artificial member is supplied. The meaning of kineplastics as given by Yanghetti is "any kind of bloodless or operative plastics which tend to economise, restore, or substitute muscular masses which can be employed towards imparting direct and voluntary movements to an artificial limb." Needless to say the variety of operations possible under this head is limited solely by the surgeon's skill and ingenuity. The moving unit or units so obtained are called by Putti "motor flaps." Any contractile tissue may be made to serve as such a unit provided it has means of securing nourishment and is covered by normally functioning skin. Certain requirements on the part of the motor flap must be met. It must be capable of withstanding considerable traction; must be painless; must be of such size and shape as to permit the applica- tion of loops, hooks, cords, and other mechanical devices for con- necting it with the mechanism of the prosthesis. A covering of intact normal skin is paramount in meeting these recpiirements. It is obvious that in selecting the structures to form such a flap, the normal anatomic relations and physiologic function of such structures must be considered, and those selected which are most active in producing the desired movements. Tendons are especially desirable. Where these are not available, muscle bundles are utilized by constructing tunnels or "buttonholes" through their substance. "Where possible, antagonistic groups should be used to make sepa- rate flaps. Missing essential elements may be supplied by various plastic procedures. The cases suited for application of these principles are: (1) primary amputations (most desirable); (2) healed stumps prepared for kineplasty at the primary operation; (3) certain healed stumps resulting from the ordinary methods of amputation. Though most applicable to the upper extremities, the method may be used in work on the lower extremities to secure independent and voluntary control on the part of the stump over flexion and extension of the knee joint of the artificial limb after thigh amputation. 674 AFTER-TREATMENT OF SURGICAL PATIENTS Stumps not suitable are lliose of which the skin is adherent, scarred, and of which muscles have atrophied to such an extent as to be only slightly contractile or which have ankylosed joints. Willingness and patience of the subject to train himself to use the new member, and the cooperation of a mechanic skilled in making artificial limits arc necessary adjuncts to complete success. The best subjects arc those between twenty and thirty years of age. Tfclinier 1 — The single motor flap, the double motor flap and the "plastic club motor" illustrate the possibilities and variations of the method. Single Motor Flap in Amputation Through the Arm. — A cuff con- sisting of skin and subcutaneous tissue is reflected from a circular incision four centimeters above the elbow fold, to the junction of the lower and middle thirds of the arm. The tendons of the biceps and triceps are severed; the nerves cut high; the soft parts re- tracted: a cuff of periosteum raised: and the bone sawed across in its lower third. The biceps and triceps tendons are sutured to- gether to form a loop extending beyond the end of the bone. The periosteum is sutured over the end of the bone, using a purse 1 string. About three centimeters Prom the border of the skin flap, two longitudinal incisions about five centimeters in length, one on the posterior, one on the anterior surface, are made. The cuff is then brought down over the tendinous loop and the corresponding edges of the buttonhole incisions sutured together, leaving a skin covered hole through the loop; after which the lower edges of the cuff are sutured. The "buttonhole" through the loop is kept patent with gauze until healing and cicatrization are complete. It is well to begin traction on the loop as soon as possible. When the prosthesis is fitted, suitable cords passed through the loop connect the stump with the mechanism of the hand, so that, when the stump muscles contract the fingers are flexed. Following relaxation of the stump, the fingers are relaxed by springs. V>y suturing the tendons of the extensors and flexors of the fore- arm together, a similar operation can be performed on the forearm. Double Motor Flap in Amputation Through the Forearm. — A cir- cular incision through the skin and subcutaneous tissue is made and the skin allowed to contract. At this new level the muscles and tendons are divided circularly to the bone. Two lateral incisions, extendine; proximally for about five centimeters from the free border of the skin, one along the radius, the other along the ulna, are car- ried to the bone, thus forming two rectangular flaps of skin. Cor- responding musculotendinous (laps are made. These flaps are re- REAMPUTATIONS 575 tracted and the bones sawed across at the base of the flaps after providing periosteal coverings. The muscles and tendons of each flap are divided in equal parts and the two portions of the same flap sutured at their ends. That is, the procedure with each flap is essentially the same as with the single flap described above. In making the "buttonhole" ring in each flap, the corresponding skin flap is folded over the end of the musculo-tendinous loop. The longitudinal edges of the skin flaps are then sutured, and temporary drains inserted at the base of each flap. Similar after-care as de- scribed above is used. By connecting one of the motor flaps with the flexor and the other with the extensor mechanism of the prosthesis, the patient has voluntary control over practically all the movements of fingers, thumb and hand. Amputation of Forearm Providing- a Plastic Club Motor. — De Francesco 22 presents the following adaptation of Vanghetti's tech- nic. After amputating in the usual fashion, longitudinal incisions about five centimeters in length are carried to the bone over the radius and ulna. Through these, about two and a half centimeters of each bone is removed by means of a Gigli saw, leaving about two centimeters of each bone in the distal end of the stump. The end of the stump and the longitudinal incisions are then sutured. Dur- ing healing, a ring is placed around the forearm proximal to the bone fragments, and traction employed to prevent contraction. When healing is complete, this ring is replaced by one of padded hard rubber, which is held in place by the knob-like end of the stump, and suitable cords connect the ring with the prosthetic mechanism. The fingers are flexed by contraction of the stump muscles and passively extended when the muscles are allowed to relax. A tenoplastic form of the technic has been devised by Vendrene, 23 and an osteoplastic operation for using the rotatory power of humeral stumps has been suggested by Elgart. 24 Full credit is due Walter S. Priest for having abstracted all the lit- erature to which reference is made in this chapter. Bibliography iFitzmaurice-Kelly : Lancet, London, 1915, i, 15. 2"Wiight: Jour. Roy. Army Med. Corps, 1917, xxviii, 259. 3 Wright : Loc. cit. 4 Huggins: Lancet, London, 1917, i, 1917. sHirsch: Deutsch. med. Wchnschr., 1899, p. 77G. ^Corner: Proc. Eoy. Soc. Med., 1917-18, xi, 7. 7Bier: Deutsch. Ztschr. f. Chir., 1892, xxxiv. .")(() AFTER-TREATMENT OF SURGICAL PATIENTS sBier: Centralbl. f. Chir., L897, p. 834. " Kochii : Textbook of Operative Surgery, 3rd English ed., 1911, Adam & < 'lias. Black, London, lostorp: Deutseh Ztschr. f. Chir., xlviii, p. 4. nKeen: Surgery, Its Principles and Practice, Philadelphia, 1909, W. B. Saunders Co. isChapple: Brit. Med. Jour., Aug. 17, 1918, ii, 153. isChapple: Ibid., Apr. 6, 1918, i. 399. Lancet, London, July 27, 1918, ii. 105. Brit. Med. Jour., Aug. 25, 1917, ii. 242. i4Neve: Brit. Med. Jour.. 1917, ii, 583. isHandley: Brit. Med. Jour., 1917, ii, 244. ifiMaryland: Brit. Med. Jour., 1917, ii. 304. iTSaiith: Lancet, London, 1918, i, 706. i8"Vanghetti : Arch. Etaliano di Ortopedia, 1899, svi. is>Gaudiani : Ann. Surg., 19i8, Iwii, 414. 2op u tti: Lancet, London, 1918, i, 791. -'Keen: Surgery, Its Principles and Practices, Philadelphia, l!n.">. W. B. Saun- ders Co., \ i. Putti : Loc. '-it. ( Jaudiani : Loc. '-if. Vanghetti : Press. Med., Ii»(i7. xv. 210. Brit. Med. Jour., 1918, ii. 269. J. de. Chir., 1908, i, 192. Cici: Press. Med., 1906, xiv 7 15. Sauerbach: Med. Klin., 1916, p. 195. ---'De Francesco: Arch. f. Klin. Chir.. 1009, ,,., 571. 23"Vendrene : I o Keen : Loc. cit. 2 1 Elera rl : I n Ke< □ : I iOC cit. CHAPTEK LY PEOCTOCLYSIS By 0. F. McKittrick, St. Louis, Mo. The administration of fluids through the rectum has become a very common practice. When one considers that it is comparatively a new addition to the means at our disposal for making postopera- tive patients safer and more comfortable, one is no less amazed at its general use than at the excellent results obtained thereby. This form of treatment is employed as routine with my own pa- tients, though in some other clinics it is used in the more serious cases only. It is particularly indicated in all forms of peritonitis, in toxemias of any kind, and in supplying fluids to generally de- bilitated and dried out individuals, where the stomach is not availa- ble. Murphy, 1 who described an apparatus which was successfully used in his postoperative cases, was the pioneer in this field, and to him we are indebted for its universal use. The giving of proctoclysis is indeed a very simple performance, but must be carried out with some idea of the laws of Nature, else one is impressed with the fact that she rejects ill-timed en- croachments, and the fluid, therefore, is not retained. Murphy, years ago, stated the well-known fact that the normal large in- testine is moderately distended, and that its mucosa absorbs water rapidly. Any overdistention, especially if suddenly produced, causes spasm of the musculature, with pain and expulsion of the material. The geueral principles upon which Murphy founded his treatment have not been changed, although improvements have been made in his apparatus from time to time. His instrument consisted principally of a fountain syringe and a large curved hard rubber or glass vaginal douche tip. The syringe, filled with warm saline, was hung eighteen inches above the pa- tient's hips, and the curved douche tip inserted into the rectum. The flow was then started by releasing a pinch cock on the rubber tubing. Fluid was thus allowed to gravitate to the rectum in drops, just as fast as they were absorbed; the flow was continued as long as it was tolerated or deemed necessary. By means of the large tip in the rectum, gas could be expelled through the tubing, to the 577 578 AFTER-TREATMENT OF SURGICAL PATIENTS reservoir, and thus this treatment could be continued several days, without very great inconvenience to the patient. In the beginning it was considered highly important to have the fluid a1 body temperature as it entered the bowel. It was soon learned, however, that with such an apparatus as Murphy used, the fluid could not he maintained at an even temperature, since heat was applied to the reservoir only. Since the fluid in the bowel was constantly being absorbed, there was a continual change in the height and temperature of the fluid in the reservoir. In order to overcome this difficulty, Elbreeht 2 devised an arrangement, by means of which the saline could he heated as it coursed through the rubber tube. By this means the amount of the fluid in the reservoir, as an important factor was eliminated. Elbreeht 's device consisted of a metal heating chamber, which was block-tin lined, contained rubber tube connections for intake and outlet for the solution, and also an opening for an electric heating unit. This unit was connected by means of insulated wires to an electric socket. It could he used with either alternating or direct currents. The metal chamber when heated by electricity was put into the bed villi the patient. When, however, it was heated by means of an alcohol or gas Lamp it was placed on a small table at the side of the bed. The fluid, then, was heated to the proper temperature, just before it passed into the body. Elbreeht also devised rectal lips of different sizes, to tit the individual case. This prevented the solution from escaping. <>r the rubber tube from pulling out. Each of these self-retaining, hard rubber rectal tips had a hole in the center, through which a catheter could he inserted. By means of them, an ordinary rubber catheter could he used instead of the hard rubber vaginal tip, which at times exerted too severe pressure on the rectal walls, or instead of the glass tip, which was easily broken. For diminishing the lumen of the tube, so as to get the required number of drops, he used a screw claiii]). as shown in Fig. 191, page 589 instead of a hemostat or the clamp accompanying a fountain syringe. By means of the screw clamp, the saline could be regulated to any number of drops per second. Elbreeht V- apparatus did not improve upon the one first used by Murphy, except that it was a most admirable arrangement for keep- ing fluid at an even temperature, it was also somewhat expensive, and therefore not generally used. Wechsler 3 used an apparatus which by heating the reservoir alone was designed to nieel the same requirements as Elbrecht's. It was similar to Murphy's except that PROCTOCLYSIS 579 the reservoir consisted of a large irrigating glass container, around which was placed a water jacket. Into this jacket, hot water conld be poured, and the salt solution thereby kept warm. When the water in the jacket became cold, it was drawn off by means of a stopcock. This arrangement was not only impractical, but also somewhat expensive. Newman 4 devised a funnel arrangement, which, he thought, would overcome the expense of the regular proctoclysis apparatus, and yet answer the same purpose. His apparatus consisted of a large iron ring stand, which suspended two glass funnels, a large one to act as the reservoir, and a smaller one to allow escape of gas from the rectum, and also to convey the drops of saline from the reservoir to the rectal tubing, which was similar to that employed by Murphy. A metal bar placed over the top caused the saline to drop from the large funnel. This bar had an opening in its center, and at this point the nut of a screw was placed. A thin rod, which was connected to this nut, extended to a rubber stopper at the tip of the funnel, and by screwing the nut drops could be secured and regulated. An electric light bulb was placed in the lower funnel. Saline dropping from above first struck the light bulb, and was then conveyed to the rectum through the ordinary rubber tubing. Newman's was the best apparatus devised to allow the escape of gas from the rectum, but it did not adequately heat the saline. For this reason it did not become very popular. McLean 5 devised another apparatus, which consisted of a tin box containing a two quart dish. Under this was placed an alcohol lamp or an electric light bulb to keep the fluid warm. The tip of a glass funnel which extended through an opening in the box was so arranged that the top of the funnel was lower than the two quart dish which held the saline solution. Strips of gauze one inch wide connected the reservoir with the funnel below. A four ply strip of gauze freed fifty drops per minute, into the funnel, and the number of drops desired was regulated by changing the size of the strip. An apparatus which previously was devised by Saxon, combined the good points of those which have been mentioned, and in addi- tion, had a thermometer placed in continuity with the rectal tube, so that the temperature of the saline could be ascertained at any moment. The reservoir was contained within a tank, permitting it to be surrounded with hot water, which when cold could be drawn off by means of a stopcock, and hot water added. A small glass "i^ 11 AFTER-TREATMENT OF SURGK AL PATIENTS cup on a glass "y" tube, served for an outlet. The objection to this apparatus was that it could not be conveniently carried from one patient to another. Babler, 7 therefore, devised a very simple apparatus, which consisted of two glass jars and rubber connections. The jar containing the saline was placed in the other larger jar, which contained hot water. The rectal tube and tip were the same as used by Murphy. The outlet for gas consisted of another rub- ber tube, which was connected by means of a "y" glass tube with the main rectal tube, and was held by means of a bent glass tube. to the side of the largest glass jar. The rectal tube communicated directly with the saline solution in the reservoir by means of bent glass tubing. If necessary, the jars could be replaced by any sort of vessels and this, with the small amount of tubing, made the ap- paratus desirable, but the number of drops could not be counted, and the amount of fluid going into the rectum could not be ac- curately known. Lawson, 8 one year previous, in order to determine the rapidity of flow, used an ordinary medicine dropper, which fitted tightly into the center of a rubber stopper. This, in turn, fitted into the top of a barrel of a urethral sa ringe. This device did not allow gas to escape from the rectum, so Dewitt." three years later, employed a similar arrangement, but simply punched holes in the stopper. This then proved an efficient instrument. Many other appliances were devised, but none seemed perfectly satisfactory. Apparently, all operators were agreed that the gravity method was the best. i. e., the reservoir should not stand more than eighteen inches above the hips. It was also generally conceded that continuous proctoclysis was better than intermittent, since too often inserting even the simplesl rectal tube, would cause ir- ritation in the majority of the rases. The apparatus of Lawson, and others who employed funnels, overcame the error of being unable to see how much fluid entered the re. -turn, and the expelled Lias was also easily taken care of. bu1 none of these methods fully met all the obstacles encountered in giving fluid per bowel. It seemed to be the prevailing opinion that the fluid should be at body temperature when it entered the body, in older to be absorbed more readily, and most of the devices were made with this point in view. It was not considered necessary to have tin 1 fluid warm in order for it to lie nonirritative or absorbable. Considering the universally good results which followed the application of this treatment, regardless of the method used in applying it. one is not surprised at Weeks' 10 statement, for without doubt, in mosl instances, PROCTOCLYSIS 581 the fluid was cold by the time it reached the rectum. In our own cases, we have observed no difference in the absorption of the fluid, whether warm or cool, and we feel this is not an important point. However, we try to have the fluid warm in the reservoir, in order not to chill the patient. The apparatus which we employ, combines all the good points mentioned above. It consists of an ordinary irrigating can, which holds one quart or more of fluid. The water which is used for the injection is poured into the can, and a temperature around 110° is maintained, by placing a bottle full of hot water into the water to be used. The outlet of the irrigating can is connected, by means of rubber tubing one-half inch in diameter, with a glass dropper, and this latter connects with the arm of a "y" glass tube. The other arm of the "y" connects with rubber tubing, which serves as an outlet for the gas, and suspends from the top of the reservoir by means of curved glass tubing, which is covered by the rubber tube. The foot of the "y" connects with a four foot rectal tube, at the end of which an ordinary No. 32 French catheter is attached by means of a short glass tube. The catheter is greased well with vaseline, and inserted six to eight inches into the lower bowel. It is held in place by means of adhesive strips adhering to the buttocks. The screw clamp, which is placed immediately above the visible dropper, regulates the flow perfectly. In in- stances where we are unable to secure the regular dropper, or a "y" tube, we employ Weeks' method, which in the main, consists in letting the water drop from the reservoir into a funnel, which connects with the rectal tubing. The drops are formed by utilizing the screw clamp. If this too can not be had, a piece of gauze, hang- ing from the solution, may be so employed as to allow the fluid to drop into the funnel. The use of the funnel is as useful a method as our regular apparatus. It is cheaper, simpler, and has other ad- vantages. The funnel can be utilized in giving enemas to relieve gas pains or to remove collections of fecal material. Keinsertion of the rectal tip or catheter is not so often necessary when using this apparatus. If at any time the bowel does not tolerate the fluid, the funnel can be taken out of the hanger and the overflow in the rectum is syphoned off. This method is particularly useful in children, since from stoppage of the tube gas collects more readily, and the bowel is more irritable than in adults. Physiologic saline solution was first considered by the pioneers in this field as the proper fluid for proctoclysis, and even today is used extensively. It is prepared by placing 8.5 grams of sodium 582 AFTER-TREATMENT OF SURGICAL PATIENTS chloride in a liter graduated flask, and then adding sterile distilled water until the 1000 c.c. mark is reached. A very common and comparatively accurate method is simply adding two level tea- spoonfuls of fine table salt to one quart of water. Unfortunately this solution has attained the name "normal salt solution." and has become so fixed in the minds of the majority of the medical profession, that the fallacy is not recognized. A normal salt solution 11 consists of the atomic weights of sodium and chlorine, 23 and 35.46, respectively, dissolved in a liter of pure water. It is made by placing 58.46 grams of sodium chloride in a graduated liter flask, and adding pure water up to the 1000 c.c. mark. Thus a physiologic salt, (that which is always used) and a normal salt solution are entirely different solutions. The former is an .85 per cent saline solution, while the latter is .5846 per cent salt solution. h would he quite a serious mistake to order "normal salt solution." meaning, all the while, the physiologic solution, and for this reason we feel justified in calling attention to this extremely common error. The method of preparing "normal saline solution" was recently investigated by Trout, who studied the methods employed by 232 different hospitals and found that they "varied from the most careful attention to minute details, i.e.. that the fluid contained potassium, calcium, and sodium chloride in varying proportions, filtered and sterilized, to the simple placing of two teaspoonfuls of table salt to one quart of tap water." A teaspoonful of salt, as Trout says, may he anything "from L15 grains to 270 grains, de- pending upon whether it is heaping or level." Considering the amount of saline which is given at times per rectum, the patient, under these circumstances, would he forced to take as much salt as is utilized as a condiment by a normal person in a month. There can he no doubl that under many circumstances, large amounts of saline administered, promiscuously, as is so often done, are injurious to the tissues of the body. Had results have followed its injudicious use in postoperative cases, with weakened hearts, and diseased kidneys. To this class of patients, Willmoth 12 would add those threatened with sudden death, dilated right heart, pul- monary edema, apoplexy, or arteriosclerosis. So often, patients with some kidney lesions, and even on a salt-free diet, are given the routine saline, after some operation has been performed. We can not reconcile such a procedure. Bvans 13 called attention to the recklessness with which saline has been given in late years. He stated that "one can not fail to he impressed with the danger of such a procedure in postoperative patients, in whom saline solution PROCTOCLYSIS 583 is given without previous knowledge of the condition of the blood pressure, the ability of the heart to handle large amounts of saline successfully, or the functional capacity of the kidneys to excrete the large amount of chloride thus forced upon them." He also, rightfully, stated that patients have died due to the use of saline alone. Such cases usually escape reporting, since, as he says the cause of death is problematic, and since the saline is used in grave surgical emergencies, the death is attributed to other causes. When one considers the numerous ways the solution is prepared, and yet in each instance the physiologic salt solution is the result which all are striving for, it would be impossible to determine the count- less number of patients suffering from the deleterious effects, from more or less poisoning due to overdosage of this substance. Actual death from saline given per rectum has been cited in a few in- stances in the literature. In a case reported by Brooks, 14 salt solution was used after an ordinary appendectomy, the nurse em- ployed a stock solution of sodium chloride in preparing the saline to be used as proctoclysis, and gave the patient one and one-half liters of the solution in two doses, as was ordered. The poisoning which resulted from the nine ounces or more of- salt, which he re- ceived, soon produced death of the patient. Campbell 15 reported a case in which a saline enema was advised, in a case of "worms." The patient, a boy five years old, received one pound of salt, in- stead of a tablespoonfnl. in a quart of water, as was advised. In five to ten minutes, the child complained of intense thirst and pains in the head. Vomiting occurred soon after this and was followed by purging. Within one and one-half hours he was unconscious, and died in convulsions five hours from the time he was given the enema by his mother. Evans cited a case of poisoning due to saline proctoclysis. This patient was operated upon for carcinoma of the uterus. "Normal saline solution" was ordered as continuous proctoclysis, and the nurse gave five quarts of this fluid within eight hours. The pulse rose suddenly to 148 per minute, became irregular and weak, and soon the patient became stuporous. By discontinuing the saline, and by using stimulants, the patient, for- tunately, was revived. Sippel 16 reported a death from saline infu- sion in which three liters of a physiologic salt solution were given after decapsulating the kidney for anuria. The anuria was relieved by the operation, but quickly returned, following the saline infusion, and resulted in a fatal termination of a normally progressing surgical convalescence. 584 AFTER-TKEATMENT OF SURGICAL PATIENTS It is a well-known fact that sodium chloride, though the least toxic of the metal chlorides, is exceedingly poisonous, when given in large amounts. Joseph and Meltzer, 17 a number of years ago. showed that 3.7 grams per kilo of body weight, was sufficient to kill healthy animals. In Sippel's ease 28 grams of sodium chloride were given, and in Brook's case 135. Normally, the body only excretes ten to fifteen grams and to add even more than this amount to the already overloaded kidneys, could hardly be expected to end otherwise than badly for the patient. Trout 18 recently experimented with plain tap water, and physi- ologic salt solution per rectum. The salt solution contained .§% to .!)', sodium chloride. In over two thousand cases, one hundred and twenty-one complained of thirst in spite of large amounts of fluid, which were yiven. Of these cases one hundred and twelve received the salt solution only, and in this number several com- plained of having salty taste in the mouth, though they did not know they were getting this mineral. lie states he would no more consider giving salt water by rectum, than he would giving it by mouth, when the patient required fluid to quench his thirst. I heartily agree with Trout, and my cases never get salt solution as protoclysis. 1 give instead a solution containing glucose '■'>' '< and sodium bicarbonate 5', in tap water. T give large amounts in eases where it is needed, even surpassing nine quarts in twenty-four hours, as given at first by Murphy. The solution is kepi going for a week at a time, niuht and day, in severely toxic or dried-out patients, especially when fluid can not he readily taken through the mouth. In my experience, this solution is more easily absorbed, less ir- ritating, and altogether a better medium to decrease nausea and thirst, than saline. The tube being in place, allows escape of gas, and pains due to Ibis are therefore less frequenl where this measure is employed. The catheter causes very little discomfort, and in many cases its presence is not known. Since Kausch's'" article in 1911, glucose has been used extensively in surgical cases. It not only supplies energy to the cells, and aids in tissue repair, but also diminishes acidosis by giving carbohydrate food to the organism. It therefore greatly aids in preventing post- operative vomiting, and since it is very little irritating, if ;it all. to the mucous membrane of the bowel, we have employed it as a routine in our plain tap water. This substance is burned in the body, is not excreted in the urine, and serves as a food, giving 300 to 5()() calories per day, to the average patient. This is not suffi- cient, however, to supply the total energy requirements of the body. PROCTOCLYSIS 585 but greatly aids in excessive nitrogen waste, and thus we get universally good results from its use. The use of sodium bicarbonate 5 per cent in the fluid given per rectum decreases the tendency to acidosis. Bibliography iMurphy: Jour. Am. Med. Assn., 1909, lii, 1248. sElbreeht : Quoted by Murphy. sWechsler: Jour. Am. Med. Assn., 1909, lii, 1251. ■iXeivmau: Jour. Am. Med. Assn., 1909, lii, 1250. sMcLean: Jour. Am. Med. Assn., 1911, lri, 1134. eSaxon: Ann. Surg., 1909, xlisr, 404. rBabler: Jour. Am. Med. Assn., 1910, liv, 870. sLawson: Jour. Am. Med. Assn., 1908, 1, 1267. sDewitt: Surg. Gynec. and Obst., 1911, xii, 166. ioWeeks: Jour. Am. Med. Assn., 1916, lxxi. 1022. "Pharmacopoeia of the United States, 1916. ix. i^Villmoth: Am. Jour. Surg., 1916, xxx, 147. isEvans: Jour. Am. Med. Assn., 1911, rvii, 2126. "Brooks : Arch. Int. Med., 1910, vi, 577. i-Campbell: Jour. Am. Med. Assn., 1912, lix, 1290. 16 Sippel: Deutseh. Med. YVehnschr, 1910, xxxvi, Xo. 1. 17 Joseph and Meltzer: Jour. Exper. Pharm and Ther., 1909. isTrout: Surg. Gvnee. and Obst., 1913, xvi, 562. is'Kausoh: Deutseh. med. Wehnsehr., 1911, xxxii, 8. The following references were also consulted: Burnham: Am. Jour. Med. Sc, 1915. el, 435. Friedman: Munehen. med. Wehnsehr., 1913, Lx, 1022. Kanavel : Surg. Gvnee. and Obst., October, 1916, p. 485. . CHAPTER LVI HYPO l)ERMO( LYSIS By Willard Bartlett, St. Louis, Mo. Tt will be readily admitted that a convalescenl patient, like any other human being, has at least three vital necessities, tie can survive but a very limited period without oxygen; life is possible for a considerably longer time without water, while the lack of food may be endured for quite an extended term. The first is. of course, a vital need; the second becomes one in a relatively short time, while the third will ulti>n• st . It must he borne ii* mind, as a fundamental principle underlying this study, that water is not absorbed from the walls of the stomach, or indeed, to any extent, until it has reached the colon: hence, one who thinks in terms of physiology readily grasps the fact that a patient who is vomiting receives no fluid into his circulatory apparatus, and therefore, profits not a1 all by any amount that is swallowed. Unfortunately, output and intake are not a1 a stand- still in such instances, since many an individual who vomits copiously, really ejects more than he drinks, which is explained by a greatly augmented secretion of upper intestinal and stomach juices. As dehydration progresses, such patients complain more 586 HYPODERMOCLYSIS 587 aud more of an agonizing thirst, no matter how much water is swallowed. In most instances where water can not be taken by the natural means, it is injected into the rectum, and although it may surprise the reader, he will find upon investigation, that by far the greater quantity of the fluid so administered, gradually finds its way into the bedding beneath the patient. Until about one year previous to the time this is written. I, like others, in the habit of following the advice of well-known leaders of surgical thought, blindly ordered the drop by drop administra- tion of water per anum. with great frequency. The year-long pro- tests of patients who were subjected to this treatment, finally led me to take up the matter with many intelligent nurses, and I suc- ceeded in eliciting the fact that a very small percentage of fluid. which is intended to reach the circulatory system in this way. ever really accomplishes this. At the same time, practically every pa- tient is disturbed by this therapeutic maneuver, and worst of all. active peristalsis is started up. in patients suffering from peri- tonitis, just that type in which the intestines should remain at rest, and fluid be rapidly absorbed instead of thrown out by the ac- tivated hollow viscera. A storm of protests has met the foregoing arguments, where presented to experienced surgeons, but I have yet to find that one of those to whom I have mentioned the subject, had given the matter personal attention, and still. I invite any man who is really interested in it to remain on duty with the nurse for an hour or two after the administration of the proctoclysis which he has or- dered. If the patient remains undisturbed, and the fluid be definitely retained in any satisfactory percentage of the patients observed. I think he had better continue to use it. This, however, has not been my experience, no matter what the technic employed: and I may adduce as the best proof of the cor- rectness of my reasoning, that my results have by no means grown worse during the year that it has not been employed in one single instance. Another way of introducing water into the circulatory apparatus, when swallowing can not lie allowed, is that of McArthur, mentioned elsewhere in this book, who lets water flow into the gall bladder through the drainage tube commonly employed in that viscus. Mc- Arthur and Matas have accomplished wonders in this way. not only in the administration of water, but of fluid nourishment as well. There is no valid objection to this method in the comparatively rare 588 AFTER-TREATMENT OF SURGICAL PATIENTS instances where the gal] bladder and cystic and common ducts are available for this purpose. However, it will be readily admitted that a comparatively small portion of our surgical work is done upon 1 he biliary apparatus. The intravenous infusion of salt solution or other physiologic fluids, has been employed with success. However, this is a dis- tinctly dangerous method and is not to be used under ordinary cir- cumstances. I can nol go here into the intricate physiologic rea- soning involved, but will content myself with mere mention of the fact Unit every surgeon of experience lias seen a terrific chill, with attendanl depression, follow the loo rapid inflow of salt solution into a vein, if be has tried to introduce a reasonably large amount in this way. Nothing is easier to produce experimentally than an edema of the lungs, dilatation of .the right heart, and a peritoneal accumulation so greal as to interfere with the excursions of the diaphragm, by the overproduction of saline into a vein. It goes then, without saying, thai the method has obvious disadvantages, and is not to be employed ;is a routine procedure. The intraperitoneal introduction of fluid is quite feasible, but is dangerous unless practiced with the greatest caution, for reasons that are apparent to any one. The likelihood of injuring an ab- dominal viseus. if the fluid is delivered through a trocar, is always present. One m.us1 not forgel the danger of interfering seriously with respiration by too much fluid preventing the excursions of the diaphragm. 'This method is employed with success by certain skilled specialists in the treatment of infantile disorders. How- ever, it seems quite reasonable to suppose that it can never occupy a prominent place in therapeutics, if it has to be used as a routine procedure by physicians at large. After having condemned, or a1 least urged the inadequacy of the last-mentioned four methods, it is only fair that I should pro- pose a siil ist i t lit o for them, and it is. indeed, with no little degree of satisfaction that I advocate the following method of subcutaneous administration, which is original with Dr. McKittrick and myself, although, il must lie staled in all fairness, thai after we had used it for ( year. Allen P>. Kauavel of Chicago, who knew nothing of our work, was the firsl to give il the public notice it deserved. The apparatus mosl commonly employed by us consists of a graduated sun c.e. glass container | Pig. ]!)] i which is connected by rubber tubing, one-half inch in diameter, and four feet long, fo a regular hypodermic needle (No. L8) three inches long, with '.■■,■_. HYPODERMOCLYSIS 589 pig. 191. — The drop by drop hypodermic introduction of water, controlled by sight feed. inch bore. When continuous hypo dermocly sis is used, the visible dropper and screw clamp, as is used in the proctoclysis outfit, and also a clamp, as is seen ordinarily with regular fountain syringes, is added. 590 AFTER-TREATMENT OP SURGICAL PATIENTS An attempt is made to gel gravity pressure by placing the con- tainer directly above the patient. This maneuver must take all the kinks out of the tube, and thereby encourage the proper flow of the stream. As to the fluid employed. Dr. McKittrick proposed that we use plain, freshly distilled sterile water. In view of the large amounts of fluid instilled, and the harmful effects which occasionally fol- low the absorption of abnormal amounts of sodium chloride, we do not countenance its use. especially in patients already weakened liv disease, or surgical trauma. The water is heated to between Fig. 192. — The needle introduced through a square of gauze. 100° to 11" P. and then poured into the warm container, which is supported on an adjustable pole. The slender needle is first thrusl through the center of a square fold of gauze (Fig. L92) (25 mesh to the inch, and 6 ply thick), and is now ready for use. This prevents the band touching the needle or contaminating the skin, which has been cleaned with alcohol, and painted with iodine diluted ';., its strength with alcohol. The fluid is now started through the tubing, and when all air has thereby been expelled, the tubing is temporarily pinched off with the thumb and finger, and the opera- tion begins. HYPODERMOCLYSIS 591 Iii unconscious patients, the needle (Fig. 193) is plunged up to its flange in the subcutaneous tissue, at a point near the outer bor- der of the pectoral muscles, midway between the nipple and the head of the humerus. By this method, the fluid extends directly into the subcutaneous tissue of both the axilla and the breast. Absorption is almost twice as fast as it is when the injection is under the breast alone. The needle is held in place by a strip of adhesive, (Fig. 193) the original piece of gauze being utilized to prevent contamination of the needle wound. If the needle remains in very long, alcohol is dropped over this region from time to time, Fig. 193. — Needle and gauze held in place by adhesive. and gauze is then placed over the exposed portion of the needle, adhesive and all. A hot water bag, wrapped with a towel, is placed directly under the axilla, and another one over the gauze, which protects the needle. Massage is not attempted, except that occa- sionally one exerts firm rotary pressure over some slowh r harden- ing area. The fluid should not run in so fast, but what, with the aid of the hot water bottles, the tissues, though very slightly edematous, remain soft and pliable. Only the one side is used at a time regard- less of the amount of fluid to be infused. Usually 1000 c.c. is given during one injection, though a much larger amount can be given if it is allowed to run in slowly. Between one and two hours is all 592 AFTER-TREATMENT OF SURGICAL PATIENTS the time needed in the ordinary ease, and frequently one hour is sufficient, tins differing with individuals. Multiple needles, although employed by some, simply add to the individual's discomfort by multiplying the sources of it. And not only this, but they seem to me to violate the most important prin- ciple here under discussion, viz.. that they may deliver the fluid with such rapidity as to incite the only serious danger possible here, that of circulatory plethora, followed by acute dilatation of the right heart, and first made evident by edema of the lungs. In giving large amounts of water, the heart and lungs are care- fully studied, and the blood pressure taken occasionally. If a dangerous degree of plethora is produced the heart heat corre- spondingly increases in rate and force, and finally the heart dilates. Then the blood pressure falls. Other less ominous signs are swell- ing of the eyelids, face, hands, and feet. The giving of hypodermoclysis is easily accomplished without pain or distress in tnosl patients not under the influence of a narcotic. There is a type of oversensitive individual in whom more than this is necessary. In such instances a very fine hypo- dermic needle is used to anesthetize the skin, with one-half per cent novocaine. The skin is then punctured, and the solution carried along the route which the hypodermoclysis needle will follow. This is inserted as soon as the patient is unable to feel any pain. The clamp is now gradually released, so as to permil the water to enter slowly, and diffuse the anesthetic ahead of it. After a few minutes the patient will experience a little pain from the pressure of the water. The tube is then clamped off. and a small quantity of y 2 per cenl oovocaine injected into it under pressure, by means of a 10 c.c. syringe i Pig. 194). The pain having ceased, the water is again turned on. and the patient can take a few hundred more c.c. when furl her injection of novocaine may fie made. If more than one reservoir full is required, more water is poured into the reservoir and the injection of novocaine repeated as often as the patienl complains of pain. This will not occur more than once or twice during the hour. In patients who may lie relied upon to let the needle alone continuous hypodermoclysis may fie employed. In ihis case, by means of a dropper and screw clamp, the water is given in drops. while the rate of flow varies with the rate of absorption. The tis- sues are not allowed to become swollen. The patient will usually take 40 to 80 drops to the minute withoul this occurring. Such a method is indeed desirable, one which permits fluid to enter the HYPODERMOCLYSIS 593 tissues to the extent that pain is caused. If this occurs, the patient, (if he is one to be trusted) may stop the flow by means of an ordinary syringe clamp, supplied for this purpose, and when the Fig. 194. — A. A hot-water bottle in position. B. Novocaine introduced repeatedly during the operation. pain ceases, he can start the solution by releasing his clamp. "When the hypodermoclysis operation is finished, the needle wound is cleansed with alcohol, and then closed by means of adhesive or a ,'.)- AFTER-TREATMENT OF SURGICAL PATIENTS little cotton and collodion. Heat is continuously applied until all traces of the fluid have disappeared, and the soreness gone. We have given fluid by this method for a period of several days. In one case, McKittrick gave 10,000 e.c. in less than three days: on numerous other occasions, we have employed large amounts with good results. We have never seen a patient show evidences of having received too much fluid, nor incurred any harmful results from the use of this method; we have on the other hand observed time and again, pa- tients who seemed in the utmost extremity of dehydration com- patible with life, make a most satisfactory convalescence when it was used. Fig. 195. Fig. 196. Figs. 1 An apparatus for maintaining the temperature of a fluid to In- intro- duced under the skin, used at Mayo Clinic. McKittrick, as far as the writer knows, is the pioneer in the use of plain distilled sterile water in continuous hypodermoelysis. Kanavel used the continuous method, bu1 physiologic saline solu- tion was introduced instead. We have seen no ill effects from the water infusions, cither in the skin or subcutaneous tissues, and the absorption seemed much quicker than wilh the saline solution. In testing out this point, McKittrick injected 1600 e.c. of plain HYPODERMOCLYSIS 595 water into one axilla of a patient, and saline into the other at the same time. The plain water disappeared from the reservoir thirty minutes to one hour the sooner, and the tissues next day were normal, so far as physical examination was possible, while those in which the salt solution was injected, were the seat of soreness, and considerable crepitus was present. As is perfectly well known to physicians, the blood pressure can not be raised above normal by the infusion of fluid into the veins, no matter what quantity be employed. Any attempt in this direc- tion simply causes extravasation. McKittrick believes on the other hand, that the subcutaneous infusion of distilled water has lowered unnecessarily high blood pressures in the cases of which he has kept blood pressure records. He goes so far as to conclude that he has seen unduly high arterial tension in chronic interstitial nephritis rendered lower in this man- ner. We must state in conclusion, that the procedure has completely supplanted the rectal administration in my service, and where in- telligently applied, seems not to have unduly disturbed the patient. has never been attended by an accident, and has given the greatest satisfaction. CHAPTER LVII BLOOD TRANSFUSION By Willard Bartlett, St. Louis, Mo. We can imagine no more striking introduction to this subject than the words of McClure and Dunn, 1 which Ave present verbatim: "From the very earliest times, the blood has been regarded as synonymous with life. It was considered by the ancients as the sea) of the soul. In the Bible we have the following: 'Because the life of the flesh is in the blood and I have given it to you upon the altar to make an atonement for your souls: for it is the blood that maketh an atonement for the soul.' Many references are made to transfusion of blood in the writings of the ancient Egyptians. It, was condemned by Pliny and Celsus. Tn the Metamorphoses of Ovid we have: 'Quid nunc dubitatis inertes? Stringite, ait, gladios; veteremque haurite cruorem, ut repleam vacuus juvenili sanguine vi ikis.' 'Why, now. do ye hesitate and do nothing? Unsheathe your swords and draw out the old blood, that I may fill the empty veins with the blood of the youth.' Libavius in 1615 reports in e De- fensione Syntagmatis arcanorum chymicorum' as follows: 'Let there be present a robust, healthy youth full of lively blood. Let there come one exhausted in strength, weak, enervated, scarcely breath- ing. Let the master of the art (the operator) have silver tubes that can be adapted one to the other; then let him open an artery of the healthy one, insert the tube, and secure it. Next let him incise the artery of the patient and put into it the feminine (re- ceiving) tube. Now let him adapt the two tubes to each other and the arterial Mood of the healthy one, warm and full of spirit, will leap into the (vessels of Hie) sick one, and immediately will bring to him the fountain of life and will drive away all languor.' ' However, the first authentic record- we have is that of Pope In- nocent VIII, who was transfused by his Jewish physician in L492. three little boys being used as donors; this doctor, whose name has been lost to science, failed to benefit his patient. No other attempts were made to perfect the procedure further than discussion of it, until Harvey's discovery of the circulation, when new interest was manifested and research work was done upon animals, but it was not before the middle of the 17th century that it was recognized 596 BLOOD TRANSFUSION 597 as a surgical procedure. 2 During the year 1666, in France, Lower first gave a method in detail, and Denny's experimenting along the same lines, successfully transfused three human beings. Following their work, many instances of transfusion were reported, sometimes from animal to man, and at times from man to man. The vessels were connected end to end or by means of a quill or cannula of silver or of bone, or indirectly by a pump or syringe. Several successful attempts were reported, but such fierce opposition was aroused that in 1668, the method was forbidden except by special permit of the Faculte of Paris. 3 This naturally had a disquieting effect, and except for a dis- cussion now and then, the method fell into disuse and was not re- vived until the 19th century. At this time, Blundell 4 in England did further experimental work helping to more firmly establish this procedure as an important step in experimental physiology. Work continued uninterruptedly, and by the middle of the century (1863), Blasius had collected 116 cases of transfusion, performed during the preceding forty years, and found* 56 successful results. In two cases alone, the serum was from animals, and in all cases the indirect method was used. Men became highly enthusiastic, great claims were advanced for transfusion and many operative methods were devised, but it soon became apparent that these claims were unfounded after Landois discovered that heterogeneous blood could not be used because of red blood corpuscular destruction, and Blasius' defibrinated blood was found dangerous because its fibrin ferment caused coagulation. The general introduction of normal salt solution, about 1875, brought about a gradual decline in the transfusion of blood until 1880, when it was again revived and followed with vigor until today. I had the good fortune recently, to learn through personal com- munication, the details of the first transfusions done in America by Dr. W. S. Halsted. He had several patients suffering from carbon monoxide poisoning, whom he treated by withdrawing blood, defibrinating the same and re-fusing it into the same indi- vidual. These were all arterial in nature, the blood being returned in the centripetal direction. We shall now turn from the historical aspect of our subject, in an effort to study the individual who is best suited to act as a donor. It is of such importance to select the right person that in our largest clinics these people are hired and kept ready to meet any emergency. 5 A Wassermann reaction must be made on them, as in the case of every other donor. 598 AFTER-TREATMEXT OF SURGICAL PATIENTS Lewisohn reminds us that "the following important facts ought to be kept in mind in connection with this question: 1. Donors can not he used a second time for the same patient without another test as to hemolysis and agglutination. 2. Blood relatives (parents and children, brothers, etc.) have to be tested just as thoroughly as strangers, as their blood often is very incompatible in spite of their near blood relationship. Cherry and Langrock have asserted that in newborn infants the mother's blood can always be used with perfect safety for a transfusion. Other workers, however, do not agree with this statement." These donors are selected by the method of Moss. 1 which is based on the principle that before the serum of one blood will cause an hemolysis of the corpuscles of another, it will first or simultaneously cause an agglutination of the corpuscles. The reverse, that all eases which show agglutination will also show hemolysis, is not neces- sarily true, occurring in only about 20 per cent of cases. Adopting this principle, all bloods are classified according to the agglutina- tive properties of their elements, into one of four groups. In se- lecting the donor then, it is advisable to have one whose blood belongs to The same group as that of the patient. If this is im- possible, the donor's blood should belong to a group whose corpus- cles are not agglutinated by the serum of the patient. Group I. — Serum does not agglutinate corpuscles of any group. Its corpuscles are agglutinated by serum of 11. Ill and IV. Group II. — Serum agglutinates corpuscles of (iroups I and II. but not IV. Corpuscles are agglutinated by serum of Groups 111 and IV. but not I. Group III. — Serum agglutinates corpuscles of Groups I and II. but not IV. Corpuscles agglutinated by serum of (iroups II and IV. but not I. Group IV. Serum agglutinates corpuscles of (iroups I. II. and III. Corpuscles are not agglutinated by any serum. Seven per cent of all donors belong to Group I; 40 per cent to Group II; 10 per cent to Group III : and 4:1 per cent to Group IV. The serum of one group will not agglutinate the corpuscles of blood belonging to the same group. In grouping the bloods, the unknown blood should be tested with a blood whose group is known. This "standard" blood must be- Long to either (iron]) II or III in order to be of value in grouping oilier blood. The group to which a blood belongs remains constant. It is in >1 influenced by age, disease or transfusion of blood belonging to another group. BLOOD TRANSFUSION 599 Technic. — A puncture wound is made in the finger and eight to ten drops of blood are allowed to flow into a small, clean, dry test tube. From five to eight drops are allowed to flow into a second tube that contains 2 to 3 c.c. of V/ 2 per cent sodium citrate solution. These tubes are centrifuged for five minutes. The fibrin and blood cells in the first tube will have clotted and settled to the bottom, allowing the clear serum to remain on top. The corpuscles of the second tube will have settled at the bottom. The supernatant fluid in this tube is carefully withdrawn and 2 to 3 c.c. salt solution are added to the corpuscles to wash them. This tube is again centri- fuged for 3-5 minutes. The supernatant fluid is withdrawn by a pipette and a 5 per cent suspension of the corpuscles in normal salt solution is made. The standard blood of the known group is pre- pared in the same manner. Then using a platinum loop, a loopful of the 5 per cent suspension of corpuscles from the blood to be grouped, (blood A) is placed on a clean cover-glass. Two loopfuls of serum of the standard of known blood (B) are placed on the same cover-glass. To prevent a possible masking of agglutination by an accompanying hemolysis which occasionally takes place, a loopful of serum of blood A is also placed on the cover-glass and all carefully mixed, and the cover-glass is placed on a hanging glass slide. If there is to be any agglutination, the clumping of the cells can be seen under the microscope in from one to three minutes. Macroscopic-ally, if there is agglutination, a brick-dust sediment will be seen in the drop. A second drop is made by using one loop- ful of 5 per cent suspension of corpuscles from blood B. one loop- ful of serum B, and two loopfuls of serum of blood A. The results of these drops are noted and then compared with the chart of groups. By using this method, blood can be grouped in from 30 to 40 minutes, and after a patient is once grouped, he does not have to be subsecfuently inconvenienced by having his blood reexamined if a second donor is to be used. Minot 7 states that hemolysis will not occur always even if the donor and recipient do not belong to the same iso-agglutination group, since only 20 per cent of sera that are agglutinate are hemolytic. Hemolysis never occurs without agglutination. Lindeman s has found that the preliminary blood tests for hemoly- sis and agglutination as done by various serologists do not always agree, and therefore are not reliable, so he examines the blood him- self, the technic being as follows: The red blood cells of the pa- tient and donor are washed three times with normal saline ; va- 600 AFTER-TREATMENT OF SURGICAL PATIENTS riable quantities of patient V serum are placed in three separate small test tubes; to each of these is added 0.25 e.e. of a 2 per cent suspension of washed blood cells of the donor. The same is done with the donor's serum and the patient's eells. Controls are made of donor's serum and donor's eells. patient's serum and patient's cells. Controls arc also made with donor's eells in normal salt solution and patient's eells in normal salt solution. The total volume in each tube is raised with normal saline to 0.5 c.c. of volume. The test tubes are incubated in a water-bath for a period of two hours, and readings are made. They are then set into the ice box overnight and readings arc again taken the following morn- ing. When a case i- urgent, the ice box test is eliminated. Since Lindeman has applied his technic of testing donors, his last 155 transfusions by the syringe cannula system have been per- formed without the loss of a single case hy death. Chills followed by a rise in temperature occurred in 16 instances. He has found that hemolysis never occurs without chills and fever unless the pa- tient dies during or shortly after the transfusion, lie infers there- fore that chills and fever in transfusion are due to hemoglobin set free in the circulating Mood. If the hemoglobin set free "s abundant, it appears in the urine; when the amount is moderate hematoporphyriu appears in the urine. It would appear to him that four conclusions as to ineompatability are warranted. 1. The preliminary hemolytic and agglutination tests when properly performed are reliable. 2. Incid hemolysis in transfusion can be eliminated en- tirely. 3. The reactions which follow transfusion when accurate tests have been made are eliminated in all except per In this per cent, chills and :'• :eur. When the quantity is 800 c.c. or less, chills and fever do not occur. 4. By careful, accurate, and complete hemolysis and agglutinin tests s anted that work is done skillfully, blood transfusion is robbed of all danger attending its use. Ottenberg and Kaliski estimated that there are toxic reactions, nut referable to agglutination or hemolysis, in 10 per cent of all -. as based on their own series "i 128 cases. < >ttenberg and Libman in their series of 212 eases of transfusions, in summarizing the untoward results due to transfusions, assign the most unfavorable reactions of their scries, including 5 deaths, to "incompatible hi 1" meaning hemolj « 'glutinatiou only or to hypertransfusion. They stal appeared in 1<> per cehl BLOOD TRANSFUSION 601 of all cases, skin eruptions, usually urticarial, occasionally petechial, appeared in another 10 per cent. In referring to the hemolytic and agglutination reactions as being an insufficient guide to the value of a given donor's blood for the purpose of stimulating a remission of the disease in pernicious anemia, they make the state- ment that "there are probably other not yet recognized dif- ferences between the bloods of donors." Lewisohn 10 reports 5 febrile reactions and 3 chills in 22 trans- fusions. Two cases with favorable agglutination and hemolysis tests, in which there were toxic reactions, are reported by Cooke in a series of 12 transfusions. Those with experience in blood transfusions have observed cer- tain toxic symptoms varying all the way from a slight chill and rise in temperature to marked anaphylactoid phenomena, and even death has occasionally resulted as the immediate sequela to trans- fusion even where the serologic tests for hemolysis and agglutina- tion have been entirely favorable. To explain this the three fol- lowing hypotheses have been suggested by Pemberton : 1. It is possible that trypsin-antitrypsin balance in the circulat- ing blood of the recipient may be so disturbed by the commingling with the donor's blood as to result in the immediate formation of serotoxin from cleavage of serum protein. 2. It is possible that the action of the protective colloids in the body cells of the recipient may be so disturbed that these cells are thereby exposed to a reaction of antigen and antibody present in the circulation of the recipient but harmless to the protected cell. 3'. There is the possibility of a toxic disturbance in the circula- tion of the recipient by the introduction of blood which, though per- fectly fluid, may nevertheless be undergoing incipient coagulative changes due to physical influences to which it is subjected in proc- ess of transfer. Now, having read the laboratory side of this important border- line subject, let us note the opinions of three experienced surgeons on it. Deaver 11 claims that too much mystery has surrounded blood transfusion and that most of the instruments for its performance are too complicated, and therefore can be of little use to the sur- geon. He points out that in 25 per cent of all cases transfused, hemoly- sis occurs. Too much attention can not be given the donors. The methods of Crile, Brewer, McGrath and others are criticized be- 602 AFTER-TREATMENT OF SURGICAL PATIENTS cause amount of blood transfused can not be measured, and while Beaver does not believe it necessary to be absolutely exact, he thinks it is best to keep within the limits of safety, for some cases require only small amounts. He employs the spurt method to de- termine the amount of blood used, the radial artery being selected because of the driving force of the heart. The blood is allowed to spurt into a small graduate; if it takes 5 spurts to reach the dram mark, each spurt will contain 12 drops, and a pulse of 80 will there- fore discharge 2 ounces in one minute. This is considered as ac- curate as il is simple. 7. — Instruments and material used in direct M 1 transfusion. The authors have had no experience with this and therefore do not endorse it, as interesting as it sounds. Percy 12 finds that the tests for hemolysis and agglutination in vitro as described by Rons and Turner, arc not dependable, and he gives a preliminary transfusion of 20 c.c. of blood intravenously by hypodermic syringe, believing that this amount of blood will in- dicate hemolytic phenomena without serious sequelae, or the full expression of the cardinal signs of fatal hemolysis which are: vomiting, respiratory distress, pain low in the back, a characteristic flush and profuse sweating followed by pronounced chills and sup- pression of urine. BLOOD TRANSFUSION 603 Blood transfusion is in reality a homologous transplant of liv- ing tissue, the tissue being a complex fluid which possesses the ability to coagulate under certain conditions. 13 According to Hart- well, who bases his opinion upon a study of the recent literature, a small dose may produce the same effect as a massive one by chemical reaction. The only condition in which a massive trans- fusion of whole blood seems indicated is after a . loss, from direct hemorrhage, of such severity that life is endangered because of in- sufficient blood to maintain oxygenation. There can be no argument against blood transfusion, properly performed, in cases of acute Fig. 198. — Dissecting out the vein. hemorrhage, the object being to replace the blood which is lost. The red cells, while quickly destroyed, serve as oxygen carriers and may tide over an emergency until the bone marrow can re- place the lost cells. The indications for blood transfusion in addition to the above are as follows : 14 1. Marked secondary anemias, either as a palliative, or as a preoperative measure. 604 after-treatment of surgical patients 2. Essential anemias. 3. Blood dyscrasias, if fresh human serum 23 injections or throm- bin are ineffective. 4. Disorders in the process of coagulation with increased sus- ceptibility to hemorrhage. 5. Deficiency of the respiratory elements sufficient in degree to impair the integrity of vital organs. 6. Chronic localized infections of known etiology amenable to treatment, immunized blood should be used in such case-. The ideal technic for transfusion involves four factors: absolute 99.- — riacing the waxed black silk cloth under thi asepsis; no blood change; ability to measure the quantity trans- fused: and ease of accomplishment for donor, recipient and operator. Of the three met hods in vogue, the direct intima to intima suture method, popularized by Carrell, and the intima to intima cannula method of Payr. Sweel and Crile (Figs. L97 to 204 . are difficult procedures and no measure of the amount transfused can be re- corded. The second direct method, the employment of a paraffin- coated tube as a connecting link between donor and recipient, is also far from ideal, as no quantitative estimation is possible and the danger of clotting is always present. In both of these, the re- BLOOD TRANSFUSION 605 eipient may infect the donor, while there is a real psychic clanger to both individuals as a result of coupling them together. The third and best method is an indirect one employing an in- termediate receptacle, either making the transfer so rapidly that the blood has been drawn and discharged into the recipient's vein in less than normal coagulation time, or by the simpler plan of adopting means to delay or prevent coagulation. The indirect methods possessing a clinical value are of three gen- eral forms: (1) Those employing syringes. (2) Those employing anticoagulates. (3) And those employing receptacles of which the Kimpton-Brown serves as a type. Pig. 200. — Placing bull dog clamps and oiling vein with a lubricant. A good syringe • method was described by Lindeman, 15 whose technic is as follows : Specially devised cannulas are painlessly in- serted into the veins of the donor and patient without the skin incision if possible. About 15 syringes are used. No syringe is used a second time until thoroughly cleaned. One operator manages the syringe of the donor and another that of the patient. One syringe is being filled while the other is emptied. A little salt solu- tion is allowed to trickle through the cannulas every now and then to prevent the possibility of any coagulation in them. It requires from six to twelve seconds to fill and empty a syringe. The largest 606 AFTER-TREATMEXT OF SURGICAL PATIENTS quantity of blood be has taken from one donor in one sitting is 1500 c.c.: the time required was fifteen minutes; 30 e.e. salt solution was used. Since the coagulation time of blood drawn into a syringe is never less than five minutes, and in this method the blood is no longer in the syringe than twelve seconds, coagulation is almost out of the question. Adults received from 1000 to 1800 c.c. in each transfusion, and the quantity stated was always taken from one donor. Xo foreign substance or anticoagulant was em- ployed in any case. By this technic the entire mass of blood is out- Fis -Win cut in ■ , I put through at one end, hemostat al out vein with saline. Washing side the body only for a period of from six to twelve seconds, re- gardless of tin- amount transferred. It passes through a minimum amount of foreign material. Miller 16 , in the hope of finding a method of performing blood transfusion which would overcome all objections to the multiple syringe method of Lindeman, devised a valve, which consists of a central body, a cylinder 1.5 inches long and 0.5 inches in diameter, with two arms extending in opposite directions. From the middle of the central body projects a cylindrical stem jusl large enough BLOOD TRANSFUSION 607 Fig. 202. — Drawing donor's vein through cannula. Fig. 203. — Vein drawn back and tied at second notch on cannula. Oil dropped into vein to prevent drying of surface. 608 AFTER-TREATMEXT OF SURGICAL PATIENTS to receive the tip of a record syringe. The two arms are connected to pieces of 12F. rubber tubing, three inches long. In the distal end of each tube a metal tube is inserted, which fits two cannulas and needles used for donor and recipient. By moving a thumbscrew back and forth, the current can be directed into either arm. By withdrawing the piston, the syringe is filled with blood, the thumb- screw is changed toward the recipient's arm and the syringe emp- tied rapidly. The operator continues to alternate the direction of the thumbscrew, filling and emptying the syringe, without discon- necting it from the valve, until the desired amount of blood lias been transfused. Placing and tying recipient's vein over cannula. Lewisohn's 10 work was begun with the idea of simplifying the technic of blood transfusion. The objed of this work was to find an atoxic anticoagulant which would prevenl the blood from clotting during the transfer from donor to recipient. From a series of animal experiments the following facts were elucidated : 1. Sodium citrate mixed with blood in the ratio of 0.2 per rent will prevenl the blood from (dotting for two to three days. 2. The coagulation time of the recipient's blood tested after tlie BLOOD TRANSFUSION 609 transfusion of citrated blood, is shortened, but after a few hours the coagulation time again becomes normal. 3. Sodium citrate is only conditionally atoxic. Animal experi- ments show that if 1 per cent instead of 0.2 per cent citrate is present in the blood, transfusions of large amounts of citrated blood are fatal. The author gives detailed reports of 22 blood transfusions per- formed by this method. The largest amount transfused at one time was 1000 c.c. In one case, 1600 c.c. were given to a patient within 24 hours. Xo untoward symptoms occurred in any of the cases. Some showed a moderate polyuria, caused by the introduction of the citrate. There were no macroscopic or microscopic changes in the urine. Hemoglobin tests taken a few days after the transfusion show that the citrated blood is clinically as valuable as unmixed blood. Even hemorrhagic conditions are no contraindication against the use of this method, as the coagulation time of the recipient's blood is shortened after the transfusion of citrated blood. The new method offers the following advantages as compared with the older: 1. The citrate method is technically as easy as an ordinary saline infusion, therefore, it does not require any special skill. 2. The donor and recipient are not in the same room, which lessens the psychic shock for the patient. Furthermore, it eliminates the risk of infecting the donor in cases of sepsis. Perhaps no one is more adept at carrying out the citrate trans- fusion than J. de J. Pemberton of Eochester, hence, I give in ex- tenso, his technic as related at the 1916 meeting of the Minnesota State Medical Society. "Since December, 1915, we have been using the citrate method almost exclusively and in this series we have employed it in 217 cases. The criticisms of the method such as the resulting polyuria, the crenation of the red corpuscles, the idiosyncrasies to citrate, the exposure of the blood to air and contamination, are all un- substantiated in the clinical application of the method. In no patient have we seen following the transfusion any untoward effect which could be attributed to the toxicity of the drug. The simplicity and sureness of technic, the safety of its employment and the proved therapeutic value of the citrated blood should recommend the method for a more extensive adoption. "The arm of the donor is prepared in the usual manner, a tourniquet is lightly applied above the elbow and the vein (medium (ill) after-tri:atmi-;nt of surgical patients cephalic or medium basilic) is either punctured with a large-sized needle or exposed by a small incision and a cannula introduced (Fig. 205). By a simple yet very ingenious little trick advised by Watson, we have been aided greatly in introducing a large-sized Kaliski (gauge 11) needle (Figs. 206 and 207) into the lumen of Fig. JO?. — Citrate transfusion as done by Pcmberton. the vein. By means of a small straight intestinal needle inserted transversely, the vein is transfixed to the skin, the needle passing through its upper segment (Fig. 208). With the end of this trans- fixing needle as a handle, the vein is then steadied and the can- BLOOD TRANSFUSION 611 nula needle, directed parallel with the line of the vein, can be readily pushed beneath the level of the transfixing needle into the lumen of the vein (illustration). The blood is received in a sterile graduated glass jar containing 30 cubic centimeters of a 2 per cent - 1 ' Fig. 206.— The Kaliski needle. ■ j . . * ! \mmmm J n ! , Fig. 207. — The Kaliski needle separated into its component parts. sterile solution of sodium citrate at the bottom (Fig. 209). While the blood is running it is well mixed with the citrate solution by means of a glass rod. After the blood has reached the 250 cubic centimeter mark, another 30 cubic centimeters of the citrate solution 612 AFTER-TREATMEXT OF SURGICAL PATIENTS is added and the blood permitted to flow until there are 500 cubic centimeters of the mixture. If more blood is desired, a sufficient amount of the citrate solution is added to maintain this ratio of .2 per cent. "The blood may be carried to the recipient's room or the re- cipient brought into the operating room. The needle is then in- troduced into the recipient's vein or the vein is exposed by a small incision (Figs. 210-214). The cannula is introduced and attached to ;i funnel or "lass irrigating flask. The rubber tubing and the bot- -\ S Kin Von or Fig. 208.— The transfusion needle introduced by the vein transfixing method. (After Pem- berton.) lorn of the flask arc filled with saline solution to prevent air from getting into the circulation. The citrated blood is then transferred into the Hash and permitted to How into the vein of the recipient (Figs. 215-217). There is no occasion for hurry as the blood will not clot. On the other hand, it is advisable to have the blood run in slowly in order to guard againsl suddenly overloading the right heart and in order to watch for any untoward effect upon the pa- tient. The marked slowing of the pulse, syncopal attacks, dyspnea. cyanosis, sensation of cardiac oppression or excruciating pains BLOOD TRANSFUSION 613 throughout the body, especially localized in the small of the back, should be interpreted as danger signals, and if these persist after temporary stopping of the flow, it is advisable to conclude the op- eration at once." I failed of a result in two instances because the mixture of blood and citrate solution clotted. Knowing of Dr. Pemberton's success in hundreds of instances, I wrote him for advice. The reply re- ceived is so illuminating that I give it in full. 17 "In perhaps three or four cases I have met with the complica- Fig. 209. — Mixing the blood with citrate solution. tion which you mention of having the blood show a tendency to coagulate. In two consecutive cases the blood clotted en masse. This was proved to be due to faulty preparation of the citrate solution in which the proper percentage of citrate was not made. The other instances have been encountered in cases in which the blood does not flow freely from the vein of the donor, in which the tourniquet has been improperly applied, when the vein is very small or iu cases where the patient has become faint and blood pressure 614 AFTER-TREATMENT OF SURGICAL PATIENTS has fallen. In such instances there is very likely to occur some change in the coagulability of the blood before it has reached the citrate solution, (probably prothrombin has been converted into thrombin . and when the mixture has been allowed to stand for ;i Fig. 210. — The recipient's it can not be punctured. c vein where skin incisi< short time clotting takes place. Of course these eomplications can be easily prevented." Lewisohn 18 wrote in 1 !• 1 7 that "five gm. of sodium citrate can be introduced safely into an adult. Larger amounts are extremely BLOOD TRANSFUSION 615 toxic. We rarely transfuse more than 1000 c.c. of blood, which "would represent 2 gm. of sodium citrate. However, even a trans- fusion of 1500 c.c. of blood would require only 3 gm. of sodium citrate, a perfectly safe dosage." "With this in mind, I have in my recent work ventured to modify the original procedure to the extent of using 50 c.c. of 3 per cent sodium citrate to each 500 c.c. of blood. I have been uniformly successful since doing this and feel that I can recommend the modification as tending to facilitate the procedure and to render the result certain. The citrate method is believed by us, destined to supersede all the others. The latter are not recommended as its equals, but given merely for the sake of completeness. Fig. 212. — A form of cannula which may be tied in recipient's vein if not punctured. I have no wish to confuse my readers by giving methods which I do not recommend or use, but feel that knowledge of the subject requires a perusal of the work of Satterlee and Hooker, 19 who employ pipettes which have been coated with 20 to 30 c.c. of a 10 per cent solution of sodium citrate. The fluid is poured into the pipette just previous to use and by rotating the instrument in a horizontal position, the interior is thoroughly coated. The excess is allowed to drain out through the tip, leaving about 1 c.c. of the solution which adheres as a thin film to the glass wall of the cylin- der. This amount of sodium citrate (100 mg.) is sufficient to trans- fuse 250 c.c. of blood when used with their cannula, and the only 61G AFTER-TREATMEXT OF SI RGK AL PATIENTS Fig. 21 entering recipient's vein. BLOOD TRANSFUSION 617 fully citrated blood is the small (about 12 c.c.) residual portion which is retained in the pipettes. Only 38 nig. sodium citrate per 100 c.c. of blood is necessary for transfusion by this technic. Weil 20 combines the syringe and anticoagulant methods in this way: the blood is aspirated from a vein and is at once well mixed with sodium citrate in a 10 per cent solution in water, in the pro- portion of 1 c.c. of solution to 10 c.c. of blood. If the mixture is made in the syringe in eases in which not more than 50 c.c. are to be transfused, the transfer can be made directly from donor Fig. 215. — Funnel tube and a form of cannula which can be used on recipient. to donee. If larger amounts are to be used, the blood is expelled into a flask, from which the syringe is filled. In drawing the blood it is well to use a three-way stopcock having communications with the needle, with a 10 c.c. syringe containing the citrate and with a large aspirating syringe. Kimpton and Brown 21 have devised a method which in point of usefulness stands next to that of Lewisohn (citrate). Their appa- ratus consists of a glass cylinder of whatever size desired, (300 to 600 c.c), closed at the upper end by a cork stopper, having a 618 AFTER-TREATMENT OF SURGICAL PATIENTS side tube a little below the cork, and a cannula leading from the bottom of the cylinder at such a curve that it will lead from the Fig. 216.— Th Fig. 21! venient compress which is included in the ends of the suture. upper convexity of the cylinder when the latter is placed on its side with the so-called side tube uppermost. BLOOD TRANSFUSION 619 "The cannula bends downward just after leaving the cylinder at a right angle. From the last bend the cannula should not be more than 2 or 3 inches long, should taper gradually, and terminate in a beveled and burnished point about 2 or 3 mm. in diameter. "A small piece of pure, clean paraffin (melting point' 50° C, 122° F.) is placed in the cylinder and the cork pushed into place. The whole cylinder is then wrapped carefully in a towel, placed on its side in an autoclave and sterilized in the same manner as are dressings. At the time of the operation, the sterile tube is unwrapped by the surgeon and held above the flame of a Bunsen burner (Fig. 218), alcohol lamp, or other source of heat, and carefully revolved un- til the melted paraffin has covered all portions of the inner surface of the cylinder, cork, and the side tube as far as the constriction. Fig. 218. — Paraffin coating in process of application. Finally the excess is allowed to run out of the cannula, while the tip is held against a sterile gauze sponge. To avoid excessive crystallization of the paraffin, the cylinder should be cooled as quickly as possible by being brought into contact with the operator's hands. A small piece of sterile absorbent cotton is next loosely inserted into the side tube as far as the constriction, to prevent contamination from the air, and the cylinder is ready for use. Convenient veins of both donor and recipient having been bared previously, a ligature is thrown around the donor 's vein proximally and around that of the recipient distally. Traction is made on the ligature around the vein of the donor, thereby elevating the vein, which is opened longitudinally with a cataract knife. The edges of the incision are held apart with mosquito forceps, small tissue 620 AFTER-TREATMENT OP SURGICAL PATIENTS forceps or fine hooks, and the tip of the tube, directed peripherally, is inserted into the lumen of the vein. The donor is directed to open and close the hand slowly, and this pumping effect causes the tube to fill very quickly (Fig. 219). A ligature around the arm above the incision will increase the rapidity of flow, but its use is Fig. 219. — Blood running into tube from donor. not always necessary. The vein of the recipient is now opened and the tip of the tube inserted, directed centrally. The cautery bull) previously sterilized or the operator's mouth (Fig. 220) is at- tached to the side tube and very slight pressure is exerted. The BLOOD TRANSFUSION 621 blood flows into the vein at a rate which is always under the con- trol of the operator." If more blood is desired, the operation is repeated with a fresh tribe, otherwise nothing remains to be done except to close the small wounds made in exposing the veins. The advantages claimed for this method are: 1. Known quantity of blood may be administered. 2. As much as 1600 c.c. can be given in 5 to 8 minutes. 3. Venous blood is utilized, so that arteries, such as the radial are not destroyed. Fig. 220. — Blood being driven into recipient's vein. 4. Transfusion may be made without contaminating the donor with the blood of the recipient. 5. There is direct communication between vein and chamber by a simple paraffin lined glass tube. There are no metal, rubber or other connections, whose edges cause resistance to the flow of blood. 6. The apparatus is simple and can be made by any good glass blower. I have never failed with this method, but must say that it is a real surgical operation. On the other hand, any physician, not an operator can do a citrate transfusion. 622 AFTER-TREATMENT OF SURGICAL PATIENTS Percy 12 reports 54 blood transfusions effected by means of a one- piece paraffin lined, glass tube i Pig. 221), holding 650 c.c. of venous i 1 The Pi blood protected from contact with air by a floating layer of sierile liquid paraffin. His method is. in reality, an enlargement and re- BLOOD TRANSFUSION » 623 finenient of the Kimpton-Brown idea. Percy is an expert operator and does his transfusion with a dexterity that will never be at- tained by most men. Thies first suggested the reinjection of the blood that collected in the abdominal cavity in cases of ruptured extrauterine pregnancy. He used whole blood diluted 3 to 2, with normal salt solution in three cases and saved them all. This method is thought too danger- ous on account of embolism, so Lichtenstein 22 injected 8 patients only after the blood had been mixed with a little Einger's solution and defibrinated. During the process of defibrination and all the time the blood was out of the body, it was kept warm (body tem- perature) by being surrounded by warm water. After the abdom- inal operation the blood was injected into a vein in the arm. Lieh- tenstein uses a contrivance similar to a salvarsan apparatus and finds that it works well. Henschen collects the blood in paraffined receptacles, strains it through paraffined gauge, or adds sodium citrate and then reintro- duces it into a vein with the Percy transfusion instrument. I feel compelled to caution the reader who intends to transfuse for the immediate treatment of profuse hemorrhage, that there is always danger of a sudden rise in blood pressure, leading to re- newed bleeding from the original source, provided the hemorrhage is not known to have been accurately controlled. AVe cruestion the advisability of transfusion where bleeding is in progress, when it has been controlled by packing, or when it has ceased spontaneously upon lowering of blood pressure. A caution regarding the danger of plethora may not come amiss. Too voluminous or too rapid a transfusion may not only exhaust the donor but kill the recipient, hence, critical observation of both must be maintained, regardless of the method used. AVhen a donor evinces faintness or shortness of breath, he has reached the danger point. Danger signals from the recipient's side, will be referable to the heart: Adz., precordial distress, restlessness, and shortness of breath. On examination there will be found fast pulse or later gallop rhythm, increased absolute cardiac dullness to the right, prominence of superficial veins, general cyanosis, and lastly subcrepitant rales, denoting pulmonary edema. As Pemberton writes: "There are two other well-recognized ac- cidents associated with and complicating blood transfusion, namely, embolism from introduction of air or clotted blood and hemolysis. The first of these is absolutely preventable by the exercise of due caution as to the technic. The third danger due to the incompati- 624 AFTER-TREATMENT OF SURGICAL PATIENTS bility of the blood of the donor and the blood of the recipient, while controllable to a remarkable degree by preliminary blood tests, is not an absolutely preventable complication." I can not call this chapter complete without mention of hemo- lysis occurring at a time when we chance it as the lesser of two evils. Pemberton writes: "In an emergency such as that following an acute hemorrhage when the life of the patient is dependent on an immediate transfusion, Ave are justified in using a donor without a preliminary test. In such instances the operator should permit the first 200 c.c. of blood to run in slowly. If the patient shows symptoms of hemolysis as evidenced by suffusion of the face, dysp- nea, syncopal attacks, marked slowing of the pulse rate and ex- cruciating pains in the back, the operation should be concluded or another donor secured." After this chapter had been senl to the publisher my coworker. Dr. George W. Ives very kindly consented to contribute an up-to- the-minute resume of the subject, which follows: The Selection of Donors for Transfusion It is obvious thai for donors healthy adult individuals should be selected whenever possible. Particular care should be exercised not to selecl as a donor an individual who is suffering from syphilis, malaria, or any other disease which may be transmitted by blood transfusion. Of even greater importance, as regards the immediate interests of the patient, is the desirability that the donor's blood be compatible with that of the recipient. Serious symptoms, and even death, have occasionally so closely followed t ranst'usions as to indicate that they are ihe result of the procedure. It is wry probable that nearly all serious effects of transfusion can he attributed to the administra- tion of incompatible blood. The accompanying diagram on page 625, which was devised by San- ford.- 1 I have found of extreme value in gaining a comprehension of blood grouping as regards isoagglutinins ; and without this dia- gram, I have usually found it impossible to make the subject elear to students and clinicians. As a practical proposition isohemoly- sins may be neglected, since when they are present, they fall into groups which parallel the isoagglutinin groups. Among other facts, the diagram illustiates that all individuals may he divided into four groups as regards the presence of iso- BLOOD TRANSFUSION 625 hemagglutinins in the blood serum. Group I includes those per- sons who hare no agglutinin, and constitutes 10 per cent of all in- dividuals; Group II includes those who possess agglutinin "A," and constitutes 40 per cent of all individuals. Group III includes those who possess agglutinin "B," and constitutes 7 per cent of individuals; and Group IV constitutes 13 per cent of individuals, and they possess both agglutinin "A" and agglutinin "B." A fundamental conception in an understanding of these blood relationships is this self-evident fact: The corpuscles of a person are immune to the agglutinin or agglutinins which may be present in their blood serum. Experiment has taught that corpuscles are always susceptible of agglutination by any agglutinin which is not naturally present in their serum. From these facts it follows that Group I serum will not aggluti- nate the corpuscles of any of the groups; that Group I corpuscles, [7Jo Agg luTinin ) ( I Agglutinin )~3" [ID fi of all perscns) (J% of all persons} X K * \Jir 3Z. (l/feglutin/n) "A" (BoTh agglutinins)'*)"*'!}" {1D% of all persons) [AJfo of ail persons) since they are not protected against either agglutinin "A" or "B," will be agglutinated by the serums of the other three groups; that Group II serum, because of the presence of agglutinin "A," will agglutinate the corpuscles of both Group I and Group III, but it will have no effect on Group IV corpuscles, as they are protected against agglutinin "A;" that Group III serum will agglutinate the cor- puscles of Group I and Group II, but it will have no effect on Group IV corpuscles, as they are protected against agglutinin "B;" Group IV serum will agglutinate the corpuscles of the three other groups because Group I corpuscles are susceptible to both agglutinins, Group II corpuscles are susceptible to agglutinin "B." and Group III corpuscles are susceptible to agglutinin "A." A prospective donor's blood presents three possibilities of rela- tionship to a prospective recipient's blood; viz., (1) The relation- ship is called ideal when donor and recipient belong to the same 626 AFTER-TREATMENT OF SURGICAL PATIENTS group; (2) The relationship is suitable when they belong to differ- ent groups, and when the recipient's serum will not agglutinate the corpuscles of the donor; (3) The donor is definitely not suitable when his corpuscles are agglutinated by the serum of the prospec- tive recipient. I know of no evidence which definitely disproves my tentative belief that from a practical standpoint the relation- ship in the second instance is as ideal as when donor and recipient belong to the same group. If this is true, the only contraindication to blood transfusion, on the basis of blood relationships, is the third relationship. A close analysis of the statements set forth shows that as a prelim- inary to transfusion, the grouping of the donor or recipient is nor imperative. The only requirement is that the recipient's serum docs not agglutinate the donor's corpuscles. It is highly advantageous in many instances that the grouping of the recipient and the donors be known. As it requires no more labor to determine the grouping than it does to determine the minimum information which is re- quired, it is my practice to always determine the groups. This i> easily carried out when a "standard" blood is available, and it possesses the advantage that an individual who is once grouped need not at a subsequent time lie tested, whether he is a recipient or a donor. Besides facts previously stated. Sanford's diagram illustrates the following important points: Group I individuals may receive the blood of the same group, and, as indicated by the arrows, the blood of all other groups. Any one may he a donor for 10 per cent of persons (Group [). Group II may receive the blood of both Group II and Group IV. Forty per cent of individuals may, Iherefore, receive the blood of 83 per cent of all persons. Group III may re- ceive the blood from Groups III and IV, or 50 per cent of all per- sons may be donors to this group. Group IV may receive only Group IV blood, hence, the Largesl group has the smallest number of suitable donors, but the members of this group may be donors to the members of all the groups. Hence, if a Group IV donor is available, it is not imperative that the grouping of the recipient be determined, and if it is known thai the recipient belongs to (I roup I, it is unnecessary to determine the grouping of the donor. Several methods for group determination have been proposed. Certainly, a method which possesses simplicity, which furnishes all the information desired, which requires a minimum of time, which BLOOD TRANSFUSION 627 requires minimum amounts of blood, and which requires no special apparatus, should he selected in preference to those methods which give less certain and less rapid results, and which require more labor and considerable amounts of blood. The writer recommends the method of Brem 24 because it possesses the following advantages: (1) It gives the complete information re- quired. (2) The test is performed with ordinary apparatus. (3) It requires less than thirty minutes in a laboratory where these tests are commonly made. (4) It requires only a few drops of blood. Brem's method may be used either to determine the suitability of the donor's blood without grouping, or it may be used to deter- mine the grouping. For the purpose of the latter determination, either Group II or Group III blood must be available. This known blood, with which the unknown bloods are matched, is called the "standard." Two centrifuge tubes are required for the "stand- ard" blood, and two for the blood of each person to be tested. The first tube of each pair should be clean and dry, and the second tube should contain about 1 c.c. of one per cent sodium citrate in 0.85 per cent sodium chloride. The blood is obtained preferably from a finger. Into the first tube about ten drops of blood are collected. One or two drops are obtained for the second tube, and immediately it is mixed with the fluid in that tube. The corpuscles should again be well mixed, just before they are used. After the blood specimens in the first tubes of each pair have clotted, the clot is separated from the glass by means of a platinum wire, and the tubes are then centrifugalized until the serums are clear. For a group determination, each blood requires two hanging drop preparations. The concavities of the slides should be rimmed with vaseline for the following reasons: (1) The vaseline seals the cham- bers and prevents the evaporation of the preparations. (2) It holds the inverted coA^er glasses on the slides. (3) It enlarges the cham- ber for the hanging drop. The test is performed and the results interpreted as indicated by the following scheme: Groups /i hi ii Til 2Loops Group 2. Serum + i 'Loop (?) Serum*- 1 Loop (?) Gorp ~ 4- J— ' •—'-♦- 2 Loops! ?) Serum + I Loop Group 2 Strum + 1 Loop GroupQ Corp= •+ J — \-h\ — 628 AFTER-TREATMENT OF SURGICAL PATIENTS In each preparation, our loop of serum, corresponding to the cor- puscles of that preparation, is used. The purpose of this serum is to protect the corpuscles against hemolysis. In the above scheme (?) indicates "unknown," (+) indicates "agglutination," and (-) indicates "no agglutination." It will be noted that with an unknown blood four results arc possible. If in both preparations there is agglutination, the tested blood belongs to Group III. This is made clear by reference to Sanford's diagram, which indicates thai a blood whose serum agglutinates Group II corpuscles and whose corpuscles are agglutinated by Group 11 serum, belongs to Group I1T. If there is no agglutination in either preparation, the tested blood belongs to Group II. If the first prep- aration shows no agglutination, and the second does show aggluti- nation, the unknown belongs to Group IV. If the first preparation shows agglutination and the second does not, the tested blood be- longs to Group I. To increase the rapidity and accuracy of the test, the following suggestions may be of service to the beginner. The whole blood specimens should be allowed to clot completely, otherwise plasma will be used in the test and a clot may form on the cover glasses, which will prevent agglutination. The serums should be free from corpuscles. A proper loop should be used. This is one which takes up and delivers a uniform drop. The loop should be flamed before passing it from one blood specimen to another. After the required drops are placed on a cover glass, the various drops are thoroughly mixed with the loop and then the preparation is inverted over the concavity of the slide. If the slides are gently rocked or rolled, agglutination will be greatly accelerated and the results may be known in a very few moments in nearly every instance. Time ag- glutination is characteristic, it is rapid and should not be mistaken for rouleaux formation. Full credit is due 0. P. MeKittrick for having abstracted all the literature to which reference is made in this chapter. Bibliography LMcClme and Dunn: Bull. .Johns Hopkins Hosp., xviii. No. 313. -Lamlois: Transfusi les Blutes, Leipsig, L875. ■ Willinotli : Am. Jour. Surg., L916, xxx, L47. tMedico-Chirurgical Transactions, L918, ix, 56. sPersona] Communication, Mayo Clinic, 1916. gMoss: Bull. Johns Hopkins Bosp., March, L910. ?Minot: Boston Med. and Surg. Jour., 1916, clxxiv, 667. sLindeman: .lour. Am. Med. Assn., L916, Ixvi, 624. BLOOD TRANSFUSION 629 oOttenberg and Libinan: Am. Jonr. Med. Sc, 1915, cl, 36. loLewisohn : Surg., Gynee. and Obst., 1915, xxi, 37. uDeaver: Am. Jour. Burg., 1915, xxix, 10. izPerey: Surg., Gynee. and Obst., 1915, xxi, 360. isHartwell: New York State Med. Jour., 1914, xiv, 535. i^Krida: Albany Med. Ann., 1916, xxxrii, 161. i5Lindeman: Jour. Am. Med. Assn., xliii, 1542. "Miller: Long Island Med. Jour., 1916, x, 1S9. I'Pemberton: Personal communication. isLewisohn: Jour. Am. Med. Assn., March 17, 1917. isSatterlee and Hooker: Jour. Am. Med. Assn., Feb. 26, 1916. 20 Weil: Jour. Am. Med. Assn., 1915, lxiv, 425. siKimpton: Boston Med. and Surg. Jour., 1913, clxix, 783. 22Lichtenstein : Miinchen med. Wchnschr., 1915, lxii, 1597. 23,Sanford, A. H. : Isoagglutination Groups, A Diagram Showing Their Inter- relation, Jour. Am. Med. Assn., Sept. 9, 1916, p. 808. 24Brem: W. V. : Blood Transfusion with Special Reference to Group Tests, Jour. Am. Med. Assn., July, 1916, p. 190. CHAPTER LVIII THE RECONSTRUCTION OP THE PATIENT By Robert S. Carroll, Asheville, North Carolina The last dressing lias been made, the last surgical advice has been given, and with too many operators the fact of a satisfactory surgi- cal recovery transfers the patient into the limbo of the dismissed. Unquestionably, most traumatic cases can be discharged, not only "recovered," but well, when the surgeon or his assistant makes the last visit. Many of the acutely ill are promptly restored to satisfy- ing health through the surgeon's interventions; ever and anon he performs miracles in rescuing chronic sufferers from beds of torture; bul all too frequently the most astute surgical skill leaves the patient mechanically repaired but far from well — sadly lacking that robustness of health which should be the crowning p-ift of medi- cal science. There will ever be operators, unfortunately, who can be ranked as high-grade mechanics only, operators who have never seen and never will see deeper into their patient's life-processes than can be revealed by the dissection of their scalpels. But not so with the true surgeon. He recognizes that behind many cases of ap- pendicitis, gall bladder infections, gastric and duodenal ulcers, in- tractable neuralgias, 1 joint and soft tissue infections lies a depraved metabolic chemistry. He recognizes that thousands of lives of comparative inadequacy, of practical uselessness, lives of continuing years of discomfort or actual suffering persist even after the best surgical skill has been utilized in their behalf. The modern surgeon is awaking, even as the entire medical profession, to the fundamental influence of nutritional disturbances as they modify health, disease and recovery, and is recognizing thai it is his or his assistant's duty to so direct the patient that recovery may mean health. The discerning surgeon also recognizes that oilier thou- sands, whom our modern intense civilization is multiplying, are ever seeking here, there and yonder, relief from symptoms which are but the expression of over-reacting mentalities — hypersensitive, sug- gestible neurotics. The dramatic elemenl of surgery appeals with peculiar emphasis to the nervously inadequate, but Hie most astute surgical refinements leave them with their oversensitiveness un- touched, with their capacity for nervous suffering unmitigated, and l heir deficient self-mastery unrecognized and unhelped. G30 RECONSTRUCTION OF THE PATIENT 631 Scrutiny of unsatisfactory surgical recoveries shows that the large majority of them are either nutritionally or neurotically inadequate, and should be properly grouped in one or both of these classes. The surgeon who is satisfied with only the best that science can give his patient can not be content with a surgical half-cure, but will see to it that each of his cases is given that discriminating analysis which recognizes the basic cause of the baffling and depressing residuum of postsurgical semiinvalidism. The Nutritional Reeducation. — In our land of wealth and plenty, abundance of the good things of life has been at the command of the many for two generations. In our age of dazzling mechanical progress, the forces of Nature have become man's servitors. Abun- dance, even superabundance, to eat and drink is the common lot — an abundance obtained without physical effort. Meanwhile, the modern brain has become the center of human activity. Steam, electricity, and petroleum have rendered the active use of human muscle needless. Today the common nutritional defect of the suc- cessful is a broken food-oxidation balance — food oversupply, with defective muscle activity. This is evidenced especially in the per- sistent use of the tissue-building foods — absolutely necessary in youth and essential to the muscle-laborer — but continued into a ma- turity which knows only nervous activity. Such faulty dietary seldom fails .by the third, usually in the second generation, to pro- duce a disturbance in the tissue chemistry which complicates every serious operation, and frequently makes impossible an ideal re- covery. And so each painstaking worker today will know the sta- tus of his patient's nitrogenous equilibrium not only by a series of accurate urea estimates, but through an equally careful tabulation of the total ammonia elimination indices. Then, as will often be the case, if the evidence of unmetabolized amino-acid excess is revealed, clear-cut, definite and far-reachingly helpful, practical advice in nutritional readjustment can be offered. Such a condition, of course, means a reduced alkaline reserve. This relative subacidosis means defective activity, not alone of kidneys and liver, but of all cell protoplasm. In such cases, appendix, gall bladder, or other surgi- cal infection is but an incident in a generalized nutritional defi- ciency. The patient's true illness is a lowering of the vital activity of brain cell, muscle tissue, and secreting cells. In these patients many surgical complications occur — postoperative vomiting, un- expected infections, persistent anemias, which are unquestionably due to reduced phagocytic activity. Frequently so-called renal, hepatic, and pancreatic insufficiencies are but inadequate terms for 632 AFTER-TREATMENT OF SURGICAL PATIENTS a far more deep-seated protoplasmic insufficiency, secondary to the chronic subintoxication of protein malmetabolism. It is astonishing how many comparatively well people are today victims of the damage of protein overfeeding, and were it not that so large a percentage of them sooner or later become surgical risks, this prob- lem would he entirely within the province of the internist. To the muscle worker many foods are necessary fuel, which for the teacher, merchant, lawyer, and housewife can only he taken with impunity so long as liver and kidneys can stand the strain of forced elimination. In our probings into anatomic and physiologic recesses, in our theories and findings in the realm of ductless glands and the specialized activities of vicious bacterial strains, our pro- fession has unwisely neglected the profoundly vital metabolic in- fluence of thai great hulk of our body — the voluntary muscles. Multiplied pounds of unutilized semiatrophic tissue hang flabby, a near-menace, in the sedentary individual — pounds of tissue capable of responding quickly to physiologic use. pounds of tissue capable of returning unbelievable foot-tons of energy to the man or woman who will give that care to muscles which will raise them to their possible state of efficiency. Other than fresh air and sunshine, there is probably no medicine so certain in its vitalizing effect as that -which comes through a short but spirited daily use of muscles which have been normally developed and trained. For the many who have never been so developed, and who have added insult to injury, year after year, by pouring into a helpless, patient stomach the tempting, yet disorganizing viands of modern culinary skill, a nutritional reeducation will be demanded. This can not be done in a few days. bu1 is best accomplished through six to eight weeks of properly ordered resl cure, to be followed, of course, by other weeks of the even more essentially importanl work therapy. For the patient who is looking for a true reconstruction, the weeks immediately following the surgical interference are espe- cially opportune. Little medicine is needed. One or two tablespoon- fuls of coarse wheat bran, toasted brown, moistened with cream and salted to taste, taken at bedtime, and a few ounces of orange juice or equal parts of orange and grape fruit pulp taken before breakfast will usually keep the bowels in excellenl condition. Four ounces of mills with one ounce of Vichy water every two hours for seven or eighl feedings for three days, with milk and Vichy rapidly increased until the patient is getting ten ounces of milk, two ounces of cream, two ounces of Vichy, with one. two or even three raw eggs each feeding, will result in a few weeks in a profound nutritional RECONSTRUCTION OF THE PATIENT 633 reeducation. Electricity is not needed. It usually overstiniulates the nervous patient and ultimately exhausts, and except as a psychic influence, is rarely beneficial. But thorough massage for half an hour morning and evening is a most excellent, practically a neces- sary, adjunct. Small doses of a stomachic, as tincture of calamus, or gentian compound, or better, tincture of valerian or asafetida before each feeding are helpful in modifying the normally active flatus accompanying this regime. Now and then, especially after the raw eggs are being pushed, suspension of one or two feedings and the giving of one ounce of castor oil may be necessary, if evi- dences of overfeeding are present. With such treatment properly carried out, the average patient will gain 20 per cent in weight in seven or eight weeks. But this comfortably fleshed, thoroughly rested patient is but partially reconstructed. She has, however, appropriated large quantities of easily digested food, and with this nutritional reserve, is in condition to receive the help which will be essentially lasting. The transition from preparatory rest to restoring work should be started slowly. The patient may sit up ten minutes the first day, increasing ten minutes daily to one hour, and twenty minutes a clay thereafter. When up an hour, ten minutes' walk may be taken, to be increased ten minutes a day to one hour. The average patient can walk three miles comfortably in this time. The next week the walking may be increased to four miles and the following week to five. Active walking should be continued daily for a num- ber of months. Other physical exercise can helpfully be under- taken when the patient is walking three miles, any active out-of- door work, carpentering, gardening, shoveling snow in winter, medicine ball, care of the lawn — work which requires active mus- cular effort. At the end of the second period of eight weeks, the majority of patients should be really robust, fit to return home and stay well by devoting one or two hours a day to earnest muscular exercise. Such a program intelligently but firmly carried out would restore many who now are but half living — unworthy products of modern professional skill. Women stand in more frequent need of the nutritional reeduca- tion here outlined than men. For the latter, usually, a nutritional modification, only, is necessary. The limiting of tobacco, the avoid- ance of alcohol, an increase in oxidation through aggressive and consistent physical effort, a decided reduction in the richer protein foods— especially after thirty years of age — and a definite addi- tion of an alkaline-producing dietary, including citrus fruits, whole G34 AFTER-TREATMEXT OF SURGICAL PATIENTS wheat breads, Irish potatoes, milk and legumes, will change numbers of unsatisfactory cases into most gratifying cures. Tt is possible for many who are now almost hopelessly unfit, under such a regime, wisely conducted, to attain a standard of physical efficiency which makes it possible for them to remain strong, robust, and adequate, with even a daily half-hour devoted to intensive exercise. No exer- cise can be considered worthy of the name which does not cause forced breathing. Ordinary breathing exercises are useless, when compared with the henefits derived from the panting which ac- companies active effort. The counsellor who thus advises and di- rects his patient, and by his personality inspires him to so alter his habits of eating and exercise thai 1 issue metabolism may be raised in its possible high potentiality, offers him not only health, hut puts into his hands thai inestimable boon, super health. The Mental Readjustment. — Unfortunately, strength of physique does not always insure peace of mind. Fears and worries and anx- ieties may depress and unnerve the strongest. The nervous sys- tem is constantly reacting to its surroundings. Overresponsiveness or misdirected response is the psychic defect which makes the neu- rotic. Lack of menial control or unwise selection of the objects of attention disturbs the nervous health and serenity of strong as well as weak. Our emotions enter into all our nervous reactions. Every act is colored or discolored by our feeling tone. A hopeful, opti- mistic outlook adds a potenl fighting quality to every surgical case, while a doubting, fearing, complaining, pessimistic attitude not only robs the patient of a certain constructive force, but dispirits operator and uurse and adds a handicap to the entire procedure which must be reckoned with. To most of us, a surgical experience presents a strong appeal to the emotional nature. The elements of pain and danger must impress even the most phlegmatic, while in the highstrung, modern neurotic, the capacity to calmly and ration- ally meet the operative situation is rarely attained. The thoughtful surgeon will therefore consider carefully his every word and act realizing their lasting importance as affecting the emotional nature of his patient. .Many of the nervous are highly suggestible, a weak- ness which, however, may be utilized by the understanding advisor to help, even as it will ever remain a definite menace in the hands of the crude or thoughtless operator. Damaging habits of feeling fre- quently have their birth in the experiences connected with opera- tive or postoperative treatment. Impatience and irritability are energy leaks which should nol be allowed t<> go on unchecked by earnest, friendly warning. Irritability is apt to begel irritability, RECONSTRUCTION OF THE PATIENT 635 so the surgeon who is the patient's friend will never react in kind to such an atmosphere, but with the wise word, the patient word, will show the temporary sufferer the lasting harm he is doing him- self by allowing such an attitude to become habitual. A more difficult type of patient to save from himself is the one who surrenders to a morbid sense of depression. To many natures, to surrender is much easier than to fight. To be hopeless requires less effort than to maintain faith; to be a quitter is much more comfort- able than to manfully play the game. Every worker with humanity feels the dead weight of these weakling leaners, and a certain amount of each worker's strength must be given to help them drag their faltering footsteps along the path of recovery. And it is a temptation to many, otherwise strong and eager in the fulfillment of the duties involved in a noble work, to dodge these depressing na- tures, many of whom are pure parasites, perfectly willing to sap the vitality and energy of surgeon, nurse, and family. In helping this type of patient, a discriminating separation of classes is as essen- tial as in the diagnosis of fractures. Many found to be sufferers from chronic autointoxication, depressed by their own poisons, can be healed through the advice given in the earlier pages of this chap- ter. A few will be found temperamentally inadequate — cases of mild constitutional inferiority. More are mere mendicant sympathy cravers. A jollying attitude is the simplest way of escape, but an unworthy one. The physician must be willing today to counsel, and to make clear to the depressed patient how absolutely one's atti- tude is of his own making ; how every mortal creates his own inter- nal weather; and how the spirit of real manhood and womanhood is capable of converting all unworthy moods into wholesome ones. Fear is the emotion which causes the great mass of nervous harm. Fear manifests itself in numberless aspects ; undue apprehension attends every step of many patients' progress through a surgical ex- perience ; and fear, as expressed through hypochondriacal ideas, lastingly discounts much perfect operative work. Many recoveries which would otherwise have been complete are alloyed by the fear element which the surgeon has carelessly allowed to persist, or recognizing, has failed to dislodge. I encounter many cases who. three, five, or even ten years after comparatively simple surgical treatment, are living the half -invalid life because they are still fol- lowing the "Don'ts" of surgeon or nurse — prohibitions as to exer- cise and work which have grown into incapacitating phobias. Many thousands are today piteously protecting themselves from any pro- ductive effort — from even sufficient exercise to keep themselves de- 636 AFTER-TREATMENT OF SURGICAL PATIENTS cently comfortable — because of their ignorant fear of tearing loose some structure which Avas the object of the surgeon's attention months or years ago. "A" can not run the sewing machine fear- ing some repaired organ will be torn loose from its moorings ; "B" likewise, can not sweep or stoop to dust; hundreds never play tennis or ride horseback or swim: thousands arc still guarding their hypersensitive scars from even the cleansing friction of a Turkish towel. It would seem that the surgeon had impressed such patients strongly with the poor quality of his work. And too frequently it is the surgeon's fault; too frequently he has left the impression that he did a poor job of mending. For instead of inspiring his patients to an early strengthening of the body and toughening of the tissues through adequate use and thus developing that high grade of tissue quality which will endure and benefit by exercise and even strain. he supports and protects, and even prohibits the very use which is Nature's only method of permanent reconstruction. Many patients are damaged through the overs olieitude of their families. In the absence of definite instruction to the contrary, they return home to be coddled and shielded and warned. Not infre- quently members of the family suffer vicariously at this stage even more acutely than the patient, and would literally protect the field of operation with armor-plate, were this possible. The true sur- geon strives to do his work in a way which will leave his patient fit for better living, rather than unfitted for normal life But through overcaution many continue to live half wrecks, because they have not had specific, helpful directions for the resumption of active exercise to reestablish normal lissiie lone — the quick reward of properly fed tissues naturally used. A few words of definite di- rection, better if written, stating (dearly when exercise may be taken. what should be done, and when the handicaps attendanl upon the operation may be absolutely ignored and normal 1 i ^ i 1 1 ?_^- resumed, will save many a neurotic from becoming chronically and incapac- itatingly hypnotized by surgery. Were proper after-treatment of surgical conditions as carefully ordered as the preparatory instruc- tions, many half-failures would be converted into thorough suc- cesses, and operations that semiinvalidi/.e be replaced by operations that cure. The surgical experience presents another and a graver danger to neurotic patients who. as a class, dread pain and stand it poorly. Many of them practically refuse to endure even discomforl without artificial surcease, and the physician's temptation is a strong one to write the order which will bring the drug comfort. There are con- RECONSTRUCTION OF THE PATIENT 637 ditions, indeed, in which every dictate demands the relief of acute suffering, but the neurotic's capacity for suffering is frequently so exaggerated that he refuses to endure even minor discomforts, dis- comforts common to ordinary experience and entirely unrelated to surgical conditions. From these are recruited many who have be- come hopelessly wretched through the thoughtless or easy-going prescription of the surgeon. His influence is a potent one. If he feels it necessary for the patient to have a hypnotic every night he remains in the hospital, why not the hypnotic at home? If the hypodermic needle is the surgeon's answer to a digestive disturb- ance, headache, or other minor complication of convalescence, what better treatment for like conditions away from the hospital? If an hour or two of restlessness is to be placated by the harmless ( ?) bromide mixture while under the surgeon's care, why not bromides for restlessness growing out of home, business, or imaginary wor- ries? And so ignorance, indifference, or selfishness on the surgeon's part has started many a poor devil toward his earthly hell. A few words of wise counsel or encouragement, a timely lavage, a dose of oil. an intelligent alteration of diet or an appeal to manhood or wom- anhood might have quickly met the situation, proved a lasting edu- cative factor, and saved unmerited disaster. Through the sedative danger the surgeon may make or mar his patient's future. The wise surgeon is primarily a wise man. The wise surgeon is a teacher, and the weeks under his care afford an opportunity for reeducation from which each normal patient will benefit. He be- lieves and he teaches that high health can rarely be given by the knife alone, but must be earned by righteous living. He is quick to see beyond his patient's surgical needs; he is able to detect the un- derlying faulty habits, and through his wisdom disclose to the pa- tient his duty to attain the health that counts and the strength that endures. And the reward which comes to such a surgeon is found in his increasing power to inspire those to whom he ministers with a determination to so attain that living becomes a joy. Our forefathers recognized in surgery only a mutilating art. To- day, more and more truly, surgery is becoming a learned, construc- tive, discriminating science. CHAPTER LIX POSTOPERATIVE TREATMENT IN CHILDREN By Willard Bartlett and J. B. Carlisle, St. Louis. Mo. It is the purpose of the writers of this chapter to take up the after-treatment of the most common conditions that come to the surgeon or practitioner of medicine for surgical operations or mi- nor surgical treatment, also to consider some of the most frequent complications that follow along with such after-treatment. After the infant has recovered from the operation, he may be placed at the breast for regular feedings. If, however, he will not nurse, he may he force-fed perferably with breast milk if it is available. Following operations Cor spina bifida it is important to keep the infant on his back when not nursing. This may be ac- complished most effectively by pinning the night dress to the mat- tress or to the sheets. Elsberg 1 says that the infant may be allowed to remain on his back following the operation provided thai suit- able dressings have been applied to prevenl the soiling of the wound by urine or fecal material. For this he uses a collodion dressing. Following operations on harelip as a rule do treatment is neces- sary unless the sutures have been placed in too tightly. If such is the case a si rip of adhesive from cheek to cheek will probably les- sen the tension sufficiently. Here again when this operation is on a young infant the feeding may be started as soon ;is possible, either by having the infant nurse or by force Heeding. V. P. Blair 2 in writ- ing of the Lane and the Brophy operations for congenital palates or lip clef is s;iys thai these operations should be done on infants as soon after birth as possible. He further states that tin 1 depressions line to the loss of blood can lie met by saline by rectum. lie gives these infants four cubic centimeters of castor oil and six hundredths of paregoric by mouth a few hours after the operation to remove the blood swallowed during the procedure. The infant is given water by mouth as soon a-- ii cries, and then is \'n\ when this will no longer satisfy. Usually these infants are fed four to six hours after 1l peration. If human milk is available, it should, of course, be given, but if no1 the feeding of modified milk should be started as -'hui as possible. Blair further states that in older infants some- times an anodyne is necessary during the firsl forty-eighl hours 638 POSTOPERATIVE TREATMENT IN CHILDREN 639 after the operation. He uses morphine or paregoric in very small doses when the infant can not be quieted by the nurse. It is often well to spray the throat of the infant with some antiseptic following the operation. He uses saline for this, gently spraying with it every two hours during the day and at the feeding times at night. He states also that the site of the operation should be carefully watched, and should signs of infection appear, the part should be painted with a 10 per cent colloidal silver solution after each ir- rigation with the saline. To children with congenital palates re- quiring plastic operations Blair gives liquids and solids for the first ten days and all food and water given for the first few days is sterile. He does not allow these patients to talk for ten days, but they are allowed to get up on the second or third day after the operation if they have no increased temperature. Various anti- septic solutions may be used in these cases as irrigations. Hemor- rhage sometimes occurs following these operations. This may be controlled by the use of astringents or by packing with gauze. In case that these measures are not effective, then the patient may be anesthetized and the bleeder sought and ligated. Sutures as a rule may be removed at the end of a week. Intubation when done entails as a rule but little after-treatment. Following the operation the infant may be allowed to nurse, but if he refuses, force feeding may be used. In the case of a child liquids and semisolids may be given. Holt and Howland 3 say that older children often experience some difficulty in taking food, and for these they recommend the device of Casselberry; namely, that of having the patient's head lower than his body while he drinks. Often in these patients the taking of food and water may cause excessive coughing. In these cases food and water may be given by a nasal tube or the stomach tube. Dyspnea may be caused by the child swallowing the tube or the tube becoming filled with mucus. The examination of such a patient should first be to see whether the tube is in place. An intubation tube should be cleansed once a day or more if the case demands. Holt further suggests that should the tube at any time be coughed up, it should not be replaced until dyspnea appears again. The length of time that the child should wear this tube is, of course, variable in dif- ferent cases. Usually extubation is done when the child's tempera- ture reaches normal. The removal of tuberculous glands in children requires little local after-treatment except in keeping the wound free from secondary infection. The general treatment is usually of much more value, 6-10 AFTER-TREATMENT OF SURGICAL PATIENTS tending to build the child's condition up with tonics, fresh air, good food, and good hygiene in general. Furunculosis which so frequently occurs in children can best be treated by stock vaccines of the staphylococcus or by an autogenous vaccine if such are available. General tonics are sometimes of value for the accompanying digestive disorders. Yeast may be used in some cases as reported by Hawk with benefit. As a rule, however, autogenous vaccines are of more value. Distant reinfections are best prevented by frequent cleansing of the patient's fingers with alcohol. Following the removal of tonsils and adenoids primary or sec- ondary hemorrhage may occur. Primary hemorrhage is usually very slighl and can be controlled with certain astringents such as adrenalin or hydrogen peroxide or by the use of pressure or packs. Secondary hemorrhage is usually more severe, sometimes becoming so severe as to require suturing as described by Coolidge. 4 This method consists, after the patient is etherized, in passing a curved needle from behind forward through the posterior pillar, the con- strictor muscle, and the anterior pillar. These three sutures thus placed will obliterate the space of the removed tonsil and are ef- fective in stopping the bleeding. The sutures may then lie removed in three or four days unless catgut has been used. Some cases of secondary hemorrhage developing three or four hours after the operation or the next day may lie stopped by simple packing and by ligation of the vessel when it can be seen. Hemorrhage following removal of adenoids may usually be controlled by packing. In children who have long been accustomed to breathing through their months it may be necessary to apply a bandage to force them to breathe through the nose until they have become accustomed to it. As a rule, following removal of tonsils and adenoids it is well to have the patients, especially young children, stay in lied a day or two during which time they should he carefully watched for the development of secondary hemorrhage. The diet during this time should be a lighl one. It is also well to spray the throat with some mild antiseptic solution for several days after the operation. If they have no increased temperature at the end of the second day. they may be allowed to get up. The postoperative treatment in empyema is a very important one 1, .■cause empyema itself may complicate any of the infectious dis- eases that are so common in children. It may also come as the resull of trauma. The opening of the thorax may be followed by drainage in a number of ways. Perhaps the method of Kinyon spoken of by POSTOPERATIVE TREATMENT IX CHILDREN 641 Holt 3 is as good a one as any. This method consists of a siphon drainage into a bottle containing saline. In those cases that he terms "desperately sick" Wyman Whittemore 5 advised a somewhat different treatment : ' ' Under local anesthesia the chest is aspirated between the ribs with a large trocar; a tight-fitting catheter slipped through this and the trocar removed. The catheter is attached to a long rubber tube that goes to a bottle half filled with water. The end of the tube is under the surface of the water. The catheter is screwed tightly into place. In this way the negative pressure of the pleural cavity is not changed and with each expansion of the lung the pus is forced into the bottle. The catheter will stay tight with- in the chest wall for about a week. The amount of drainage for each twenty-four hours is measured. At the end of five or six days an electric suction is attached to the tube. This works constantly, and when the twenty-four hour amount of pus is down to two ounces, I remove all drainage apparatus. In those cases not quite so severe the Lilienthal operation is used. ' ' The postoperative treat- ment in both of these cases is practically the same. G-ood food, fresh air, regular breathing exercises are to be insisted upon and also the "blow bottles" in some cases. Whittemore does not think that bottles are of much value. In some cases in which the drainage of the cavity is insufficient it is sometimes necessary to irrigate. These irrigations may be done with saline, but more recently many are doing them by using the Carrel-Dakin solution. It is the practice at the St. Louis Children's Hospital to use the Wilson tube in drainage and in those cases which require irrigation Carrel-Dakin solution is used in small amounts at frequent intervals. The general after-treatment in all cases is essentially the giving of good food, plenty of time out of doors in suitable weather, and the forced expansion of the lung. James y apparatus which is a blowing device of two bottles is sometimes very effective in expanding them. Frequently the temperature will again rise following insufficient drainage of the cavity, due to a developing pneumonia, to empyema of the opposite side, to pericarditis, or to otitis. All of these condi- tions must be carefully watched for and treated early if they appear. In the chronic cases of empyema practically all the treatment that is necessary is to keep the wound as clean as possible, promote ade- quate drainage, and in general attempt to increase the resistance of the patient. Beck's paste may be used in these cases. It is well to remember that in the acute cases a drainage tube left in too long will often lead to a fistula. 642 AFTER-TREATMENT OF SURGICAL PATIENTS Stricture of the esophagus in children is not uncommonly seen due to lye or other powerful caustics. Such cases as these are often not seen by the surgeon until late after the swallowing of such ma- terials. The starvation and the extreme water hunger in these cases when seen often demand an immediate gastrostomy as pointed out by Hubbard. Following such a treatment the surgeon should attempt to pass I possibly retrograde) whalebone filiforms or the smallest bougies as soon as possible. Certain of these cases can have tin' esophagus after a long and tedious process, dilated to a point where after several days the gastrostomy wound may be closed and the feeding by mouth resumed. These patients should return to the surgeon for regular dilatations of the esophagus. In the case of the child, this point must be thoroughly impressed upon the parents so that not one of these dilatations shall be missed. Another point which is of equal importance and was brought ou1 in the article referred to above is that these patients are often for a long time fed upon liquids and semisolids which do not furnish sufficient nourishment and lead to malnutrition and lack of proper development. They, he say'-, may be allowed to eat all kinds of foods if they are taughl to masticate well what they do eat. In certain cases where the stricture of the esophagus is of such a nature that the bougie or the small whalebone filiforms can not be passed from above an attempt may be made to have the child swal- low a string and if successful then the dilatation can be attempted from below through the gastrostomy wound. The postoperative treatment of pyloric si miosis in children is a very important one. and one about which a great deal has been written. [Most writers, however, are agreed upon one point, and that is that the postoperative treatment is usually of as much im- portance as the operative treatment itself. For this condition in infants there are two methods of after-treatment which are very different. Green and Silbury 7 write of the after-treatment follow- ing the Rammstedl operation as follows: "The infant must have breast milk in small quantities, gradually increased. The method of the Babies' Hospital in New York is followed. The feeding is started two hours after the operation, or when the baby is awake from the anesthetic, with four cubic centimeters of breast milk and the same amount of barley water every three hours, in- creasing by four cubic centimeters of breast milk every other feeding until we get the breast milk up to thirty cubic cen- timeters and then we give thirty cubic centimeters of breast milk every four hours during the da\ and at night. The baby is POSTOPERATIVE TREATMENT IN CHILDREN 643 not allowed to nurse the mother for from five to seven days after the operation, and when it does, is weighed before and after each feeding to determine the amount obtained. Castor oil is given twenty-four hours after the operation. Practically every case that we have treated has received an anteoperative hypoder- moclysis and some few have received it after the operation. The greatest care must be taken not to chill the infant during the opera- tion, and after it external heat should be applied." In general the cooperation of the surgeon and the pediatrist is required in these cases to insure success. Thompson 8 says "that shock and hemor- rhage must be avoided after the operation and that shock may be combated with warm saline infusions or transfusions and by mild stimulations if necessary. Rectal feeding or saline enemata may he employed for a few hours or longer. Food per orem can be ad- ministered in a few hours or the next day and this is often necessary on account of the precarious condition of the child and its impera- tive need for nourishment." Morse and Cabot 9 also recommend postoperative salt enemata. They say that feeding may be begun in the child as soon as the effects of the anesthetic are passed. They recommend human milk diluted with three parts of water, the strength being gradually increased, but if breast milk can not be obtained, then whey is the next best gradually to be strengthened by gravity cream to 1 per cent of fat. They consider it best to feed one dram every hour, increasing the amount and lengthening the interval between the feeding. Most surgeons now have adopted the Rammstedt operation in preference to the older gastroenterostomy which is attended by a higher mortality, more shock, and a slower convalescence. In a case where a gastroenterostomy is done the infant can not be fed as soon after the operation and the feeding in general must be more cautiously carried out than in the case of the infant upon whom the Rammstedt operation has been done. Holt and Howland 10 recommend another treatment. The infant is given one or two teaspoonsful of breast milk every two hours alternating with the same amount of water. The amount is gradually increased and the interval is lengthened until at the end of forty-eight hours the infant is getting an ounce of milk every three hours and the same amount of water between the feedings. At the end of a week or ten days the infant may be put back to the breast and allowed to nurse, but care should be taken that it does not nurse too long or does not get too much at any one feeding. Holt further states that hypodermoclysis is of value at the beginning of the operation and 611 AFTER-TREATMENT OF SURGICAL PATIENTS after it. In these eases 100 to 240 c.c. of saline, to which 3 per cent of glucose has been added may be given to relieve the lack of water. The importance of the after-treatment in these cases can not be overestimated. With an early recognition of the condition, a Rammstedt operation in the hands of a good surgeon, and then careful treatment afterwards by an experienced pediatrist the chances for the infant's recovery ought to be very good. Umbilical hernia rarely occurs in children under four that is not amenable to mechanical rather than surgical treatment. If, how- ever, this treatment will not suffice, and the child has to under- go an operation, then the after-treatment consists in meeting hemorrhage, should it occur, or shock, and the feeding of the infant. Shock may be treated with saline and glucose solutions. The treat- ment of hemorrhage is the same as that for hemorrhage in other abdominal conditions. The feeding may be begun as soon as the child is over the operation, the nature of the feeding and the times for it depending on the age of the patient. Very strenu- ous efforts at play must be avoided for a few weeks after he is up at the end of ten days. The prognosis is one hundred per cent good. Intestinal obstructions due to malformations of the intestines are sometimes seen in the newborn due to atresia or absence of the rectum, colon, or anus. The mortality in these cases is usually very high due to the late period at which they are recognized or to the marasmus existing at that time. Should an operation be done on these infants, the after-treatment will depend a great deal on the nature and the extent of it. but in general it will be the same as that following an operation for an umbilical hernia. The after-treatment in cases of obstruction following intussuscep- tion is very important, but as a rule presents nothing different from that accorded obstruction due to malformation. Lack of water is often of very grave importance in these conditions. This can be combated by giving water, saline or saline and glucose if preferred, subeutaneously. intravenously or into the peritoneal cavity. This last method is the one employed at the St. Louis Children's Hospital in eases of anhydremia with good results. Although appendicitis is a disease usually seen in adults, it may be seen in infancy and is frequently seen in children. The after- treatment in such cases occurring in children is much the same as that in adults. Those general principles outlined by Ochsner," may be followed. In his uncomplicated cases in which drainage has not been used the patients are given no food by mouth for POSTOPERATIVE TREATMENT IN CHILDREN 645 three to seven days according to the conditions. Gastric lavage is em- ployed in patients who are nauseated, nutrition being supplied to these patients by rectum. Solid foods are not usually given until two weeks after the operation. The stitches are removed on the tenth to the fifteenth day and then adhesive is placed over the wound for support. In those cases demanding drainage boric acid dressings are used. As a rule in the uncomplicated cases patients are kept in bed two weeks. A resulting ventral hernia in children is so rare that it hardly deserves mention in this treatise. In general the temperature in these cases of appendicitis in chil- dren should be carefully watched, and should any sign of peri- tonitis develop, all feeding by mouth should be stopped if it has been started. The lesion may then be treated as is done in adults with hypodermoclysis, morphine, etc. Renal calculi are very common in infancy according to Holt and Howland. 12 The postoperative treatment in these cases depends on the type of operation that is done. If the pelvis is opened and the calculi removed, the after-treatment will be simple unless hemorrhage or a urinary fistula develops. A urinary fistula would demand a second operation if possible. The feeding of these in- fants, like the feeding of infants following the Eammstedt opera- tion, is sometimes very important. The general measures to be followed in such a feeding are to give breast milk if possible in small doses, increasing the amounts and finally when possible the return of the child to the breast. Water hunger if it occurs fol- lowing the operation can be relieved by saline infusions. Os- teomyelitis is so fully considered in the chapter "Surgery of the Extremities" that it will be omitted here. It can occur in infants, but more frequently is seen in children. Scuclder 13 says that fully one-third of the fractures of the clavicle occur in children under five years of age. The treatment in these cases after the deformity is corrected lies in the immobilization of the part for two weeks or more. The arm should be inspected especially in warm weather to see that no chafing of the part oc- curs. All the dressings should be daily removed, the parts bathed with soap and water, powdered and the dressings replaced. If the union is firm after two weeks or two weeks and a half, the cast may be removed and the shoulder can then be put up in a simple retentive swathe and sling, at first inside the clothes and later outside them. Massage may be given to the forearm, elbow, and shoulder after the first week together with passive motion of the elbow. If the dressing chafes or slips, it may need frequent renewal. 646 AFTER-TREATMEXT OF SURGICAL PATIENTS Fracture of the shaft of the humerus sometimes occurs in the newborn and has for its after-treatment the same principles as outlined above for fractures of the clavicle. Scudder treats the fractures of the femur in the newborn by flexing the leg upon the body. The after-treatment in these cases consists in the daily massage of the leg and the preventing of the parts from chafing. In general, fractures in infancy are uncommon but they are rather common in children. The general treatment in all cases is the protection of the skin and the proper immobilization of the part to insure correct healing of the fracture. As a routine it is well to take a second x-ray picture of the fracture after ten days or two weeks to see whether or not the bones are properly approximated. Burns, when seen in children, are most commonly those of the extremities. The use of paraffin dressings or the dry heat treat- ment is used in most hospitals now. This heat may be applied by means of a tent over the extremity which has an electric light bulb on the inside. When crusts form on these burns they should be removed and a dressing of scarlet red applied. In the case of the more serious lesions a Thiersch graft may be applied. As in the case of adults it is also necessary to produce proper elimination of the toxins of a severe burn through the kidneys, skin, and the bowels. Full credit is due J. B. Carlisle for having abstracted all the lit- erature to which reference is made in this chapter. Bibliography lElsberg: Diseases of the Spinal Cord and Membranes, 1916, p. 187. sBlair, V. P.: Surgery of the Mouth and .laws. St. Louis, 1917, C. V. Mosby Co., ed. 3, pp. 195-215. ■Holt and Howland: Diseases of Infancy and Childhood, New York. 1917, D. Appleton & Co., ed. 7. pp. 1055-1057. ■*Coolidge: Diseases of the Nose and Throat, Philadelphia, 191.1, W. B. Saun- ders Co., pp. 205-206. 5Whittemore, Wyman: P>oston Med. and Surg. Join-., 1918, elxxviii, 360. cHubbard: Section on Laryngology, Otology, and Ehinology, Tr. Am. Med. Assn., Chicago, June, 1918, p. 31. "Green and Silbury: Hypertrophic Stenosis of the Pvlorus, Surg., Gvnec. and Obst., February. 1919, p. 159. sThompson: Congenital Hypertrophic Stenosis of the Pvlorus in Infants, Surg., Gynec. and Obst., 1906, iii, 521. oMorse ami Cabot: Hypertrophic Stenosis of the Pylorus in Diseases of Nu- trition and Feeding, p. 217. loHolt and Howland: Diseases of Infancy and Childhood, New York, 1917, D. Appleton & Co., ed. 7. p. 328. nOchsner: Handbook of Appendicitis, 1902, Chicago, G. P. Engelhard & Co. isHolt and Howland: Loc. fit., p. 646. i'S,.„ilder: The Treatment of Fractures, 1911. CHAPTER LX POSTOPERATIVE TREATMENT IN OLD AGE By Willard Bartlett and C. R. Fancher, St. Louis, Mo. Before considering postoperative treatment in old age, it would be well to consider that every old person has a definite and more or less constant pathology. Certain modifications at once arrest your attention. Every one is familiar with the appearance of an old man or woman. We find as we look at an elderly individual, a great change has come over the face. The roundness of youth has departed; the cheeks are shrunk; the eyes have receded; the lips are drawn in. The gait becomes shuffling; the foot is no longer lifted free from the ground as the aged individual walks along. The skin becomes thin and satiny, while disappearance of fat and muscle tissue beneath it throws it into wrinkles, the hair after becoming white falls out, the muscles waste away and grow weak; and the ligaments which bind together the bones stretch and weaken. Deprived of its strong muscular and ligamentous sup- port, the back bends forward, the bones become rarefied and the cartilaginous structures become ossified. The bones break more easily and heal with greater difficulty than in a young person, all of which correspond to a general atrophy of the individual, for, at the same time stature diminishes and the weight of the body generally decreases. This emaciation is the consequence of a morbid process which exerts its action upon the muscles of organic life and upon the greater number of the organs, e. g., the brain, spinal cord, nerve trunks, lungs, cardiovascular system, kidneys, and blood- forming organs all participate in this retrograde process. Of what does this change in the collective organs and tissues con- sist? First : In the slightest degree, it is a simple process of atrophy, the cellular elements of the parenchyma, the muscular, and perhaps also the nervous tissues, progressively diminish in volume, but without any demonstrable change in structure. But in a more ad- vanced stage atrophy is accompanied by degenerative action ; i. e., the tissues undergo a modification in their anatomic and physiologic activities, and we find that they are the seat of pigmentary, also fatty degenerations, and calcareous incrustations. G47 648 AFTER-TREATMEXT OP SURGICAL PATIENTS No one will fail to observe that if these changes have attained a pronounced degree, they will go beyond the limit of the physi- ologic state, since they have the power to produce of themselves. functional derangements which at times are extremely grave. The generative and muscular systems undergo so evident an enfeeble- ment that it is not necessary to dwell upon this point, and with regard to the nervous system of organic life it is veil to recall the well-known lines of Lucretius. "Praeterera gigni pariter cum corpore. et una crescere sentimus, pariterque senescere mentem" — De Nat. lucrum, ii, 446. Mental changes may manifest themselves as a senile dementia, confusion, mania, melancholia, or as a senile "paranoia." This is of considerable importance in considering the various mental condi- tions, the whims and fancies which sick old people are liable to have. The functions of the respiratory apparatus are as a whole trener- ally decreased. This will be evident when Ave consider for a moment the pathology of the senile lung and thoracic cavity. The senile lung is emphysematous. The Avails of the arteries are inelastic, large numbers of capillary vessels have been obliterated and in- termixed throughout the en lire structure there is always found a diffusion of carbonaceous material. The senile lungs can not be perfectly inflated, and present a livid appearance. Thin surfaces are uneven and look as though they were crumpled. Not only do the previously mentioned factors decrease the respiratory func- tions, but also the musculature of the chesl becomes atrophic: the costal cartilages become ossified, all of which prevent or hinder the complete filling of the lungs. Many investigators think that these changes begin as early as the thirty-fifth year and reach a maximum about the seventy-fifth year. The cardiovascular system is profoundly involved in senility. The heart, like every other organ in the body, undergoes atrophy and sIioavs various degenerative changes which directly lead to an in- efficient organ. The heart usually becomes small and brown with tortuous coronary arteries, which are visible through the watery, broAvnish fat. The fat of the epicardium usually disappears and its cells become separated by a fluid which gives a gelatinous ap- pearance to the tissue. The decrease in the size of the heart makes it too small for the coronary vessels, which, therefore, lake the tortuous course above mentioned. Each heart muscle cell is greatly reduced in size, and there show at tin 1 poles of the nuclei certain POSTOPERATIVE TREATMENT IN OLD AGE 649 brown pigmentations which constitute the so-called "brown atro- phy" of the myocardium. Besides the senile changes that take place in the heart, the very important sclerotic changes that take place in the vessels are of next importance ; the effects of this sclerotic change causing, of course, an abnormal vascular wall, which is inelastic and gradually encroaches on the vascular lumen. This decrease in cross section of the vessels causes a decrease in the quantity of blood brought to any given organ; also causes an increase in the amount of cardiac work clue to the increased peripheral resistance. The kidneys are affected in senility, the change usually found being the so-called "arteriosclerotic kidney," in which the organ is contracted, and the thickened capsule generally adherent. On section the kidney shows macroscopically certain localized areas of atrophy. There is a disappearance of the pelvic fat, and a marked decrease in the cortical and pyramidal portions. 1 In the senile kidney the urine is generally decreased. The urine analysis shows hyaline and granular casts and usually a trace of albumin. The amount of albumin varies greatly with the food and the amount of exercise taken. Casts may occur without the albumin. It is not to be regarded as a grave sign to find any of the above in a senile individual. The liver in senility shows a flabby, shrunken organ usually of a dark color made up of lobules far smaller than normal; often whole layers of liver tissue disappear ; so that on the surface of the organ, blood vessels, bile ducts, and the fibrous skeleton of the liver lie exposed. All of these senile changes must play a very important, yet comparatively unknown, part in the metabolism of the indi- vidual, also on the metabolic changes going on in the liver itself. The liver is known to have something to do with the metabolism of the more complex amino acids, and it is conceivable that a per- verted liver metabolism might have something to do with the pig- mentations which are so common in aged individuals, due of course, to the incompletely broken-up amino acids which contain color groups. The skin is affected more than any other single organ in senility. It, like any other organ, undergoes definite changes ; since it is dependent on other systems of the body for its well being, and in order to maintain its equilibrium, i. e., chemical and physical, must- have the proper food and environment. The senile skin shows very important changes which really mark the beginning of the end. The causes are not known, but they usually start in the ves- 650 AFTER-TREATMENT OF SURGICAL PATIENTS sels of the true skin. This decreased nutrition allows infection, causes itching- and gangrene; There are also changes in the con- nective tissues; there is an atrophy without adequate repair, in- stability and irritability of the epidermal cells, which have a ten- dency to a typical and rapid transformation. Therefore, we find pigmented plaques and warts which, along with the previously men- tioned factors, predispose to carcinomata, hence they are poten- tially cancers. Sir James -Paget once said, "If we live long enough, we will all die of cancer," and from senile skin findings this is quite true. Most dermatologists are agreed that senility of the skin does not mean in all cases age in years, bu1 skin changes are some- times due to processes not well understood. Senile skin changes are usually first noticed on the dorsum of the hands and the sides of the neck. One of the most striking alterations in the skin of an old individual is the lack of repair. The slightest amount of trauma very frequently will cause a very severe dermatitis or an ulcer. From what has been said it is quite evident that old age is es- sentially a period of involution, of diminished power for sus- tained expenditure of energy, and, commonly, of a lessening in the general range of activities. The organism begins to reveal gradual and increasing changes in its structure, all of which are expressive of senescence.- Noticeably is this the case of the cardio- vascular system. The heart no longer has the power to drive the blood with its former energy, while the vessels present walls no longer soft and yielding, but now rigid and with a narrowed lumen. The changes of function that ensue, are, however, in a vast majority of mankind, entirely normal and in no sense pathologic. There is a quantitative reduction, but this is usually limited in degree so that the individual may continue to discharge his functions normally to the end of life. It is only when this reduction is excessive, and espe- cially when it is associated with qualitative changes, that it be- comes pathologic. The surgical after-treatment in the aged does not differ in the main from the postoperative treatment of adults. In the first place, age is a contraindication to operations of the more serious nature. Old individuals can not stand shock; their fighting powers, one might say. are far Prom what you would expect in an adult. Some of the more salient points to be considered in the after-treatment are as follows : 1. During the operation and after the operation the patient should be kept warm. This may be accomplished by having a warm operat- POSTOPERATIVE TREATMENT IN OLD AGE 651 ing room, covering the patient with previously warmed blankets, or surrounding him with hot-water bags. 2. The preparation of the bed is quite essential. It should be prepared before the patient comes from the operating room, i. e., previously warmed by the use of warmed blankets, hot-water bags, electric bakes, etc. 3. When the patient arrives from the operating room, he should be carried by at least four people, and should be gently placed in bed, and snugly covered. Hot-water bags or an electric bake may be used to maintain the desired warmth of the bed. It is very es- sential that aged individuals receive all of the heat possible. They are in a way analogous to an infant that has to be kept in an in- cubator. The factors involved in the two cases are quite similar. 4. The patient's room should be well ventilated, quiet, and prop- erly heated. It is a good idea to get aged patients out into the fresh air and sunshine as soon as possible ; and if climatic condi- tions are favorable, this point should never be overlooked. 5. The processes of elimination are very frequently embarrassed in the aged by reason of senile changes previously considered. Fluids should be forced unless some contraindication is present. They may be administered by rectum, mouth, subcutaneously, or into a vein. Patients should have a daily bath and all of the avenues of excretion freely opened. 6. Among all the complications found in senility the most feared are perhaps the various forms of pneumonia. For the consideration of bronchopneumonia and lobar pneumonia the reader is referred to any standard textbooks of medicine. Ether pneumonia and hy- postatic pneumonia are the two forms with which we are directly concerned. The ether pneumonia is not so frequent in the aged as it was at one time. It might be disposed of by stating that it is always much safer to give the ether by the open method. 7.- Hypostatic pneumonia is primarily limited to aged individuals and those who have an enfeebled cardiovascular system, or to in- dividuals who lie in the recumbent position, or any position at all for a long period of time; the treatment is obvious. a. Patient must be examined regularly (always look for physical signs around the bases of the lungs). b. Patient should be turned frequently and not be allowed to oc- cupy the same position for any great length of time. c. Cardiovascular and excretory systems should be stimulated. d. Free bleeding may be resorted to and as much as 10-20 oz. of blood may be removed. Some advocate aspirating the right auricle, 652 AFTER-TREATMEXT OF SURGICAL PATIENTS but this seems to be a very heroic measure and should only be used as a last resort. 3 Hypostatic pneumonia is always to be feared in fracture cases, especially in fractures involving the hip or spine. 8. Bedsores, or decubital ulcers, are very likely to occur in bedridden patients. The parts most exposed to pressure become red and congested, and finally ulcerate, or gangrene supervenes. Bed sores are not usually extensive or deep, but if the patient is de- bilitated or paralyzed, the process may extend rapidly and in- volve deeper structures. Bed sores may be so extensive as to in- volve bone, causing necrosis and caries (the so-called acute lied sore). 4 Cases have been known in which the spinal canal was opened up. and in this way, death may ensue from a meningitis. To prevent the occurrence of bed smrs the nurse or attendant should see that the draw sheet and bed linen are placed smoothly, and without creases, also that there is no contamination by urine or feces. "The skin of the back should be daily washed with some nonirritating soap; rubbed with a soothing, strengthening, and hardening application, such as ;i mixture of brandy and white of egg, then dusted over with a powder consisting of equal parts of zinc oxide, starch, and boric acid. If the skin becomes red. it should be painted with a mixture of tincture of catechu and liquor plumbi subacetatis, which, when dry, leaves a powdery film on the surface. It must be protected from pressure by a circular water bag or an air pillow." 1 Paralytic or very debilitated pa- tients should be placed on an air mattress. When an open sore forms, fomentations are required during the more acute stages, also irrigations with saline are very beneficial; later the open sore may be dressed with a boric acid ointment; 4 occasionally touching up the ulcer with AgN0 3 stimulates granulation, the primary pro- cedure, of course, being to keep the open sores (dean. 9. The elimination via the gastrointestinal tract must he assisted in all cases of constipation. The condition or kind of operation done, will, of course, influence the administration of a cathartic. Ordinarily, patients not having abdominal or rectal operations should have a bowel movement al least once a day. If this is not possible, any of the following measures may he resorted to: 1. Saline, soap suds, or oil enema t a. 2. Castor oil or any of the less drastic cathartics. 3. In case a fecal ma^s becomes impacted in the lower sigmoid or rectum, this should be removed by means of a spatula or by the fingers. POSTOPERATIVE TREATMENT IX OLD AGE 653 Constipation and gastrointestinal upsets are very frequent in the aged, due to the fact that the musculature of the intestine becomes more or less atonic and the secretions are greatly decreased. 10. The diet is one of the most important parts of the postopera- tive treatment. As was previously stated, aged individuals are like infants in many respects. 5 Their metabolism due to senile changes is going the wrong way. As was previously stated, the senile changes of every cell and gastrointestinal secretion have taken place. So it is evident that an aged individual is not able to me- tabolize as a younger person. It has been estimated that an in- dividual at rest or doing light work requires about 2500 calories. This should be composed of very easily digested and tasty foods. Aged individuals handle bland and liquid diets very well. These, of course, should be well balanced, they can not take care of the heavier foods. This is partly due to the fact that their secretory functions are somewhat inhibited; also their mastication is deficient. Senile individuals may be nourished frequently by the adminis- tration of eggnogs and malted milk, which are very nourishing and thankfully received by the patient. Here, again, the kind of operation will greatly determine the diet, especially the method of administration; also if the patient is a diabetic or a gouty in- dividual, it is the duty of the dietitian to provide a diet which is free from, or very low in. carbohydrates in . the former, and a very low protein, or protein-free, diet in the latter. 11. Urinary retention is very common in elderly individuals. This may be due to abnormal conditions in the kidney, bladder, cord lesion, prostatic hypertrophy or to a urethral stricture. As pre- viously stated, the sclerotic kidney may be a factor in diminished urinary output. The only treatment is to force fluids and administer diuretics. The arterial condition is sometimes helped by giving potassium iodide, sat. sol. gtt. x t.i.d. If a calculus is the cause, the only treatment outside of surgery is to keep the patient free of pain while the stone is being passed. Patients very frequently pass stones spontaneously, or they may be removed by mechanical means. Papaverine, one of the alkaloids of opium, is supposed to affect the musculature of the ureter in a specific manner, causing a series of relaxations and contractions. This, however, is only experimental, but may be tried. The papaverine should be given in % gr. doses, and not repeated oftener than every six hours. The bladder may be the etiologic factor, the retention being due to an atonic musculature or to a lesion of the central nervous system. The senile bladder is very easily infected and if one is 654 AFTER-TREATMENT OP SURGICAL PATIENTS not strict in the technic of catheterization, a very severe and per- haps fatal cystitis may ensue. Patients with urinary retention should he catheterized regularly. In cases of prostatic hypertrophy, urethral spasm or stricture, it may lie very difficult to pass a cathe- ter. It is always better to catheterize the patient according to the clock than to wait for him to complain of a full bladder. It is also to be borne in mind that large catheters pass better than smaller ones. If the retention is prolonged during the first tAVo to three weeks, the patient should be guarded from cold and exposure. Not infrequently a certain amount of fever is produced, which usu- ally passes off in the course of a few days, or increase, together with symptoms of a chronic cystitis running on to a fatal issue at the end of three to four weeks. The only treatment of the simpler cases is to keep the patient warm in bed, to limit his diet, to administer quinine and perhaps opium and to keep the bowels open. During the continuance of catheter life, the patient must be warned to live very quietly, and abstain from all excesses, especially as regards eating and drinking; strenuous exercise must be forbidden, precautions must be taken to insure protection from the cold and dam]). The administration of alkalies, if the urine is strongly acid, so as to diminish the irri- tability of the bladder is always a good procedure. It should always he borne in mind that incontinence is never present when the bladder is empty, but is always found when the bladder is full. Incontinence is most frequently found in spinal cord conditions and in prostatic hypertrophy. In this type of pa- tient it is far better that he lead a catheter life, because if the bladder is not completely drained, there may result back pressure phenomena which will lead to dilated ureters and hydronephrosis, and ultimately to uremia. It is not an uncommon thing to see old people showing mild symptoms of uremia, especially gastrointestinal symptoms, many of which are due to urinary retention, and are to be relieved by proper catheterization. Besides the use of the catheter in urinary retention, hot stupes applied to the suprapubic region, hot rectal irrigations, sitz baths, or perhaps the psychologic effect of allowing the patient to hear running water will very frequently make him void. 12. Needless to say, efficient laboratory work consisting of com- plete urine and blood examinations should he routinely done. Urinary findings have a special meaning clinically in an aged in- dividual, for as previously stated, we always expect to find a few- hyaline casts or perhaps a trace of albumin. POSTOPERATIVE TREATMENT IN OLD AGE 655 In the previously mentioned points we have summed up the more important things to be thought of in the postoperative treatment in the aged. Be it always borne in mind that the aged individual is on the downward trend and does not respond to treatment like a younger adult. Full credit is due C. R. Fancher for having abstracted all the lit- erature to which reference is made in this chapter. Bibliography iMacCallum, J. M. : Pathology, Philadelphia, 1917, W. B. Saunders Co. 2Von Miihlmann: Das Altern und der physiologische Forderungen zur physiolo- gisehen Wachsturnslehre, 1910. sOsler: Medicine, 1918. 4Rose and Carless: Manual of Surgery, New York, 1917, Wm. Wood & Co. sLusk: Science of Nutrition, Philadelphia, 1917, W. B. Saunders Co., ed. 3. The following references were also consulted : Charcot, J. M. : Diseases of Old Age, 1881. " Manning, Chas. : Child, Senescence, and Rejuvenescence, 1915. Meyer, A. W. : Lectures on Osteology, 1916, Stanford University. Minot: Age, Growth, and Death, 1912. Rubner: von Leyden's Handbuch der Ernahrungstherapie, 1903, i, 153. Stimson: Textbook of Fractures and Dislocations, Philadelphia, Lea and Febiger. CHAPTER LXI SYMPTOMS AND SIGNS OF IMPENDING DEATH" By 0. F. McKittrick, St. Louis, Mo. At the door of each and every life the grim reaper deatli will knock. Just when and how it will come no one can tell, and yet in spite of the millions of observations upon this, the most tragic phenomenon of life, practically nothing' has been written. Neither have very great efforts been made to critically study this phase of disease, and we of the twentieth century must suffer the con- secpiences of our negligent medical forefathers. It is a matter of common observation that the relatives, particularly the women who nurse the sick one, feel the presence of this weird specter much more quickly ami keenly than does the physician himself. Possi- bly if he could have seen so far as they, a different and more effi- cient treatment might have been given with years of useful life added to the patient's career. At any rate, if the possibility of death could be foretold, the prognosis would be less often faulty. The signs of impending death were first commented on by Hip- pocrates 2500 years ago. Nothing of material importance has been added since his time except a few facial sinus noted by the late Austin Flint. Others have, no doubt, attempted work along this line only to have their efforts discouraged by the tradition that patients often get well despite the sentence of death pronounced by the medical judge. The medical profession is not only called upon to answer this question thousands of times daily. bu1 a correct solution of the problem is now required also by certain municipalities. Failure to realize that death is certain within forty-eight hours of the time a patient is moved from one institution to another is punishable by a fine. However, no one can say in the light of our present day knowledge of medicine jusl when fatal outcome might develop in the course of such complications as angina pectoris, myocarditis. cerebral hemorrhage, postoperative thrombosis or nephritis. Neither can the sudden unaccountable deaths, which occur daily in hospitals, be foretold. Such instances are rather an exception. 'Much of the matter in this chapter is taken from Reilly's article: Signs ami Symptoms of Impending Death, Jour. Am. Med. Assn . 1916, lxvi, 160. SYMPTOMS AND SIGNS OF IMPENDING DEATH 657 and are not included in the class of cases which is discussed in the following. According to Reilly 1 "death usually occurs as a result of heart failure, respiratory failure, asthenia, vagus failure, or shock." When this last occurs, however, the centers in the medulla are the con- trolling factors rather than any one organ. There are few single symptoms pathognomonic of death, but when two or more are considered, a positive statement regarding its ap- proach often can be made. In the following sentences Reilly men- tions, in the order of their importance, some of the more common danger signals which warn us of the oncoming scythe-bearer. When one of them is present others are also very apt to assert themselves. An irregular pulse for the first time in the disease or its dis- appearance from the wrist with the patient recumbent is alarming, except in cardiac disease or in sudden severe hemorrhage. In the latter if there is much factitious behavior, death invariably occurs. Pulsus alternans, appreciated by the finger, means death within a short time. This is most common in fractures of the skull. In adults, except in heart block, a pulse under 80 means that death is at least twelve hours away. In the aged, however, the pulse is often slow until death. In these old people a pulse of 140 means death within a few hours. In children with a pulse under 120, death is rare within six hours. A pulse of 100 in coma usually means that death is eight hours off at the most. Such statements are taken to mean, of course, that the pa- tient is safe for this length of time. A pulse mounting gradually to 160 presages death, except in pericarditis ; and generally speak- ing, a pulse which increases in rapidity hour by hour is adequate warning of approaching death provided other signs of very serious illness are present; but the approach can not be foretold by the pulse as reliably in children and the aged as in adults. Cases of auricular flutter are very deceptive, the pulse may be 150 or more with extreme prostration, and still recovery often occurs. Gallop rhythm, not associated with rheumatic endocarditis, is always fatal. Of like import, is a persistent, firm pulse in coma accompanied by hemiplegia. In all infectious diseases a strong pul- monary valve sound indicates that immediate fatal termination is improbable. In very sick patients who are free from cardiac disease, a dis- appearance of the pulse at the wrist when the hand is raised 658 AFTER-TREATMENT OF SURGICAL PATIENTS vertically above the head, indicates that the end may be expected within twenty-four hours. Blood pressure change is not as good an indication of impending death as one would suppose, probably because of the fact that it is not practical to have observations made often enough. We know, however, that the blood pressure steadily drops as the end ap- proaches. A blood pressure of 230 falling suddenly below 100 without hemor- rhage, means a fatal issue; likewise when it steadily falls in any adult to 40. Cheyne-Stokes' respiration in the sick practically always heralds death except in uremia or cardiorenal disease. Rapid breathing following this phenomenon indicates that it is at hand. A marked disproportion between inspiration and expiration, espe- cially if accompanied by rapid pulse, except in shock or hemor- rhage, is a terminal sign. Continued sighing under these same con- ditions of sternomastoid breathing in a patient free from asthma or obstruction to the larynx, heralds death. According to Shrady, a persistent up and down motion of the Adam's apple foreshadows a rapidly fatal outcome. "White frothy mucus from the nostrils announces the end. Absence of pupillary reaction to light except in syphilis, brain diseases, optic atrophy, fainting or hemorrhage immediately pre- cedes death ; a sluggish reaction is serious. In most cases the pupil dilates widely just before the end. A film over the eyes or tight closing of the eyelids, with a firm, rapid pulse, is a sign of impending fatality, as is a turning of the eyes outward. In children a passive congestion of the conjunctival vessels means approaching death. Other signs which no doubt are noticed even before those men- tioned above, but which are of secondary prognostic value, are stated below. The facies show markedly the hand of death ; there is noted a pallor, the eyes are sunken and hollow, the temples are collapsed, the nostrils are pinched, and the ears which are cold and trans- parent have the lobes turned outward. Finally the lower jaw drops, the eyes become fixed and a haziness comes over the cornea. Aside from any intrinsic pain there appears a look of great mental distress, though the patient is unmindful of the fact. It seems as though the body is conscious of the impending danger, while the mind is oblivious to it. In such a facies every one recognizes the SYMPTOMS AND SIGNS OF IMPENDING DEATH 659 fact that death has already opened the door for the final departure. A temperature of 108° F., except in heatstroke, is fatal; likewise a rising temperature on the second day after the onset of hemi- plegia. Loss of sphincter control is always a grave sign, especially when coma is present. In peritonitis a fatal indication is a bright yellow discoloration of the tongue ; likewise, black vomit coming on forty-eight hours after operation. Persistent and uncontrollable hiccough appearing in a serious complication is usually the forerunner of death. The appearance of large amounts of indican in the urine or transudates is a fatal indication. Subsultus tendinum and car- phologia, except in typhoid, are of grave import. Fibrillary heart-tremor in electric shock is always fatal. Except in diseases of the central nervous system, the disappear- ance of the peripheral reflexes is usually a fatal sign. Edema of the glottis in patients over 45 years of age is followed by death in a few hours. It has been said that there is a peculiar odor to the breath in many dying patients. In rooms which have not had the best of ventilation, this is especially noticed. It is likened unto decayed apple blossoms or acetone. Some think it resembles horse-radish very closely. When once noticed it is not soon forgotten. Fortunately few patients realize that death is at hand. The most prominent passion during life will very likely present itself during the last hours. The loss of interest at this time in things which formerly interested the patient, is a bad sign. The presentiment of a fatal issue by the patient in cases where the condition is not particularly alarming, and when he shows very little or no interest in the consultation over his bedside, is not en- couraging. Likewise when a uremic patient becomes jolly and joyous, the end is often very near at hand. More than half of our patients die in coma. The blood pressure falls, the pulse becomes fast and ultimately irregular, the skin be- comes cold and clammy, finally the well-known death rattle appears in the throat and the end has come. Sudden Death. — Sudden death is not uncommon among individ- uals who were previously known to be the victims of no disease. Should it then be a matter of surprise that this distressing accident occasionally happens among those who have recently been sub- jected to the stress and strain of a major surgical procedure? 660 AFTER-TREATMENT OF SURGICAL PATIENTS Few operators indeed escape the occurrence, at some time or other during their experience, of sudden unexpected and unex- plained deaths among their patients. Many eases are reported in the literature, but many more have passed unnoticed, not gaining the attention of the medical profession at all. During recent years, however, more light has been shed on this subject with the result that through the efforts of Draper. 2 1850 cases have been collected. Ferrario and Sermoine of Milan studied 1043 cases, Wescott, coroner for Middlesex district, London, reported 303 instances, and Bro- nardel of France called attention to 1000 cases more. Later on Blake in this country collected 225 eases. These figures are suffi- cienl to show that a factor uncontrolled by any means on the part of the surgeon must be reckoned with in surgery, and that this factor is not of little importance. The p< riod of life during which sudden death is most apt to oc- cur, according to the various mortuary records, seems to be after the age of 55. Nex1 in frequency comes the span between 40 and 55, while about one-fourth of all sudden deaths occur before 40. It must therefore be apparent that youth and even childhood are not entirely free from this occurrence. The causes which are usually given in death certificates for these unexpected deaths, are status lymphaticus, myocarditis, ar- teriosclerosis (particularly of the coronary arteries), thrombosis and embolism, of which the pulmonary variety forms 80 per cent, hemorrhage from the pancreas, acute dilatation of the heart, rup- ture of the heart, and valvular lesions of the heart. Recently the thymus gland in children and young adults has been noted as a causative factor as reported by Rehn, 3 Colin.' Lange, 5 Zander and Keyhl, 6 Caille, 7 Falls/ Hart.' 1 Mettenheimer, 10 Forret 11 and others. The conditions under which these deaths occurred, according to Blake 12 who particularly studied this phase in his own collection of cases, were the following: (a) unusual exertion, one-fifth; (b) moderate exertion, one-fourth; (c) deep emotion or psychic shock less than one-fifth; (d) the remaining cases occurred during rest or sleep. Blake therefore concludes that emotion, exercise, and exertion are frequently the exciting cause of sudden death. These same factors are attendant upon a surgical operation. Be further states that the effects of apprehension and fright are very obvious, while the effect of the anesthetic upon the pulse, respiration, skin, and kidneys is precisely thai of moderate exercise; furthermore, the ef- fects of long-continued and very serious surgical interference are SYMPTOMS AND SIGNS OF IMPENDING DEATH 661 again precisely analogous to very severe exertion. We have, there- fore, in the routine of modern surgery, reproduced with considerable accuracy the precise conditions under which a majority of sudden deaths occur. The deaths which have been attributed to the anes- thetic are more than likely coincidental and would have occurred with equal certainty under any other procedure which produced these conditions. Considerable work has been done in attempting to determine the cause of sudden deaths under anesthetics. Henderson 13 states that most of the deaths belong in one or the other of two general classes: those the result of primary respiratory failure, and caused by a cessation of the heart beat. It is well-known that carbon dioxide in the blood is the normal stimulant to the re- spiratory center. This is maintained at a constant level Jby the normal breathing. During anesthesias, however, the sensitiveness of the respiratory center is very much altered. Too light, and especially an intermittent, administration of the anesthetic, ether excitement, fear, pain, and intense emotion, which may accompany the anesthesia at times, increase this sensitiveness greatly, produc- ing at once ver}^ rapid respiration, which in turn overventilates the lungs. This causes a decrease of the carbon dioxide of the blood, and a condition known as acapnia. The respiration, receiving no further stimulation from the inadequate amount of carbon dioxide, soon ceases. Unless artificial respiration is at once instituted, the patient dies. The acapnia not only causes an increased sensitiveness of the re- spiratory center, but this condition produces deleterious effects upon the heart. This organ becomes under those new conditions hyper- susceptible to the anesthetic, so that the amount which under normal conditions would not be harmful, is now sufficient to cause it to even cease its contractions. When this occurs before the respiration ceases, the case is considered as belonging to the cardiac class. Woolsey, 14 while not decrying the acapnia theory of Henderson, states that "any agent capable of so changing the molecular state of nerve matter as to arrest its function if carried into the blood, first acts upon the nerve cells. Each change produced in one of these, be it the decomposition of a molecule or, as is more probable, the isomeric transformation of a molecule, implies a disengagement of molecular motion or nerve force, that is immediately communi- cated to neighboring molecule, each molecule being a center of dis- charged nerve force, and in the act of being incapacitated for further transmittal of motion." He further informs us that the C62 AFTER-TREATMENT OF SURGICAL PATIENTS nerve cell then being quickly acted upon and discharging as quickly as the successive molecular transformations are wrough in it, there results a general nervous chaos, a tempest of incoordinate nerve force discharge, and as can be easily seen a corresponding disor- ganization of the action of vital organs which depend upon fine nervous coordination for their control. The surgical procedure with its attending trauma has as primary causative factors, first, the afferent nerve assault of fear and ap- prehension of the operation ; second, the afferent nerve assault of the anesthetic, especially if it is imperfectly maintained throughout the operation; third, the afferent nerve assault of the operative per- formance and the condition for which it was performed. All these elements, in greater or lesser degree, combine toward the end of determining the degree of central nerve disorganization which Woolsey believes is the cause of fatal terminations of other- wise good operative risks. The more we know of the real nature of these sudden deaths, the better we shall be able to avoid them. As has been said before, no one can designate with certainty the individual who is doomed to suddenly die, or the time or manner of its occurrence, but Ave do know many of the pathologic conditions which predispose to it and the circumstances under which it is most apt to occur. While attention has already been called to the complications which most frequently cause death, special notice must be taken of status lymphaticiis which is comparatively frequent; and there is another condition known as status thymicolymphaticus in which an enlarged thymus gland is found in association with the general enlargement of the lymphatic tissue. Not alone does this condition materially complicate operations upon children, but it has caused sudden death in adults, particularly in goiter operations, as re- ported by Rehn, Gluck, and Dwornitschenko. In order to diminish the instance of such calamities it is ab- solutely necessary for more thorough histories to be taken and complete examinations of patients to be made before operations, even of a minor character, are attempted. It is also important to try as far as possible to diminish preanes- thetic fright, apprehension and intense emotion. Every case which unfortunately terminates in this way should have an autopsy. By Ihis means additional causes may be found and more information be obtained to stimulate careful scrutiny of a subject, which has so often been a matter of great humiliation and sorrow. SYMPTOMS AND SIGNS OF IMPENDING DEATH 663 Bibliography lEeilly: Jour. Am. Med. Assn., 1916, lxvi, 160. sDraper: A Text Book of Legal Medicine, 1907. sRehn: Arch. f. klin. Med., 1906, lxxx, 468. ^Colm: Deutseh. med. Wchnsehr., 1901. sLange: Verhandl. d. Gesellsch. if. Kinderb., Karlsbad, December, 1902. sZander and Keyhl: Ibid. ^Caille: Arch. Pediat., N. Y., 1903, xx, 180. sFalls: Surg., Gynec. and Obst., 1916, xxii, 713. 9Hart: Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1909, xii, 321. loMettenlieimer : Jahrb. f. Kinderh., 1897, p. 655. nForret: Theses de doct., Paris, 1896. "Blake: Ann. Surg., 1909, 1, 43. isHenderson : Surg., Gynec. and Obst., 1911, xiii, 161. lAVoolsey: Surg., Gynec, and Obst., 1912, xiv, 350. CHAPTEE LXII POSTOPERATIVE MO-RTALITY By Willard Bartlett. and B. L. Adelsberger, St. Louis. Mo. Postoperative mortality, as it will be discussed iu this chapter, will be subdivided into two groups; surgical mortality, and opera- tive mortality. By surgical mortality we mean the death of the pa- tient from any cause if that patient has been operated upon. By operative mortality we mean the death which is, directly or in- directly, the result of the operation; the disease for which the op- eration was performed not necessarily being fatal. 1 These mortality figures, however, are largely influenced by the type of cases re- ported. Under the list of surgical mortalities we shall attempt to give the mortality rate from anesthetics, and under operative mor- talities, the mortality rate from the various operations themselves. In connection with this it will be also necessary to discuss, briefly, the relationship of anesthetic mortality and postoperative complica- tions. As a matter of historical interest it might be permissible to men- tion a few facts regarding the introduction of ether anesthesia, its mortality then and follow it roughly up to the present time. The Medical GazetU on March 5, 1847. reported 28 operative cases in which ether had been used as an anesthetic — 2 of these cases were fatal. In the same year the London Chemist for April re- ported another death from ether anesthesia in which the patient failed to recover from the effects of the ether. This fact, failure to recover from the effects of ether or death before the anesthesia was complete caused physicians to fear the use of ether, and led Sir James Y. Simpson to investigate the anesthetic value of chlo- roform. However, the dangers of chloroform were immediately seen by an initial fatality on Jan. 28, 1848, and then both ether and chlo- roform were regarded as being unsafe. In 1^>4 The Royal Medical and Chirurgical Society reported 100 deaths from chloroform, cov- ering a period of years from 1848 to 1865. From 1865 to 1876, 101 more deaths from chloroform were reported and of these 210 deaths, 90 per cent occurred before the anesthesia was complete. From ISSli to 1889, 130 chloroform deaths were reported. 54 per cent of which occurred either before or during the operation.-' The mortality rate is thus shown to be very high and the true cause of death was not POSTOPERATIVE MORTALITY 665 fully appreciated until the relationship between cardiac fibrillation and chloroform syncope was realized. Levy 3 in analyzing the cases reported by the Royal Medical and Chirurgical Society in 1864, states that in 62 per cent of the cases it was shown that the patients died under light anesthesia and that 87 per cent of the deaths were not due to an overdose; also, that out of the whole series of 98 cases there is no evidence that any patient died of overdosage. From this, he concludes that these deaths are due only to cardiac fibril- lation and chloroform syncope. In 1912, 71,052 cases of anesthesia administration with 24 deaths were reported. 4 Of these, 20,613 were chloroform administrations, death occurring 1 in every 2,060 cases; 11,859 were ether cases with a fatality of 1 in 5,930. This series also includes 10,230 cases in which chloroform was the primary anesthetic followed by ether. The mortality here was 1 in 3,410 cases. In the same year Bevan at the American Medical Association meeting reported the following deductions : 1. That the use of chloroform as an anesthetic for major opera- tions is no longer justifiable. 2. That for minor operations the use of chloroform should cease. 3. That chloroform is sometimes found convenient in initiating anesthesia in alcoholics or difficult subjects. The first two points have been accepted without hesitation, but in regard to No. 3 recent investigations show that chloroform should never be used as a preliminary drug. In obtaining figures for anesthetic mortalities at the present time one meets with many difficulties. To determine the total number of administrations would be impossible ; also, we can not find any standard by which we can determine what constitutes an anes- thetic death. Various opinions have been given and a few are mentioned. Roberts 5 concludes that death in general anesthesia in the majority of cases is due to improper administration of the drug with subsequent poisoning. Williams 6 believes that anesthetic deaths reported as such are not always the result of the anesthetic. Other men attribute status lymphaticus as a cause. Henderson 7 says that "in a large majority of deaths of cardiac type, the ex- pressions hypersensibility to anesthesia, heart disease, or status lymphaticus are mere excuses, and that the patient is killed by the method of administration of the drug." He further says that it is not the anesthetic agent at the time which kills the patient, but instead, the treatment, which the patient receives half an hour or so earlier is really the cause of death. 666 AFTER-TREATMENT OF SURGICAL PATIENTS Many deaths which occur during or following an operation can not be said definitely to be caused by the anesthetic, neither can we definitely estimate the influence the anesthesia had in produc- ing these deaths. In such cases of postoperative deaths the result of septicemia, peritonitis, hemorrhage and emboli of the lungs, heart, or brain, Ave can not consider the anesthetic as a cause of death. In cases of death the result of aspiration pneumonia, suffo- cation from pressure on the larynx during operation, we again can not lay the cause of death to the anesthetic, although death might not have occurred had no anesthesia been given. So in giv- ing the figures on anesthetic deaths, Ave hope to adhere as closely as possible to those occurring from overdosage or improper adminis- tration, bearing in mind that with improper administration such complications as cardiac and respiratory failure may result. We must also consider those deaths due to delayed chloroform poisoning, of which 82 are reported in the literature. 8 Braun states that late chloroform poisoning presents the picture of acute yellow atrophy of the liver. Graham attributes it to the HO set free in the tis- sues when the chloroform is oxidized. The mortality rates from various anesthesias Avill be considered as follows: Deaths under: I. Ether. II. Chloroform. III. Ethyl Chloride. IV. Nitrous Oxide-oxygen. V. Spinal Anesthesia. VI. Scopolamine. VII. Local Anesthesia. VIII. Other methods. I and II. Under Ether and Chloroform UNDER ETHER UNDER CHLOROFORM REPORTER CASES DEATHS MORTALITY RATE C k.SES DEATHS RATE Eiehardsonio Julliardii Ormsbee 12 St. Barth. Hospital 13 German Sur. Society I* Neuberis GwathmeyiG McGrath" 8,431 314,738 92,815 37,277 56,333 1 L,859 294,653 49,057 1 21 4 4 11 2 65 1 1 1 1 1 1 in in in in in in 1 t,987 23,204 8,318 5,121 5,930 4 ^33 35,162 524,507 152,260 I2.9S7 240,806 20,613 L6,390 1,300 11 161 53 33 116 10 8 1 1 1 1 1 1 1 in 3,196 in 3,258 in 2,837 in 1,300 in 2.075 in 2,061 in 2,04S Average mo rtality rat c 1 in 8,010 1 in 2,665 POSTOPERATIVE MORTALITY 667 The average mortality under ether was 0.012 per cent while that under chloroform was 0.038 per cent or three times that under ether. W. H. Keen has collected 262,002 cases of ether administration from various sources, with 34 fatalities; the mortality being: 1 in 7,705. 1S III. Under Ethyl Chloride REPORTER CASES DEATHS REFERENCE Soullier 8,417 Bull. Med. Paris, 1895. Lotheissen 2,550 1 Ware: Med. Rec, April, 1901. Newman 1,867 1 Cumston: Boston Med. and Surg. Jour., January, 1905. MeCardie 12,000 4 British Med. Jour., March, 1906. Luke 2,000 Lancet, London, May, 1906. Lee 5,575 1 Internal Clinics, iv, 19th Series. Herrenknecht 3,000 ■1 i ' 8 Munchen. med. Wchnschr., December, 1907. Webster 1,880 Surg., Gynec. and Obst., April, 1909. Steida 1,000 Med. Klin., March, 1912. Zanda Miller 6.648 1 Jour. Am. Med. Assn., November, 1912. Hornabrook 18,813 Austin Med. Gaz., April, 1914. Greene 5,000 Am. Jour. Surg., July, 1915. Ware 15,000 Am. Jour. Surg., July, 1915. In addition Peterka 19 reports 9 deaths out of 100,971 cases of ethyl chloride anesthesia, or a mortality rate of 1 in 11,219. Out of 53,403' cases collected by Miller 20 he reports 4 deaths or a mor- tality of 1 in 13,365. IV. Under Nitrous Oxide-Oxygen REPORTER CASES DEATHS REFERENCE Gwathmey Jones Lower and Crile Teter 8,585 13,000 34,946 23,952 Jour. Am. Med. Assn., Nov., 1912. Ohio State Med. Jour., Aug., 1915. Anoci-Association, 1915. Jour. Am. Med. Assn., November, 1912. Of 1,500,000 cases collected and reported in the Birmingham Medical News for April, 1893, 2 deaths were recorded. Buxton in 1900 21 reports 1,001,000 cases with one death. The mortality rate by others, Gwathmey 22 has been placed as 1 in 20,000 which might be considered high as compared with others. V. Under Spinal Anesthesia REPORTER CASES DEATHS REFERENCE Risch Chaput Kronig and Gauss Colombani Gray Hohmeier 315 7,000 1,000 1,100 300 2,400 2 3 1 12 Zeit. f. Gyn., July, 1907. Anesthesia; Gwathmey, 1914. Munchen. med. Wchnschr., Oct., 1907. Wien. klin. Wchnschr., Sept., 1909. Anesthesia, Gwathmey, 1914. Arch. f. klin. Chir., xciii, No. 1. Jonnoesco 2,963 2 Bull, de L'Acad. de Med., 1910. 668 AFTER-TREATMENT OF SURGICAL PATIENTS V. Under Spinal Anesthesia — Continued. REPORTER CASES DEAT 1 1 S REFERENCE Violet and Fisher 270 1 Lyons < Ihir., Nov., 1910. Kohler 7,780 12 Brit. Med. Jour., Jan., 1910. Hahm 708 8 Brit. Med. Jour., Jan., 1910. Helm 1,419 P.cit. /.. klin. Chir., Lxxi-v. Barker 2,354 O Anesthesia, Gwathmey, 1914. Grwathmey 521 Jour. Am. Med. Assn., Nov., 1912. Bainbridge 1,065 1 Jour. Am. Med. Assn., Nov., 1912. Allen 320 Jour Am. Med. Assn., Nov., 1912. Babeock 5,000 11 Am. Jour. Obst., Nov., 1914. Gellhorn 63 Jour. Am. Med. Assn., June, 1914. Merenes 169 Ann. Surg., Dec, 1913. This series of cases gives a mortality rate of 1 in 515. Other in- vestigators report cases as follows: Strauss, 22,717 cases with 46 deaths, Chiene, 12,000 cases with 36 deaths, the average mortality heing 1 in 623. 23 VI. Under Scopolamine REPORTER CASKS DEATHS reference Maass 1,499 11 Therap. Monatsehr., Aug., 190."). Roith 1,000 L8 Miiuchen. med. Wchnschr., 1905. Muhsam 28,809 5 Med. Klin., June, 1912. Viron and Mori 1 2,000 25 Progres. med., xxii, 1906. Beach L,000 Am. Jour. Obst., May, 1915. Etongy 2,000 Am. Jour. Obst., May, L915. The average mortality in 1liis series was 1 in 666 cases. II. ( '. Wood, Jr.. lias collected 1,988 cases of scopolamine anesthesia from the literature and reports a mortality rale of 1 in 221. VII. Under Local Anesthesia. No accurate list of cases could be obtained, but a certain number of fatalities have been reported by such men as Proskauer, 24 Lichtenstein, 25 Miller, 26 Grwathmey, 27 and 6 case's by Plemming. 28 VIII. Under Other .Methods. Death from anesthesia is also met with when oilier methods of administration arc employed. Pikin 29 reports 12 cases of intravenous anesthesia with 1 death. Homans and Hassler report 1 death out of 350 eases.* 1 Woolsey reports 5 deaths from intratracheal anesthesia, 33 while Robinson reports 7 deaths out of 1402 cases. - The following men reporl deal lis from rectal anesthesia: Weir l. ;; Baum 2. :;1 Carson 2. " Cunningham 1.'" In regard to postoperative complications referable to anesthetics. Homans 37 divides these into three groups. 1. Complications which depend directly upon the anesthetic and result from inhaling or aspirating infected material into the lungs. 2. A condition of hypostatic pneumonia due to enfeebled circula- tion and failure to keep the lungs (dear. 3. Emboli. POSTOPERATIVE MORTALITY 669 It lias been shown by Graham 38 that the "reduction of the phago- cytic power of the blood after an ordinary ether anesthesia con- tinued in different experiments over periods of 2 days to 7 weeks in duration." We are thus shown how ether will lower the natural resistance of the body and make the patient more liable to infection. With regard to the effects of ether on the lung tissue itself Chap- man 39 states that ether has an irritating effect on the lung tissue with subsequent swelling of the alveoli and congestion, and in some cases even hemorrhage which is proportional to the amount of ether given. From these two observations one can easily see how patients may readily contract such complications as aspiration or hypostatic pneumonia. Miller 40 states that ether lowers the coagulation time of the blood which he thinks may play an important part in the production of postoperative emboli or thrombi. In regard to the fatalities due to lung complications Homans 41 reports a collected series of 15,043 laparotomies with a death rate of 4.4 per cent; from Boston hospitals he reports from a collection of 3,089 laparotomies with a mortality of 0.4 per cent due to these same complications. Out of a collection of 6.825 operations Beekman 42 reports lung complications in 87 with no deaths. Considering next the heading, operative mortality, it might be well to consider, briefly, the evolution of antiseptic surgery and its bearing on the mortality of operations. Lucas Championniere has been cpioted as saying that there were only two periods in surgery — that before Lister and that after Lister. With the advent of the nineteenth century, surgery was revolutionized. The cause of pu- trefaction of animal and vegetable material, was being investigated and many theories were given only to be cast aside, until Pasteur made his famous studies on the fermentation of alcoholic beverages. He showed that not only the fermentation of beer and wine was due to living organisms, but that all putrefactions were due to the same cause. In 1845 a step further in the support of the germ theory of disease was made by Semmelweiss who discovered that puerperal fever in the General Hospital at Vienna was due to infection borne from the dissecting room on the hands of the students, and, by insisting on hand cleansing with chlorinated lime water he reduced a mortality rate of 12.24 per cent to 1.27 per cent. In 1862 Pas- teur's experiments lead him to the conclusion that suppuration was but a fermentation of flesh and that this might be prevented by destroying the germs that caused it or by preventing their entrance. To this end he urged the use of boric acid for surgical purposes. In 1878 he advocated the use of bandages and sponges which had 670 AFTER-TREATMENT OF SURGICAL PATIENTS been previously heated to a temperature between 130° C. and 150° C. and water which had been previously heated to 110° C. or 120° C. Up to this time no adequate surgical dressing had been in- troduced, though in 1854 the use of carbolic acid was made by Lemaire of Paris, and in 1855 it was first employed at St. Mary's Hospital in London. The great values of these discoveries as applied to surgery were left to be demonstrated by Lister. When Lister entered the Uni- versity of Glasgow as Professor of Surgery in 1860, tetanus, ery- sipelas, septicemia, pyemia and hospital gangrene were scarcely absent from the wards. There was no knowledge of their cause or any means to prevent them. Lister then insisted upon scrupulous cleanliness in the wards, frequent washing of the hands of all at- tendants either at operations or at wound dressings, and frequent changing of the dressings of suppurating wounds. To overcome the decomposition of the injured part Lister advised the use of carbolic acid in the dressing so as "to destroy the life of the floating par- ticles" (microbes). He also observed that dead tissue when pro- tected from external influences was absorbed. This led to the idea of catgut ligatures. It is not necessary to chronicle every step in the advance of asepsis, but suffice it to say that by this time opera- tions were performed with success which formerly could have ended only in failure. In 1877 Lister still employed carbolized gauze, car- bolic spray, and oiled silk but was ever on the lookout for improve- ments, and when bichloride of mercury was proved to be more powerful than carbolic acid, he experimented with it and suggested the gauze dressing impregnated with double cyanide of mercury and zinc which is still used by many. Ultimately when the carbolic spray was found inadequate to destroy bacteria in the dust. Lister abandoned it. but nevertheless paved the way for our modern methods of surgery. Today figures from the London Hospital show that 98 per cent of operative wounds heal by tirst intention, whereas, 50 years ago 80 per cent were attacked by hospital gangrene. 43 The following mortality lists of various operations are made from a variety of sources, but represent those from reliable hos- pitals or operators. Not every operation practiced is tabulated, but only those which are considered worthy of mortality figures, either on account of their severity or from their common occurrence. A. Alimentary System. 44 I. Lymph-adenoid : Tonsillectomies ami adenoidectomies ; ~<7 \ cases, 2 deaths. Oclisner reiiorts 593 cases with no deaths. 4 ^ POSTOPERATIVE MORTALITY 671 II. Esophagus : Gastrostomies for carcinoma; 13 cases, 8 deaths. These deaths were due to the malignancy of the disease. III. Stomach, Pyloris and Duodenum. Gastroenterostomies for neoplasms: 70 cases, 5' deaths. Ulcers, either excisions or resections: 67 cases, 1 death. Mayo,46 out of 1000 cases of ulcer, irrespective of operations, types or cases, reports a mortality of 2.4%. In malignancy of the stomach, gastrostomy being done, Mayo 4 ? reports an immediate mortality of 25 to 55%. In the same operation and cause, McCosh reports a mortality of 30%; Robson, 38.3%; Czerny, 38.5%; Mukulicz, 32%. IV. Liver and Biliary Tract: Choleeystostomies — choledochotomies — cholecystectomies, etc. : 210 cases with 14 deaths. The Mayo brothers report the following series of operations for a period of ten years : 4S Removal of benign tumors, 311 cases, 8 deaths. Removal of malignant tumors, 17 cases, 3 deaths. A later report^ of 1500 cases operated upon shows 66 deaths or a mortality of 4.43%. Of the first 1000 cases 845 were choleeystos- tomies with a mortality of 2.1% ; of the last 500 the mortality for the same operation was 1.47%. The mortality of cholecystectomies for the first 1000 cases was 3.13% and for the last 500 cases 1.62%. Their figures for operations on the common duet are as follows: Stones — partial obstruction, 105 cases, 3 deaths, mortality 2.9%. complete obstruction, 29 cases, 10 deaths, mortality 34%. with infection, 61 cases, 10 deaths, mortality 16%. malignancy, 12 cases, 4 deaths, mortality 33%. Ochsner^s reports 124 cholecystectomies with 7 deaths; and 39 choleeystostomies with 2 deaths. V. Intestines. Appendectomies, 625 cases, 20 deaths. Ochsner reports 655 cases with 3 deaths. *s Hernias — Epigastric, 12 cases, no deaths. Femoral, 43 cases, no deaths. Ventral, 35 cases, no deaths. Umbilical, 23 cases, 5 deaths. Inguinal, 506 cases, 4 deaths. Ochsnei'45 reports — Femoral, 7 cases, 2 deaths; Inguinal, 68 cases, no deaths; Ventral, 15 cases, no deaths; Umbilical, 4 cases, no deaths. VI. Rectum and Anns : Hemorrhoids, ligation and excision by various methods, 186 cases with no deaths. Fistula and Fissure, 43 cases and no deaths. Resection of rectum, 20 cases, 2 deaths. Ochsner-ts — Hemorrhoids, 87 cases, no deaths. Obstruction, 17 cases, 9 deaths, operation late. Resections and colostomies for carcinoma, 12 cases, 2 deaths. 672 AFTER-TREATMENT OF SURGICAL PATIENTS B. Vascular System:** I. Varicose veins and ulcers, excision, 164 oases and 1 death. C. Ductless Glands. it I. Hypophysis — transsphenoidal, sellar decompressions, etc., 7-1 oases and 2 death-. II. Thyroid. Partial Thyroidectomy : Adenoma, cysts, etc. 25 rases, no deaths. Colloid. - •! deaths. Hyperthyroidism, 29 cases, 1 death. Dysthyroidism, 5 cases, no deaths. Oehsner reports 128 cases with 4 deaths. Kocher reports 11 deaths from partial thyroidectomy for benign ths from v 7<> cases or a mortality of a little more than 1%. His later mortality figure is .", out of every 1000 cas< D. Xervous System:'** I. skull: decompressions, craniotomies, etc., for tumors, trauma, hemor- rhag - s, 7:; deaths. K. Reproductive System:** I. B Removal for benignancy, 29 cases, no deaths. Oehsner, same, 32 cases, no deaths.* 5 Removal for malignancy, 61 cases, 1 death. Oehsner, same, •"•! cases, no deaths. IL Uterus: Hysterectomies, al dominal and combined routes. 83 cases, '2 deaths. Mayo reports 504 myomectomies from January 1. 1891, to September 1. 1916, with 1 deaths or a mortality of 0.8 Ochsner's figures are as follows: Hysterectomies and Panhysterectomies -. 4 death-. III. Uterine Appendages: Salpingectomies, salpingo-oophorectomies, 119 cases, 1 deaths. Oehsner 1 " —on salpinx. 41 eases. 1 death. on o\ ary. 1 I cases, 2 deaths. IV. Prostate: Prostatectomies or Prostatomies, 61 cases, 5 deaths. Ochsner,*s same operation, 25 cas s, 2 deaths. P. Respiratory System.** I. Pharynx: Tracheotomy, 2 cases, no deaths. II. Lungs and Pleura-: Tho] : 36 deaths. Oehsner.'" same operations, -".ii cases, I deaths. G. Skeletal: 1. Osteomyelitis, acute and ehronic, 14( 2 deaths: Tuberculous, x -. no deaths; Actinomycotic, 2 eases, m, deaths. POSTOPERATIVE MORTALITY 673 H. Urinary System: 44 I. Kidney: Nephrectomies, 21 cases, no deaths. Nephrotomies, 81 cases, 5 deaths. II. Ureter: Ureterotomies, 17 cases, no deaths. III. Bladder: Supra-pubic cystotomies, 29 cases, 1 death. Ochsner,' 4f >, 25 cases, no deaths. We will not attempt to summarize or lay down any conclusions regarding- postoperative mortality as discussed in this chapter, since in doing so we would only make a repetition of the figures already given. The tabulated figures themselves serve the best deductions and conclusions that we can offer. Full credit is due B. L. Adelsberger for having abstracted all the literature to which reference is made in this chapter. Bibliography General reference is made to the American Year Book of Anesthetics and Analgesia, i, containing Miller's article "Mortality Under Anesthetics," from which the figures in Sections I to VIII, inclusive, of this article were taken. iSkeel: Mortality of Abdominal Surgery, Jour. Mich. State Med. Soc, Febru- ary, 1915. 2British Med. Jour., 1889. sLevy: Cardiac Fibrillation and Chloroform Syncope, Am. Year Book of Anes- thetics and Analgesia, i. 4 Muhsam: Med. Klin., 1912. sRoberts: Surg., Gynec. and Obst., August, 1911. e Williams: Clinical Jour., December, 1908. ^Henderson : Surg., Gynec. and Obst., August, 1911. sMiller: Mortality under Anesthetics, Am. Year Book of Anesthetics and Analgesia, i. QGraham: Researches on Late Chloroform Poisoning, Am. Year Book of Anes- thetics and Analgesia, i. ioHewitt: Anesthetics, New York, 1912, Macmillan Co. nlbid., 138. izlbid., 138. islbid., 139. i 4 Eisendrath: Am. Med., November, 1902. isMuhsam: Med. Klin., June, 1912. isAnesthetics, 1914. iTjour. Am. Med. Assn., October, 1913. isKeen: Boston Med. and Surg. Jour., December, 1915. isBeit. z. klin. Chir., 1912. sojour. Am. Med. Assn., November, 1912. 2iBuxton: Anesthetics, Philadelphia, 1900, P. Blakiston's Son & Co. 2 2Gwathmey: Anesthetics, New York, 1911, D. Appleton & Co. 23Miller:8 2 4 Proskauer : Therap. d. Gegenw., December, 1913, liv, No. 12. 25Lichtenstein : Ibid., February, 1901, xvi, No. 2. 26MUler: Jour. Am. Med. Assn., January, 1914. 674 AFTER-TREATMENT OF SURGICAL PATIENTS 2'Gwatlnney: Anesthesia, New York, 1014, D. Appleton & Co. 28Miller:8 2oPikin: Wein. klin. Wchnschr., Mar. 5, 1910. -"Ann. Surg., December, 1913. siWoolsey: New York State Med. Jour., April. 1912. -Rnl'inson: Surg., Gynec. and Ohst., March, 1913. • W, ir : Med. Rec, New York, May 3, 1884. 34Baum: Ztschr. f. Chir.. March, 1909. -•"Carson: Interstate Med. Jour., May, 1910. scCunmngliam : Boston Med. and Surg. Jour.. May, 1909. 37Homans: Bull. Johns Hopkins Hosp., April, 1909. 38< irahani: Jour. Am. Med. Assn., 1910. apman: Ann. Surg., 1904. i"Miller:8 nMiller:8 42Beekman: Surg., Gynec. and Obst., May, 1914. *3Lecture Memoranda. Am. Med. Assn. meeting, St. Louis, 1910. "Peter Bent Brigham Hospital Reports, 1913-1917, inclusive. *50ehsner: Augustana Hospital Report, 1917. "Mayor Ann. Surg., 1911, p. 313. *7Mayo: Ann. Surg., xxx, 251. isMayo: Ann. Surg., x.wv. *9Keen: Surgery, Philadelphia, W. B. Saunders Co. si Mayo Clinics. COLUMBIA UNIVERSITY LIBRARIES This book is dile omthe date indicated below, or at the expiration of a dellniteweriod after the date of borrowing, as provided by the rilles c| the Library or by special arrange- ment with the Liblarial in charge. DATE BORROWED DA^S^eUE DATE BORROWED DATE DUE C28(l14l)M100 COLUMBIA UNIVERSITY LIBRARIES (hsl.stx) Rd 51 B28 C.1 v. 1 The after-treatment of surgical patients 2002124653 ^ \- iJxX > t% I