ffflSBSBPteBss* RD32 SI8 H 1Q?^ 054268 910 Emergency surgery, f Columbia Stato? rsrttp College of pfjpsictans; anb ismrgeons Hibrarp Digitized by the Internet Archive in 2010 with funding from Columbia University Libraries http://www.archive.org/details/emergencysurgery1910slus EMERGENCY SURGERY SLUSS THE LEATHER BOUND SERIES OF MEDICAL MANUALS BINNEE. Operative Surgery. By John Fairbairn Binnie, A. M., C. M. (Aberdeen); Professor of Surgery, Kansas State University; Member American Surgical Association. Volume I. Fourth Edition. Operations on the Head, Neck, Nerves, Trunk, Genito-Urinary System, xi+832 pages Illustrated by 713 Engravings, some of which are printed in colors. Flexible Leather, Gilt Edges, Round Corners. $3-5° Volume II. Vascular System, Bones and Joints, Amputations, viii+553 pages. 550 Illustrations. Flexible Leather, Gilt Edges, Round Corners. *3-5o GREENE. Medical Diagnosis. Third Edition. By Charles Lyman Greene, M D , of St. Paul, Professor of the Theory and Practice of Medicine in the University of Minnesota. With 7 Colored Plates and 248 other Illus- trations. i2mo. 725 pages. Flexible Leather, Gilt Edges, Round Corners. *3-So HUGHES. Compend of the Practice of Medicine. Ninth Edition. By Daniel E. Hughes, M. D., late Chief Resident Physician, Philadelphia Hospital. Revised by Samuel Horton Brown, M.D., Assistant Dermatologist, Philadelphia Hospital. With Illustrations. 785 pages. Flexible Leather, Gilt Edges, Round Corners. $2.50 KYLE. Manual of Diseases of the Ear, Nose and Throat. Second Edition. By John Johnson Kyle, B. S., M. D., Clinical Professor of Otology, Rhinology and Laryngology in the Medical College of Indiana; Otologist, Rhinologist and Laryngologist to the City Hospital, Indianapolis; Member of the American Laryngological, Rhinological and Otological Society. With 169 Illustrations. Flexible Leather, Gilt Edges, Round Corners. $3-°° SLUSS. Emergency Surgery. Second Edition. By John W. Sluss, A. M., M. D., Professor of Anatomy, Indiana University School of Medicine; formerly Professor of Anatomy and Clinical Surgery, Medical College of Indiana; Surgeon to the Indianapolis City Hospital. With 605 Illus- trations. xiv+748 pages. i2mo. Flexible Leather, Gilt Edges, Round Corners. $3-S0 STEWART. Manual of Surgery. By Francis T. Stewart, M. D., Professor of Surgery, Philadelphia Polyclinic; Associate in Surgery, Jefferson Medical College, Philadelphia, etc. 504 Illustrations, ix+778 pages. Flexible Leather, Gilt Edges, Round Corners. $3-5° THAYER. Manual of Pathology. 131 Illustrations. General and Special. By A. E. Thayer, M. D., Professor of Pathology, University of Texas; formerly Assistant Instructor in Pathology, Cornell Medical School. With 131 Illustrations. 711 pages. 12 mo. Flexible Leather, Gilt Edges, Round Corners. $2.50 THORNDKE. Manual of Orthopedic Surgery. By Augustus Thorndike, M. D., Assistant Surgeon to the Children's Hospital, Boston; Member American Orthopedic Association. 191 Illustrations. i2mo. Flexible Leather, Gilt Edges, Round Corners. $2.50 *** Other Volumes in Preparation. P. BLAKISTON'S SON & CO. Publishers : : PHILADELPHIA EMERGENCY SURGERY FOR THH GFNFRAL PRACTITIONER BY JOHN W. SLUSS, A.M., M.D. PROPESSOR OP ANATOMY, INDIANA 1'MVERSITY SCHOOL op MEDICINE; FORMERLY PROl OF ANATOMY AND CLINICAL SURGERY, MEDICAL COLLEGE OP INDIANA; BDROBOM TO THE INDIANAPOLIS CITY HOSPITAL; SURGEON TO THE CITY DISPENSARY; MKMHER OP THE NATIONAL ASSOCIATION OF MILITARY SURGE' SECOND EDITION, REVISED AND ENLARGED WITH 605 ILLUSTRATIONS SO.ME OF WHICH ARE PRINTED IN COLORS PHILADELPHIA BLAKISTON'S SON & CO. 1012 WALNUT STREET 1910 First Edition, Copyright, 1908, by P. Blakiston's Son & Co. Second Edition, Copyright, 1910, by P. Blakiston's Son & Co. Itlo Printed by The Maple Press York, Pa. DEDICATION TO MY PRECEPTOR, DR. E. B. EVANS, TYPE AND EXEMPLAR OF GENERAL PRACTITIONERS, IN MEMORY OF DAYS SPENT TOGETHER, THIS LITTLE WORK IS INSCRIBED PREFACE TO SECOND EDITION The fact that the first edition of this hook was sold out within one year is particularly gratifying to the author because it indicates that the results of his effort to make a useful and practical book have met with the approval of the profession. In preparing this second edition of the "Emergency Surgery" the effort has been to profit by the suggestions and criticisms of the various reviewers of the first. It is hoped, in consequence, that its usefulness has been increased and that it will continue to find favor with its readers. A new chapter on the general technic of Laparotomy has been added; each subject has been carefully reviewed; and in many in- stances new matter incorporated. Thus, for example, Spinal Anes- thesia is described in detail and Subphrenic Abscess and Pericardio- tomy more fully considered. Doctor Helen Knabe has contributed some new illustrations, and the skiagrams are the work of Doctor Albert M. Cole, of Indianapolis, to whom thanks are due. T. \V. s. vi 1 PREFACE TO THE FIRST EDITION. This is a Surgery for the general practitioner; written not to instru< t his leisure hour, but in the hope sometime to serve as a guide out of uncertainty in a time of stress. Its merits and demerits should be reckoned from that point of view alone. If, occasionally, the form of expression seems dogmatic, it merely comports with the constant aim to be practical; certainly that aim has denied any place to theoretic al discussions and has curtailed reference to the various views of recog- nized authority. An absence of bibliography, it is hoped, therefore, will not be regarded as discourtesy to the many writers, teachers, and practitioners whose ideas have been so freely appropriated. Among the text-books more constantly consulted are Senn's Practical Surgery, The American Text-book of Surgery, Walsham's Surgery, Treves' Operative Surgery, Lejars' Chirurgie d'Urgence, Veau's Chirurgie d'Urgence et Pratique Courante, Von Bergmann's Chirurgie, and Binnie's Operative Surgery. The Annals of Surgery, the American Journal of Surgery, the Inter national Journal of Surgery, and the Journal of the American Medical Association have been prolific sources of information. For advice and aid in many ways in the preparation of this book, Bpecial thanks are due Drs. John J. Kyle, James H. Ford, A. \V. Brayton, and Gustav Bergener. The original illustrations are the work of Dr. Helen Knabe. To the publishers, through whose counsel and patient criticism the book has grown into its present form, a grateful appreciation is to be expressed. J. W. S. DC CONTENTS PART I. CHAPTER I. Tine General Practitioner as an Emergency Surgi His Duties and Responsibility: Equipment i CHAPTER II. Emergency Antisepsis. Operation in a Private House . . CHAPTER III. Anesthesia 11 CHAPTER IV. Sutures; Methods and Materials CHAPTER V. Drainage ag CHAPTER VI. Dressings, Bandages, Splints CHAPTER VII. Shock 49 CHAPTER VIII. Hemorrhage 5 | CHAPTER IX. Wounds: General Principles 68 CHAPTER X. ds of Special Regions 78 CHAPTER XI. Gunshot and Other Wounds in Military Practice taa CHAPTER XII. Gunshot Wounds in Civil Practice 155 xi x ii CONTENTS. CHAPTER XIII. Fractures CHAPTER XIV. Injuries to Joints 2 S CHAPTER XV. Injury and Repair of Tendons 2 £ CHAPTER XVI. Injury and Repair of Nerves CHAPTER XVII. Abscess 3 1 CHAPTER XVIII. Phlegmon: Acute Spreading Infections 3f CHAPTER XIX. Acute Osteomyelitis CHAPTER XX. Septic Arthritis CHAPTER XXI. Foreign Bodies CHAPTER XXII. Burns, Scalds, and Frost-bite PART II. CHAPTER I. Tracheotomy, Laryngotomy, Esophagotomy CHAPTER II. Urgent Thoracotomy. Repair of Injury to the Lungs. Re pair of Injury to the Pericardium. Repair of Injury to the Heart. Puncture of the Pericardium. Pericardiotomy. CHAPTER III. Empyema — Purulent Pleurisy CHAPTER IV. Urgent Craniectomy; Trephining . . . CONTENTS. XI U CHAPTER V. VaStoid Abscess j^ CHAPTER VI. General Technic of Laparotomy 163 CHAPTER VII. Laparotomy for Traumatism 469 CHAPTER VIII. Appendicitis; Appendicial Abscess; Purulent Peritonitis . . 488 CHAPTER IX. Acute Intestinal Obstruction 508 CHAPTER X. Artifical Anus; Temporary', Permanent 519 CHAPTER XI. >RANGULATED HERNIA CHAPTER XII. cal Cure of Inguinal Hernia 557 CHAPTER XIII. al Cure of Femoral Hernia 567 CHAPTER XIV. UTERECTOMY. INTESTINAL ANASTOMOSIS 573 CHAPTER XV. I PERFORATE ANUS . . . . ' 584 CHAPTER XVI. ion of the Pedicle of Ovarian or Uterine Tumors; of •: Spermatic Cord; of the Pedicle of the Spleen; of Omentum 589 CHAPTER XVII. pture and Hemorrhage of Tubal Pregnancy' 597 CHAPTER XVIII. kean Section 604 CHAPTER XIX. .'TIRE OF THE URETHRA 60S XIV CONTENTS. CHAPTER XX. Acute Retention; Catheterization; Supra-pubic Puncture; Cystotomy; Urinary Infiltration 619 CHAPTER XXI. Suture and Ligation of Arteries 638 CHAPTER XXII. Practical Amputations 649 CHAPTER XXIII. Dilation of the Sphincter Ani; Operation for Piles; Opera- tion for Anal Fistula 703 CHAPTER XXIV. Phimosis; Paraphimosis; Circumcision; Hydrocele; Castration 710 CHAPTER XXV. Ingrowing Toe-nail 721 CHAPTER XXVI. Removal of Small Tumors 724 CHAPTER XXVII. Skin Grafting 727 lNDEX ■ 733-748 EMERGENCY SURGERY. UIAI'TKR I. THE GENERAL PRACTITIONER AS AN EMERGENCY SURGEON: HIS DUTIES AND RESPONSIBILITY. EQUIPMENT. Surgery is no longer reserved to the elect few. That its beneficence shall he denied a place in every practitioner's art is repugnant t<> the spirit of the times. Modern life is complex: every profession and every calling has its specific duty to perform. Whether the medical profession shall continue to play nohly its large part in the social drama depends upon the general practitioner. The hope of the profession rests in him. But there is a price to pay the age for high (pespect. That price to the medical profession is nothing less than the fulfillment of its therapeutic promise and the realization of its surgical opportunity. The opportunity is golden; for, with the wonderful Improvements in surgical technic, the field of emergency surgery, that is to say, the indication for immediate intervention, has been remarkably hroadened and the time finds the puhlic singularly favor- able to that form of relief. The "horror of the knife," of all that pertains to surgery, has Income a tradition, like the practice which gave it birth. Indeed, the puhlic is trained to expect that, in the face of grave emergencies, the practitioner will do something effective; however serious the required intervention may he, if it hut offers hope, the doctor is expected to ai t. Our predecessors — even those able and willing — often found their hands tied under such circumstances by the ruling policy of "let alone and let die." It is a part of their glory that they conceived, planned, and attempted in the face of tremendous obstacles, most of the interventions of urgency which are current to-day. 2 THE GENERAL PRACTITIONER AS AN EMERGENCY SURGEON. The surgical opportunity, then, of the general practitioner is clear, and his duty as well. The professional spirit, the humanities, his conscience, make it incumbent upon him to know and act. This he must do or drop to the rear in the march of progress, which does not halt for the timid or unwilling. But the task imposed is heavy, the responsibility large; for the gen- eral practitioner often finds himself isolated, remote from special counsel, perhaps compelled to act alone. That he does not always rise to the surgical emergency and do all that he might do even under unfavorable circumstances, may often be laid in large part at the door of his training. He knows often what he ought to do, yet knows not how to do it. Happily the courses of instruction are now generally planned to do away with this strange antithesis between theory and practice: a theory, modern, scientific, positive; a practice, as Lejars says, still often full of error and based on empiricism age-old. But this must not be; for, now that the indications for operation are exactly defined and one's duty obvious, vague conception of an opera- tion as something far away and desperate, must give way to clear notions of the resources of surgery, of surgical therapeusis. Every doctor must familiarize himself with the technic of interventions which he must undertake at times, if he is not to be inexcusably remiss in an almost sacred duty. Surgery in one respect is a handicraft, and as such requires its certain tools of first necessity. If, as has been said, emergency surgery always comes in the nature of a surprise, then the surprise will at least be less complete if one has an equipment and has it prepared. Every doctor should have an emergency bag supplied with mate- rials: hand brushes, soap, a fountain syringe, hypodermic syringe, catheters, flasks of alcohol, ether, chloroform and carbolic acid, bi- chloride tablets, a package of sterile compresses, sutures, bandages, a box of plaster of Paris, and certain instruments. Hand Brushes. — These are almost indispensable for emergency sur- gery. They should be kept well wrapped and should be cleansed with soap and hot water and sterilized by boiling for i minute before using. New brushes should be boiled in soda solution for five to ten minutes. \\ I [SEW [( S. 3 If brushes are lacking, one may scrub the bands and the field <>f operation with sterile gauze. In the hospital where the cleansing at the time of operation has been preceded by another disinfei tion. gauze may be used to the exclusion of the hand brush. Fountain Syringe or Irrigator. — One may use the full rubber out fit or, what is better, a porcelain container and a long rubber tube with glass nozzles. It is absolutely essential that the whole be steril- ized by boiling. It is nonsense to sterilize, as is often done, the cannula' and container, and neglect the tube. The glass nozzles are likely to be broken if plunged directly into boiling water or if cooled too rapidly. If the porcelain container is used, it may be boiled ami then singed with burning alcohol. It takes up but little room in the bag, and the tube and nozzles may be wrapped up and packed in it and the whole wrapped and kept clean and dry. This outfit is almost indispensable, for in many emergencies the only adequate treatment is by hypodermoclysis or intravenous infusion. The Antiseptics. — The alcohol must be kept in a well stopped tla^k and the carbolic acid or lysol, also. The bichloride may be in the form of tablets, so that the strength of a solution may be readily calculated. The most commonly employed is the formula containing mercury bi- chloride 7.3 gr., citric acid 3.8 gr. This tablet in one quart of water makes a 1 to 2000 solution, which is as strong as need be used. One to three pints makes a 1 to 3000 solution, and so on. Instead of the tablets, one may keep a concentrated solution of bichloride in alcohol. Bichloride of Mercury, 5j- Alcohol, 5]. One teaspoonful to a quart of water makes a 1 to 2000 soluti< 'ii ; One teaspoonful to 3 pints, 1 to 3000, etc. Many English operators prefer a solution, 1-4000 biniodide of mer- cury. A one-half ounce bottle of Tr. iodine should be carried ami will be found excellent for emergency sterilizations of the skin. Anesthetics. — One should keep on hand at least one pint of ether and four to six ounces of chloroform. Cocaine for local anesthesia is best kept in tablet form and the solutions made extemporaneously. For example, 2 1/2-grain tablets of cocaine to t teaspoonful of sterile water makes a 2 per cent, solution; 4 1/2-grain tablets to a tea- 4 THE GENERAL PRACTITIONER AS AN EMERGENCY SURGEON. spoonful of water makes a 4 per cent, solution; 10 1/2-grain tablets, a 10 per cent, solution. This is not exact, of course, but furnishes a good working rule for the emergency. Ethyl chloride for local freez- ing is put up in small containers convenient for the emergency bag. Sterile Gauze. — Too frequently the practitioner commits the error of depending upon absorbent cotton for his sponges and compresses. Absorbent cotton, as found on the market, is scarcely ever aseptic. Even if it is, it is almost certain to be contaminated in getting it out of the package. A supply of sterile gauze is one of the best means of promoting an aseptic operation. It should be kept in a hermetically sealed package of metal or glass. ' In lieu of the gauze compresses ready sterilized, one may carry a supply of ordinary gauze which can be cut into appropriate sizes, and sterilized at the time of operation. It is a good idea to cut two sizes; a small for compresses and wipers, a larger to cover the field of opera- tion. All these pieces should be folded once and the borders hemmed. A ball of cotton may be hemmed in between the layers, which makes a still better sponge. Sutures and Ligatures. — If these materials are not already sterilized and in a special package or container, such as a sealed tube of alcohol, catgut must be ruled out, for its preparation takes too much time. One should take care to have several sizes of silk, especially the o and 00; for these are the sizes required in intestinal work. Silk and silk- worm-gut may be sterilized as needed. Catheters and bougies should be kept in a metallic box. Rubber and metal catheters are always readily sterilized by boiling. Rubber catheters deteriorate rapidly unless properly cared for. They may break unexpectedly, the result of an unnoticed change in quality, and a piece be left in the bladder. Drainage Tubes. — These should be preserved in a box or bottle which may be boiled thoroughly before opening. Plaster should be kept in a tin box with tight cover and may be loose or already rolled. A supply of roller bandages is, of course, always kept on hand, from which the plaster bandages may be made. Instruments. — Any list which might be enumerated must, of course, be subject to the widest variation. But the feeling of greatest confi- i \ui OS [NSTRUMENTS. dence goes with the consciousness <>i" having th< ry things with which to act. On the whole, the doctor should pride bimsell upon the completeness <>f his outfit, rather than upon his ability to improvise. One should have as the minimum: scalpels, two of amputating knives, scissors, grooved director, dissecting forceps, artery forceps — the more the better — two retractors, a law, a bone chisel, needle holder and needles, tracheotomy tubes, and an Esman h lube. The instruments most frequently used may In- put together in a small metal case, while the others may lie kept in larger cas< wrapped, or rolled up in a bundle. Cleaning instruments and preserving them from rusl is a matter <>\ no small importance. After each operation they should be taken apart, scrubbed with soap and warm water, wiped with gauze satu- rated with alcohol, and dried thoroughly. If the cleansing has been delayed, it may be necessary to immerse them for a short time in a solution of potash, and finally cleanse in the manner described. If any stains still persist they should be polished with chamois skin. Formaldehyde, certain acids, and iodine in too (lose proximity, tarnish and spoil instruments in spite of care. A dish or two of calcium chloride in the instrument case will absorb moisture and tend to prevent rusting. Too often the practitioner neglects his instruments because, perhaps, not often used; and, in the emergency, he finds himself with knives rusty and without an edge, scissors that will not cut, and forceps that have no grip. He will certainly gain time by spending a little time in carrying out these small details. CHAPTER II. EMERGENCY ANTISEPSIS. OPERATION IN A PRIVATE HOUSE. The preparation for an urgent intervention outside of an operating room resolves itself into a question of asepsis or antisepsis, and around this point gathers a multitude of details. But it is necessary only to proceed systematically and intelligently to achieve excellent results. The time was when the idea prevailed that an aseptic operation was scarcely possible outside a hospital. This was a harmful notion which restrained many a practitioner from an effort that might have saved his patient's life. Every day it is demonstrated that aseptic work is not peculiar to formal operating rooms. Bonney, of Philadelphia, writes that he has done many major opera- tions in the homes of the poor in the midst of the most unsurgical surroundings; nevertheless, the results have been excellent. Most of these operations were for urgent abdominal, pelvic, or genito-urinary disease, and though such work is often time-consuming and laborious, yet it shows what can be done in the case of necessity. Bonney at- tributes his success with inflammatory conditions to complete removal of diseased tissue and free drainage in pus cases. Van der Walker (Month Cyclopedia of Pract. Med., Aug., 1906) says that for thirty years he has operated in farm houses throughout central New York with as good results as those obtained in the hospital with which he was connected for many years. He goes further and concludes that, for many reasons, it is desirable that there should be a return to more home operating, and that the hospital ought to go back to the original purpose, the care of the homeless and sick poor, and not invade the home with the arrogant assurance that only within its walls can the surgical case be cared for. But this is aside from the main point: the practitioner may feel 6 BOILING I in [NS1 R1 Ml assured that with decision, knowledge, and tysU m, < \ "i i in: n wns. be prolonged, wrap the lower Limbs In blankets, and speak for 1 1 ■ > t irons or water bottles. Third Step. — Everything having boiled sufficiently, carry thi into the operating room and empty the contents of ea< li into it- spe< i.il receptacle, which of course must firsl be sterilized. If these bowls have not been boiled, as previously < I i r«i ted, now is the tinu- to sterilize them by singeing with burning alcohol. Into eai li pour two or three s|)oonfuls of altolml andsetiton fire, in the meantime till lug the dish in various directions so that the flame is brought in contact with the whole inner sulfate. When this is done, lift the compn and instruments out of their boilers, place them in these sterile dishes and cover them with an antiseptic solution. This protects them from (possible contamination until the operation begins. Do not open the bag of compresses till needed. Remember to use only a sterile dipper, if necessary to dip out the sterile water in preparing the various solutions. Fourth Step. — Direct the assistant to begin the anesthesia, and now prepare your hands. As Lejars remarks, this is a "science and art," the first duty of the surgeon. They are not to be prepared by a desul- tory rinsing in soapy water, or parboiling with a hot antiseptic solu tion, but by a patient and systematic scrubbing. Get your sleeves rolled up and pinned. Have before you two wash basins, one with hot and the other with cold sterile water. Pare the nails. Begin with soap and hot water. Lather the arms up to the elbow, and rub the soap in until the skin seems saturated and soft. Then begin with the brush; scrub the palms, the dorsum of the hand, between the ful- lers, all about the nails. One need not rub the skin off, to be sure, but the disinfection must be complete. The water should be changed several times, if possible; next rinse in cold sterile water and then rub vigorously with alcohol to remove all the oils in the skin; finally soak in bichloride solution. The cleansing will probably occupy ten nun utes. The antiseptics used vary with the operator, but, after all, it is the soap and hot water which is most important. Rubber gloves are always used by some operators and doubtless to some advantage. They are probably an extra guarantee against infection, but are b) no means indispensable. As good plan as any, perhaps, is to use them IO EMERGENCY ANTISEPSIS. always where infective processes are likely to be met with ; and thus the operator is protected ; and, besides, his hands are kept free from septic agents which might be difficult to remove. Fifth Step. — In the meantime the anesthesia has progressed. When it is well under way, prepare the field of operation, which we assume has been previously shaved, by scrubbing with soap and water, followed by alcohol or ether and bichloride solution. Harrington's solution is much employed and consists of Mercuric chloride, .8 g. Acid hydrochloric, 60 c.c. Water, 300 c.c. Alcohol, 640 c.c. Konig refrains from scrubbing; and, instead, paints the field of opera- tion with Tr. of iodine, first shaving the part after an ordinary bath (Berlin. Klin. Wochenschrift, April 26, 1909). However, certain regions, as the scrotum and perineum, are too sensitive for this method of preparation. But, whatever method may be employed, the disin- fection of the skin must be, in every respect, as thorough and vigorous as that of the hands, and must extend well beyond the proposed line of incision in all directions, for one can never tell where the incision may finally end. A large area is almost as rapidly prepared as a small one. For example, in laparotomies the whole abdomen should be included, as well as the lower half of the thorax. In hernia operations, the abdomen as far as the umbilicus, the groin and the genitals. In amputations of the leg, the thigh should be included in the cleansing; and in amputations of the thigh, the whole region of the pelvis. Again wash your hands. An untrained assistant changing the bowls may spoil the sterilization by getting his fingers or thumbs inside. Direct him how to lift and carry a bowl with his palms against the outside. Having completed the final cleansing of the hands, cover the field of operation on the four sides with four sterile towels or large com- presses and fasten them with sterile safety pins or artery forceps. Time gained by relaxing in the least any of these precautions of asepsis and antisepsis, is irretrievably lost; it is the operation, now begun, which must progress rapidly. CHAPTER III. ANESTHESIA. Anesthesia is necessary in most emergency operations, not only to obviate pain, but because it is often essential to a good operation. Unfortunately, on the other hand, it adds to the doctor's task and pre- sents some special difficulties. In certain grave conditions, as intestinal occlusion, strangulated hernia, or abdominal traumatism, it may be the actual cause of death, however carefully administered. Not only in emergency work, but in any case, general anesthesia should be cautiously induced and narrowly watched; and for this reason it is especially embarrassing to the doctor compelled to entrust it to the untrained in cases of urgency. Chloroform has the advantage that it requires no special apparatus for its administration; and the smaller bulk is an item of importance, especially in military practice; moreover, it is much more pleasant to the patient. Unfortunately, it is many times more dangerous than ether, even in the hands of the skilled. In lieu of a special inhaler, such as Esmarch's, fold a handkerchief, napkin, or compress several times to form a square. Begin by pouring on several drops and gently approaching it to the mouth and nose of the patient. The inhaler should be managed with the left hand, leaving the right hand free to raise the eye-lid, or feel the pulse, or handle the container. Do not hold it too close to begin with, but give the patient plenty of air; in other words, give the chloroform well diluted. Give the patient time to get accustomed to the odor. Advise him to breathe through the mouth and distract his attention as much as possi- ble; get his confidence, flatter him, and, in the meantime, study him and test him. The few minutes spent in this way will soon be regained. Pour on five or six drops of chloroform at a time; and, as the respira- tion becomes deeper, hold the inhaler closer, giving the chloroform less 1 2 ANESTHESIA. diluted with air. Replenish the supply every half minute, sprinkling it on the under side of the compress and quickly inverting it over the face. As the stage of excitement comes on, push it more. When the anesthesia is complete, reduce the dosage but increase the frequency of renewal. The drop method is ideal after the anesthesia has been attained. Small doses frequently applied mean the smallest total amount, which must be the anesthetist's constant aim (Fig. i). The good anesthetist is not the one who can use the largest amount of chloroform without death, but the one who can hold the patient merely unconscious and relaxed with the smallest amount possible. Fig. i. — Chloroform container. If the patient coughs or shows signs of nausea, increase the dosage at once. Do not begin the preparation of the field or any part of the operation until the anesthesia is complete. Keep the pulse, the pupil, the face, and the thorax under constant surveillance, for in this way alone may one determine the prognosis, good or bad, of the anesthesia. The anesthesia is usually described as occurring in three stages: the first, stage of excitement; the second, loss of consciousness; the third, loss of reflexes or stage of surgical anesthesia. There is a fourth, stage of paralysis of the automatic centers, but this is a stage which the good anesthetist will never reach. The excitement of the initial stage, in which the patient struggles or talks at random, is followed by loss of consciousness, but the reflexes ETIIF.K A\l SI III SIA. I | arc active, the pulse is full and bounding, the pupils respond to light, the eye lid resents the corneal touch, the skin is sensitive, the face is flushed, and the breathing deep and regular. Beware at this time of sudden blanching of the fate, of dilated pupils, of weakened pulse, or disturbed breathing. If these symptoms arise, Withdraw the anesthetic and prepare for artificial respiration. The patient is not ready for the operation and yet he may die in this stage. Often pallor and dilated pupils precede vomiting, but when the pulse and respiration are good, the nausea is to be quieted by more chloroform. When the reflexes are finally abolished, the pulse should be full. though perhaps a little slowed, the respiration quiet and regular, the pupils slightly contracted, and the face moderately pale. Any marked deviation from this standard during the operation is a matter for concern. Weak heart action, uncertain respiration, dilated pupils, deep pallor or cyanosis, mean approaching paralysis of the automatic cen- ters governing the circulation and respiration, and the anesthetic must be withdrawn until the symptoms improve under measures employed to stimulate. In the case of the average adult, one and one-half to two ounces should be sufficient for the first hour and much less subsequently. Children and the debilitated require less. Ether has the disadvantages in emergency work that it is dangerous to use near a light or lire, and that its administration is a little more com- plicated; but, beyond that, its anesthesia is never attended by sudden death in the early stages, as is that of chloroform. It is followed by less shock after abdominal operations or other prolonged intervention. Bronchial affections are its chief counterindications. An inhaler may be fashioned out of a newspaper rolled into a cone, cotton or gauze being fastened in its apex, on which the ether is poured. Begin with a drachm; let the patient get accustomed gradually to the ether, diluting it well with air by holding the inhaler an inch or so from the face and gradually approaching. In that way, the feeling of suffocation is avoided. As the patient approaches unconsciousness, hold the mask 14 ANESTHESIA. closely so as to shut out the air, and the stage of anesthesia will be I quickly reached without excitement. If one proceeds timidly at this stage, the anesthesia will be hard to obtain and much more ether will be required. Once the reflexes are j abolished, use small quantities, frequently applied. The "drop method" may be employed with ether as well as with chloroform, and reduces the danger to the minimum. The accident most to be feared is respiratory paralysis. The signs indicating the favorable progress of ether anesthesia during ! the operation are: pulse full and regular; respiration deep and slightly snoring; face flushed; and pupils slightly dilated. Cyanosis is the J signal for more oxygen. Any disturbance of the respiration demands j immediate attention. For excessive mucous formation, Ford recom- mends spraying on the mask at intervals of five or six minutes, when necessary, an adrenalin solution. Three parts of water to one part adrenalin solution (i-iooo) are used in an ordinary atomizer. Ford claims that it also acts as a circulatory stimulant. Occasionally patients will be found who do not take ether well, but who will take chloroform without the least untoward effect. TREATMENT OF THE ACCIDENTS OF ANESTHESIA. Certain measures are recommended as forestalling the dangers of anesthesia ; though they are, as a rule, more appropriate in the general surgery of hospitals. A preliminary gastric lavage will save embarrassment in certain cases. In fact, this should be an invariable rule, when compelled to operate on patients who have eaten only a short time previously. A. preliminary subcutaneous injection of normal salt solution will sustain the patient in the cases of anemia and grave septic infection. Many surgeons precede a chloroform anesthesia by hypodermic injection of morphia or strychnia. Boldt (Med. Record, May 29, 1909) condemns as dangerous the practice of preceding a general anesthesia by the morphia-scopolamine narcosis. He recommends, however, for patients who are apprehensive and nervous a single I ARTIFICIAL RESPIRATION. I 5 dose of morphia and atropia thirty minutes before the anesthesia is given. This is desirable too in operations on regions in which the reflexes are more active, for there is scarcely a doubt that some of the circulatory disturbances under chloroform are reflected from the field of operation. This is true of the testicle, the spermatic cord, the anus. and the peritoneum. None of these methods lessens the anesthetist's responsibility and duty to watch every point. If the circulation grows weak, the pulse small, rapid, compressible, due to the effect of the anesthetic agent and not to shock or hemorrhage, withdraw the agent and lower the head, draw out the tongue and begin artificial respiration, and the danger is usually soon passed. Hypodermic injection of stimulants, such as strychnia or camphor- ated oil, often do good under these circumstances; but when the circulation is paralyzed and syncope has supervened, their use is illusory. Do not waste time preparing them, though an assistant may do so; but proceed to make rhythmic traction on the tongue, and artificial respiration, both being carried out methodically. If an assistant is at hand, carry out the two measures simultaneously; otherwise, try the tongue traction first, or at least get it pulled out well. Traction of the tongue to do good, must be rhythmic. The tongue must be caught up carefully with forceps and no force must be used. Often the tongue is seriously injured by the feverish pulls of the agitated operator, who has quite forgotten that the maneuver is effectual only when rhythmic. Likewise, the artificial respiration must be rhythmic. Grasp the patient's elbows and draw them gently and steadily up- ward until they meet above the head. The pectoral muscles are put upon the stretch and the chest expanded and inspiration produced. At the same time the tongue is drawn outward (Fig. 2). The arms are next brought with a steady movement to the chest wall and the diaphragm compressed. (Stage of expiration.) At the same time, the tongue is permitted to retract (Fig. 3). These movements are to be repeated at the rate of about twenty per minute and should be persisted in without intermission for at least :i half hour before giving up hope of resuscitation. Direct compression of the heart is a procedure of real value and it may often be readily managed through the abdominal walls. In the i6 ANESTHESIA. case of abdominal operations, the hand may be passed up the to dia- phragm and the heart seized and kneaded in that manner. The vomiting after anesthesia is often troublesome and is usually in| direct ratio with the amount of the agent used. Every effort should; Fig. 2.— Stage of inspiration. Tongue should be drawn out with this movement. {Stewart.. be made to hasten its elimination from the blood by keeping the skir warm and active, and helping the kidneys with saline enemata. These enemata also diminish thirst. Warm soda water drunk freely help: FlG 3 — Stage of expiration. Tongue permitted to drop back in mouth. to wash out the stomach and thus hastens relief of actn Five to fifteen drops of aromatic spirits of ammonia hypo or, well diluted, by mouth, often does good. Other forms of general anesthesia will not often be of I", \|. .WKSTIII SIA. '7 Emergency practice for obvious reasons, however valuable they may otherwise be. It is hardly necessary, therefore, to consider nitrous oxide or ethyl chloride and their conveners; or general anesthesia by ■ray >>i" the rectum, which promises to l»e of value in operations on the la. e, mouth, Deck; and thorax. LOCAL ANESTHESIA. The doctor, isolated and without assistants, will many times find aid and comfort in local anesthesia by hypodermic injection; hut to be efficient, it must he properly induced. A definite technic must be followed. Either cocaine or stovaine may he used, the latter safer, the Fig. 4. — Local anesthesia; method of introducing needle. (Veau.) '! r slightly more active, the two used alike. Having determined tie line of incision, pinch up a fold of skin (Fig. 4), introduce the needle at one end of the line and push it into the skin, but not through the skin. The injection is intradermal (Fig. 5). As the needle is steadily ad- vanced, the syringe is emptied slowly, and the line of injection is in- licated by the formation of a wheal. When the needle has entered length, it is reintroduced in the same line and in advance of the pre- vncture, hut within the area already anesthetized. In this way, !,,•„. rst puncture is felt. When the line of incision has been in- ter miii i this manner throughout its entire length, it will he com- l h< ' sensitive after a wait of one to two minutes. The width ^i 1> : of anesthesia will depend upon the rate' of movement of the 11. 1 . through the skin (Figs. 6, 7). It need hardly be said that the ANESTHESIA. needle and solution must always be sterile. It is better to pour the solution out into a sterile dish or glass, rather than to aspirate it from the bottle. The air must be forced out before the needle is introduced; care must be taken not to throw the injection into a vein. Fig. 5. — Local anesthesia; the needle does not penetrate the whole thickness of skin; " intra -dermic " injection. (Veau.) When an area, rather than a line, is to be infiltrated, in a case where some dissection is anticipated, Schleich's method is better, in which the needle is plunged directly into the tissues and a sufficient quantity of Fig. 6. — Local anesthesia; the zone of infiltration is narrow when the needle is pushed for- ward and emptied rapidly. (Veau.) Fig. 7. — Local anesthesia; the zone is broad when the needle is introduced slowly. (Veau.) the solution discharged to raise a wheal. The needle is then reintro- duced alongside the wheal for another injection. The anesthesia may be renewed from time to time during the operation. SCIILEIUl'S SOLUTION'. 19 Si hlei< h's formula is as follows: NO. I, STRONG. Cocain. Hydrochlor., Morphin. Hydrochlor., S( "lii Chloridi., Aq. Destillat., NO. 2, NORMAL. Cocain. I [ydrochlor., Morphin. Hydrochlor., Sodii Chloridi., Aq. Destillat., NO. 3, WEAK. Cocain. Hydrochlor., Morphin. Hydrochlor., Sodii Chloridi., Aq. Destillat., gr. in. gr. I gr. in. 3 iii, 3 iiss. gr. iss. gr. |. gr. 111. 5 iiiss. gr. ,'.. gr. ,', gr. in. o iiiss. Two or three drops of a 50 per cent, solution of carbolic acid may he added to preserve. The solution must be kept cool. Twenty-five Fig. 8. — The finger may be anes- thetized by a circular injection at its base. (Veau.) Fig. 9. — Complete anesthesia "i finger induced by deep injections on each side. The upper and lower needles represent the primary circular injection. {Veau.) ayringefuls of Number 1, fifty syringefuls of Number 2, and 500 of Number 3, may be used without danger. The patient should not be permitted to sit up during the anesthesia 20 ANESTHESIA. if cocaine is used, for it exposes him to the risk of heart failure. It is safer to keep him recumbent for a half hour or so after the operation. If a finger or toe is to be amputated, first make an anesthetic ring involving the skin only (Fig. 8), and follow this with two deep lateral injections to obtund the main nerve trunks (Fig. 9). Bier has lately introduced a method of intravenous anesthesia; which, it is to be hoped, will prove practical in the hands of the general practi- tioner. Its use is limited to operations upon the extremities and this is the technic: The limb is first elevated and a constrictor applied from the hand (or foot) upward. The limb is thus emptied of blood. A tourni- quet is next tightly applied, one above and one below the proposed field of operation. The principal vein is next exposed in the distal portion of the field, the incision being made under local anesthesia by Schleich's method. The vein once exposed is opened, a cannula introduced and 50 to 100 c.c. novocaine solution injected under considerable pressure. In three to five minutes a complete local anesthesia is produced. At the end of the operation the solution is allowed to escape; the veins are then washed out with normal salt solution and the tourniquet removed. The technic must be carefully studied before attempting the pro- cedure. SPINAL ANESTHESIA. Spinal anesthesia with stovaine can only very rarely be of use to the general practitioner in emergency work, although it is of value under certain circumstances. It is of special use in operations involving the anal and perineal regions. By this method the heart and lungs are not dangerously affected. It is a solace to those patients whose dread of a general anesthesia is greater than their dread of death, and who will refuse operations of absolute necessity rather than take ether or chloroform. The most definite contra-indication is uncertainty of asepsis, since the chief danger of the procedure is meningitis. It should not be used in the young, in advanced arterio-sclerosis, in cases of septicemia, or central nervous disease. The average duration of the analgesia thus produced is one hour. The effects are fairly uniform; SPINAL ANESTHESIA. 21 tin- chief after effects arc headache and nausea. One of the author's patients, operated for hernia under spinal anesthesia complained for several months of loss of sensation in the penis and rectum, though not materially interfering with the functions of either. The preparation employed by the author is that of ( 'ha put : stovaine, iogr. ; sodii l hloridi, 10 gr.; distilled water, i c.c. This is put up in hermetically sealed am- poules, each containing i c.c. of the solution, which is sufficient lor an injection. Bier regards cocaine as the most dangerous and tropaco- caine the safest, and this latter he employs in doses of 3/4 to 1 grain. The syringe employed must be easily sterilized and with a capacity of at least 2 c.c. A long platinum needle is best. A special glass syringe with needle for this injection can be readily secured. Technic. — The patient's back, the instruments, the solution, the operator's hands, are duly prepared. The needle is attached to the syringe and the contents of an ampoule aspirated and the needle de- tached. The patient sits bending forward to make the lumbar spines more prominent and to enlarge the intervertebral foramen which is to be traversed by the needle. Locate the iliac crests and mark their position with the finger nails. The line connecting the highest points of the iliac crests intersects the fourth lumbar spine which is next to be located in the middle line. The next spine above is marked and be- tween these two points the puncture is made. Hold the left index finger on the third lumbar spine. Hold the unattached needle in the right hand, and enter its point just below the third lumbar spine a little to the right of the middle line, and push it slightly upward and inward at an angle sufficient to meet the spinal membranes in the middle line. Tushing the needle steadily upward and inward it can be felt to reach the resisting ligamentum subflava and finally the puncture of tin- membranes is announced by the (low of spinal fluid from the needle. Hold the finger over the outlet until the syringe can be attached; then let sufficient fluid run in the syringe to make 2 c.c; in other words, make a mixture in the syringe containing equal parts of stovaine solu- tion and spinal fluid. The clear spinal tluid becomes milky on meet- ing the anesthetic solution. Now slowly inject the mixture, and when the syringe is emptied, withdraw the needle with a rapid movement ami seal the puncture with collodion. It will require no further attention. 2 2 ANESTHESIA. Have the patient lie down and now prepare for the operation. In ten to fifteen minutes the anesthesia begins. The patient complains of a pricking sensation in the feet and numbness in the legs. A pinch or a pin prick will be felt but will not be painful. If the pain becomes too severe in the course of the operation, a little chloroform or ether can be employed. If the anesthetic zone does not extend high enough, in- cline the body slightly, head downward. During the operation the patient's face is tikely to be congested and his head will throb. After- ward there is likely to be a severe headache for a little while and per- haps some nausea. The site of puncture may be numbed with cocaine, so that the spinal injection is painless. If the point of the needle engages against the vertebra, withdraw slightly and change the direction as the judg- ment dictates. The most common mistake is in directing the needle too much upward. Only very rarely will one fail to reach the spinal canal if the landmarks are well defined. Hollander (Deutsche Med. Woch. schr., Jan. 14, 1909) protests against the way in which many surgeons are turning away from spinal anesthesia and indicates the many advantages of the method. One of his chief arguments in its favor is its prevention of post-operative paral- ysis of the bowel in abdominal work. He mentions 60 operations of this class, including the appendix, stomach, pancreas, kidney, gall- bladder and uterus operated under spinal anesthesia, all of which promptly recovered. Jonnesco reports most favorable results with the stovaine modified by the addition of strychnia. He does not hesitate to puncture the cord at the cervico-dorsal juncture. Under spinal anesthesia he performs operations on every part of the body (Pr. Medical, Oct. 13, 1909). CHAPTER [V. SUTURES; METHODS, AND MATERIALS. Sutures arc applied with a view to maintaining the coaptation of divided structures. This is necessary to facilitate repair and re-tore function. Suturing serves the additional purpose of < he< king hemor rhage from the smaller vessels. There is no part <>i" the surgi technic that deserves more attention than the selection and use of sutures. It is of special importance to the emergency surgeon who faces infection in every direction. His suturing, however, he may absolutely control and make aseptic, and this may be the only different e between success and failure. Various materials are used, some quite commonly, other- rarely and for a certain purpose; catgut, silk, silkworm gut, silver wire, kan- garoo tendon, and horsehair. The three first named will inert all the requirements of the emergency surgeon. No material is available which does not have a certain strength and which cannot be made aseptic. For emergency work, these materials must be already prepared. The creation of a proper suture from the raw material is a matter of time and care. The general practitioner will do better to buy his sutures put up it form available for immediate use, being first assured that they come from a reliable source and are put up in a manner to keep them Sterile. Much suture material on the market has neither of these qualifi< ations. Silk has the advantage of lending itself t<> emergency sterilization by boiling and immersion in an antiseptic solution, nor i- it readily « taminated when once sterile; but it should not be boiled in lution, which makes it brittle. It has the disadvantage of not absorbable. It may be used in buried sutures, but it- in that respect grows more and more limited as the art i and preservation of catgut improve-. It may be used in interr 2 -> 24 SUTURES, METHODS AND MATERIALS. skin sutures, suture of nerves, of tendon, and of the intestine, but muscular tissues do not tolerate it. Catgut is the ideal material for the buried suture. The chromicized gut has ample strength and is so prepared as to resist absorption in a certain tissue for a certain time; but it should be remembered that occasionally chromicized gut becomes practically unabsorbable and, acting as a foreign body, gives rise to persistent sinuses. With a little attention to this detail, a suture may be selected which will resist ab- sorption until repair is complete. Plain catgut can be used in those tissues only which rapidly unite. It is ideal for suturing the peritoneum and for ligating vessels except the very large ones. It is very easily con- taminated. It should never be used where there is pus as a buried suture. The three qualities which catgut for suturing must possess are: sterility, tensile strength, and absorbability. If a certain brand of catgut produces stitch-abscess persistently; if, properly used, it still breaks inopportunely; if it refuses to be absorbed, then there is some- thing wrong with its manufacture. The occasional surgeon Lacking opportunity to test all the brands, must therefore fall back upon the manufacturers reputation and guarantee. Silkworm-gut is very strong, non-elastic, uon-absorbable, readily sterilized, and is much employed where the wound is large and deep and the tissues tend strongly to spread apart. Most surgeons employ it to suture the skin and fascia after laparotomy. The pagenstecher celluloid linen is in high favor with some surgeons; it is more flexible than silkworm-gut and absorbs moisture without softening. The methods of suturing adapted to emergency surgery are the interrupted suture and the continuous suture. Others occasionally em- ployed in general surgery are the quilled, the quilted (Fig. 10), the twisted, and the button sutures. The continuous suture is used in aseptic wounds only. Therefore, accidental wounds will only, on rare occasions, permit its employment. It has the advantage of being very rapidly applied, but is less sure than the interrupted suture. A little practice is essential, for it is not al- together easy. Its success depends largely upon the assistant. This is the mode of making the continuous suture: Commence by THE CONTINUOUS SUTURE. 25 The quilted suture. (Moullin.) passing the suture at the upper angle of the wound. Make three successive knots. Two are sufficient for catgut. The short thread is caught in forceps and retained till the suture is completed, at whi< h time it is cut off close to the knot (Fig. 11). The needle traverses, successively and obliquely, first the one lip of the wound and then the other; each time the assistant seizes the thread at the point of emergence, and holds it tightly until the surgeon makes a new point of emergence, when the assistant takes a new hold. In this manner, the tension of the suture is made absolutely uniform. The mode of arrest of the continuous suture fig is important. In making the terminal knot, the suture must not be allowed to relax. To accomplish this, the surgeon slips the index finger in the last loop instead of pulling the thread all the way through, as was done with all the others. Traction with this finger holds the line of suture tight while the terminal thread on the one side is knotted three times with this loop on the other side (Figs. 12, 13). If the continuous suture is long, its stability is insured by crossing the threads at the middle of the line of suture (Fig. 14). The suture is thus interrupted at its mid- dle in this manner: the needle is simply passed back under the last loop, at the time care being taken that the suture does not slip. The succeeding steps are the " Me ^i of TSLt same as before ( Fi § s - J 5> l6 )- The suturo Assistant holding the suture tight while the com pleted, the loose ends are cut off close needle is passed again. ( v eau.) r > to the knot. The interrupted suture is generally employed in suturing the skin, and may be of silk, silkworm-gut, silver, etc. It must not be absorb able. These sutures may be placed deeply or superficially, in the one 26 sutures; methods, and materials. Pip. 1 2. — Completing the continuous suture; holding the suture tinht with finger through loop whili . ready to tie. Pio. ii. —Method "f ty- ing compute'] continuous suture. ( I ■ Fig. 14. — Continuous su- ture interrupted in its course (Hartmann.) Fig. 15. — Method of interrupting the con- tinuous suture in its course. Needle passed back under last loop. (Veau.) Fig. 16.— The needle has been passed through the loop which is drawn down tight and the suture proceeds as before. (Veau.) Fig. 17. — Method of passing deep inter- rupted sutures. (Veau.) THE INTERRUPTED SUTURE. 2 7 case where there is much tension, in the other for mere approximation. The deep sutures are placed two or three centimeters apart. . The needle is entered one centimeter from the edge and emerges Fig. 18. — Tying interrupted sutures. Forceps everting lips of wound to se- cure coaptation. (Veau.) Fig. 19. — Method of passing superficial sutures. {Veau.) the same distance from the other side. The thread is concealed through most of its extent (Fig. 17). None is tied until all are passed. The lips of the wound are brought to- gether as the knots are tied. (Fig. 18). A few superficial catgut sutures may be necessary if the deep sutures do not completely approximate. They are passed through the thickness of the skin alone and very close to the edge of the wound (Fig. 19). No knot should be drawn too tight. It may interrupt the circulation and defeat repair. The knot should be made to one side of, and not over the wound (Fig. 20). If all goes well, the sutures may be removed toward the eighth day. Remaining too long, they favor infection. Fig. Hou to do it. Hon not to do it> 20. — Sutures must not be tied too tight. (Moidlin.) 28 sutures; methods, and materials. Method of Removing Sutures. — Seize the loop with a dissecting forceps held in the left hand. With a pointed scissors divide the thread close to the skin, being careful not to cut between the knot and the forceps, else one will be trying to pull the knot through the skin. Suppose, in spite of care, infection occurs. The temperature reaches ioo 1/ 2° on the following day. On the second day following, it is a little higher. Upon removal of the dressing, the skin around the wound is found to be reddened and swollen. Re- move two or three of the middle sutures at once. Secure drainage and use a wet dressing. This will usually check the infective process and pus formation. The subcuticular suture is of great service in aseptic operative wounds, wherever it is especially desired to prevent a scar. It is made in this manner: Introduce a small needle threaded with catgut, one-fourth inch above the upper angle of the wound, and let it penetrate the skin and emerge exactly at the upper angle. It next penetrates the face of the skin incision, taking a bite first on one side and then on the other exactly opposite method of passing and (Fig- 21). At the end, the needle traverses the skin at the lower angle of the wound in the same manner as it entered at the upper angle; the sutures are then tightened (Fig. 22) until the edges of the wound are exactly coapted. The ends are secured from slipping either by knots or by pasting them down with collodion or adhesive plaster. If the thread is not absorbed, it may be removed about the sixth day by clipping one end close to the skin and then gently drawing it from the other end. Cannaday (J. A. M. A., Jan. 4, 1908) uses pagenstecher linen and after starting the suture secures the loose end by a half bow knot. The terminal thread is secured in the same way and slipping or loosening is thus prevented. Fig. 21. Fig. 22. The subcuticular suture; CHAP! l.k V. DRAINAGE. Drainage may justly be regarded as a matter of antisep I prevents sepsis by creating a current which moves away from the wound, and by depriving the bacteria of their chief pabulum— tl dates. Drainage facilitates repair by relieving tension. In the manner it relieves pain. But when these points arc made I is said, for drainage is by no means an unmixed good. < >n the trarv, it is a necessary evil and for these reasons: in reality il foreign body; it necessitates frequent renewal of dressings; it may injure granulations; it keeps the wound open and delays healing; in the abdominal cavity it sometimes predisposes t<> fistula, hernia, intestinal obstruction. Nor is the profession by any mean- >>i one mind regarding the indications and contra-indications. It is a matter in which one cannot be dogmatic. The rule of practice mu necessity vary with the patient, the operator, and the environment. The emergency surgeon, the general practitioner, will more often drain than the hospital surgeon in formal operatioi V to the fundamental principles involved. Aseptic wounds, as a rule, do not require drain... Infected wounds or those suspected should always he drained infection of any kind demands an outlet. Accidental wounds are presumed to la- infected, whei wounds are presumed to be aseptic. A- an ex. eption to the rule that aseptic wounds do nol age, note that those in which there is of necessity much oozing do better with temporary drain putation stumps, and breast amputations. Suspected wounds are not drained after the third has not made its appearance n<>r seems likely to .!■ 20 30 DRAINAGE. Infections are drained as long as there are any discharges. The means of drainage in emergency practice are three: tubes, gauze, and open wounds; or combinations of the three. Rubber tubes, the larger the better in proportion to the infected cavity, are the best means of draining large cavities, and are the sole means of draining abscess cavities and large infections. They should be fenestrated, and may be improvised from rubber catheters. Wherever used, they must be cut off close to the surface and, in the case of cavities, must be anchored by suture or safety pins. Gauze. — Plain sterile gauze, which drains by capillarity, is an effi- cient means of removing exudates, such as serum and blood. It has the additional advantage that in appropriate cases it may be at the same time employed for hemostasis. It has the disadvantage that it soon ceases to drain, acquires adhesions, and is painful to remove. Tubal and capillary drainage are advantageously combined in the "gauze wick" and "cigarette drain." A "gauze wick" drain is made by splitting a tube of the required length and fitting it loosely with a strip of gauze. When the tube is carried to the bottom of the cavity, the projecting gauze is brought in contact with the oozing surface, is hemostatic, and finally may be removed without disturbing the tube. A cigarette drain acts on the same principle and is essentially a series of wick drains, one within the other. To make a "cigarette drain," take a ten inch square of rubber tissue, cover it with four or five layers of sterile gauze, and roll the whole into a slender cylinder. "Wick" and "cigarette" drains should be removed on the second or third day. If infection is present at that time, a tube should be sub- stituted; a tube must be employed if infection develops later. Tubes employed in the drainage of pus cavities should be removed, cleaned, and reinserted at least every third day, and are to be shortened pari passu with granular repair. As has been said, an open wound is a means of drainage, and for that reason accidental incised wounds are, as a rule, not completely sutured. Lacerated wounds not reparable need no other drainage than that afforded by the gauze dressings. To note briefly some examples of drainage: Abscesses are always to be drained with tubes. DRAINAC1 . Acute spreading infections are to be drained with tul Accidental incised wounds are to be drained with tul mply by rubber tissue if the wound i^ small. Operative wounds of the soft parts in emergency practice are i best drained superficially — all the Layers are completely dost the skin. A few strands of catgut between the li|» of the wound will often he all that is necessary for drainage and has the adv. int.. requiring no change of dressing. An empyema or purulent peritonitis must be drained with I Many thoracic and abdominal conditions are to be drained with the wick or cigarette drain. If there is no probability of infection, if there is not much oozing, do not drain at all. In compound fractures and compound dislocations drain only the skin wound. If infection develops, deep drainage must be substituted. Further details will he given in connection with the various operations requiring drainage. CHAPTER VI. DRESSINGS, BANDAGES, SPLINTS. The emergency surgeon needs no great variety of dressing materials. If he has sterile gauze and sterile absorbent cotton, he can efficiently meet all the indications so far as dressings are concerned; for these materials furnish in the highest degree the properties which pertain to a good dressing. A good dressing is sterile, absorbent, and pro- tective. It need be nothing more; it must be that. For emergency work it is better to buy these materials already prepared and ready for instant use. But they must come from a reliable source. Even the most trustworthy products are not always aseptic. In major oper- ations they should be re-sterilized if possible. Of course the surest way to sterilize is by steam. Still these materials exposed to the high heat in the closed oven of the kitchen stove might reasonably be expected to be germ free. Medicated gauze is often useful but not essential, nor so much employed as formerly. It may be improvised by dusting the plain sterile gauze with the preferred antiseptic powder at the time of dressing. For that matter all of the dressing may be impro- vised for temporary use from muslin, linen, or cheesecloth. Towels or sheets may be prepared by boiling for fifteen minutes in soda solu- tion, rinsing in cold sterile water, wringing out the water, and com- pleting the drying process on the stove. From these materials one may provide not only dressings, but compresses and sponges for the operation. An aseptic wound requires that the dressing be dry; whatever slight serous oozing there may be is thus rapidly absorbed. Septic wounds require a dressing moist with some antiseptic solution. For one thing, the moist gauze conforms better to the irregularities of a lacerated wound. Again, the antiseptic agent exerts some slight destructive effect, perhaps, upon the germ already in the wound and 3 2 OKI S is a more effective si reen against those trying to gel in. M and bichloride gauze are the mosl commonly used. I present, sterile.' gauze saturated with peroxide of hydi recommended. The dressings must be ample. Too often an aseptic operative wound eventually becomes infected merely because not sufficiently : The dressings must not only be thick enough, but they mu widely beyond the limits of the wound. It is a poordn if one can lift its edges and inspect the wound. The frequency of redressing is variable. In general, the fewer dj ings the better. The aseptic operative wound should need but dressings. The original dressing is removed when ti taken out on the eighth to the tenth day. The septic wound may need to lie dressed daily. A wound | ably infected but not septic, one in which a drainage tube was used, will need to be dressed on the second to the fifth day, when the drain age tube is removed. The frequency of dressing thereafter will de- pend upon the degree of sepsis. In changing the dressing of a sterile wound, every precaution must be taken against infection. Many a fine operative result is spoiled by carelessness in changing the dress The hands, the solutions, the instruments, must be prepared. It is good practice in the case of any kind of wound to change tin- dressing whenever soiled, for sterile exudates may become good cul- ture media. One may, however, follow Semi's suggestion, dus the saturated area with boro-salicylic acid or other anitseptic powder and covering with an additional layer of cotton and band Pain or rise of temperature after the first twenty four h<>::r> is an indication to change the dressing ami inspect the wound. A loosened dressing calls for renewal. The dressing that slips or rub<. is a very poor one. When the dressings are adherent to the wound face, they are to be saturated with warm sterile water or with pen of hydrogen. The latter is excellent when the dressing com blood. When changing the dressings any undue movement ol the parts must be avoided. The principles of support and fund rest are not to be neglected even for the is reached and a half rotation is made, by a twist of the wrist. The beginner is often observed to make a complete turn of the ban instead of a half turn. This tightens the bandage, but does nol uniform compression. In making the turn, the thumb of one hand steadies the lower edge of the bandage, while the Other hand n the half turn mentioned. The reverse should always be made in the same vertical line and should, if practical, correspond to the wound, in order to give it the advantage of the extra thickm The bandage is then continued on around the leg until the outside is again reached when the reverse is repeated. The "figure-of-eight," the second means of taking up the sla< k, is most useful in the n of the joints, and at the calf. Bandage for the Foot. — (Fig. 24.) Begin near the toes turns, reversed as the ankle is neared. Encircle the ankle with the "figure-of-eight" turns and continue the spiral turns up th< is desired to cover the heel, the firsl turn should cross the upper of the heel and over the Front of the joint; the second tun the lower half of the first; the third turn overlaps the uppei 36 DRESSINGS, BANDAGES, SPLINTS. first. The roller on the third turn reaches the dorsum of the foot, and is carried obliquely across toward the little toe and the foot is covered Fig. 24. — Bandage of foot. {Heath.) Fig. 25. — Bandage of foot. Heel covered. (Heath.) by spiral turns which progress upward, or it may be applied as indi- cated in Fig. 25. The spica of the foot is indicated by Fig. 26. If it is desired to cover the toes, back and forth folds extending from Fig. 26. — Spica of foot. (Stewart.) in front of the ankle to a corresponding point on the sole may be run on and held in place by additional circular turns about the foot. Bandage for the Leg. — Begin above the ankle with spiral turns, pro- BANDAG] POB mi i i ,. \n,, Fig. 27. Pic. 18. Bandage of leg. Fie. 29. — Figure ofi"S" of knee. (Heath.) 38 DRESSINGS, BANDAGES SPLINTS. gress upward and, as the calf is approached, use the reverse (Fig. 27); or a "figure-of-eight" may be employed throughout (Fig. 28), but the latter does not fit so well about the calf as the former. Bandage for the Knee. — This may be a continuation of the leg band- age or may include the knee alone; in either case it is a "figure-of-eight" running from below the patella around the outer side of the knee, across and up behind the knee to the inner condyle. Now make cir- cular turns about the thigh. From the inner condyle, cross the knee Fig. 31. — Spica of groin. {Heath.) obliquely downward and outward to the head of the fibula; make a circular turn about the leg below the knee, and, when the patellar line is reached, begin over again the "figure-of-eight," lapping the preced- ing one (Figs. 29, 30). Bandage for the Groin. — Begin at the inner end of the groin and carry the roller upward and outward to the iliac crest, around to the opposite crest, obliquely across the belly toward the pubes, around the thigh to the starting-point. Repeat these turns as often as necessary, each overlapping the preceding (Fig. 31). BANDAGES POH 1 1 1 1 BR KAST . Pic. j!2. — Bandage for breast. (//• Pig. .;.(. — Bandage for both bn 40 DRESSINGS, BANDAGES, SPLINTS. The Double Spica. — The right groin is bandaged as described above. When the roller, carried about the body, reaches the left side of the pelvis, it leaves the original track, follows the left groin downward and Fig. 34. — Finger bandage. {Heath.) Fig. 35. — Spica of the thumb. {Heath.) thence around the thigh; is then carried across the belly and around the body to the right groin again. These bandages may be applied with the patient standing or with the pelvis on the Volkman rest. Fig. 36. — Bandage for all the fingers. {Heath.) For the perineum and pelvis, one may use the "St. Andrew's cross," which, after a turn about the body, crosses over the left groin, behind the left thigh just below the nates, obliquely upward across the peri- BANDAG1 POB THUMB. ncum, over the right groin toward the right iliac spine. It th< around the left iliac spine and down the Left groin a< rosa the Bandage for the Breast.- Begin with two <>r three turns about chest; carry the roller across the breast to the sound side; it under the affected breast to the opposite shoulder; across 1 k to the breast again and up over the shoulder; and then around the again (Fig. 32). Both breasts may l>e bandaged at tin- same time, carrying the turns about first one breast and then the Other I . Fig. 37. — Bandage for arm. (//. Bandage for the Finger. — Begin with two or three turns about the wrist, and then carry the bandage across the dorsum of the hand base of finger, and run it down to the tip by two or three oblique I bandage from the tip to the base by regular circular turn-. From the base, carry die bandage across the dorsum of the hand and around the wrist again (Fig. 34). Bandage for the Thumb. — Begin at the ulnar side of the carry the bandage across the dorsum around the wrist for 42 DRESSINGS, BANDAGES, SPLINTS. Next carry the roller obliquely across the dorsum of the hand and toward the radial side of the thumb, as near the tip as desired. Secure by a circular turn and then carry the roller back to, and around, the wrist again and so proceed, progressing toward the base of the thumb (Fig. 35). Bandage for all the fingers and thumb, see Fig. 36. Bandage for the Hand and Arm. — Begin with circular turns around the wrist and then carry "figure-of-eight" about the wrist and hand; finish with spiral turns progressing up the arm (Fig. 37). Spicafor the Shoulder. — Begin on the arm about the insertion of the deltoid and make two or three circular turns about the arm. Next carry the roller across the shoulder, approaching the sound axilla Fig. 38. — Spica for shoulder. {Heath.) Fig. 39. — Bandage for head. {Stewart.) Fig. 40. — Barton's bandage. {Gould's Ill.ust. Diet.) from behind; across under the axilla and over the breast to the injured shoulder and around the arm again (Fig. 38). Bandage for the Neck. — The shoulder and head must be included in the bandage for the neck if it is to be effective. Begin on the shoulder and carry the roller through the axilla and around the neck once or twice. Take the turn next about the neck and beneath the jaw, be- hind the ear on the sound side, over the top of the head, down in front of the ear on the affected side. Next carry the roller horizontally around the neck and then beneath the jaw once more; again vertically around the head, but this time it passes in front of the ear on the sound side and behind the ear on the affected side. Carry the roller now a BANDAG1 POH nil III \i>. Fig. 41. — Capitcllum. (Heath.) 44 DRESSINGS, BANDAGES, SPLINTS. third time beneath the jaw and, finally, from the occiput around the forehead to fix the other turns. Bandage for the Head. — A dressing may be secured in many instances by simple turns about the forehead and occiput; but the bandage may be made to hold firmer if, as it approaches a certain point, it is raised in one turn and lowered in the next. It has the appearance of a spiral reverse (Fig. 39). Barton's bandage may be used (Fig. 40). Begin at the top of the head, carry the roller beneath the chin, up to the vertex, across and to a yL ' # - it /SSrt Fig. 43. — Showing manner in which eye is covered and the ear engaged in one slit in the bandage and the occiput in the other. Fig. 44. — Showing sound eye free and manner of tying together the two ends of the bandage on the sound side. point below the occiput. From this point, carry it forward to the chin and on to the occiput. Bring it up to the top of the head and again beneath the chin and proceed as in the beginning. Figs. 41 and 42 represent one method of applying the recurrent or capitellum to the head. Morley describes a useful and practical bandage for the eye (J. A. M. A., Mch. 27, 1909). Take a piece of muslin, or gauze, long enough to go about the head and wide enough to cover the orbital region. At its center cut a round hole for the ear of the affected side and further back an oblong slit for the occiput. Trim the bandage so as to uncover the sound eye. Split the two ends and tie these tails tight enough to prevent slipping. WOOD] \ SP] i The crossed bandage for both eyes is a figure of eight with turns about the head I Fig. 45). Bandage for a Stump. Begin with circular spiral turn- somi tance up the limb. Carry the bandage back and forth over thi of the stump, and finish by more i ircular turns. SPLINTS. To immobilize, to prevent muscular contraction, <>r to secure fun< tional rest, splints play a large part in surgical practice. Theemer gency surgeon must be familiar with the principles regulating their employment and with the practical details of their use. \ splii I have rigidity; it should be light. A number of materials offer these properties in varying degrees, though none are ideal perhaps, or univer sally applicable — wood, metal, leather, wire, card- board felt, plaster of Paris, silicate' of potash — each has its special field of usefulness. More especially employed in emergency practice are wood, metal, and plaster. Wooden Splints. — Wood is the material usually most available when temporary splints must be improvised. Often these splints may be used for permanent fixation, though not so much so per- haps as formerly. From soft wood — a thin pine wood -the appropriate form may be readily whittled; and, when applied, well wrapped so as to conform to the pari-, furnishes fixation at once light and rigid. The splint must be wider I the limb and long as the part to be immobilized, but not so loin; as to produce discomfort. Tin- sound limb may be used pattern in modeling the splint. Such splints have the disadvantage that they are hard to keep in plan-. A number of thin wi strips may be glued to felt, or held together by adhesive plasti form effective fixation in certain fractures of the humerus and thigh, On this principle the Dutch cane splints are constructed for emergencies of warfare. Gooch's splint is made from a pme I 2 feet long and 6 or 8 inches wide and 1 1 inch thi. k. p 46 DRESSINGS, BANDAGES, SPLINTS. and then split in strips 3/4 inch wide. Before the ordinary wooden splint is applied, it should be padded with absorbent cotton 2 to 4 inches thick and wrapped with a gauze roller. The cotton should be distrib- uted to correspond to the irregularities of the limb. The splint is molded to the limb, and held in place with adhesive strips while the roller bandage is applied. Metal splints as ordinarily employed are scarcely available in emergency practice. These materials cannot, as a rule, be readily worked into shape; but, on the other hand, if ready-made, are likely not to fit. However, in case of necessity, a splint could be cut from tin or from wire gauze. Wire gauze, indeed, forms part of the outfit of the military emergency bag. It can be patterned, molded and bandaged to the part; the cut edges should be turned over or covered with cloth. Plaster. — Plaster of Paris, on the whole, is the material best adapted to the exigencies of emergency practice. It is not too bulky, cheap, easily obtained, and readily prepared; once applied, it is not unduly heavy and furnishes a firm support. It has the special advantage that it can be molded to the part; the disadvantage, that it may be difficult to remove when applied as a roller bandage. Plaster is spoiled by exposure. One should buy a good quality and keep it dry. Old plaster should be baked before using. Plaster may be applied on a roller bandage or on strips to make a molded splint. The splint form is better when the parts must be frequently inspected or when much swelling is anticipated. The plaster roller may be prepared from the ordinary gauze roller or from crinoline. The latter is perhaps the best. The rollers should be about 4 yards in length; 2, 3 and 5 1/2 inches in width. To prepare the plaster bandage, pour the plaster on a table or in a wide shallow basin. Start the loose end of the roller through the plaster, rubbing it in thoroughly, and as fast as it is im- pregnated have the assistant re-roll it (Fig. 46). These bandages will keep indefinitely in an air-tight container. Prepared in this way they are much more satisfactory than if bought ready-made — and certainly much less expensive. Method of Applying. — When the limb is ready, washed, and covered with glazed cotton or stockinet, the plaster roller is set in a pan of warm I'l \^l I K SP] l\ I-. water deep enough t<> cover it. When the bubble ready to apply. Seizing it at each end, wring it gently. B making a few oblique turns at tir-t to se< ure the dressing t know what he is talking about, ho vever tut id Ins expression may appear. A little later he may be in active delirium \iv increase, not too long delayed, in the I >!• >< >• I pressure and if tendant improvement, is a cause for hope. It may take m before the reaction is ( omplete. Any aggravation of the symptoms alter reaction is once undet indicates a return of the shock, hid points to hemorrha It is true that, as a rule, when on, e improvement begins the outlook is favorable, but the prognosis must alu ays be guarded in tin- 1 ase of the elderly. An old flagman was brought to the City Hospital with both limbs crushed off, having fallen under a passing engine. He a- in full shot k and had lost some blood from a scalp wound. He was almost pul and vet his mind seemed clear. His condition precluded operation. His wounds were trimmed of mangled tissue and t arcfullv « leansed and wrapped in moist antiseptic compress until su< h time as formal ampu- tation might be undertaken. Under the treatment for shock he gradually improved. His circulation and respiration grew stronger, but not sufficiently so to favor operation. At the end of twenty four hours he began all at once to grow weaker, fell into a stupor, and in a few hours died. If the amputation had been undertaken, he would have died on the table, and thus another fatality would have Keen charged to active intervention. The treatment of shock has been the subject of much n in recent years. The most diverse opinions exist and tin- most diverse methods have been proposed, but we have learned from the experience of ("rile and others that it i- as important to know what n what to do. The whole list of cardiac and spinal stimulants so commonly ii jected hastily, indiscriminately and collectively, are shown to be not only useless, but distinctly harmful. The patient doubtles covers not on account of, but in spite of. such treatment. In ordinary cases, these dire< tions are suffii ient to be borne in mi disturb the patient as little as possible; lower the head; keepthi warm; attempt no operative measures until the symptom- .ire imp: 52 SHOCK. unless it be to check hemorrhage, or to amputate in certain crush- ing injuries. Adrenalin chloride is the most generally useful remedy to raise blood pressure in shock pure and simple, and given hypodermically or intravenously, it very seldom completely fails. Crile was enabled by means of intravenous infusion of adrenalin and salt solution, combined with artificial respiration and thoracic pres- sure, to arouse a human heart after it had ceased to beat for nine min- utes, and its action was thus sustained for one-half hour. It must be given in small doses, frequently repeated. The effects are powerful, but fleeting. Hypodermically, give 5 to 15 minims of the 1-1000 adrenalin solu- tion and repeat every 20 or 30 minutes. Intravenous infusion is even more satisfactory and certain. Give continuous infusion of adrenalin salt solution until there are signs of reaction. One teaspoonful of 1-1000 adrenalin added to one quart of normal salt solution is of sufficient strength. Normal salt solution alone is effective within certain limits, but finds its greatest field of usefulness in shock coexistent with hemorrhage. In shock uncomplicated by extensive loss of blood, the saline solution must be used sparingly, perhaps better by enema or hypodermoclysis; used in large quantities intravenously, it may eventually defeat the end for which it is employed by acting as a mechanical obstruction to respira- tion. For it must be remembered that under such circumstances it finds its way into the thoracic and abdominal tissues and interferes with the movements of the diaphragm and ribs by its mere presence. According to Crile, 320 c.c. per kilo of body weight led to such accumu- lation of fluid in the splanchnic area as to embarrass respiration. Do not give, then, more than two or three pints of normal salt solu- tion injected slowly, in uncomplicated shock. (For technic of in- travenous infusion, see page 56.) Crile's pneumatic suit seems to be entirely trustworthy as a means of raising blood pressure; but, of course, cannot be used in the shock occurring in emergency practice. The prevention of shock is always something to be considered in operative work. Morphia, 1/4 grain hypodermically, before the anes- PRi \ i \i [ON "i S K. 53 thesia, is a real aid. " Blocking" the nerves by< o< aine injei tions above the site of operation is Likewise advantageous and is recommended by Cushing and Crile. The nerve may be exposed in its course under local anesthesia and in turn injected. In abdominal work the viscera must be handled with care; for, as Byron Robinson has shown, shock from this source is directly propor- tionate to the amount of manipulation or traction upon the viscera. CHAPTER VIII. HEMORRHAGE. DEFINITIONS. i. Arterial hemorrhage is due to wounds of arteries and is character- ized by spurting and the bright red color. 2. Venous hemorrhage is due to wounds of the veins and is character- ized by dark color and steady flow. 3. Capillary hemorrhage is characterized by persistent oozing and spontaneous arrest. 4. Parenchymatous hemorrhage is due to wounds of those organs and tissues in which the small arteries terminate directly in veins; no capillaries intervening, as in the erectile tissues. 5. Primary hemorrhage occurs immediately after the injury. 6. Intermediate or reactionary hemorrhage occurs within twenty- four hours and is due to the release of clots or the slipping of the ligature. 7. Secondary hemorrhage occurs after twenty-four hours, before the cicatrization of the wound, and is usually due to sloughing or suppu- ration or the too rapid absorption of the catgut ligature. 8. Internal or concealed hemorrhage occurs when the blood is emptied into one of the large cavities; abdomen, thorax or cranium. CONSTITUTIONAL EFFECTS OF HEMORRHAGE. The constitutional effects of hemorrhage vary with the amount and the rapidity of the loss of blood. Thus a comparatively small amount of blood poured out rapidly will produce more marked symptoms than a much larger amount drained away slowly. The constant accompaniments of severe hemorrhage are pallor, dizzi- ness and faintness, rapid and weak pulse, subnormal temperature, 54 M ^GNOSIS "l hi IfORSHAG] , 55 rapid and irregular breathing, frequent yawning or sighing, nausea, and vomiting. Fatal hemorrhage, or one likely to be so, is indicated by livid lips blue anger nails, dilated nostrils, pallid mucous membranes, dyspnea, ringing in the ears, syncope, collapse and unconsciousness. Subsequent to the arrest of a dangerous hemorrhage, occur rapid and irregular pulse, rise of temperature, asthenia, a disturbed mental con- dition, usually muttering delirium. This is hemorrhagic fever. As the general condition improves, the mind gradually clears up. The lowered vitality following the hemorrhage favors the development of various inflammatory processes, and one must carefully watch for the onset of these. The diagnosis of hemorrhage is not difficult except in the case of internal hemorrhage, or when shock is present. In the case of bleeding into the cranial cavity, various forms of paralysis and nervous disturbances, together with the general symp- toms, will form the basis of the diagnosis. In the case of bleeding into the thorax and abdomen, the symptoms, the physical signs, and the history of the case will point to the condition. (See Injuries to Thorax and Abdomen.) When shock is also present it may be almost impossible to tell how much of the symptoms are due to the one or the other, for the symptoms of shock and hemorrhage are practically identical. It is useful to remember that the symptoms produced by shock are usually immediate and tend to improve, except in the fatal cases. On the other hand, the symptoms of unchecked hemorrhage tend to grow worse. TREATMENT OF HEMORRHAGE. The First Indication is the Arrest of Hemorrhage. Constitutional measures are then applied with a view to supporting the heart's action. In moderately severe cases give 1 2 ounce of whiskey or a hypodermic of strychnia {i,6o t<> i, 20 gr.), or of adrenalin chloride, and repeat ever}' hour until the symptoms have improved. Apply warm blankets, hot water bottles, or hot irons well wrapped. 1 >o not burn the patient. Keep him quiet, with head Lowered. Attend to the ventilation. As 56 HEMORRHAGE. soon as possible give warm drinks and a nutritious but easily digested diet. Do not overstimulate, as the reaction in that case will be un- duly severe. In the dangerous cases of hemorrhage, in addition to these measures, do not fail to employ normal salt solution either by enema, subcutaneous injection, or intravenous infusion. In the gravest cases, enemas will be of no avail, for absorption has practically ceased. Hypodermoclysis will be a little better. For this purpose employ: 1$ — Sodii chloridi., 5 i. Sodii bicarb., gr. xv. Aq. destill., o xvi. The necessary apparatus: a carefully disinfected fountain syringe or a funnel with rubber tubing, a large needle (an aspirating needle). One- half pint or more of the solution is injected by this means under the skin over the abdomen or breasts. Intravenous Infusion. In the gravest cases, the same solution by the same means may be injected into the venous circulation. Select a vein at the elbow, employ the strictest asepsis, and expose the vein by incision. Loosen it from adjacent tissues by careful blunt dissection and slip three catgut ligatures under it. Introduce the needle, or else the vein may be opened and a cannula used. The cannula or needle is to be held in place by tying the middle ligature. Slowly inject a pint or more of the solution, the temperature of which should be 105 to 115. Withdraw the cannula, remove the middle ligature, and tie the two re- maining. Close the wound and dress aseptically. Keep the funnel full during the injection, so that no air may be carried into the vein. Crile recommends direct transfusion from the vein of a well person into that of the patient, but of course this method is scarcely available in emergencies of general practice. Parke-Davis & Company market a sterile salt in sterile tubes which needs only to be emptied into a liter of sterile water to form a solution for instant use. The formula used is as follows: Calcium chloride, 0.25 gm. Potassium chloride, 0.1 gm. Sodium chloride, 9.0 gm. ARRI ST OF III iffORKB \7 Remember that intravenous infusion is not to be employed until the hemorrhage is arrested. Ill MOSTASIS — ARREST OF HEMORR I IAC.I . ; GKNKRAL PRINCIPLES. Spontaneous arrest of hemorrhage is due to several factors: contrac- tion and retraction of the injured vessels, diminishing blood pressure due to weakening heart action, formation of a clot; these are the agents which nature employs. Capillary hemorrhage tends to spontaneous arrest, likewise the arterial hemorrhage of lacerated wounds. Hemostatic measures locally applied are chemical, thermal, and mechanical. (A) Chemical remedies, chiefly styptics, are now very rarely em- ployed. Such as are used are expected to favor the formation of a clot without doing violence to the tissues. In a persistent capillary hemor- rhage, dioxide of hydrogen or acetanilid is often useful and harmless, but the most useful remedy locally applied is adrenalin chloride. The i-iooo solution is commonly used. (B) Thermal hemoslasis is that induced by heat. Hot water or hot normal salt solution alone will usually arrest a moderate bleeding. Use the solution as hot as can be borne by the hand. Hot solutions are especially useful since they serve the double purpose of antisepsis and hemostasis. The actual cautery may be necessary in spongy tissue where the oozing is persistent but ill defined. The iron should not be hotter than a dull red and must be held in contact for some moments. Cold may be used but is much more likely to lower cellular vitality. (C) Mechanical hemostasis includes (i) direct pressure, (2) com prcssion, (3) acupressure, (4) forcipressure, (5) torsion, (6) ligation. (1) Direct pressure is of large service especially in " first aid" treat- ment. The finger or thumb is pressed directly into the wound, or on each edge of the wound. If the pressure is to be prolonged, the finger will tire and a plug or tamponade of gauze must be substituted. Gauze wrung out of a sterile solution is packed into the wound. Direct pressure is sufficient in the slight hemorrhage of operative wounds. The assistant presses a gauze compress on the bleeding sur- 58 HEMORRHAGE. face, withdraws it by a gliding movement, and the bleeding practically ceases. In general, the larger the vessels, the firmer and more prolonged must be the pressure. In severe hemorrhage, direct pressure, is of course, a mere temporary expedient. Parenchymatous bleeding is checked by direct pressure. The wound of the organ is lined with a layer of gauze. In this gauze cavity, complete the tamponade. This compress should be withdrawn within twenty-four to forty-eight hours. It may be painful to pull out. Release a little at a time, or soften the adhesions with peroxide. 2. Compression aims to occlude the vessel above or below the wound. In the emergency, a finger is applied to an artery at some con- venient point along its course at some distance above the wound. Pressure is most effective if the vessel lies closely over bone. Large veins are similarly compressed below the wound. In the case of wounds of the extremities, the main vessels, including both the vein and artery or either alone, may be compressed by the tourniquet. The pressure is made firmest over the vessel by laying oyer its course a body such as a small roller bandage, before the con- stricting band is applied above the wound (Figs. 51, 52). The simplest and most convenient tourniquet is a rubber band or tube. After being tightened, the crossed ends are caught and held in place by an artery forceps. It must always be remembered that the tourniquet is likely to cut off all the blood supply to the extremity and if too long applied will produce gangrene. Paralysis may follow from pressure on the nerves. Wrap the arm with towel and apply the tourniquet over that. Capillary oozing is frequently troublesome after the constriction is removed. Constriction is objectionable on that account. 3. Acupressure is now seldom used and yet, under certain circum- stances, may render great aid. The artery may be deep and retracted or imbedded in scar tissue or aponeurosis and cannot be seized by the forceps. In such a case a needle passed under the artery and secured with a figure-of-eight ligature wound around its protruding ends will press the artery between it and the tissues and stop the flow (Fig. 47). \i:ki -l .)l III MORRH \«.i . 59 i. Forcipressure, the control of hemorrhage by seizing the ends of the bleeding vessels with Forceps, is the expedient most commonly em ployed in operative wounds. In the accidental wounds of Large trteries, it affords immediate control of the hemorrhage. For the small vessels such pressure is sufficient, the forceps remaining at- tached for a certain length of time. The end of the vessel should be seized with as little other tissue as possible. If it is a large vessel it may he cleared by a moment's dissection. 5. Torsion is added to forcipressure, if that is not sufficient (Fig. 48). Before removing the forceps, it is given t\yo or three turns on its long axis. The inner coats of the artery are ruptured and con- Fig. 47. — -Acupressure. (Moitlliu.) traded, producing the same conditions favorable to hemostasis as are found in the artery in Lacerated wounds. If the artery is a little larger, it is drawn for 1 2 inch out of its sheath, a second forceps grasps it higher up and is held stationary, while the lower one twists the in- tervening segment, the purpose being to avoid injury to the sheath and the vasovasorum. In making torsion, do not pull at the same time, for fear of tearing the odier tissues instead of twisting the artery. Torsion must not lie used where the tissues are loose or cellular. Torsion is of advantage especially in plastic surgery, for it leaves no ligature behind to interfere with repair; hut it is not so certain as ligation. 6. Ligation is finally necessary in bleeding from the Larger vessels. Employ catgut, chromicized or plain, and occasionally silk. 6o HEMORRHAGE. Lift the attached forceps so as to create a pedicle around which pass the thread and tie the first knot (Fig. 49). In tying the second knot, two things are kept in mind; to tie tight enough that the thread will hold when the forceps is removed, and not to include the tip of the forceps in the ligature. The forceps is usually removed as soon as the first knot is tied, so that one may be assured the suture is not badly placed before completing the knots. The first knot is secured by a second if silk is used, and by a third if catgut is used. The threads are then cut short, silk 1 mm. and catgut 2 or 3 mm. Catgut is the preferable ligature and a No. 2 is amply strong for an artery the size of the radial. Fig. 48. — Torsion. (Veau.) Fig. 49. — Showing method of tightening the ligature. (Veau.) Ligation en masse may be employed in parenchymatous hemorrhage, capillary oozing, or bleeding from a deep wound. A catgut suture is carried around the bleeding area by a well curved needle, and all the tissues so included are tied; or, in the case of parenchymatous bleeding from a surface, a catgut suture may be carried around the area and subsequently tightened after the manner of the purse string. HEMOSTASIS IN SPECIAL FORMS OF HEMORRHAGE. (a) Capillary — pressure, hot water, ice, adrenalin, peroxide, acetani- lid, alum, ligation en masse. (b) Venous — pressure, compression, forcipressure, ligation, removal of all obstruction to venous flow above the wound. (c) Arterial — pressure, compression, forcipressure, torsion, ligation. BEMOSTASIS IN SPECIAL FORMS OF HEMORRHAGE. 6l (d) Parenchymatous pressure (tamponade), heat, ligation en masse. (e) Intermediate hemorrhage reopen the wound, turn out the clots and treat hemorrhage as if it were a primary one. (f) Secondary hemorrhage reopen the wound, turn out riots, and apply compresses. If possible catch the ends of the bleeding vessels. If the hemorrhage is alarming and it is impossible to control it by com- presses or forcipressure, apply the tourniquet, in the case of an ex- tremity, and ligate the artery in its continuity above the wound. If this fails and the artery cannot be tied higher up, amputate. Fig. so. (g) Operative hemorrhage — In spite of artery forceps, the bleeding remains to the unexperienced one of the bugbears of operative work. In many operations it is the chief drawback to rapid work; more time is lost in catching and tying bleeding points than in doing the actual operation. Oftentimes the field is masked by a general oozing, and the procedure must halt until the wound can be packed with hot com- presses, which will usually be all that is necessary. Gentle and momentary pressure with a gauze compress is usually all that is necessary in capillary bleeding. In operations in the various cavities, as the nose, mouth, rectum, in the mastoid operation, etc., the hemorrhage, even if not disconcerting, is often very troublesome and some special measures are required. I'nder the circumstances, Parke Davis' adrenalin gauze, which is cut in narrow strips, may be picked in the cavity for a moment and on its removal the operation may proceed (Fig. 50). "62 HEMORRHAGE. FIRST AID IN DANGEROUS HEMORRHAGE.* It is rare that the regulated measures for hemostasis can be applied first hand in a dangerous hemorrhage. There are certain temporary and makeshift but extremely useful procedures which the surgeon should keep in mind, if for no other reason than that he may give pre- cise and definite instruction to the layman who may have to play the part of surgeon for the time being. Intelligent first aid is the chief factor in saving life in most cases of dangerous hemorrhage both in military and civil practice. Whoever has to meet these emergencies must keep cool. He must remember how to apply three principles of treatment, position, direct pressure, compression. i. Position. — In case the upper extremity is wounded: hold the arm above the head. If it is the lower extremity: put the patient on his back and elevate the limb. If it is the face or scalp: place the patient in a sitting position. 2. Direct Pressure. — The wound is small, the bleeding is dangerous: plug the wound directly with the thumb or finger, or press firmly on each edge of the wound; or, in any case and better still, if supplied with a first aid packet, stuff the wound tightly with gauze and bandage firmly. It should be emphasized that a finger must never be thrust into a wound except in cases of greatest urgency and where other means less likely to cause sepsis are not at hand. 3. Compression. — The bleeding vessel is recognized and its course is familiar: compress it with the fingers at some convenient point or, in the case of the extremities, by constricting the limb. In lieu of the tourniquet, knot a handkerchief, apply the knot over the artery and tie the handkerchief tightly around the limb. If it is not tight enough, a stick may be slipped under the handkerchief and given a few turns, end for end. A suspender, a rope, or a wire may, if necessary, be similarly employed. It must be remembered that, on the whole, circular constriction is not without its dangers, and it must not be recommended without reserve to the layman. * See also "First Aid on Battlefield," page 148. COMPRESSION OF PRINCIPAL ARTERIES. 63 The principal arteries near the surfai e have ea< h < ertain points « here compression is most effective. The temporal and occipital furnish most of the dangerous bleeding in st alp wounds. The temporal may be compressed just in front of the upper part of the ear. The occipital may be compressed in its course from the tip of the mastoid upward toward the occipital protuberance. The entire blood supply of the scalp may be shut off temporarily by a bandage encircling the head, passing from the forehead, above the ear, to the base of the skull and thence upward, just above the other ear, to the forehead again. The facial is compressible as it crosses the body of the jaw just in front of the masseter muscle. • The coronary arteries, supplying the lips, are compressed by seizing the lip between the forefinger and thumb. The carol ids are controlled by compression of the common carotid over the transverse process of the sixth cervical vertebra. Wounds of the vessels of the neck, however, are of such extreme danger, including, as a rule, both arteries and veins, that bleeding should be controlled by direct pressure in the wound. Nothing can be so well trusted here as the finger. The subclavian is compressible against the first rib behind the middle of the clavicle. The shoulder is slightly raised to relax the cervical fascia and the finger or a padded stick pushed directly down upon the artery behind the clavicle. The circulation of the entire upper ex- tremity is thus controlled. The brachial is compressible against the middle of the humerus or the tourniquet may be applied over any part of the artery (Fig. 51). The radial and ulnar are not compressible except just above the wrist; and. therefore, bleeding from them must be controlled by dim 1 pressure in the wound, or by the tourniquet, or by compression of the brachial. The palmar arches are not directly compressible, but hemorrhage from the palm is controlled by grasping firmly a round body as a billiard ball, an apple, a stone wrapped with gauze, and bandaging the 04 HEMORRHAGE. hand in this position. If this is not practical, the tourniquet may be applied to the forearm, or the brachial compressed. The digital arteries are always easily controlled by constriction of the finger above the wound. The femoral artery is compressible in the middle of the groin against the ramus of the pubes, but great pressure is required here to control its flow (Fig. 52). It may likewise be compressed lower down against Fig. 51. — Compression of brachial. (Moullin.) Fig. 52. — Compression of femoral. {Moullin.) the shaft of the femur. The tourniquet is, in this instance, the safer temporary hemostatic, a compress of some sort intervening between it and the artery. The popliteal is not compressible. Bleeding must be controlled by direct pressure or by compression of the femoral. The tibials likewise. They may also be controlled by flexing the knee forcibly upon a pad, holding the pad in place by a cross piece TREATMENT OF 1 IMS 1 AX IS. 65 pressing forcibly againsl the popliteal space, and in turn held in place by a bandage around the flexed leg (sec Fig. 103, p. 152). The dorsal and plantar arteries can best be controlled by direct pressure or by compressing the tibials and peroneal as they cross the ankle. The arteries of the surface of the trunk most likely to produce danger- ous hemorrhage are the internal mammary, the intercostals, and the deep epigastric. These can be controlled temporarily only by direct pressure, either with the linger or gauze packing. The method of compressing the intercostal is represented in Fig. 53. \\ ]l EPISTAXIS. Epistaxis is a form of hemorrhage often , , , . . . , Fig. S3. — Tamponing the troublesome and requiring Special treat- intercostal artery. R, ribs; A, . artery; W, gauze. (Walskom.) ment. It may occur in one or both nostrils. The simpler cases are relieved by the erect position, holding the arms above the head, by the reflex effects of cold to the back of the neck, or by pressure over the root or sides of the nose. If these measures fail, the nostril may be syringed with certain solutions: hot water; antipyrin, 5 to 10 per cent., which is especially recommended in the Am. Text-Book of Surgery; adrenalin, 1 to 1000. The patient must not blow his nose, as this eliminates the clot. In the more severe cases try tamponing the anterior nares. If a nasal speculum and a good mirror light are available, the anterior nares may be systematically plugged through the speculum with adrenalin gauze ; or, by such means, the bleeding point may be discovered and loin hed with the point of the cautery, with silver nitrate, or with chromic acid. The International Journal of Surgery gives this practical suggestion: a layer of cotton is wound around a pen holder until the desired thick- ness is obtained and then withdrawn. The cotton cylinder is then moistened, Squeezed dry, and inserted into the nasal cavity. If the projecting end is now moistened, it will swell up and 'thus produce sufficient compression. 5 66 HEMORRHAGE. If these various measures fail, then the posterior nares must be plugged. For this purpose, in emergencies, an ordinary soft rubber catheter is available, in lieu of the Bellocq cannula (Fig. 54). It is threaded and passed directly backward through the inferior meatus un- til its point emerges below the soft palate. The thread is caught with forceps, drawn out through the mouth, and held while the catheter is withdrawn. One end of the thread projects from the nostril and the other from the mouth, and a pledget of cotton is tied to this latter end Fig. 54. — Tamponing posterior nares. {Stewart.) and traction made on the other, by which means the tampon, guided by the index finger, is drawn up behind the soft palate and into the pos- terior nares. When the tampon is tied on it, it is a good plan to leave the thread still long enough to hang out of the mouth, which will greatly facilitate the removal of the plug; otherwise forceps are re- quired or else the tampon will have to be pushed backward into the pharynx. Any plug put into the anterior nares must be secured by a silk thread, lest, becoming dislodged, it may drop into the larynx. The plugs must not be left in for more than two days, and should be moistened before removal with a mild antiseptic solution. Hertzfeld (J. A. M. A. ? March 13, 1909) describes a case of serious hemorrhage ik i \r\ii Niui i i'i-i wis. 67 from the nasal cavity treated with perborate of soda. A strip of moist bprated gauze i/a inch wide was covered with powdered perborate of soda and packed tightly into the anterior nares. The hemorrhage ceased immediately. The perborate may be insufflated directly into the cavity. A grayish-white foam immediately issues, nascent oxygen is liberated, and the bleeding checked. CHAPTER IX. WOUNDS. GENERAL PRINCIPLES. DEFINITIONS. A wound is the solution of the continuity of the soft tissues, due to trauma. (a) Subcutaneous wounds are traumatic lesions of the deeper tissues without any definite break in the skin. Such wounds are more commonly called "contusions." (b) Open wounds are those accompanied by a solution of con- tinuity of the integuments. i. Incised wounds are open wounds produced by sharp or edged instruments. 2. Stab wounds are those produced by sharp-pointed instruments. 3. Punctured wounds are those produced by blunt-pointed instru- ments. " 4. Lacerated wounds are those produced by tearing or crushing. 5. Gunshot wounds are those produced by projectiles; shot, bullets, cannon balls. A penetrating wound is one in which the vulnerating instrument reaches a body cavity. A perforating wound is one in which the vulnerating body passes through the cavity. An aseptic wound is one in which there is an absence of the germs of inflammation. A septic or infected wound is one in which the germs of inflammation are present. A poisoned wound is one in which some agent destructive to tissue is present. An operative wound is one produced by the surgeon's knife, and is presumed to be aseptic. 68 -i B< i i wi OUS WOUNDS. 69 SYMPTOMS AXIi CHARACTERISTICS OF WOUNDS. All wounds produce more or less pain, hemorrhage, and loss of Function; in addition, the severer wounds produce constitutional disturbances, such as shock, although shock may also occur in slight wounds. Hemorrhage depends upon the number and size of the blood vessels involved; pain, upon the character of the tissue and the extent of nerve injury; loss of function, upon the amount and kind of tissue destroyed; shock, upon the mode of injury and the tissues concerned. Subcutaneous wounds vary widely in the amount of tissue divided. There may be any degree, from a mere strain of a few fibers, with slight intercellular exudation (bruises), to total division or widespread laceration of the various layers of subcutaneous tissue. The pain is dull and aching. The hemorrhage is usually slight, but occasionally may be dangerous. If the hemorrhage is slight, it pro- duces merely subcutaneous discoloration, most marked in lax tissues; if moderate, it produces an ecchymosis; if serious, a hematoma. Contusion of the nerves may produce paralysis, usually temporary; or the nerve may be completely divided in subcutaneous wounds, and the paralysis be permanent. Shock is nearly always present in some degree. Treatment. — Subcutaneous wounds are nearly always aseptic, and an effort should be made to keep them so. The first principle of treatment is functional rest. It may be secured in bed, or by the use of splints, slings, or bandages. Mere voluntary immobilization is not often sufficient. Apply a cotton compress and bandage; a flannel bandage firmly laid on, alone, often gives great relief. Evaporating lotions, in the case of superficial contusions, often do good. Tincture of arnica and witch hazel are common domestic remedies. The following solution, freely and immediately applied, will often prevent a " blacked " eye. ty — Ammoni. chloridi., gr. v. Alcohol, ."» i. Cold, while often giving relief, must be used with caution, since .1 7° WOUNDS. GENERAL PRINCIPLES. too long application will lower the vitality of the tissues and interfere with repair, or will even precipitate death of the injured tissues. Heat, in the form of a hot water bottle or hot flannels, is better. If the extravasations of blood are moderate, they may be let alone; or if persistent and interfering with repair, they may be aspirated. In either event, after the inflammatory symptoms have subsided, massage is useful to hasten absorption, promote nutrition, and insure repair and restoration of function. In those cases of severe injury, where the subcutaneous hemorrhage is marked and continuous, and where a hematoma forms, the skin must be incised without delay, the clots turned out, the wounded vessels secured, and the wound subsequently treated as an open one. Incised wounds are characterized by sharp and severe pain, free bleeding, and a tendency to gape. The slight actual destruction of tissue, the comparative cleanliness of a cutting instru- ment, the free bleeding, and the gaping present conditions most favorable for trans- forming an infected wound into an aseptic one, or at least practically so. At any rate, many presumably infected incised wounds heal with the same readiness and absence of inflammatory symptoms as aseptic opera- tive wounds. Treatment. — For the arrest of hemorrhage, ordinarily, a compress wrung out of hot water or normal salt solution is sufficient. If this does not have the desired result, the bleeding vessels are to be seized with artery forceps and ligated. The hemostasis must be complete. The wound is next carefully cleansed of clots and foreign bodies, using normal salt solution, sterile water, or very weak antiseptic solutions. Under favorable circumstances, that is to say, if there is a reasonable certainty that the wound has been rendered practically Fig. 55. — Repair of in fected incised wound of thigh (Veau.) OPERATIVE WOUNDS. 71 sterile, it is closed. If sepsis is feared, a small tube or capillary drain must be employed (Kig. 55). In the first instance, the wound is as carefully closed by suture as an operative one. In the second case, sutures are employed, but are placed further apart, leaving the wound free of access for cleansing solutions and for the free escape of the exudates. If drainage is employed, it may usually be dispensed with after the third day, if no sepsis arises. It is safer to regard all large incised wounds as infected. If the wound is closed, it must be carefully watched for signs of infection, and, on their appearance, be reopened without delay; or the sutures Fig. 56. — Method of making an incision. (Veau.) may be placed and left untied until the probabilities of infection have been determined. A wound sealed on the surface and infected below is a calamity. After repair of the aseptic incised wound, a dressing of plain sterile or borated gauze is applied, and over this absorbent cotton and bandage. In certain instances, as with incised wounds of the face, the dressing may be dispensed with, the slight serous exudate being allowed to dry and form a crust, which protection is quite adequate. Operative wounds are incised wounds, and the aim is always to make and maintain them aseptic. Aside from preliminary steriliza- tions, there is a proper method of making these wounds, which is essential in keeping them aseptic and promoting repair. 72 WOUNDS. GENERAL PRINCIPLES. The aim should be to do as little violence as possible to any tissues incised. The cutting instrument must be sharp, and the tissues evenly and smoothly divided. To make a good incision, fix and slightly stretch the tissues on either side of the proposed line of section, with the left thumb and index finger. Never put the skin on the stretch on one side only. The first stroke of the scalpel should divide the skin for the whole length Fig. 5 7. — A good incision. (Veau.) previously determined (Fig. 56). Determine beforehand the lengtrT of incision required. The inexperienced operator is inclined to make the wound too short but it may be subsequently lengthened. When the skin and subcutaneous connective tissue are divided, identify the deep fascia before incising it; it is an important land-mark in nearly every part of the body. All the layers must be cut without any gashing or notching. The incision in the deeper layers should not be quite so 4.M Fig. 58. — A bad incision. (Veau.) long as in the superficial layer. The good incision gives an equally good view of all parts of the cavity (Fig. 57). The bad incision creates irregularities which interfere with inspection, not to speak of repair (Fig. 58). Stab wounds differ from incised wounds only in their greater uncertainties. Their narrowness and depth make it difficult to determine what organs and tissues have been involved. i \( i r \ 1 1 d \\"i \i'S. 73 In order to make a doubtful diagnosis sure, to repair an injured structure, t<> control hemorrhage, and, to insure antisepsis, it is often accessary to enlarge the wound. In other respects these wounds are treated on the same general principles as incised wounds. Punctured wounds are peculiarly a source of worry. They are most prone to become septic for two reasons; first, infection is very likely to he carried into the wound, and, second, it is likely to be retained. The vulnerating instrument is usually unclean; portions of it may he broken off and retained; other foreign bodies, such as shreds of clothing, sources of infection, may be pushed in and overlooked, in- asmuch as the narrow tract makes exploration difficult. The tissues are not divided, hut are pushed apart, and tend to close as the instru- ment is withdrawn: The vessels are little wounded, so that bleeding, the best agent for disinfection, for washing out the invading micro- organisms, is wanting. The bottom of these wounds may be shut off from the surface, so that the oxygen-hating bacillus of tetanus finds there a congenial lodging. The Ircalmml, for all these reasons, must be circumspect. In doubt- ful cases, it is better at once to lay open the wound and thoroughly disinfect and search for foreign bodies. In any event, the wound must he carefully syringed with cleansing solutions. Peroxide of hydrogen is particularly indicated if tetanus is anticipated. If sup- puration is threatened, early and free incision and drainage are imperative. Counter openings may be required to facilitate the removal of foreign bodies or inflammatory products. Lacerated wounds are characterized by the great destruction of tissue, comparatively speaking. "They are peculiarly the product of modern times." The machinery of rapid transit and manufactory is largely responsible. Boiler explosions contribute a number. Gun- shot wounds, especially of the face, are likely to he Lacerated wounds. The- manner in which the injuries are produced, the tearing and crushing of the tissues, gives such injuries the following character- istics: 74 WOUNDS. GENERAL PRINCIPLES. (i) There is slight primary hemorrhage. (2) There is frequently reactionary or secondary hemorrhage. (3) Shock is usually present. (4) Infection seldom fails to develop. (5) Deformity is likely to result. The following are the reasons: (1) Primary hemorrhage is slight, out of all proportion to the destruction of tissue, because the coats of the torn vessels curl up and contract, the ragged, uneven surfaces favor coagulation, and the presence of shock lowers the blood pressure. (2) Reactionary hemorrhage occurs because of the smaller vessels losing their plugs of clotted blood when the blood pressure is restored. Secondary hemorrhage occurs because of the suppuration, which is the rule rather than the exception, unless prevented by treatment. (3) Shock is always present in some degree because of the injuries to the nerve trunks. In crushing injuries to the extremities, it is sometimes difficult to relieve shock until the mangled nerves are completely divided by amputation. Sometimes under these circum- stances, the shock is immediately fatal. (4) Infection is coincident with the injury because of the grime which is ground into the tissues. The vitality of the tissues adjoining those which were killed outright is greatly lowered, and the power to resist microbic invasion lost. An invading germ and lowered vitality are the two factors always essential to suppuration. Treatment of Lacerated Wounds. — (1) Hemostasis, (2) relief of shock, (3) antisepsis, (4) support. (1) Hemostasis is usually not difficult. It may be necessary to catch up a bleeding vessel with forceps and ligate, but more often pressure with gauze pads wrung out of hot normal salt solution suffices. Unless the hemorrhage is severe, sterilize the adjacent skin with soap and water, bichloride, or alcohol, before beginning exploration. (2) Shock is treated on general principles. Maintain the body heat, lower the head, and keep the patient quiet. In severe cases, injections of adrenalin and salt solution are to be employed: (See shock.) (3) Antiseptic measures follow the arrest of hemorrhage and shock. TREATMENT OF LACERATED WOUNDS. 75 Begin by covering the wound with sterile gauze, and dun scrub the adjacent skin with soap and sterile water, then with bichloride, 1-2000, and finally with alcohol. Next cleanse the wound. By repeatedly flushing with normal salt solution or very weak bichloride or other antiseptics, an effort is made to rid the tissues, as much as possible, of dirt and debris. Porter, of Fort Wayne, says with regard to cleansing wounds (Amer- ican Medicine, September, " 1906), that it is an easy matter to overdo in our attempts to render an accidental wound aseptic. By the use of too vigorous scrubbing, too harsh mechanical means, too hot water, or too strong antiseptic solutions, more harm than good may be done. The resisting power of the tissues is perhaps the most potent single factor in preventing infection, and it may be diminished by too much antiseptic zeal. We must remember that in spite of our efforts some germs will be left for nature to take care of, and we must not make it impossible for her to do it. "Personally," says Porter, "I find myself using more care, more time, more patience, more soap, more water, and less vigorous scrubbing, less curettement, and weaker germicides." The grime and grease of machinery are most readily removed by pouring on gasoline. It is not always possible to determine to what extent the tissues are fatally injured. In the case of crushed wounds of the extremities, it may be necessary to wait until a line of demarcation appears, so that no useful tissues shall be unnecessarily sacrificed. Drainage is a matter of antisepsis. It is a sine qua mm in the case of lacerated or crushing wounds, but there is usually little trouble in this respect for the reason that these wounds are not sutured and drainage is provided for in the dressing. (4) Suture of the skin wound is not possible, as a rule, but certain of the deeper structures may demand such repair. A divided nerve trunk, tendon, or muscle requires approximation. Sometimes coapta- tion of the wound, even though incomplete, will lessen the time required for granulation. The dressing must fill two requirements; it must absorb the dis- charge and also keep out infection. The most commonly employed dressing consists of a loose but lil>eral covering of bichloride «>r borated 76 WOUNDS. GENERAL PRINCIPLES. gauze applied to the wound, and over this a covering of absorbent cotton held in place by a bandage, which is applied for the purpose also of giving equal pressure and support to the wounded tissues. The frequency with which the dressing must be changed will depend upon the degree of infection. The author has derived much satisfaction in the treatment of this class of wounds from the use of the ointment mentioned on page 409. After the wound has been cleansed, the ointment is applied and the whole covered with gauze and bandaged. It tends to relieve tension and pain and promote repair. The gauze does not adhere to the surface of the wound and so the change of dressing is facilitated. The aim in general is to disturb the tissues as little as possible, and no change is made except to. meet the indications of some phase of sepsis. Infected wounds may not be recognized as such from the first, but soon the processes of inflammation manifest themselves. Pain, red- ness and swelling, accompanied by certain constitutional states, such as fever and rapid pulse, are the cardinal symptoms. The sepsis may produce no results more severe than temporary disturbances of the character named. On the other hand, it may result in suppuration, which prolongs repair and produces unwelcome cicatrices; or, even worse, the infection may spread so rapidly as to involve extensive areas, rendering the tissues brawny with serous exudates and overwhelming the heart and kidneys with toxins before suppuration has time to appear. It is these uncertainties which make infection so much to be feared, and make its prevention the largest element in the treatment of ordinary wounds. When once the sepsis has a definite foothold in a wound, the treatment has two objects: to destroy the germ and remove and neutralize its toxins; and to sup- port the tissues in their struggle. Irrigate the wound cavity at least once daily with weak antiseptic solutions, such as bichloride, peroxide, lysol, or iodine; provide the freest exit for the exudates, employing drainage tubes, if there is a cavity. Never pack a suppurating cavity with gauze. Apply a moist gauze dressing, moistening it with alcohol, bichloride or boric acid, or other antiseptic solutions, or, what is perhaps as well, with INFECTED WOUNDS. 77 normal salt solution. This may or may aol be i overed with absorbent cotton. Whatever other qualities the dressing may possess, it must be absorbent. Sometimes in the case of the extremities, prolonged immersion in warm normal salt solution dot's good. After granulation once begins, it may be stimulated and the wound kept healthy by the use of dusting powders, antiseptic ointments, or balsam of Peru. The latter has been lately very highly recom- mended, in the treatment of wounds generally. CHAPTER X. WOUNDS OF SPECIAL REGIONS. WOUNDS OF THE SCALP. Certain anatomical features determine the special character of scalp wounds, and must be kept in mind in prognosis and treatment. The blood vessels converge toward the vertex; they are the occipital, posterior auricular, superficial temporal, supraorbital and temporal, any one of which may give rise to troublesome bleeding, and all of which are subcutaneous instead of subaponeurotic, as elsewhere. They are firmly connected with the dense tissue of the scalp and for that reason do not readily contract when divided; for this reason the bleeding from scalp wounds is copious and without much tendency to spontaneous arrest. The vessels are somewhat difficult to catch with artery forceps. The aponeurosis of the occipito-frontalis is the dividing line in prognosis: wounds that do not penetrate it are less likely to become infected, nor do the conditions favor spread of infection. A wound perforating the aponeurosis is always a matter of concern ; for, owing to the loose cellular tissues which connect the aponeurosis with the peri- cranium, an infection may spread very rapidly and in every direction. All scalp wounds are presumably infected, yet the free bleeding minimizes the infection, and the rich blood supply of the tissues favors rapid repair. Scalp wounds do not gape unless the aponeurosis is divided, and contused wounds often resemble incised wounds. Contusions may result in the formation of hematoma beneath the skin, but they are of little moment. Evaporating lotions are sufficient to hasten absorption. A severer injury may cause a hematoma under the aponeurosis. Glancing blows, other things being equal, are more likely to cause the tumors, rupturing the vessels of the subaponeurotic areolar tissue. Such a tumor is likely to be extensive. It may be the source of error 78 oi'KN WOUNDS OF SCAM'. 79 in diagnosis, giving the examining finger the sensation of a depn fracture, being hard around the borders, and soft in the center. U the tumor is of such size as to put the skin greatly od the stretch, it may be punctured. This is preferable to incision, for there is less chance of infecting the exudate. Absorption always takes place so thai the least interference possible- is the best treatment. A hematoma may form under the pericranium, usually in children in whom the bone has a rich vascular supply. Here, also, it is ab- sorbed in time, and intervention is rarely, if ever, necessary. Open Wounds. — The treatment of these wounds, of whatever character, may be expressed in certain general formulae. The first step consists in cleansing the hair of the blood, which is not always an easy task. Warm water is best to dissolve out the clots, or peroxide of hydrogen. The next step consists in removing more or less of the hair, depend- ing upon the gravity of the wound. In all serious cases, the whole scalp must be shaved. Begin by cutting the hair with the scissors, and then apply the razor; the "safety razor" facilitates this work. Next cleanse the scalp with ether, to dissolve the oil which is always present, and follow this with alcohol; otherwise the ether will interfere with the soap and water cleansing which follows, and which is freeh- and vigorously applied. In the meantime, a light gauze packing prevents the soap and water running into the wound. Once the scalp is cleansed, Un- wound itself is to be cleansed. Strong antiseptics are distinctly to be avoided. Sterile water, normal salt solution, or peroxide are perhaps the best. An irrigator or syringe is not to be used, but the solution may be squeezed out of a compress into the wound. Be assured that every particle of foreign matter is out of the wound before considering repair. Complete hemostasis is an essential to rapid healing, and the time and patience spent in securing it are by no means lost. If the bleeding vessels cannot be ligated in the ordinary way, the ligature may be carried on a needle through the tissues surrounding the vessel. The oozing may be entirely controlled by a few minutes' pressure with a 80 WOUNDS OF SPECIAL REGIONS. hot antiseptic compress. The main thing is not to get discouraged or be in too great a hurry. The cleansing and hemostasis completed, the coaptation follows. In the case of contused wounds, the ragged edges are to be trimmed away. The suturing is an important step in facilitating reunion. Even wounds that do not gape heal all the more quickly for suturing, silk being probably the best material. In many cases of incised wounds which are not deep, the suturing may be firm and no drainage required. In the great majority of cases, however, drainage is necessary, and may be secured by incomplete suture, by a tube, or, following Von Bergman, by strips of gauze. If a large segment of the scalp has been loosened, every effort must be made to readjust and suture it accurately, though the drainage must be ample. Oftentimes with those who have been even almost completely scalped, the results have been excellent. The dressing will usually consist of sterile gauze and absorbent cotton held in place by bandage. In the case of minor wounds, and where no infection is feared, it is sufficient to smear the line of suture with sterile vaseline and cover with flexible collodion. WOUNDS OF THE PINNA. Many forms of injury befall the ear. It may be bruised, cut, or lacerated, and much or little of it lost. Even a slight loss is a dis- figurement, and any very serious loss of tissue results also in some disturbance of hearing. A laborer came into the City Dispensary with half an ear cut off and hanging by a mere thread of tissue. The sharp edge of a spade wielded by a co-worker had produced the injury. The almost dis- carded member was carefully sutured in place with silk. Some sloughing occurred along the edges of the wound but eventually the repair was complete and almost without a scar. These tissues possess great vitality, and the completeness of repair after much mutilation is often surprising. Large portions of the ear may be cut off completely, and yet if immediately sutured in careful coaptation, union will occur. There may be some sloughing along the line of union, but eventually there is but little scar tissue left. win \i>s OP THE Ill's. 81 In every case, then, of incised wound, an effort must be made i<> suture. The hemostasis must be complete, and if there is much laceration, the edges of the wound must be trimmed. Silk is the besl suture material in these cases. WOUNDS OF THE FACE. Accidental wounds of this region, more than any others, approxi- mate aseptic wounds. These wounds do not gape much; the tissues are very vascular, so that the conditions are most favorable for repair. The chief aim is to avoid scar tissue and the consequent disfigurement. To attain that end the suturing must be delicate, the coaptation per- fect. The sutures must be as small as possible and as few as possible. The subcutaneous stitch may be employed if the wound is extensive and dee]). In ordinary incised wounds extensive dressings may be dispensed with, and the line of suture may be covered with collodion or, as Von Bergman, who dislikes collodion, suggests, the wound may be amply protected by the scab formed by the dried exudates. WOUNDS OF THE LIPS. Wounds of the lips are likely to bleed considerably, but the hemor- rhage is easily controlled by compressing the lip between the thumb and index linger, and then the coronary artery may be Iigated on each side of the wound. When the division is complete, begin the repair by suturing the mucous membrane (Fig. 59) with catgut. Suture the skin by continuous or interrupted suture of tine silk or catgut. The greatest care must be exercised when the border of the lip is reached; the coaptation must be exact or the result will be a disappointment. A small drain in the skin wound is usually advisable. 6 FlG. 59. — Suturing wound of lip. {Vtau.} 82 WOUNDS OF SPECIAL REGIONS. WOUNDS OF THE TONGUE. Wounds of the tongue, which are not as infrequent as one might expect, may give rise to a disagreeable hemorrhage. The tongue is to be drawn out of the mouth and compressed with the fingers above the wound or by a pair of forceps covered with rubber tubing or with gauze. (Fig. 60.) -Suturing wound of tongue. A, tongue controlled by tenaculum forceps. _B, fi passed and tied. C, second suture passed, using the Reverdin needle. {Lejars.. Suture the bleeding points, employing deep sutures of catgut, No. 3. Every quarter hour the mouth should be washed with a solution of chloral, 2 grains to the ounce, until the oozing and pain have subsided. WOUNDS OF THE EYE-LID. A wound of the eye-lid is to be repaired like a wound of the lip, by two lines of suture. First suture the mucous membrane with fine catgut. Then begin the suture of the skin at the free border, where WOUNDS OF Till. M ik. 83 the edges oi the divided tarsal cartilage are to be very accurately coapted (Fig. 61). If drainage is used, it must be small and proje< 1 from the middle of the wound. WOUNDS OK THF NECK. One has but to consider the multiplicity of the structures in the neck to realize that wounds of this region are likely to be complicated. Whether the wound be incised or contused, a stab or a gunshot wound, there are the dangers that arise from hemorrhage, asphyxia, and infection. The most common wounds, per- haps, are those which arise from attempts at suicide. That these attempts are often abortive, and the danger done much less than one might expect, are due to the fact that the tissues are yielding and the vessels recede as the head is thrown back; the knife may be directed against the lower jaw or spend its force on the cartilages or hyoid bone; the arm may lose its force at the moment the larynx is opened, or from failing resolution. In these attempts at suicide, the wound in right-handed people usually begins on the left side high up, and runs obliquely downward to the right, becoming less and less deep. Not infrequently the wound may appear jagged, or give the impression of two or three slashes, from the folding of the skin before the pressure of the knife (Fig. 62). In the graver cases, hemorrhage is usually the first consideration. If a carotid is wounded, a geyser of blood spurts out and the patient's life is in the hands of the first comer, for there is no time to call for skilled aid. If the internal jugular is wounded, the hemorrhage is scarcely less dangerous and perhaps even more difficult definitely to control. Air may enter the venous circulation and death immediately ensue. In either case anything but intelligent first aid will fail. The carotid may lie controlled by pressure downward and backward Fig. 61. — Incised wound of upper lid. Tarsal cartilage sutured first, (t WOUNDS OF SPECIAL REGIONS. at the base of the neck, compressing the vessel against the transverse process of the sixth cervical vertebra; or the bleeding may be tempo- rarily controlled by direct pressure on the bleeding vessel in the wound. &. Yi«*M t p IG 62 — Incised wound of neck involving the larynx. 1, platysma; 2, sterno-mastoid; x int jug vein- 4, vagus nerve; 5, ext. jugular vein; 6, com. carotid art.; 7. upper part of wound in thyroid cartilage opening into larynx; 8, sup. thyr. art.; 9, st. hyoid muscle; 10, sterno-thyroid muse. When the surgeon arrives upon the scene, he finds the wound filled with a great clot, for it cannot be expected that the first aid will do anything more than partly check the bleeding. His first effort must WOUNDS OF Till EYE. 85 be to cleanse out the dots and locate both ends of the bleeding vessels, clamp them, and ligate. Blind damping of the tissues en masse is absolutely unsurgical. It' the ends of the divided vessel cannot be located, the wound is to be enlarged over the course of the vessd, using the anterior border of the sternodeidomastoid muscle as a guide. If the character of the wound or the region predude mat, then the artery must be exposed below the wound and ligated. It may happen, especially in secondary hemorrhage, that the carotid on the opposite side also may need to be ligated either temporarily or permanently. The internal jugular may be difficult to expose and ligate because of its thin and friable walls. Even small openings in the vessel may call for circular ligation, for lateral ligation is usually unsatisfactory. Outside of the hospital, suture can scarcely be considered. If the trachea, in its upper part, or the larynx is opened, it is better to do a tracheotomy lower down and attempt repair of the wound. In many cases, however, if the wound is not extensive, it is sufficient to close the wound by flexing the neck, omitting the sutures, and leaving nature to repair the opening in the air passage. If the esophagus or pharynx is perforated, repair should be at- tempted; but drainage must be employed and the external wound left open, for, in the act of swallowing, particles of food may be forced into the wound to set up infection. If infection or inflammation of the respiratory tract arises, it is to be treated on general principles. Divided nerves should be repaired if possible, although often the difficulties are too great to surmount. WOUNDS OF THE EYE. Morrison, of Indianapolis (Indiana Medical Journal, Feb., 1907), has denned the injuries of the eye, whose treatment must most often be instituted by the general practitioner. From the diagnostic point of view, he classifies them under two heads: (a) Those without superfit ial lesions of the ball. (b) Those with more «>r less extensive open wounds'. (a) The first may lead the practitioner into grievous error in prog- nosis and injudicious lark of treatment. No blow over the eye should 86 WOUNDS OF SPECIAL REGIONS. ever be considered lightly. While the majority of such cases lead to no serious consequences, the exceptions are of sufficient frequency to be of importance. It is possible for the so-called "concussions" to lead to subsequent inflammation or degeneration of the deeper structures of the eye. So, then, though no treatment is to be instituted in the absence of symp- toms, yet the case must be kept under observation for some time, the vision tested, irregularities of the pupil noted, and evidences of in- flammation sought for. On the other hand, there may be a hemorrhage into the anterior or posterior chambers, accompanied by pain, protrusion of the eye-ball, and swelling of the lids. Under such circumstances, put the patient to bed at once and apply iced cloths to the eye, this treatment to be kept up until the symptoms begin to subside, when it is probable that the blood has clotted and the hemorrhage ceased. In addition to, or instead of hemorrhage, there may be disarrange- ment of the retina, lens or iris, accompanied by disturbance or destruc- tion of vision. Put the patient to bed in a darkened room, and drop into the eye a solution of atropia, four grains to the ounce, followed by the appli- cation of cold cloths for at least twenty-four hours. Later a bandage is to be applied and the patient permitted to go about. Any subsequent disturbance calls for an examination by an oculist. (b) Deep, penetrating, non-infected wounds of the globe are serious in various degrees, depending upon the region involved, though they usually heal kindly. Injuries of the sclero-corneal junction or ciliary body often lead to sympathetic ophthalmia, and may require early or late enucleation. The treatment is simple. Prevent infection by the free use of boric acid solution, followed by one or two drops of the atropine solution, and the application of a sterile eye dressing. Rest in bed is indicated. Every wound of the sclera of any moment requires suture, which is the best means of preventing infection. Infected wounds require an immediate and circumspect treatment. If the vitreous is involved, the eye is almost certain to be lost. The prognosis is somewhat better if the cornea alone is involved. WOUNDS OF THE EXTREMITIES. 87 The eye is to be irrigated with warm, sterile, saturated solution of boric arid, followed by a few drops of the atropine solution, the whole to be repeated every two or three hours, until the redness passes away. In the meantime, heal or cold is to be applied, depending upon which gives the most comfort, except in the case of the cornea, where heat is always the better application. Morrison recommends as the best eye pad, several thicknesses of sterile gauze held in place by a single thickness of bandage or a strip of adhesive plaster so that it can be frquently changed. To sum up, then, the chief ends of the emergency treatment are two; asepsis and conservation. Only very rarely will the question of enucleation present itself as an emergency. The careful examination which should be given every injured eye, should be preceded by a regulated asepsis. Prepare the hands; prepare the orbital and palpe bral regions by patient washing with warm sterile water and soap, avoiding all pressure or rough handling which may aggravate the ocular lesions. Cleanse the conjunctiva of the grosser dirt and im- mediately instill a few drops of cocaine solution. In a few minutes the cleansing of the globe and palpebral may be completed without pain, and a careful examination made and the treatment instituted. If suture is required, use a small curved needle held with a forceps, employing catgut No. 00, and above all, a minute care and a light hand. The suture should not pass through the entire thickness of the sclerotic coat, but only through the conjunctiva or the most superficial layers of the sclera. The reunion will usually be perfect if the sutures are carefully passed and slowly tied. (See, also, Foreign Bodies.) WOUNDS OF THE EXTREMITIES. Wounds of the extremities call for varied application of all the principles of treatment of wounds, hemostasis, antisepsis, and suturing. Only thorough familiarity with these principles will give one address in the management of the individual case, for no two injuries are exactly alike. It will be advantageous to exemplify these principles with special reference to wounds of the extremities. WOUNDS OF SPECIAL REGIONS. AN INCISED WOUND OF THE WRIST. In such a case, there may be copious bleeding; a large artery, the radial, for example, may be involved. Begin the treatment by elevat- ing the arm and applying circular constric- tion to secure a temporary hemostasis (Fig. 63). Next cleanse the field and then the wound itself. Separating the lips of the wound, locate and clamp the superficial veins (Fig. 64). It is not likely that they will need to be ligated. Search for the artery; both ends must be tied and it is not necessary to separate the companion vein. The two are ligated together (Fig. 65). Release the constrictor. The oozing is nearly always very free at first, due to temporary vaso-motor paralysis, but it is not at all serious. Apply compresses for a few minutes, thus arresting the capillary bleeding, and if a new point spurts, apply a ligature. Inspect the wound carefully and if a tendon or nerve is divided, it must be immediately sutured (wound at bend of elbow. Fig. 66). A STAB WOUND OF THE THIGH. (Fig. 67.) The femoral has been wounded and the hemorrhage is furious. Direct an assistant to make firm digital pressure over the artery as it crosses the pubes, nor must this pres- Piff. 6 3 .-incised wound of wrist. sure be relaxed. If his fingers tire, a second Tourniquet applied. (Veau.) ass i s tant may press upon the fingers of the first (Fig. 68). Enlarge the wound freely in both directions in the course of the artery. Sponge out the clots; identify the aponeurosis A STAIS win \i> or Tin; TIIICII 89 and divide il in order to expose the artery; isolate the artery by ( .ire- ful blunl dissection and find the two ends, which is often diffil nil when the artery is completely divided (Fig. 69). When both ends are found, ligate with catgut No. 3, or silk. No. 2, fFig. 70). Tic the injured vein next both above and below. It is to be tied separately from the artery (Fig. 71). The possibility of including a nerve in the ligature must always be borne in mind and no ligature is to be finally tied until certain that no nerve is to be thus compressed, Pn 64. — Incised wound of wrist. Bleed- ing vessels clamped. (Veau.) Fig. 65. — Incised wound of wrist. Vessels ligated. (Venn.) to become later a source of pain. Remove the pressure and catch any more vessels that might bleed; employ free drainage and suture incompletely. Apply >lerile gauze dressing, absorbent cotton, and a bandage, making moderate pressure, and maintain the limb in moderate ele- vation. Renew the dressings on the third day, and if there are no complications, remove the drainage. Remove the sutures about the eighth day. Certain complications may arise. If the ligatures were imperfect, 9° WOUNDS OF SPECIAL REGIONS. hemorrhage may ensue; the operation has to be repeated and the vessels tied again. If infection occurs, if the temperature reaches ioi° F., open up the wound and establish better drainage, which is the best means of preventing secondary hemorrhage. Gangrene sometimes follows the ligation of a main artery. Watch the temperature of the extremity and look for pulsation in the arteries below the ligature. If pulsation is present, be in no haste to amputate. If gangrene does not develop before the fourth day, it is not likely to do so. Fig. 66. — Wound at bend of elbow, i, Basilic vein; 2, median cephalic vein; 3, biceps tendon; 4, bicipital fascia; 5, brachial artery; 6, brachial vein; 7, median nerve. Crushing and lacerating wounds of the extremities, as Lejars says, give rise to the most perplexing problems of emergency surgery. The questions present themselves in this form: To amputate, or not to amputate? and if the latter, when, at what point, and by what method ? In order not to be vacillating in his treatment, every doctor must have his principle of action settled once for all. Lejars states his guiding principle and rule of action in this manner: CRUSHING INJURIES TO Tin: EXTREMITIES. 91 Above all, save the patient's life; save the limb wherever possible, or at least limit the mutilation to the minimum. Clinically, he places these injuries in two groups: (a) those in which a segment of the limb is crushed or otherwise injured without periph- Fig. 67 thigh. Fie. 68. — Stab wound of thigh. Com- pressing artery while the wound is en- larged. (IVjk.) eral involvement, and (b) injuries extending from the hand or foot upward. (a) Suppose a case: An arm has been run over by the wheels heavy vehicle. The member is flail-like, although the skin is not broken, and there are no particular points of bleeding. Palpation 9 2 WOUNDS OF SPECIAL REGIONS. Fig. 69. — Exposing the wounded vessel. (Veau.) Fig. 70. — Isolating and ligating the artery. Fig. 71. — Ligating the vein. (Veau ) (Veau.) CRUSHING INJURIES To Till. EXTREMITIES. 93 through the skin over the injured segment shows that the deeper structures have been reduced to a pulp, both muscle and bone. Still, below the wound, the radial and ulnar arteries are found to pulsate. This is an absolute indication against amputation. The immediate treatment must be limited to a careful disinfection of the member, the repair of any superficial wounds, a complete envelop ment in absorbent cotton, and immobilization. The immobilization is an essential feature, for by that means any. bending and stretching of the vessels is prevented and repair favored. If die skin is broken and the bone crushed or shattered and exposed, the injury is a compound fracture and is to be dealt with accordingly, but the prognosis always depends upon the blood supply. If in the case instanced, there is absolutely no pulsation in the prin- cipal arteries, it is certain that a part of the limb is lost; yet an im- mediate operation is not indicated. There are two reasons for this; first, that the shock may subside, and second, that too much of the limb may not be sacrificed, which latter an immediate amputation nearly always means. Proceed to a most rigorous disinfection and await a line of demar- cation. This is the rule to which there are two exceptions, one apparent, and the other actual. If the injury is a crushing one and the member hangs by shreds of tissue, there is absolutely no use in waiting; but the completion of the ablation does not require an amputation, it is merely what Lejars terms a "regularization." Trim up the tissues sparingly and remove enough bone that a proper stump may be formed, and then patiently cleanse the wound with hot sterile water or normal salt solution, followed by alcohol. Suture completely and then cover the wound with sterile gauze sat- urated with alcohol; finally cover all with a thick layer of cotton firmly bandaged. Almost always by this means a better functional result may be obtained than by a formal amputation quite above.- the site of injury. There is an actual exception to the rule of conservatism. The case is seen late and there are already signs of approaching infection. It is 94 WOUNDS OF SPECIAL REGIONS. not safe to delay and risk the sepsis which menaces. It is better, under such circumstances, to proceed to immediate amputation. (b) Crush or laceration extending from the hand or foot upward. Suppose you are called to treat the foot and part of the leg, or a hand and part of the forearm, which have been crushed and lacerated. The member appears injured beyond remedy. Will you immediately proceed to amputate ? By no means — or at least, not as a rule. If the case is seen immediately, the first effort should be devoted to combating shock and infection. It is not altogether on account of shock that one waits; there are other even more important reasons. The first is that you may not amputate high enough; the second, that you may amputate too high. One cannot always determine from the first how high the devitalized tissues extend. There may be vascular injuries or muscular lacera- tions which are concealed by a sound integument, and which may later be the source of gangrene. Out of this grows the necessity of a secondary amputation, which is always a matter of chagrin to the surgeon and an element of danger to the patient. On the other hand, tissues which appear devitalized may finally survive and thus preserve a function which might otherwise have been sacrificed. It is true that a few inches more or less of the arm or leg, for instance, may make no great difference in the usefulness of the stump; it is quite otherwise when the question is that of amputating immediately above or below the elbow or the knee, or through them. Nor do rules of conservation apply with equal force to the foot and the hand. As Simons, of Charleston, S. C, says (International Journal of Surgery, August, 1906), injuries of similar degree affecting the upper or lower extremity demand different treatment, because of the much greater freedom of collateral circulation in the former rendering gan- grene less probable. Where conservatism or excision would be proper in the upper extremity, amputation would be called for in the lower limb. Extensive comminution and loss of bone of the foot may demand amputation because, if saved, the member may be useless as a means of locomotion, and should give way to a vastly more useful artificial limb. TK1 A I Ml \ I 01 IN.II RU S TO THI. HAM'. 95 ( treat laceration of the soft parts of tin- foot, with free i omminution of bone and injury to vessels, always demands amputation; for the destruction of the skin of the heel and sole will result in a cicatrix which can never bear the weight of the body and may never be anything but a source of suffering and discomfort to its possessor. But, aside from these exceptions and others to be noted, the rule holds in this class of injuries, to avoid amputation and devote one's skill to preventing infection. The prevention of infection is the sine qua turn; if the efforts in this direction are going to be half-hearted, it is better to amputate at once. Immediate amputation, again, is indicated if the wound is seen some hours after the accident, and is found soiled and dirty and mani- festly infected. Under these conditions, con- servatism is not the best course, for there are too many chances that the attempt at disinfection will fail; that, in spite of the best efforts, sepsis will arise. Or, if there are already present the symptoms of dangerous sepsis, it is no longer a question of saving a limb, but of saving a life, and it will be the part of conservatism to amputate well above the suspected level. With regard to the conservative treatment of these severe crushing and lacerated injuries of the hands and feet which most surgeons would be prone to amputate, Reclus, of Paris, has emphasized the value of thorough and patient disinfection of the skin and then of the wound, together with a trimming away of the devitalized fragments of skin and bone. He then "embalms" the member in gauze saturated with an antiseptic pomade, crowded into all the recesses of the wound, and the whole covered by a thick dressing of absorbent cotton and bandaged. This dressing is left undisturbed until repair is complete, unless the temperature should rise or a disagreeable odor develop. Fig. 72. — Ball of gauze for support of fingers. (Marsee.) 9 6 WOUNDS OF SPECIAL REGIONS. Fig. 73. -Thumb pinched off leaving square- ended stump. (Marsee.) Joseph Marsee (Ind. Med. Jour., April, 1896) has made some useful observations with respect to the treatment of common injuries of the hand, which are well worth repeating and which, as he points out, appeal especially to the young man just beginning his life's work, for such will prob- ably constitute the bulk of his surgical practice for some years. There is a natural tendency, in the popular mind, to measure an injury by the size of the member involved, and the man who would insist upon the best advice in other cases, will fly to the nearest doctor's sign when "only a finger" is involved. But Marsee concludes, from his own experience, that the young practitioner is an accomplice in spoiling a good many hands before he learns to do them justice. On the other side, it is not too much to say that the best human skill is none too good when em- ployed in repairing injuries of the most mechanically perfect human member. The majority of these injuries occur in workers with machinery; the hand, therefore, is always soiled and gen- erally greasy. This grease must first be removed. Nothing is better for this purpose than ordinary gasoline or benzine, which may be poured into the hand directly from the bottle. The fluid will find its way into the smallest recesses of the wound, washing out the grime and preparing the way for the other antiseptics. The benzine is poured on until all the grease is removed, and the disinfection is completed in the ordinary way. Fig. Amputation com- (Marsee.) I -K' I VI Ml NT OF IN M Kll S TO MM HAND. 97 1 " 1 - Fig. 75. — Amputation of index finger. Head metacarpal retained. (Marsee.) Even slight wounds of the fingers and palms should be treated by enforced rest by a splint or plaster-of-Paris dressing, complete enough to preclude all motion. This prophylaxis is not regarded as unneces- sary by those who have seen the most marked deformities, the gravest constitutional disturb- ances, and even death, result from trilling wounds of the hand. Enforced rest which leaves nothing to chance, to caprice, or the patient's med- dling is alone reliable. Under such treatment, the rapidity with which alarming symptoms some- times disappear is truly remark- able. If a plaster casing is used, it should extend from several inches above the wrist to the ex- treme tips of the fingers, the thumb being also enclosed if necessary. When finger wounds are extensive and parallel with the long axis, it is better not to suture them at once, for the swelling will gen- erally be extensive and the stitches will cut out. After the inflammation has subsided, the edges may be freshened and ap- proximated. Nor does Marsee advise immediate splinting in the case of crushing injuries of the fingers, for fear that the circulation may be interfered with. However, that the crushed member may not be wholly un- supported, a soft ball covered with cotton and wrapped with gauze is applied to the palm so that the fingers may be spread out over it comfortably (Fig. 72), and the whole dressed with absorbent cotton and lightly bandaged. The ball, 7 Fig. 76. — Amputation of index finger. Head of metacarpal removed making much more sightly hand. (Marsee.) 9 8 WOUNDS OF SPECIAL REGIONS. Fig. 77. — Loss of ring finger. Dorsal view. (Marsee.) as Marsee indicates, though unsightly and bulky, has no other fault; it is light, absorbent and wonderfully comfortable, and needs only a trial to be appreciated and adopted. It should be used until the tissues are beyond danger, though it takes several days, a week or a month No time is lost, for healing cannot begin until vitality is restored, and this will always be slow in such cases, a fact which should be brought thoroughly to the patient's knowledge from the beginning, that the doctor may not be blamed for the tardy convalescence. With regard to methods of amputating fingers, opinion is divided on the question as to which is the more desirable, a palmar flap, or a slightly longer finger with a dorsal flap cover- ing the stump. There can be no doubt that a palmar flap is desirable, and Marsee believes in securing it, even at the expense of sacrificing more of the finger. If more than half the phalanx is gone, it is always better, in his opinion, to amputate at the joint line and thus avoid a flexed stump. If a portion of the distal phalanx remains, the nail should be re- moved and the matrix dissected before the flap is adjusted, or some deformed fragment of nail may be left to vex the patient. It is , . , . r , Fig. 78. — The loss of the ring finger better, in removing a finger at a i s hardly noticed when distal half of . . , , , n- .1 •. it the metacarpal bone is excised, joint, to cut off the knobby pro- {Marsee.) ■ ink Kirs th mi'. thorax. 99 iections of the condyles on the palmar surface and to scrape off the exposed cartilage. If the finger is pinched off squarely, one must always insist in re- moving enough of the bone to give a good flap, for if the patient has his way and the stump heals by granulation, the result will be unsatis- factory and the doctor, event- ually, will have to bear the blame (Figs. 73, 74). If the whole finger requires amputation, the head of the metacarpal bone will require special attention and the pro- cedure will be different with the different fingers. Remove the heads by oblique section in the case of the index and little fingers (Figs. 75, 76). Generally re- move the head of the meta- carpus in the case of the ring finger, cutting back far enough to let the heads of the adjacent bones fall together (Figs. 77, 78). Do not remove the metacarpal head of the middle finger unless the appearance of the hand is the chief consideration. Marsee states as the reason for this, that it tends to let the other fingers fall away from the thumb and thus interferes with ready apposition (Fig. 79). Fig. 79. — The stump of the index finger falls away from thumb when head of middle metacarpal has been removed. (Marsee.) INJURIES TO THE TRUNK. INJURIES TO THE THORAX. Certain elementary notions must be clearly comprehended and kept in mind in order to make a definite diagnosis of these injuries. These notions relate to the anatomy, pathology, and symptomatology of the thorax. With respect to the anatomy, one must keep in mind the IOO WOUNDS OF SPECIAL REGIONS. location of the principal vessels of the chest wall and mediastinum; the relations of the viscera to the ribs; and the normal areas of reson- ance and dullness. In addition, it is necessary to recall the signs and significance of the principal primary complications possible in any form of serious violence to the thorax, viz.: hemoptysis, hemothorax, pneumothorax, emphysema, and hemo-pericardium. Hemoptysis, following an injury to the thorax, whatever its nature, is significant of one thing- — that the lung has been involved. The de- gree of injury may be in a manner estimated by the amount of blood expectorated. In the dangerous cases, the blood pours from the wounded lung tissue into the bronchus and gushes from the mouth. In other cases, there is only a slight spitting of blood, leading to the belief that the lung has not been seriously torn. It might be mistaken for a hematemesis, but the presence of rales in the bronchus of the affected side (or of both) and the light color of the blood and its admix- ture with air, point to the character. of the hemorrhage. Hemothorax, an accumulation of blood in the pleura, is nearly always the result of injury to the lung; although, of course, the internal mammary artery or the intercostals may occasionally be the source of the extravasation. Gravity determines where the blood will accumu- late and therefore the patient's position will modify the physical signs. The symptoms and signs are both modified by the quantity of blood and the rapidity with which it is poured into the pleural cavity. In the slighter forms, there is scarcely any disturbance of breathing and only slight dullness over the base of the lung. In the graver forms, the lung is collapsed and crowded toward the hilum, so that there are symptoms of asphyxia added to those of in- ternal hemorrhage. The face is pale, the skin moist and cold, the patient is impelled to sit up and gasps for breath, the pulse is rapid and thready, and the patient may thus go on to death. Inspection reveals a slightly bulging chest wall; percussion, a complete dullness; and auscultation, an absence of fremitus and of the vesicular murmur. Often there is an immediate rise of temperature, due to absorption, and which is to be distinguished from the temperature of infection by its earlier appearance. No attempt to evacuate the extravasated blood is to be made in the IN JXTRH S TO THE THORAX. IOI moderately severe cases; in others, of more urgency, an aspiration may give some temporary relief, tiding the patient over a critical point. Finally, in rart- rases, the magnitude <>l" the hemothorax will be su< h as to demand an immediate intervention, with the purpose in view of exposing the lung and repairing the wound in its substance. Subse- quently, even it' the case is mild, infection may occur and is to be treated as any other empyema. Pneumothorax. — Air may enter the pleural cavity from without through an opening in the chest wall, or from within through a rupture in the lung tissue. In the first case it enters during inspiration, and in the second, during expiration. The physical signs and symptoms grow out of the pressure within the pleural cavity and the consequent collapse of the lung. The chest wall on the injured side is distended, the intercostal spaces bulged out, the viscera are displaced, the ribs motionless, the vesic- ular murmur absent. If a coin laid on the front of the chest is tapped with another coin, the sound will be heard at the back. The symp- toms are principally those of dyspnea. If there are no complications, the air is gradually absorbed and the function of the lung restored. In extreme cases, puncture will relieve the intrapleural pressure; and in the case of a valvular wound in the chest wall, which permitted entrance of the air but not its exit, enlargement of the wound is indicated. If air and blood accumulate simultaneously — if a hemo- pneumo- thorax exists — the physical signs will be altered, but not the symptoms. Emphysema. — The subcutaneous cellular tissue may become charged with air and practically the whole body be involved. It is nearly always due in the marked cases to puncture of the lung by a broken rib. The air esc aping from the lung is prevented, by the close contact of the pleural surfaces, from entering the pleural cavity, and is forced into the loose tissues of the ruptured chest wall. In other rarer cases the inner aspect of the lung is wounded, and the air escapes into the tissue- of the mediastinum, and follows them up into the neck. In ordinary cases no treatment is indicated and the air is soon ab- 102 WOUNDS OF SPECIAL REGIONS. sorbed. However, in the severer forms, the symptoms of asphyxia and cyanosis may supervene and then free incision over the infiltrated zone may be required. Hernia of the lung is a rare complication, and may be immediate or secondary. In the first case, the pulmonary tissue is forced through the breach in the chest wall by violent expiratory effort. In some cases where the skin is not broken, the hernia may be felt as a crepitant tumor beneath the skin. In the secondary cases, it forms more slowly, and is often due to the weakening of the thoracic wall by inflammatory processes. Hemo-pericardium. — Blood in the pericardial sac follows injury to the pericardium. It develops more rapidly and, of course, the out- look is much more grave if the heart is also wounded. The symptoms are those of syncope induced by the compression of the heart by the accumulated fluid; the signs are those of increased cardiac dullness. The apex beat is lost, the heart sounds muffled, the precordium bulged. It is upon the signs that one must depend for ^the diagnosis, for the symptoms are often complicated by those of shock and by those which originate in other injuries in the thoracic region. To repeat, then, when you reach the patient suffering from some form of chest injury, you will observe the character of his respiration and his pulse; whether his condition is immediately serious or not is to be determined at once by that means. If the circumstances permit, you will proceed to a systematic examination. Learn from the suf- ferer the location of his pain and the character of his chief distress. Note the appearance of the sputum, if there is cough. Inspect the chest wall for change in outline and mobility and location of apex beat. Determine by percussion the limits of the lung resonance and heart dullness; and by auscultation, the presence or absence of the vesicular murmur or of rales. The case may be so grave that exact diagnosis is unnecessary; or, again, it may require the most minute examination and judicious weighing of the symptoms and signs to make a correct forecast of the eventualities, and to formulate a treatment which will leave nothing to regret. CONTUSIONS OF Till MUST. IO3 CONTUSH »\s OF THE CHEST. Simple contusions of the thorax, without fracture of a rib or the ster- num (which are considered elsewhere) and without symptoms point ing to internal injury, need but brief consideration. A hematoma i> likely to form. The pain and soreness disappear rapidly in the young, but are extremely persistent in the aged and the rheumatic. Strapping and massage with liniment are usually sufficient. On the other hand, following simple contusion, there may be a de- gree of shock out of all proportion to the trauma. A man of thirty, apparently in good health, received a slight blow- oxer the chest in a friendly scuffle. The blow was slight, and yet it seemed to touch a vital spot and made him gasp for breath. It was with difficulty that he reached home and for two weeks he seemed upon the verge of a pneumonia. A month later he was still unable to work, and an examination at this time revealed grave organic lesions of the heart. It was greatly dilated and not a single valve seemed to be performing its function fully. In spite of rest and treatment, his condition gradually grew r worse, and in six months he died with a general anasarca. We must consider that the heart, as well as other organs, is liable to contusion and that from such injuries acute endo- carditis may result. In graver contusions, such as crushing injuries, it is rupture of the lung which is always to be feared and which is usually evidenced by a large hemothorax. It must always be remembered that such an injury may occur without fracture of the ribs or sternum. Lejars cites the case of a boy eleven years of age, whose chest was run over by a wagon. He arose immediately after the accident, but fell again unconscious, with blood pouring from mouth and nostrils. This hemorrhage did not long persist, but on the fourth day the temper- ature rose and he was taken to the hospital. His condition was alarming, the pulse weak with a rate of 104, his face cyanosed and the dyspnea intense; his heart was displaced to the right, and on the left side were the signs of marked hemo-pneumothorax. A puncture removing 1S0 (1. of the exudate gave but temporary relief. The pulse continued to grow weaker and the dyspnea more intense, and 104 WOUNDS OF SPECIAL REGIONS. an urgent intervention was indicated. The pleura was opened and the lung found retracted toward the hilum. In the upper lobe a tear was found, 7 cm. long, and running upward, and backward from the cardiac incisure. The wound gaped freely. The lung was drawn into the opening in the chest wall, and the pulmonary wound repaired with five sutures of silk which included considerable tissue to prevent their pulling out. The coaptation was perfected by a few superficial sutures. The upper lobe was sutured to the parietes and a tamponade with gauze completed the operation. The outcome was unfortunate, for death occurred on the second day, but the autopsy found the lips of the lung wound well agglu- tinated. There was no costal fracture. The symptoms of rupture of the lungs are the same whether a rib be broken or not: hemo-pneumothorax, abundant and increasing; a spreading emphysema; symptoms of grave anemia; to all these may be added more or less quickly, the symptoms of pleural infection. The treatment, except in the cases of extreme urgency, must be con- servative and expectant. Shock must be combated, the patient kept absolutely quiet, and the dyspnea relieved by the sitting posture, and, if possible, by inhalations of oxygen. The anemia can be relieved by injections of small quantities of nor- mal salt solution frequently repeated. A puncture will partly empty the pleural cavity, affording great relief; and, eventually, the remaining exudate will be absorbed. It may happen that after two or three days the symptoms will improve. But in the worst cases, where the dyspnea is progressive and menac- ing, and the heart rapidly growing weaker, the responsibility cannot be shifted. It is indicated to operate at once, to open up the thorax and repair the tear in the lung, to do an urgent thoracotomy (see page 423). OPEN WOUNDS OF THE THORAX. Non-penetrating wounds of the chest wall are of slight significance and are to be treated on general principles. Penetrating wounds of the thorax derive their significance from the WOUNDS OF PL] I RA AND I I WG. 105 particular viscera and vessels which may happen to he involved. On the i linical basis, then, these wounds may lie divided into three classes: .1. Wounds which involve the pleura or Lung. B. Wounds which involve the diaphragm. (.'. Wounds which involve the pericardium and heart. A. WOUNDS OF THE PLEURA AND LUNG. In whatever manner the wound may be inflicted, there are three elements of danger: hemorrhage, asphyxia, and infection. These are the factors which will determine the line of treatment, and without some urgent indication from one of these sources the treatment must he conservative. There are many things which stand in the way of radical procedures such as are employed in the case of ahdominal wounds. In the first place, the operative technic is difficult; there is a marked disturbance of respiration following free access of air to the pleural cavity; the exact location of the lung lesion cannot often be determined; and, finally, there is always, as Lejars remarks, so much guesswork in the prognosis, that we are constrained to give the patient the benefit of the doubt and leave the case to take its natural course. It is best to proceed in this wise: If the case is seen from the first, supervise the transportation. Too much importance cannot be at- tached to the dangers of rough handling. As has been said elsewhere, the nearest shelter is the best. Cut away the clothing, scrub the skin adjacent to the wound, and wash out the wound itself with alcohol or sterile salt solution. If, on opening the lips of the wound, a bleeding point is seen, catch it up and ligate. If there is oozing from the depths, it is best to disregard it for the present. This constitutes the primary intervention except for suture of the wound, which follows. Apply a dressing of sterile gauze, plain or soaked in collodion. Cover this with a layer of absorbent cotton and apply a firm bandage encircling the whole chest. Place the patient on his back with the head and shoulders slightly elevated. Absolutely prohibit conver- sation and movement of any kind; and, in the meantime, keep the patient under close surveillance. 106 WOUNDS OF SPECIAL REGIONS. In general terms, then, the treatment of any ordinary open wound of the chest involving the lung and pleura is to be summed up in two words, immediate occlusion and immobilization. But there are conditions which demand immediate intervention. These are acute anemia or asphyxia, which may follow hemorrhage, external or internal; and hernia of the lung. External hemorrhage may follow any extensive wound of the chest wall, welling up from its depths or flowing by spurts during expiration. If there is no hemoptysis, it may be inferred that the lung is not wounded; but, in any event, the first treatment must be directed to- ward the intercostals and internal mammary. It may be that a tempo- rary hemostasis will be necessary, and the tamponade described on page 49, will be indicated. The definite hemostasis requires a free enlargement of the wound. If pressure made against the lower border of the rib by an aseptic finger introduced through the enlarged wound causes cessation of hemorrhage, it is certain that it is an intercostal artery that is at fault. It may be difficult to clamp; it may be necessary to resect a rib, or to detach the periosteum, which will carry the artery with it. A curved needle threaded with catgut is then carried around the artery. The ligature is tied and the hemorrhage thus controlled. The internal mammary may require ligation above and below the wound. Internal hemorrhage is in every way more serious, for to the anemia is added the asphyxia which follows the compression of the lung. The patient is pale, anxious, with cold extremities, weak pulse, and sighing respiration; the chest wall bulges; the normal resonance and vesicular murmur are altered; in short, there are all the indications for an increasing hemothorax or hemo-pneumothorax. But even in the presence of these grave symptoms, it is by no means always indicated to operate. One must be content to repair the wound, occlude and immobilize, and wait awhile. But when the wound is- followed by an immediate and complete hemothorax, or when the symptoms and signs point to a rapidly ap- proaching fatality, one must .stand by with folded hands and see the end come, or operate; for there is nothing else of any use. An urgent thoracotomy must be done. WOUNDS OF PLEURA AND LI 107 Hernia of the Umg is rare. The tumor is of variable size and is at first crepitant, but rapidly darkens and becomes hepatized. The indications for treatment depend upon the time which has elapsed and upon the condition of the tumor. If the wound is recent and the lung intact, the hernia must be reduced. Begin by a careful disinfection of the wound. Cover the tumor with an aseptic com- press and tuck its edges under the whole circumference of the wound. A steady pressure over the central portion of the tumor will expel the air little by little; and, by reducing its volume, favor the reduction of the tumor. The compress is to be left until the skin wound is partially sutured, since by that means one may prevent the sudden pneumothorax which sometimes follows reduction. If the lung has been wounded, it must be repaired by suture, or by ligation and resection before being reduced. If some time has elapsed, it is as unsafe to reduce it as to reduce a doubtful herniated gut. Lejars insists upon resection with the thermocautery. Around the base of the tumor pass a ligature threaded on a blunt needle. By tying the ligature, a pedicle is formed which is to be amputated with the thermocautery. The stump is carefully disinfected and reduced, the chest wall repaired, and drainage instituted. Finally, in the case where the tumor is already gangrenous and slough- ing, it is necessary to limit the treatment to antisepsis, leaving the slough to detach itself, and happily a cure may follow such spontaneous amputation. Ax tell reports a case of open wound of the chest which illustrates what the doctor's patience and nature's efforts may accomplish in conditions apparently most desperate. (American Jour. Surg., Feb. 1909.) A shingle sawyer of twenty-eight, robust and muscular, fell against a great circular saw revolving many thousand times per minute. Sections of the second, third, fourth, fifth and sixth ribs were cut away, these segments varying in length from one inch at the second to three inches at the fourth and fifth ribs. The costal pleura was com pletely destroyed over the seat of the greatest injur}-. The lung and 108 WOUNDS OF SPECIAL REGIONS. pericardium were exposed. There was one ^puncture of the lung from which the air bubbled and emphysema followed. All the inter- costal arteries, veins, and nerves in the injured area were severed. The pectoralis major was completely separated from the chest, and a part of the pectoralis minor. The wounded man, thrown from the saw, fell face downward into a dust pile and the whole exposed surface of the wound was filled with sawdust and grease. He was carried to the hospital and attempt made to repair the damage. "Over 450 spiculae of wood fiber were picked out piece by piece from the chest cavity and the surface of the lung. Several large lumps of greasy dust were removed from the depths of the chest cavity." All the ragged edges of the costal pleura, skin, and muscles were trimmed away. The jagged and uneven ends of the severed ribs were cut off smooth in order to bring the periosteum over them. To take the place of the costal pleura destroyed, a flap was stripped off the pector- alis major from near its attachment to the humerus; left attached near the free end of the divided muscle, it was turned forward toward the sternum and sutured to its margin, to the intercostal muscles, and the periosteum of the stumps of the ribs. The severed muscles were drawn together by cable sutures and the skin flap drawn into place and incompletely sutured. Ample drainage was installed. The inter- vention consumed several hours, something like 180 sutures and liga- tures being required. The emphysema was enormous at first, ex- tending from the scalp to the knees, but disappeared after 48 hours. At the end of six weeks the patient had practically recovered without adhesions or restriction of the lung. B. WOUNDS AT THE BASE OF THE THORAX. Wounds at the base of the thorax require a separate consideration, for the reason that both the thoracic and abdominal cavities may be involved through wounds of the diaphragm. It must be remembered that the d'aphragm corresponds to the level of the fifth rib in the right nipple line, and to the level of the sixth rib in the left. In stab or gunshot wounds, the lung on the one hand, and the stomach, intestine, spleen, and liver on the other, may be wounded simul- WOUNDS IT mi BAS1 01 im THORAX. 109 taneously; so that, compared with the thoracic wounds just considered, those at the base arc much more i omplicated with respect t<> prognosis, diagnosis, and treatment. Ludlow, of Cleveland (Annals of Surgery, Jinn-, [905), reports a case which illustrates this subject and exemplifies the treatment in general. The patient had received two stab wounds in the left side, inflicted with a candy maker's knife which had two blades set in a heavy handle. One wound entered at the ninth interspace in the axillary line, and through it protruded omentum. The blade had entered the chest wall obliquely and the skin acted as a valve; but, when the skin was retracted, the air rushed in and out of the pleural cavity with each respiration. The hemorrhage from the wound was slight. The second wound was situated directly below the first in the elev- enth interspace. Omentum protruded from this wound also, and the bleeding was slow, but apparently increasing. Operation.- — Ether anesthesia; a careful cleansing of the field. A digital examination revealed the fact that the upper wound, traversing the pleural cavity without injury to the lung, had perforated the dia- phragm. The finger passed through these wounds, met the finger of the other hand passed through the lower wound, in the abdominal cavity. The lower wound was enlarged, revealing an active hemorrhage from the spleen. The cut surface of the spleen was pulled into the wound and a spurting artery clamped. The splenic wound was four centi- meters in length and extended almost through the substance of the organ. The cut surfaces were brought into apposition by mattress sutures of plain catgut No. 2, on a curved round needle. This controlled the hemorrhage. Neither by palpation or inspection could any wound of the Stomach or intestines be found. The diaphragm was then repaired with chromic gut No. 3. The operation was accomplished without the resection of a rib. A small cigarette drain was left in both wounds and the external wounds sutured. The week following the operation there was some discharge' of blood and debris, but no active hemorrhage. The recovery was uneventful and complete. These wounds at the base of the thorax involving the diaphragm. IIO WOUNDS OF SPECIAL REGIONS. will nearly always present an omental hernia. It is often necessary, after enlarging the thoracic wound by resecting a rib or forming a costal flap, to resect the protruding omentum ; and, at the moment of reduction of the stump, one may have an unobstructed view of the wound in the diaphragm. If blood oozes from it, there is abundant evidence of a wound of an abdominal viscus. If there is no bleeding, introduce a finger through the opening in the diaphragm and examine the stomach and adjacent structures. If no injury is found, and the examining finger is not covered with blood, proceed at once to repair the diaphragm. A curved needle is best, and interrupted sutures. If there are wounds of the abdominal viscera, they may possibly be repaired through the phrenic wound; and, in fact, if at all possible, it is the method of election. By this route one may readily reach the convex surface of the liver on the right side, or on the left the greater curvature of stomach. Still, if the exploration is difficult, if the bleeding is abundant, it is better to lose no time, but to do a median laparotomy at once, gaining additional room, if necessary, by a transverse incision, following the costal arch. Subsequently the wound in the diaphragm may be re- paired through the thoracic opening. Wounds of the diaphragm of whatever form, perforations, or rup- tures due to crushing injuries to the chest, are likely to be the site of herniae. . Especially in the latter class of injuries, must one be on his guard for this injury. Sometimes there are certain signs which point at once to the presence of a diaphragmatic hernia; the displacement of the heart, the bulging of the lower intercostal spaces, and the presence on auscultation of sounds which in no way resemble the vesicular murmur. In these cases, it is best to open up the eighth intercostal space and resect the ninth rib, which will usually give a free access to the site of injury. C. WOUNDS OF THE PERICARDIUM AND HEART. Not every precordial wound will reach the heart. Such a wound may be followed only by a slight emphysema and is to be treated by aseptic occlusion. \\t>i;\DS OF THE PERICARDIUM AM) IIKART. Ill If the wound has actually penetrated to the heart, death is usually bo rapid that no measure <>r relief can be considered. K it is a gunshot wound, death results from shock and hemorrhage; if it is a stab <>r punctured wound, shock plays a very minor part. It is not very likely thai any small size stab wound of the heart interferes at once seriously with the heart's action, unless it involves the "coordination renter," which, it is claimed, lies in the upper third of the inter-ven- tricular groove. If the wound in the pericardium be small or valve-like, the blood is retained within the cavity and the constantly increasing intra-peri- cardial pressure effects the softer and more yielding of the structures within the sac — viz., the pulmonary veins and the descending vena cava and the auricles; in this manner, the venous current to the auricles is cut off and the agitated heart works to no purpose. The sense of oppression, the cyanosis, and venous engorgement all bear witness to the compression of the auricles. In the meantime, the pulse grows miserably weak and rapid; the apex beat is lost, the heart sounds are muffled, the pericardial dullness is augmented, and the thoracic wall bulged. In this manner from "heart tamponade," death soon ensues. If the wound in the pericardium is large and the pleura opened, the hemorrhage rapidly fills the pleura producing hemo- thorax, scarcely less distressing than the hemo-pericardium. If the opening in the thoracic wall is free, the hemorrhage is external; the blood spurts from the wound or wells up continuously, uncon- trolled by pressure or occlusion, and death ensues from hemorrhage, simply. In spite of all this, however, a wound of the heart is not to be con- sidered as inevitably fatal and beyond surgical skill. The number of reported cases saved by timely intervention is constantly increasing and will increase all the more rapidly as time goes by. Any wound of the heart sufficiently large to produce hemorrhage, whether external or internal, is potentially fatal. The only measure of relief is operation. The pericardium is to be exposed and opened, the heart relieved of pressure, and the wound repaired. The question arises as to how late an operation may be undertaken. 112 WOUNDS OF SPECIAL REGIONS. but this cannot be answered by a general formula; as long as there is life, there is hope in skillful intervention. In the cases reported, the great majority were operated not later than six hours after the injury. Regarding the location of the wound in the heart, the right and left sides are injured with equal frequency, but the ventricles are in much greater danger than the auricle in the proportion of seventeen to one (Vaughn). The external wound may be located over any intercostal space, but the great majority will be found in the fourth, fifth, and third. Vaughn, who has carefully studied the statistics of operations for these injuries, and who reports his second successful case of suture of the heart (J. A. M. A., Feb. 6, 1909), offers the following conclusions: that there is no longer any question as to the propriety of the operation, but that its mortality is probably the same as it was twelve years ago when the operation was first introduced. Probably little more can be done to prevent death from hemorrhage, but the prevention of the great cause of death following the operation, infection of the peri- cardium, remains a surgical problem yet to be solved. The principles of asepsis and drainage as applied to the operation, are yet to be more carefully worked out. (See Repair of Injury to Heart, page 427). INJURIES TO THE ABDOMEN. I. Contusions. II. Wounds. I. Contusions of the abdomen occur in many" ways; they may be the result of severe blows, the kick of a horse, from falls, or from the crush of heavy wheels of vehicles. The gravity of such an injury is proportionate to the amount of visceral injury, but this is often not apparent from the first. Whether the viscera are injured or not, there is always some degree of shock. In the first hours following the injury, in the doubtful cases, the therapeusis must be limited to the treatment of shock. If trans- portation is necessary, it must be done with the greatest care. • Once the patient is placed in bed, his clothing must be removed, his head lowered, the extremities kept warm, and repeated injections IN! I K 1 1 S I'd Mil ABDOMEN. 113 of normal salt solution or adrenalin made, as tin' charat ter of the shot k indicates. In the meantime, tin- case is to be studied and it is to he decided whether or not there is a rupture of an organ, or other source of hemorrhage. The responsibility is a heavy one, for an internal injury overlooked or discovered too late, is likely to result in death. The patient may rapidly recover from the shock, but this by no means proves the absence of a visceral hurt. In the typical case of grave injury, the symptoms of shock are only temporarily relieved by the injections; rather, they are shortly replaced by those of internal hemorrhage. The pulse remains small and fre- quent, the skin cold, the face anxious and drawn. The abdomen is distended and tender to the least pressure, especially in the zone of direct injury. There is dullness in the tlanks. There is no escape of gas from the bowels, or passage of urine. The patient is restless and frequently sighs, and seems to realize his impending fate. In such a case, the indications are plain. There can be no excuse for delay, for awaiting the signs that can only be those of beginning peritonitis. Prepare for an immediate laparotomy. But suppose the case is not accompanied by the typical symptoms. How shall we determine in two or three hours whether or not there is a grave lesion? A conclusion must be reached from the study of two fat tors: (a) the pulse, and (b) abdominal tension. (a) The pulse, disturbed at first by the shock, rapidly approaches the normal perhaps, but within a half hour or sooner, it can be deter- mined that it is getting weaker and more rapid. Such a change is particularly indicative of hemorrhage. If there is any discrepancy between the pulse and temperature, Lejars insists that the former is the safer guide, for a subnormal temperature resulting from shock may persist long after the other symptoms have disappeared. (b) The abdomen may or may not be swollen, but over the site of the injury the abdominal muscles soon begin to grow rigid, and resent the least touch, under which they may be felt to contract and stiffen. This rigidity, localized ;it first, tends to spread and include the entire abdomen. 114 WOUNDS OF SPECIAL REGIONS. The tension is usually augmented by progressive meteorism. If one has attentively observed the case, it will be seen that it, also, is at first localized, but rapidly becomes general. Dullness in the flanks is a valuable sign when present, but its absence settles nothing. It may be masked by the distended stomach and in- testine; again the blood may not collect in the iliac fossa, but may flow directly into the pelvic cavity, especially if the hemorrhage is on the left side of the mesentery. These modifications of pulse and temperature, of abdominal tender- ness and tension, must be taken as sufficient indication for urgent in- tervention; for the prognosis does not, in reality, depend more upon the nature and multiplicity of the visceral lesions than upon the time of intervention, for every hour of delay adds to the chances of infection and sepsis — elements which the early operation may practically eliminate. Another eventuality: The case is not seen until infection has fixed itself upon the peritoneum; the pulse is weak and rapid and progress- ively growing worse; the temperature is subnormal, the extremities cold; a marked tympanites, with persistent vomiting, perhaps comes on. Then, indeed, it is late to operate — especially when that means a long and tedious laparotomy. Every doctor must answer for himself the question, "Is it too late?" As Lejars says, we must extend as far as possible the limits of intervention in such cases, for it is the last re- source; and, even though the mortality is very great, the occasional unexpected recovery legitimizes the operation. (See laparotomy for traumatism, page 469.) II. Wounds of the Abdomen* — Clinically, these fall into two groups, (a) those in which there is doubtful perforation of the peritoneum, and (b) those in which perforation of the peritoneum is quite obvious. (a) The patient presents himself with a wound of the abdominal parietes, of doubtful depth. It is easy to determine, once for all, whether the peritoneum has been perforated (and upon that the prognosis depends) by passing a probe or grooved director. But one should certainly do nothing of the kind. There is a definite mode of examination to which one must rigidly adhere. *For gunshot wounds, see pages 135 and 159. WOUNDS OF THE ABDOMEN. IIS Begin by a hurried inquiry into the circumstances of the injury, and the character of the weapon. Disinfect the hands for an opera- tion. Finally scrub and disinfect the abdominal walls. Not until this is completed, is the wound ready to be examined. Carefully separate the lips of the wound with finger or retractors; and, as you proceed, carefully wipe each layer as it is exposed. If necessary to facilitate inspection, enlarge the wound; this will often be the case, especially where the vulnerating instrument has entered obliquely. Dividing the various layers, the peritoneum is reached and found intact; there is no oozing from below the level of the muscular layers, and, if this finding accords with the other signs observed, you may con- clude at once that the wound is non-penetrating. In such a case, care- fully cleanse the wound and repair each layer separately by continuous suture with catgut; the skin with silk or silkworm-gut; cover with sterile gauze, a thick layer of absorbent cotton, and a firm abdominal binder; and thus have been taken the best steps to prevent infection or ventral hernia, which is often the result of these wounds. If the wound is penetrating, the mode of procedure depends upon whether it is a (a) narrow, or (b) a large incised wound. (a) A stab wound is the type — a thrust from a knife, dagger, or bayonet. There may be persistent oozing of blood alone, or blood mixed with bile and urine, or "food products." Such a mixture is pathognomonic of visceral injury, but nothing can be decided from its absence. The persistent hemorrhage is strongly suggestive of serious injury to an organ, especially where it coexists with a fading pulse, pallor, tympanites, and rigidity and tenderness of the belly wall; yet the ab- sence of all these signs gives no assurance of the absence of a visceral injury. In any event, then, an exploratory laparotomy is indicated; for only by that means can one assure himself of the conditions. Ordinarily, the wound itself is enlarged for the purpose of exploration, but in the case of more than one wound, or when the abdominal walls are very thick, it may be advantageous to resort at once to median laparotomy. In either case, the abdominal opening should be large enough for rapid Il6 WOUNDS OF SPECIAL REGIONS. work. If the laparotomy is done at the site of the injury, it will be wise to disarrange the viscera as little as possible, when sponging out the exudates. Carefully inspect whatever parts present, and often the lesion will be revealed by this first search. If a median laparotomy is done, as soon as the cavity is opened proceed to the site of the injury; cover the adjacent coils of intestine with compresses, thus preventing their possible infection. The lesions are only rarely multiple or difficult of repair in this class of abdominal injuries. (b) Extensive Incised Wounds. — These wounds are produced by in- struments with a long cutting edge, or by the ripping cut of small knives. Horned animals occasionally produce them. The chief characteristic of these wounds is eventration, always present .in some degree. If the case is seen immediately, the mode of procedure is very definite. But only too often the patient's efforts have augmented the hernia, or he or his friends have made untimely at- tempts to reduce it. Having cleansed the hands and the abdominal walls in the usual way, begin next a systematic cleansing of the eventrated mass. Cleanse it with warm sterile water, or normal salt solution, rubbing gently with the fingers, every inch of the projecting bowel or omentum. Only in the thoroughness of this step is there any assurance of success. If any visceral wounds are discovered in the cleansing process, they are to be repaired at this time. Once the cleansing and repair are complete, proceed to reduce the hernia. The wound may need to be enlarged; if this is necessary, slip a finger under an angle of the wound to serve as a guide, and divide the tissues with scissors. The other angle may be treated in the same way. Catch up the peritoneum with forceps along the whole length of each side of the wound. Now lift on the forceps, and in this way create a sort of funnel with smooth sides, over which the bowel readily glides in reduction. Do not attempt to reduce by rough pressure, which may contuse the bowel. If "taxis" fails, there is a method which will surely succeed. Spread a large compress over the mass; tuck its edges well under the entire circumference of the wound; and, with both hands, make a WOUNDS OP THE SPIN] . 117 gradual pressure on the mass enveloped in the compress, coaxing the refractory Loops into place with the fingers, and at the same time push- Rig the compress further under the abdominal walls. The assistant, in the meantime, lifts up on the Forceps attached to the peritoneum, raising the abdominal walls as the hernia recedes. When the reduction is complete, leave the compress in place, se- cured by forceps until repair of the peritoneum is nearly complete. Repair the abdominal watt; begin by suture of the peritoneum with small catgut. If the tension is great, it may be necessary to include the mus- cular plane in the suture. Xext repair the muscular layers separately by continuous catgut suture; in the same manner, the aponeurosis, and finally the skin, with interrupted silkworm-gut sutures. Drainage is a question which always arises, but Lejars assures us that, if the cleansing is carefully carried out, drainage is in no wise necessary. If the case is seen late, but there exist only a few soft ad- hesions between the bowel and the walls of the wound, the same dis- infection is carried out, the adhesions around the orifice gently broken up, and the mass reduced, as before. Drainage is quite indispensable, if there are already the signs of a beginning peritonitis. If the mass has become the site of a purulent peritonitis, the coils ag- glutinated by false membrane, and gangrenous, there is nothing to do except to keep applied moist antiseptic compresses, which must be frequently renewed. If the patient survives, whatever intervention is needed, may be undertaken later. (See also gunshot wounds of ab- domen and laparotomy for traumatism.) WOUNDS OF THE SPINE. Wounds of the spine, even in their slighter forms, require a guarded prognosis. How they will eventuate can never be certainly foretold. Death may ensue immediately from injury to the cervical part of the cord;or, in the case of the lumbar region, death may be delayed, but is as certain, because of secondary lesions. Again, recovery may ensue but at the cost of paralysis, variable in its form and gravity. Finally, recovery may appear to be complete and even then years after some form of degeneration may manifest itself after the injury has long been forgotten. Il8 WOUNDS OF SPECIAL REGIONS. As in the case of the skull the whole gravity of the traumatism de- pends upon the medullary lesion. The treatment must of necessity be conservative; only when the cord is obviously compressed should active intervention be considered. WOUNDS OF THE VULVA AND VAGINA. The chief danger in wounds of these parts is hemorrhage, especially when the vulva is involved and its venous plexuses torn. These wounds may be contused, lacerated or punctured, and more frequently occur from falls astride some object, and by that means the bulb of the vagina is crushed against the ramus of the pubes. Forcipressure and ligation may be ineffectual to control the bleeding and often the only recourse is tamponade, first disinfecting the wound and the region adjacent, and afterward applying a T bandage and bringing the thighs firmly together. Perforating wounds of the vagina call for a most careful examination, for not only may the vaginal walls be involved, but the rectum, bladder, or peritoneum as well. Careful suturing is here the best means of controlling hemorrhage. Peritonitis may result from such injuries or more remotely, fistuke or astresia of the vagina. Any serious hemorrhage following coitus calls for an examination. It may ensue from a tear of the hymen, or of the posterior wall of the vagina. Cases are on record in which the tear penetrated the rectum. Deep suturing serves at the same time to control hemorrhage and to promote repair. WOUNDS OF THE PENIS, SCROTUM AND TESTICLE. The penis may be fractured ; and, if the urethra is not involved, the hemorrhage will be subcutaneous. Unless the extravasation is very large and progressive, there is nothing to do but to bandage the organ and put the patient at rest. Otherwise it will be necessary to expose and suture the break in the corpus cavernosum. But with such a pro- cedure one may expect a severe hemorrhage. Open wounds of the erectile tissues of the corpora cavernosa or corpus spongiosum may be expected to bleed freely. It is usually advisable to pass a sound to woinds or rni: s< im>i i m. 119 determine the integrity of the urethra, suturing it first, ii" involved, and then carefull} 1 oapting the erectile tissues. In the case of wounds of the scrotum merely the integuments may be penetrated, or more deeply the tunica vaginalis or the testicle as well. It must be remembered that any considerable wounding of the tunica of the testicle may result in hernia of the parenchyma. The scrotal tissues must not be roughly handled in cleansing, and F1G.I80. — Suture of wound of testicle. A, beginning its repair; B, wound in l_ testicles repaired. C, tunica vaginalis. (Lejars.) the sutures must not be too tight, for there is a tendency to edema and sloughing. The repair of these various structures must be conducted separately. If the tunica vaginalis is opened up and the testicle herniated, it must be carefully cleansed and returned and the tunica sutured, with or without drainage, depending upon the probabilities of infection. If the tunica be destroyed, and the testicle remains sound, it must be pre- served, covering it as much as possible with such serous covering as remains. Incised wounds of the testicle call for suturing of the fibrous coat with catgut. The tunica vaginalis is next repaired with a continuous suture (Fig. 80), and finally the scrota] wound is sutured. If the testicle is lacerated, or if seen late and manifestly infected. WOUNDS OF SPECIAL REGIONS. it must be removed without delay. Expose the spermatic cord as high up as possible, and at that level ligate the various elements sepa- rately and firmly, and resect. Trim away any infected tissues in the scrotum and repair, making drainage (Fig. 8"i). Cotton, of Boston (Amer. Jour. Urol., Nov., 1906), describes a case of injury to the testicle resulting from a blow on the scrotum by a batted base-ball. Shock and excruciating pain ensued, gradually subsiding coincident with the development of a large scrotal hematoma. l njJE Fig. 81. — Emergency castration. A, transfixion of the cord and ligature of one-half. B, ligature carried around the entire cord. (Lejars.) Operation. The superficial tissues were infiltrated with blood. A rent an inch long in the tunica. vaginalis. Bleeding from the sper- matic artery. The tunica albuginea was torn in shreds, the parenchyma destroyed. "The testis had evidently exploded under the swift impact, as a full bladder bursts under a blow." After removal of clots and irrigation, the tissues were sewed up layer by layer with catgut and without drainage, and light pressure applied. Convalescence un- eventful. WOUNDS OP RECTI \t. 121 WOUNDS OF THE RECTUM. Wounds of the rectum arc rare. 'They arc usually punctured wounds due to falling upon pointed objects, gunshot wounds, or tears accom- panying fractures of the pelvis. The chief dangers are hemorrhage and infection. Wounds of this region are usually self-evident, though their extent may be a matter of doubt, so that every such injury demands a care- ful examination. The examination calls for inspection. To depend upon touch alone may lead one into grave error. In every serious injury of this character, anesthetize the patient, dilate the anus, and by the use of retractors expose the wound. Douche \vith hot normal salt solution. If the hemorrhage persists, the bleed- ing points are to be clamped with long forceps and an attempt made to suture en masse, for at that depth it will be hardly possible to ligate the vessels. Sometimes in lacerated wounds, the oozing can be con- trolled only by tamponing the rectum firmly, packing around a large tube in the center. Suturing these wounds is not so desirable as one might at first think, for the sutures may conduct sepsis to the deeper tissues. Do not suture, then, unless the wound is easily accessible, recent and clean. If the sutures are used, frequent irrigations of normal salt solution must be employed and the bowels kept quiescent for several days. If the rectal wound has penetrated the peritoneal cavity, which fact may develop in course of the examination, or may be suspected from the tympanites and tenderness of the abdomen, the better plan is to proceed to a laparotomy. The abdomen is to be opened in the middle line, the patient put in the Trendelenburg position, the pelvis cleansed, and the wounds re- paired by two tiers of sutures. If the small intestine should become herniated through a rectal tear, laparotomy is again indicated, reducing tin- hernia by traction from above. If the herniated loop protruding from the anus be gangrenous, in order to avoid infection of the peritoneum the- affected segment Should be resected and the two ends temporarily ligated before pro- ceeding to the laparotomy. Once the abdomen is opened, the two ends of the bowel are to be pulled up and anastomosed. CHAPTER XI. GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE.* Gunshot wounds are essentially contused, punctured, or lacerated wounds, or combinations of all of these, differing from wounds pro- duced by other means only in their potentialities. If the gunshot wounds of military service differ from those seen in civil practice with respect to their character, prognosis, and treatment, it is because the bullets in each case differ with respect to hardness, initial velocity and range, and because the wounds are produced in different environments. The modern army bullet (Fig. 82) is of small caliber, is jacketed with steel, has a very high initial velocity, and long range. At close range, such a missile is tremendously destructive to all the tissues alike, producing the conditions of crushed or lacerated wounds. On the skin at medium or long range, the wound of entrance is small, less than the diameter of the ball; likely to be dirty. The wound of exit is larger, more irregular and bleeds more freely (Fig. 83). The pain in skin wounds is often moderate, usually a burning sensa- tion, and the shock not severe. The fascia presents a smaller opening than the skin, the fibers being split, rather than cut in twain, and for this reason the wound tends to close, oftentimes materially interfering with drainage. The muscles are contused, lacerated, and are likely to be infiltrated. The tendons are quite likely to be pushed out of the way and not wounded. At other times, they are partly or wholly divided. The blood vessels may be pushed aside, but more frequently are more or less torn, and one of the frequent causes of immediate death is hemor- * Authorities specially consulted: Makins, Stevenson, Senn, Von Bergman, Fischer, Havard, De Wreden, Osuki, and various contributions to the Jour. Assn. Military Surg. INJURY TO NKRVKS 123 page. Yet even in the case of laceration of large arteries, there may be spontaneous hemostasis. Aneurism (Fig. 84) is the common sequel if the artery is grazed or contused, requiring double ligation and excision. Martini-Henry. Fie. 82. — Types of cartridges. (Makins.) Guedes. Lee-Metford. Mauser. Krag-Jorgensen. When not pushed aside, the nerves may be contused or divided, re- sulting in paralysis — immediate or remote — neuralgias, or trophic disturbances, such as wasting or contracture of muscles, or blanching of the skin, corresponding to the distribution of the nerve. Even though the nerve itself is not injured, these conditions may result from its 124 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. inclusion in scar tissue. It is often indicated to expose the nerve and clear it of exudates or to attempt suture (see repair of nerves). Bone presents a wide variation in the character of the lesions pro- duced. There may be mere puncture, there may be extensive com- minution, or any grade of injury between these two extremes (Fig. 85). Fig. 83. — Showing small entrance wound, and large irregular wound of exit. (Makins.) The character of the injury will depend upon two factors, the character of the bone and the range of the bullet. (a) If the bone is soft and cancellous, the tendency is toward per- foration; if it is hard and compact, the tendency is toward comminution. The articular end of the long bones, the short, and the irregular CHARACTB R OF BON] l I SION. 125 bones are Likely to be merely perforated. On the other hand, the shaft of the long bones, the skull, the scapula, arc much more likely to be shattered. (b) At long range, perforation is rather to be expected; at very close range, comminution is the rule. So far as the long bones are concerned, transverse fracture rarely occurs, and if longitudinal fracture occurs, its tendency is to stop short of the articulation (Fig. 86). With respect to the bones of the limbs, it is to be noted that the exit wound will be the more comminuted (Fig. 87). Perforating fractures without solution of continuity, are often difficult of diagnosis, because of the absence of characteristic symptoms. The diagnosis is to be made by reference to the track of the bullet, palpation, bone dust in the wound of exit, etc. (Fig. 88). Comminuted fractures present an excessive mobility, and often crepitus is hard to elicit. Owing to "local shock," the limb may be quite powerless and yet painless. Primary shortening is often absent by reason of the muscular relaxation due to shock. Even though healing takes place uneventfully, a large amount of callus is likely to be thrown out; and, for a long time, the union will not be strong. Acute osteo-myelitis may follow infection. On the other hand, necrosis may occur late and after the wound has apparently quite closed. In the bones of the skull is frequently seen the so-called "gutter fracture," in which there are usually two apertures in the scalp, con- nected by a trench ploughed through the outer table and diploe. (Figs. 89,90). The corresponding part of the inner table is comminuted exten- sively and perhaps depressed. Fig. 84. — Traumatic aneurism. (Mouttin.) 126 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. The length of the gutter depends upon the surface curvature, and the antero-posterior are more serious, as a rule, than the transverse (Fig. 91). Fig. 85. — Types of fracture of long bones. (Makins.) A* primary lines of stellate fracture. B, stellate on one side, transverse on the other. C, complete wedge broken out. D, incomplete wedge. E, oblique fracture. The joints present effects peculiarly variant; the capsule alone may be injured; the articular ends of the bones may be guttered or pene- Fig. 86. — Lower end of femur, showing tendency to fissures to stop short of articular ends. (Makins.) trated with or without injury to the capsule; there may be much shattering, fissures radiating in all directions; or the joint may be in- TYPES OE GUNSHOT FRACTURE. 127 yoked by extension from the wound of the shaft. The bullet may be retained in the joint cavity. Effusion into the joint is a constant symptom following perforation, a mixture of blood and synovial fluid. Of the great cavities and viscera, each has its own particular symp- tomatology. The cranium, according to Von Bergman, presents the following 'AF Hi i 1 m '."*-' BJ k ff^ 4 . M< V S ; - - - w WMSi B '- jfflirt an 1 * "-" ■ - ■M ■', QA B '■-■?•'" EH '» ! ■?'■' •' < 1 1 .-, i 1 _B^HP Fig. 87- — Small wound of entrance and large wound of exit of left leg. Frag- ments of bone carried to right leg producing large irregular wound requiring amputation. (Makins.) lesions: at short range, the skull and scalp are torn to pieces; at 160 feet, the scalp is preserved, hut the skull is shattered; there are two Openings with lacerated edges with brain exudate, the wound exit always larger than that of entrance. At 320 feet, there arc two openings, each surrounded by a series of concentric fissures in addition to radiating fissures (Fig. 92). 128 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. Fig. 88. — Oblique perforation implicating both epiphysis and diaphysis, with large frag- ment at exit. {Makins.) A -' mmm - B >0?£33^ Fig. 89. — Transverse section of "gutter" fracture. (Makins.) A, no loss of substance. B, Comminution. Gl NSHCH FRACT1 R I OP SKI I I , 12g At 1000 feet, tin- radiating fissures still appear. At 5600 feet, entrant e and exit wounds are clean-cut holes. At Sooo feet, there is only the wound of entrance, and the bullet lodges in the brain. De Wreden, of the Russian Army, says that only beyond a range of 1200 steps, did the Japanese bullet perforate so as to permit of recovery. The injuries to the dura mater are analogous to those of the skull. PlG. 'jo. — Gutter fracture perforating skull in the center of its course. (Makins.) The brain itself, semifluid, is torn to pieces at short range, through bydrodynamic action. At long range, the bullet merely traverses the brain, producing areas of contusion in the neighborhood of its track. There may be a diffuse hemorrhage throughout the brain, the ventricles being Tilled with blood. The symptoms are such as belong to concussion, compression, con- tusion, or laceration in general. 9 130 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. "The vast majority of gunshot fractures of the skull are accompa- nied by more or less marked symptoms of brain injury: paresis of certain groups of muscles; paralysis, motor and sensory; loss or im- pairment of special senses, usually sight or hearing; Jacksonian epilepsy; twitching and contraction of certain muscles; signs of brain irritation, due to injury of the cortex — in fact, all the symptoms of brain damage, in all their varying combinations. Usually the symptoms are in correspondence with those to be expected in consequence of in- jury to the brain cells evidently implicated, but occasionally symptoms Fig. 91. — Superficial perforating fracture; roof lifted at both openings. (Makins.) arise which are not to be accounted for by such direct inference; they must be due to injury to outlying portions of the brain, produced by vibration or wave action, communicated to the comparatively fluid brain by the passage of the bullet." (Stevenson, Report from South African War.) The spine is seriously injured in proportion as the cord suffers. Aside from the cases in which the cord lies in the track of the bullet and is partially or completely divided transversely (Fig. 118), there are those cases in which there is no anatomical lesion of the cord, per- haps nothing more than perforation of a vertebra, yet the functions of . the cord are markedly depressed. This is "concussion" of the cord, ..I NSHOT FRACTURE OF SKI II 13 1 which Makins (Surgical Experiences in South Africa) describes in detail. The degree of concussion, and therefore the degree <>f functional depression, depends dire< lly upon the velocity of the ball. In slight spinal concussion, the symptoms consisl in loss of cuta- neous sensibility, motor paralysis, and vesical and rectal incompetence, persisting for a few hours or even two or three davs. PlG. 93. Ivxu-nsivcly comminuted gunshot fracture of the skull. (.SVnii after von Hcrgmann.) Recovery begins with return of sensation, often modified, followed later by return of motor activity. "Severe concussion, contusion or medullary hemorrhage, may be considered as lesions of equal degree as to severity, bad prognosis, and unsuitability for active interference; all characterized by the same- essential phenomena, viz.: symmetrica] abolition of sensation and motility, absence of any sign of irritation in the paralyzed area, and I32 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. loss of patellar reflex. These severe injuries are all accompanied by profound shock. The patient lies still, with eyes closed, great pallor of surface, the sensorium benumbed, the pulse small and irregular, respiration shallow" (Makins). In addition to these lesions, there are such as arise from compression, either of bone or from a lodged bullet. But, as Makins says, it may be assumed that a bullet injuring the vertebra sufficiently to displace bone, has, at the same time, produced grave lesions of the cord. If the pressure is due to the bullet, it argues that its velocity was low and that there may be no serious lesion of the cord and that the symp- toms are those of compression alone. Compression due to extra-dural hemorrhage can rarely produce serious symptoms. The chief surgeon of the Russian Army in the Manchurian cam- paign confirms the notion previously held as to the great gravity of wounds of the spine. The thorax may or may not be penetrated by the impact of a bullet, though penetration, of course, is the rule, and these wounds consti- tute a large part of the casualties of battle. The non-penetrating wounds present no features of especial interest. The skin and muscles may be injured in various degrees between simple perforation and serious laceration. The clavicle and scapula may be fractured; the axillary space may be involved, with serious results. The penetrating wounds cross the thorax in every direction, trans- versely, longitudinally, and obliquely. Those which traverse the thorax longitudinally, and are received while firing or advancing in the prone position, are noteworthy in that the abdominal cavity is usually also involved. The abdominal cavity is also likely to be penetrated when the base of the thorax is crossed. If a rib is involved, the bone injury is usually limited, and these fractures are considered of importance only when the intercostal ar- tery is wounded. In many of these fractures from the army bullet, the ordinary symptoms are absent, either because of the localized char- acter of the injury and absence of contusion of the soft parts, or be- cause the fragmentation in the track of the bullet is so complete as to preclude crepitus. The lungs, almost certain to be involved in perforating wounds of WOUNDS OP THE EEART. 133 the chest, escape with remarkably slight damage, owing to their elasticity. "In point of fact, there is no reason why a perforation by a small- caliber bullet should be much more feared than a puncture by an ex- ploring trocar, and the danger of the two wounds is possibly very nearly the same" (Makins). Those which pass near the root of the lungs are very likely to involve the great vessels, followed by rapid and fatal internal hemorrhage. Certain symptoms manifest themselves in most cases of lung injury in some degree. Shock, if it exists at all, is not usually serious and arises rather from the injury to the chest wall; nor are pain and dysp- nea prominent. Colonel Havard, U. S. Military Attache, with the Manchurian Army, instances cases where soldiers walked twelve to eighteen miles after being shot through the lungs. Hemoptysis is fairly constant, but not persistent longer than two or three days. Cough is seldom troublesome and pneumothorax is rare. Hemothorax is very frequent, but in the great majority of cases is due to hemorrhage from the chest walls — to the intercostals rather than to the lung injury (Makins). The symptoms of a hemothorax reach their full height on the third or fourth day. The pain is severe, the pulse and temperature rise, dyspnea is prominent, respiratory movement on the affected side is annulled, and there are the physical signs of fluid in the pleura. The course of the temperature is a matter of concern, for the fever suggests empyema. It seems always to rise pari passu with the in- crease of blood in the pleural cavity, often declining after the third or fourth day, always falling after a paracentesis and rising anew with fresh at i ess of pleural hemorrhage. On the other hand, the fever of infection arises later, persists, or gradually mounts higher. Perforating woundi of the heart in warfare Makin regards as cer- tainly fatal, believing that the cause of death is not hemorrhage, but sudden stoppage of the heart action. Semi believes that death usually occurs from compression of the heart, due to hemorrhage within the pericardium. In those cases where, from the anatomical features, the heart would seem to be in- J 34 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. volved and yet presents no symptoms of injury, the inference must be that it escaped, owing to change in position and size incident to contraction. Colonel Havard (Journal Ass'n Mil. Surg.) writes of the Japanese Fig. 93. — Perforating wounds of small intestine. A, entry. B, exit. Note slit-like character and eversion of mucous membrane; localized ecchymosis more abundant around exit aperture. (Makins, from St. Thomas Hospital Museum.) bullet, that it has been known to pass through the heart without fatal effect. Penetrating wounds of the abdomen are seldom simple in character, for it only rarely happens that a single viscus is involved. The one symptom which, if it occurs as all, is common to wounds of all abdom- PENETRATING WOUNDS <>K Till ABDOMEN. 135 inal organs, is peritonitis. The sources of hemorrhage are numerous. The degree of injury to every organ decreases with increased range. The small intestine is naturally the structure mosl frequently wounded and, of course, its perforations are multiple (Fig. 93). Pain, collapse, vomiting, and peritonitis are nearly always present, although present also in wounds of the stomach and large intestine. The peritonitis is more widespread in the case of the small intestine than in the case of the stomach and large intestine, because of the greater activity and motility of the small intestine. Vomiting of blood may he taken to indicate perforation of the stomach. The stomach and intestines escape "explosive" effects in proportion as they are empty at the time of injury. The bladder, when wounded, may present two openings, both may be extra-peritoneal, both may be intra-peritoncal, or one may be intra- and the other extra-peritoneal. An extra-peritoneal wound bleeds the more profusely; an intra-perit- oneal wound permits the escape of urine into the peritoneal cavity. Hematuria, or suppressed urination with an empty bladder, points to the character of the injury. The liver is likely to be simply perforated or notched, though at close range "explosive" effects are observed. The chief result is hemorrhage and, in some cases, an escape of bile, due to injury to the gall-bladder or the bile ducts. The spleen, if merely perforated, gives rise to hemorrhage, usually insignificant, unless its main vessels are involved. The kidneys give rise to either extra- or intra-peritoneal hemorrhage, which is not serious unless the perforation involves the hilum. Shock IS nearly always present as well as hematuria and frequent urination. The pancreas: there is no way by which injury to the pancreas may be diagnosed. It may be merely inferred from the course of the bullet. It is so situated that it cannot be reached by a bullet without injury to other organs more likely to give due notice o!" their affront. PROGNOSIS AND TREATMENT. Flesh wounds, uncomplicated, heal without difficulty. On the field of battle the first-aid dressing is applied, and in the simpler cases 136 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. need not be disturbed. Ordinarily it will need to be changed at the field hospital. The wound is to be regarded as an aseptic one, unless the contrary is demonstrated, and treated as such. Soap and water as a means of sterilizing the skin cannot be so gener- ally used as in civil practice, on account of the difficulty of supplying sterile water in the midst of a campaign, so that antiseptic solutions must often suffice. Tr. iodine is the most convenient. If the bullet has lodged, under no circumstances is it to be probed for; although if its location is superficial, it may be removed at the time of the first dressing. The aim of the dressing is to secure antiseptic occlusion, and, as much as possible, immobilization. TREATMENT OF GUNSHOT FRACTURES. The treatment of gunshot fractures of the extremities varies in de- tail, depending upon the character of the injury to the bone and to the soft parts. Three clinical varieties may be recognized: simple per- forating fracture; extensive comminution with moderate injury to the soft parts; and extensive comminution with great laceration and de- struction of soft parts. (a) The treatment of simple perforating fracture is exceedingly simple, — is, in fact, nothing but the treatment of the skin wound, viz. : aseptic occlusion and immobilization. The result is invariably good, provided infection is kept out of the wound. (b) By moderate injury to the soft parts is meant more or less en- larged wounds of entrance and exit, without extensive laceration. In such a case, it is the opinion of most authorities, that conservatism will give the best results. The skin in the region of the wound is sterilized and the wound also, if obviously infected, although it is usually sufficient to cleanse the skin — nothing more — and apply an antiseptic dressing, and immobilize. A variety of splints are available for the fixation. "Immobilization is a more difficult problem. In practised hands, plaster-of-Paris splints answer most requirements, except in the case of the thigh ; but the splints take time to apply and also to set firmly, and, TREATMENT OF <;i NSHOT WOUNDS. 137 as something needing frequenl removal, are ool altogether suitable for 6eld hospital work. Of all the Splints I saw in use, I think the Fig. 94. — Dutch cane field emergency splint for lower extremity, {Makins!) best were wire splints and the Dutch cane folding splints (Figs. 94, 95) for the thigh and Leg; wire gauze splints with steel margins or strips of ordinary card board applied with some variety of adhesive bandage i38 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. for the arm and forearm; and plain wooden splints of various lengths for any situation." (Makins, Surgical Experiences in South Africa.) Senn says, referring to the Spanish-American war, that it is a source of regret that fixation of the fractured limbs by plaster-of-Paris splints was not more generally practised. Owing to the want of reliable Fig. 95. — Cane splint for upper extremity. (Makins.) plaster of Paris, we had to resort to various kinds of splints and single- and double-inclined planes. In some cases extension will also be required. Transportation is to be avoided as much as possible, for the reason that it always aggra- vates the difficulties of keeping the wound sterile. There is no advan- I Kl \ 1 M 1 \ I' u| ,,( NSIHil I \i \< I I K IS. 139 age which transportation will situ re which will offset the advantage of an aseptic wound. (c) The third class of cases, those with extensive comminution and treat destruction of the soft parts, always raises the question of amputa- tion. The question of viability hinges upon the blood supply, and if it is determined definitely that it is cut off, immediate amputation is indicated. On the other hand, if the blood supply is yet intact, however much the bone may be shattered, it is advised to sterilize the wound, get the fragments in as good position as possible, and dress antiseptically and immobilize as before. In any case of doubt either as to repair or in- fection, this conservatism is proper. Later a line of demarcation or a dangerous sepsis may call for am- putation; on the other hand, the suspected tissues may heal without interruption. If infection occurs, osteomyelitis may arise and a fatal issue is likely in such a case. Senn sums up in this manner the modern treatment of recent gun- shot fractures: 1 . No probing of the wound. 2. No primary debridement. 3. Early efficient first-aid dressing. 4. Immobilization of fracture, preferably by plaster splints. 5. Immobilization combined with extension, if there is a tendency to undue shortening. 6. First-aid dressing must not be removed, unless this becomes necessary by the appearance of local or general symptoms that indicate the existence of wound infection. Each of the bones of the extremities presents a few special features, which may be hurriedly noted. The humerus is quite frequently wounded. The most characteristic Complication is musculo-spiral paralysis, either immediate or remote. As a rule, perforation of the upper end gives little trouble to the joint. The ulna and radius are usually injured separately. The ulna, on account of its superficial location, is often the seat of explosive exit wounds. This is also true of the lower end of the radius. 140 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. The phalanges suffer much, the tendons are lacerated and acquire adhesions, or the fingers may be completely carried away. With respect to the treatment, the perforating wounds of the humerus are cleansed and occluded. The comminuted wound is wiped clean of debris, an ample dressing applied, and the arm immobilized with light splints. Pasteboard splints are as good as any, applied wet, molded into shape, and fixed with adhesive strips. Th.e femur is quite often wounded and is a fertile source of mortality. If! s M* * ■** &t & Fig. 96. — Hodgen splint for fractured thigh. (Moullin.) There is a tendency to great shattering of the shaft, although, owing to its deep location, the wound of exit is rarely "explosive." Trans- verse fracture is rare. Perforation of the lower extremity is common. These fractures are nearly always accompanied by shock, both con- stitutional and local. As a result of local shock, shortening is often delayed, only to be quite marked when the muscles regain their tone. The prognosis is extremely bad in the case of the upper third, but better for the middle and lower third. Punctured wounds and com- minuted fracture with small skin wounds are treated by aseptic occlu- sion and immobilization. Tk! \l\ll INT 01 Gl NSHOT WOUNDS OP JOINTS. 141 Comminuted fracture with Large wound of exit requires a more formal cleansing, first of the skin and then of the wound, with removal of the fragments of hone which will stand no chance of reunion. The wound is not sutured and drainage is usually unnecessary. If trans- portation is necessary, plaster of Paris is the safest dressing. For the field hospital. Makins recommends some adaptation of the Hodgen splint as the best, most practical, and efficient {Fig. 96). Uncontrollable hemorrhage, great injury to the soft parts, or grave infection calls for amputation; but this is very rare, as the result of these wounds. The tibia and fibula present condi- tions of special importance. The soft parts are often severely injured, the vessels are implicated and, in the case of the ends of these bones, the joints are involved. Suppuration is common, followed by secondary hemorrhage and purulent arthritis (Fig- 97)- Conservative treatment is the best rule — asepsis, careful dressing, im- mobilization. In ordinary cases, any form of splint will do, but the plaster of Paris is probably the most satisfactory. The fool is important in respect to these injuries, for not only arc several bones involved, but also several joints. Infection, unfortu- nately, is not uncommon. The first dressing must insure immobilization in a good position. Fig. 97. Perforation of lower third of tibia. (Maki)is.) TREATMENT OF GUNSHOT WOUNDS OF THE JOINTS. Makins says: "We had merely to do our first dressings with (are. fix the joint for a short time, and be careful to commence passive motion as soon as the wound was properly healed, to obtain, in the great majority of cases, perfect results." 142 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. Infection is the chief danger. If suppuration occurs, an immediate arthrotomy is indicated, except in case there is much comminution and disorganization, when amputation will be the safer measure. The shoulder- joint may be involved directly or by fissure from the shaft. Perforating wounds furnish an excellent prognosis. Aseptic occlusion and immobilization usually effect a cure in three or four weeks. In the severer cases, cleanse thoroughly, ligate bleeding vessels, restore the parts as nearly as possible, pack lightly with gauze, cover amply, and infection will usually be avoided. The elbow may be injured along with the humerus and ulna; the prognosis is worse when the humerus is involved. The olecranon may be perforated without injury to the joint. Anchylosis is frequent, but even if suppuration occurs, a good joint may be obtained. The joint is immobilized in the position of flexion. The hip-joint seems not to be very frequently wounded, but the prog- nosis is bad, both on account of infection and complications, such as wounds of the bladder, rectum, great nerves, etc. Anchylosis and shortening in an abnormal position must be expected. Greatly lacerated wounds call for amputation; the moderately severe, for conservative treatment. The knee-joint is very frequently wounded, and the damage is always serious; any or all of the component structures may be injured. Per- foration of the joint without injury to the articular surfaces is a possi- bility. Hemorrhage into the joint is a constant feature. This hemar- throsis disappears in about a month in the favorable cases. Under conservative and expectant treatment, the results are sur- prisingly good. On the battle field, the wound is covered with a first- aid dressing, and some sort of splint applied. At the dressing station or field hospital, the dressings may be removed and further cleansing applied if necessary, and the limb immobilized in extension. As soon as the flesh wound has healed, passive motion is to be begun. If sup- puration occurs, arthrotomy must be done without delay. The ankle is usually involved along with several bones and joints, either directly or by Assuring. The degree of comminution is variable. On account of the foot coverings, these wounds are nearly always badly infected and phlegmons are frequent. iki\i\ti\i OF GUNSHOT WOUNDS 0] mi SKULL. [43 For these reasons secondary amputations arc frequent, 1 >u t the treal niciii must be conservative. Immobilize the foot at a right angle and he on guard for suppuration. I Kl A TMENT ()!•' GUNSHOT WOUNDS OF THE SKULL AND MRAIN. Perforating wounds of the skull will always he a certain source of mortality. The fatalities increase as the range shortens and as the Rise is approached (especially the hase in the middle and posterior fossa), due to destruction of the automatic centers <>r to their depression following concussion, hemorrhage, or intra-cranial edema. The most recoveries follow injury to the frontal lobes and the occipital lobes, although blindness may result from the latter class of injuries. Primary union of the scalp wound is an element in favorable prog- nosis, since by this means infection is often shut out. First aid on the battle field will look to the hemorrhage and the use of the first-aid dressing, which should aim to include both the wound of entrance and exit. If the visible hemorrhage is dangerous, do not pack the wound, for that will only cause compression. A few strips of sterile gauze, loosely placed in the wound, will favor both hemostasis and antisepsis. At the dressing station or, better still, at the field hospital if the Symptoms are not too urgent, a craniectomy must be done. All surgeons experienced in recent wars agree on the necessity of exploring every such wound as soon as possible. Shave and cleanse the scalp and then cleanse the wound. Raise a tlap with the base toward the blood supply and with the entrance bullet hole in the center. Enlarge the wound in the skull sufficiently to introduce a finger and determine the presence or absence of frag- ments within the cavity. Enlarge the wound as necessary, to clear the brain of debris. All splinters must be removed. The brain pulp and clots are to be wiped out with sterile gauze and the wound closed with only such drainage as the original wound of entry will afford. (See Urgent Craniectomy.) The subsequent treatment requires the patient to be kept as quiet as possible, his diet limited and bowels kept open. 144 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. If sepsis occurs, there must be no hesitation in reopening the wound. "Such cases of sepsis needed secondary exploration, and the won- derful success of this operation was perhaps one of the most striking experiences of the surgery in general." (Makins, Surgical Experiences in South Africa.) TREATMENT OF GUNSHOT WOUNDS OF THE FACE. The chief dangers in gunshot wounds of the face are hemorrhage and interference with respiration. These wounds are also much predisposed to infection. The eye, the fifth and seventh nerves are most likely to be involved. If hemorrhage cannot be controlled by ordinary means, the facial, the temporal, or even the external carotid arteries may need to be ligated. Careful cleansing and packing with iodoform gauze secure excellent results. TREATMENT OF WOUNDS OF THE NECK. These wounds are always dangerous, and yet in no region does the unexpected more frequently happen in the passage of a bullet. The fact of hair-breadth escape of important structures is explainable only by the small size of the army bullet and the mobility of the structures. The commonest form is the transverse or oblique track. Such wounds as are not immediately fatal are likely to permit recovery. If sepsis occurs, it usually has its origin in the air passages or esophagus. Injuries to the trachea commonly give rise to broncho-pneumonia, hemoptysis, or emphysema. Many patients with injury of the esophagus will die of sepsis, with perhaps a gangrenous condition of the esophagus. Such wounds of the large vessels as do not produce immediate death give rise to many instances of arterio-venous aneurysm. The spinal nerves or the pneumogastric may be injured. If the recurrent laryngeal is divided, hoarseness, aphonia, laryngeal cough and occasional vomiting will be the result. Stevenson reports cases with injury to the cervical sympathetic, in which the most prominent symptoms were suppression of sweating, myosis, and pseudo-ptosis rREATMENT OF GUNSHOT WOUNDS 01 mi ABDOMEN. 145 on the injured side. As a rule, no special treatment aside from ami gepsis is required. Tracheotomy may Ik- called for; and it* the spine is fr.u lured, immobilization will he necessary. tk 1 \1\11 \i op \\ ON I III l.\ ITU FIELD. IS' The ideal fixation splint in such cases would be the plaster-of-Paris splint, hut this method of fixation is entirely out of the question on the firing line and must be reserved for tin- dressing station or field hospital. This first-aid fixation must he extemporized. The sound leg may serve as a splint for the wounded one which is held in place Fie. 102. — Forced flexion of forearm in arresting hemorrhage from the brachial artery opposite the elbow-joint or any of its branches below this point. (Scun.) by belt, gunstrap, handkerchief, etc. Tin- rifle, bayonet, and saber are always available as splints (Figs. 105, 106, 107). A fractured humerus may be splinted to the side of the body. A well-padded bayonet will meet the indications in fracture of the fore arm. The wire netting cut in the shape corresponding to the fixation of the different fractures of the limbs should be carried to the front by 152 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. the sanitary corps in sufficient quantities to meet the expected require- ment. Splints made of this material, well padded, will answer an ex- cellent purpose' as first-aid fixation, as they can be molded into shape and can be used subsequently to strengthen the plaster bandage at the dressing station. (4) The first-dressing station is the most important place for skilled aid. This primary depot of the wounded should be established in a sheltered place as near as possible to the firing line, protected as much as possible against the fire of the enemy. . (5) Probing of recent gunshot wounds must be prohibited by the most stringent rules. Under no circumstances should attempts be Fig. 103. -Genuflexion in the'treatment of hemorrhage from the popliteal artery and its branches. (Senn.) made to remove bullets until this can be done under strict aseptic precautions in the hospital, and then only in those cases in which such operation is clearly indicated and the exact location of the bullet has been determined by palpation through the intact skin or by the use of the "X-ray." (6) The surgeon's most important duties at the first-dressing station are: (a) Inspection of first-aid dressing. If it is in its proper place, label to this effect that it may not be unnecessarily removed at the hospital. If defective, it must be renewed or more securely fastened. (b). Application of plaster splints to the fractured limbs; the wire- netting splints are cut into strips and incorporated in the plaster-of- Paris dressing. THK FIRST l'kl SSINC STA'I 1"V 153 (c) Emergency Operations. The operative treatment of gun.-liot wounds must be limited to the most urgent cases. The definitive arrest of hemorrhage — of dangerous external or internal hemorrhage — stands pre eminent in the list of emergency operations. Iodized cat- gut is the proper ligature material for field servii e. Intra-cranial and intra-thoracic hemorrhage should not he interfered with outside of a well-equipped hospital. Dangerous intra-abdominal hemorrhage calls for prompt operative interference. Abdom- inal section under such circumstances, in a tent, may contribute much in lessening the mortality from hemorrhage by a resort to ligature, suture, or aseptic tamponade. By pursuing this aggressive course, some lives .may be saved by prompt interference which would be lost by the let-alone treat- ment. Wounds of the larynx and trachea which have given rise to respiratory difficul- ties, either from emphysema or hemorrhage, call for an immediate tracheotomy. Resection, as a primary operation for pene- trating gunshot wounds of the joints, is obsolete. Amputation must be reserved for cases in which a limb has become mangled by a can- non ball or fragment of shell or in which the fracture is complicated by division of the principal blood vessels and nerves. Laparotomy in the field, for gunshot wounds of the abdomen, with a view of finding and suturing perforations of the gastro-intestinal canal, has not yielded in practice the anticipated results, and hence must be restricted to exceptional cases. Clinical experience has shown that in a fair percentage of cases penetrating wounds at and above the level of the umbilicus, inflicted in the antero-posteriiir direction, do not implicate the gastro-intestinal canal, and in such cases conservative treatment yields better results Fig. 104. — Temporary treatment of penetrating wound of chest by antiseptic tamponade and immobiliEa- tion by circular compression. (5<.->iu.) 154 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. than operative. On the other hand, in wounds involving the small intestine area, more especially when the bullet takes an oblique or Fig. 106. — Gun splint. (Senn.) Fig. 107. — Stick and blanket splint. (Senn.) transverse course, we may confidently expect to find from three to fifteen perforations, and it is this class of cases in which immediate laparotomy offers the only chance of saving life. (7) The surgeon's field case should be light, compact, and the in- struments wrapped in a canvas roll, so that instruments and envelope can be quickly sterilized in boiling soda solution. CHAPTER XII. GUNSHOT WOUNDS IN CIVIL PRACTICE. The projectiles of the ordinary fire-arms of civil life differ from those used in warfare, in that they are composed of soft lead, are easily deformed, are of slight initial velocity, and are usually fired at short range. The revolver and pistol, flobert and shot-gun produce the wounds most frequently seen. Of the shot-gun it may he said that the wounds which it produces arc very likely to be either greatly destructive or comparatively harm- less. At close range the charge, acting as a single body, lacerates and shreds the tissues; at long range a number of small perforations are math'. The dangerous wounds, then, have all the characteristics of lacera- ti >ns and demand the treatment of lacerated wounds in general. It must always be assumed that foreign bodies have been carried into the tissues and that these wounds are therefore infected. It is the bullet wound of the revolver, however, which it is most practical to consider. To a limited extent, its pathology is similar to that of the army bullet, and it is unnecessary to state again the cffci t of a bullet upon the various tissues. It is expedient to consider at once, with especial reference to treatment, the bullet wounds of certain localities. WOUNDS OF THE HEAD. The region of the brain is usually wounded in attempts at suicide, and it is the right temple or forehead which is mosl frequently -elected. The vertex, postero-lateral, and occipital regions are seldom wounded and only then as a result of accident or assault. As medico-legal questions are often involved in these cases, it is a '55 156 GUNSHOT WOUNDS IN CIVIL PRACTICE. wise practice to make careful and systematic examinations. Learn as much as possible about the character of the fire-arm, the nature of the projectile, the position of the patient at the time of injury. Ex- amine the ears and nose for blood, inspect the mouth, examine the head for a wound of exit, or see if the bullet can be located beneath the scalp. Next examine the wound itself, but not until the field and wound have been sterilized. Begin the disinfection by shaving the scalp about the wound. Wash with soap and water and then with alcohol or bichloride. Enlarge the wound by a cross incision, if necessary, and wipe out with sterile gauze, removing all forms of foreign bodies. Finally examine the skull. If you find a mere depression without penetration, it is sufficient to pack the opening with sterile gauze and bandage. Later the bullet may be located with the "X-ray" and removed, if it becomes troublesome. If the bullet is visible and re- movable without much difficulty, it is better to take it out at once. If the ball has penetrated the entire thickness of the skull and lodged within the cavity, the size of the orifice will be some index as to its probable depth; if the orifice is large, it argues for close range and deep lodgment. If the opening is small, comparatively speaking, it is likely that the ball has not penetrated deeply. Note the direction of the fissures. If the base is involved the prognosis is always serious. Note the condition of the dura: it may be lacerated and the brain tissues may exude. If such is the case, the bullet is obviously in the brain, but its exact location must remain a matter of doubt. It is not ex- pedient to explore for it; it is not even advisable to attempt to disinfect the cerebral wound. It is sufficient to remove all fragments of bone and debris and wipe the wound dry with sterile gauze. On these two points, however, there may be some difference of opinion. The American Text-book of Surgery insists upon the value of disinfection of the entire cerebral track of the bullet and of through-and-through drainage under certain circumstances; also upon the advisability of attempting to locate the bullet by the aluminum gravity probe, and to remove it. Still it may be said that the general practitioner has done his duty and done it well if he has cleansed the skull and dural wounds and controlled the GUNSHOT WOUNDS OF THE SPINK. 157 lemorrhage. (For further details of treatments, see Urgent Craniei tomy.) GUNSHOT WOUNDS OF THE SPINE. A man was brought into the City Hospital shot in the back with a H revolver. Except that he was paralyzed from his hips down and without control of his bladder and bowels, his condition was good. This positive primary paralysis pointed to grave injury to the cord. At the operation it was found that the bullet had smashed into the spinal canal and there lodged, completely obliterating in its course Fig. 108. — Complete division of spinal cord; bullet retained. a considerable segment of the spinal cord. Suture of the cord was out of the question, so the poor fellow — a man of great vitality — was condemned to linger in living death for many weeks. Happily not all cases of gunshot wound involving the cord are be- yond relief. Whenever the symptoms point to severe injury of the cord — whenever there are notable disturbances of sensation and motion — and improvement fails to take place shortly, it is bad practice to delay. It is indicated to cut down upon the spine, remove a spinous 158 GUNSHOT WOUNDS IN CIVIL PRACTICE. process, trephine into the canal, and cautiously cut away the arches. It may develop that the symptoms are due merely to pressure of frag- ments of bone which are to be removed. If after gunshot wounds of the spine there are no cord symptoms or if they are mild and tend to improve, it is better not to operate. The smaller the projectile the less the likelihood that operation will be required. Without some positive indication in the cord, therefore, aseptic occlusion is the treatment to pursue. Probing is all the more perilous because infection may be carried directly to the spinal meninges. GUNSHOT WOUNDS OF THE FACE. These may result from shots into the mouth with suicidal intent. Small bullets may remain imbedded in the hard palate or posterior pharyngeal wall. The instinctive tilting of the head backward gives the bullet a characteristic course through the hard palate or the root of the nose, and, owing to the involvement of the base of the brain, such wounds are deadly, except with quite small fire-arms. In other cases there are grave comminuted fractures of either jaw. Sometimes there are powder burns and disintegrations suggestive of explosions. The chief dangers in cases not immediately fatal are from inter- ference with respiration and from hemorrhage. These wounds are also predisposed to infection, and as a result of sepsis secondary hemorrhage is not infrequent. Paralysis of the facial nerve may occur. The salivary glands or their ducts may be injured and give rise to a troublesome dribbling of saliva. Marked interference with respira- tion may call for immediate tracheotomy. Arteries may need to be ligated and ligation may be difficult owing to their relation to the bones. The oozing, always marked, is to be controlled by pressure. The natural contour is to be restored as much as possible after a thorough cleansing, and the wound cavities packed with iodoform gauze. GUNSHOT WOUNDS OF THE THORAX. Gunshot wounds of the thorax do not differ from other wounds in this region except in their graver prognosis. (See page 105, Wounds of BULLET WOUNDS OF THE ABDOMEN. 150. Thorax, and page 132, Military Practice.) Sucb as involve the great lessels ai the root of the Lungs and most of those which involve the heart are not even of interest from a standpoint of treatment because so rapidly fatal as to preclude intervention. Such wounds as are not obviously fatal, whet her they involve the pleura and lungs or the pericardium and heart, present three sources of ■anger: hemorrhage, asphyxia, and infection. These are the three conditions which determine the line of treatment, and which have ■ready been discussed under the head of Wounds of the Thorax. Aside from these symptoms of urgency, the treatment must be con- servative and expectant — quite different from gunshot wounds of the abdomen. Begin by covering the wound with an aseptic compress and then carefully disinfect the field. Finally cleanse the wound itself and dress antiseptically. Avoid probing or other explorations. Transportation must also be avoided, for there can be no doubt that it is often disastrous. In the country, where ambulances are out of the question, the nearest shelter is the best. If it is evident, finally, that the hemorrhage is increasing, as indicate! 1 by the symptoms and physical signs, conservatism is no longer rational and the wounded lung should be exposed and the tear repaired. Kiitner, of Leipsic, proposes in the future when dealing with these wounds to evacuate the extravasated blood if it is not promptly ab- sorbed, suturing the pleura without drainage. In the case of an al- ready collapsed lung it does not appear that there would be increased danger operating without the aid of a Sauerbruch cabinet. BULFFT WOl/XDS OF THF ABDOMFN. With reference to prognosis and treatment, these wounds fall into three clinical groups: those which are obviously penetrating and ac- companied by grave visceral lesions; those which are doubtful both as to penetration and visceral injury; and those which are probably benign. (A) One concludes that a certain wound is grave no1 from observing the escape of gas and fecal matter or hemorrhage innn the wound, 160 GUNSHOT WOUNDS IN CIVIL PRACTICE. for these are too infrequent to be relied upon, but from the general condition, which alone is of sufficient significance. The pulse is small and rapid; the face is drawn and pale; the belly wall is distended and resistant to the least pressure; dullness of the iliac fossa and flanks develops and there may be vomiting of stomach contents or of blood. The persistence of these symptoms for the first two or three hours is sufficient to dispel any illusion of the more sanguine that the case is not dangerous. There is but one thing to do, operate as soon as possible. This is a principle so definitely established that the citation of a long list of eminent authorities is unnecessary: a rational doctrine that all may accept. There are contingencies of time and place, of septic environment which would insure that the operation itself would likely be fatal, but those conditions are very exceptional in civil practice with the doctor who has the "savoir-faire." An exceptional condition does not alter the principle, and he who does not act at once, must incur the reproach of having refused the wounded the best resource of safety. There is another consideration. One may not be called to see the case until after two or three days have elapsed and may then encounter one of two eventualities: one almost certain, the other unlikely. In the first, there are the signs of general peritonitis. Under these circumstances, again, the rule is to operate, though only as a forlorn hope. On the other hand, it may be that despite the apparent gravity of the wounds, the pulse is good, there is no vomiting, the abdomen is not tender, there has been a passage of flatus or a movement of the bowels. Although we know these appearances are often deceitful, that it may be only the lull which precedes the storm, yet we are perfectly justified, under these circumstances, in maintaining an "armed expectancy." Under such circumstances, control peristalsis with a little morphia, impose an absolute quiet and absence of food, and in the meantime have the patient under vigilant surveillance. Fysche reports a case of abdominal gunshot wound, which shows the value of drainage and which might be taken as an indication of the course to pursue in certain desperate cases, where, for example, the LAPAROTOMY FOR BULLET WOUNDS. l6l circumstances of time or place, the condition of the patient, or the isola- tion and lack of skill of the operator precluded a more rational and definite pro< edure. A boy of fourteen was shot through the abdomen at close range with a large-caliber revolver. The bullet entered just to the inside of the right anterior-superior spine. There were all the signs of shock and internal hemorrhage. The abdomen was opened with immediate es- cape of blood and fecal matter. The first portion of the small intestine examined revealed a perforating wound. This and two other wounds were repaired, but the boy's condition called for haste and a hurried examination developed seven more perforations of gut and mesentery along the six feet exposed. The abdominal incision was closed with through-and-through sutures with a large deeply placed drainage ,vick in the lower angle. He was freely stimulated and given large enemas of normal salt solution. The drainage was removed on the second day and from the opening there was a free fecal discharge. On the third day his bowels moved naturally. Thereafter the fistula closed rapidly and in a month he seemed quite well. (Montreal Med. Jour., May, 1909.) (B) The case is one of doubtful penetration and therefore doubtful visceral injury. you are called immediately. You find nothing more than a bullet wound in some part of the anterior abdominal wall. The pulse is good, the abdomen is neither rigid nor tender, and there is no other in- dication worth noting. Now, what are you to do? Wait several hours watching for some indication? Hut this is a dangerous formula, subject to various inter- pretations, for, as Lejars asks, what shall be regarded as the first "indication"- the weaker pulse, the tympanites, the altered fades? But these are the signs of beginning peritonitis. It is better, as Brown, of St. Louis, and many others have so defi- nitely determined, to answer the question resolutely in these terms: prepare at once to operate; determine whether the wound is a penetrat- ing one or not, ami if so, proceed with the laparotomy — provided, of bourse, that the situation is such that it can be done without very 1 62 GUNSHOT WOUNDS IN CIVIL PRACTICE. grave danger from the operation itself. It may develop that the operation is not necessary, but it will very much more frequently be- come evident that it is indispensable. Admit that these urgent laparotomies are difficult, that they strain every resource of emergency antisepsis and surgical skill, that the per- forations are often multiple, that one never knows just what he must meet. Admit that some recover from these wounds without operation, but are we authorized by that to expect in another case so fortunate a denouement ? Admit that the patient has several chances of recovery without operation perhaps, but let us remember we have no means of calculating such chances even in the more favorable cases, and cer- tainly the chance of an exceptional process cannot give more hope than an early, regulated, and aseptic intervention. It is prudence which commands operation. As Lejars says, this seems the wisest course: Prepare for a laparotomy. Begin by cleansing the field of operation and then the wound, which is enlarged, cutting from above downward, layer by layer. If the peritoneum is found uninjured, repair the in- cision carefully, first trimming the devitalized tissues away; under these circumstances, one may safely prognosticate a recovery. If you find the peritoneum perforated, slightly enlarge that wound also, that you may get some idea as to the conditions: a flow of blood, bile, intestinal contents, or urine may indicate what one may ex- pect. But the fact alone of perforation of the peritoneum is an indication to open the abdomen in the middle line — to do a median laparotomy. The median incision will be above or below the umbilicus, depending upon the level of the bullet wound (see Laparotomy for Traumatism) . (C) There are, finally, as. Lejars points out, certain bullet wounds which, even though penetrating, may be regarded as unlikely to have produced serious results. These are such as are produced by pistols in which the bullet is quite small and impelled by an insignificant charge of powder, so that its force is practically spent in traversing the abdominal wall. And even though the digestive tube should be wounded, the opening GUNSHOT WOUNDS 01 THE JOINTS. 163 is not large enough for the contents to escape, for the mucous membrane acts as a plug and repair quickly takes pla< e. In such a rase, there being no doubt as to the facts, it is perhaps wiser not to operate, but to treat by aseptic occlusion. Nevertheless it is the part of prudence, however sanguine of the outcome, to keep the case under close watch for some days. GUNSHOT WOUNDS OF THE JOINTS. The knee, which is the joint most frequently wounded, may serve as a type. Suppose it is wounded by the discharge of a fowling-piece, a not uncommon accident. The character of these wounds is variable. It may be that only a few shots at long range have penetrated the joint, or it may happen that the whole load has torn its way into the joint structure. But whatever the condition, no active intervention is called for if the case is seen at once. Cover the wound with sterile gauze, provide a temporary splint, and supervise the transportation. Once provided with shelter, proceed to carry out a methodical cleansing and examination. Cleanse the held first and then the wound itself. If the wound was received at long range and probably only a few shots have penetrated the joint cavity, the careful cleansing, antiseptic dressing, and subsequent immobilization will be all that is required to bring about an uninterrupted recovery without loss of function. If the wound was received at close range and the joint is freely pene- trated by the shot, which have carried in shreds of clothing and other foreign particles, the treatment is quite different. Suppost- the joint is swollen, dark blood oozes out, and the cavity is exposed through lacerated wounds: in such a case conservatism will not cure. Prepare to operate immediately. Open the joint and with hot normal salt solution freely Hush out the shot, fragments of bone and cartilage, Mood clots and other debris. Do not be sparing of time and patience. Trim away the lacerated tissues. If satisfied with the cleansing, suture the deeper layers over the joint SO as to close it completely, and drain only the superficial wound; otherwise, drain the 104 GUNSHOT WOUNDS IN CIVIL PRACTICE. joint cavity as well. Apply an antiseptic dressing and immobilize, and expect a good result. The situation is again different if the case has been treated first by the uninstructed. The wound is seen some time after injury and found covered with dirty cloths, or a handkerchief, the worse for usage, is stuffed into the wound. No covering at all is always better than any- thing less clean than a sterile dressing. The treatment is the same as before — in every way as rigorous and systematic — but there are not the same certainties by any means that it will head off sepsis. You cleanse, drain, immobilize, and watch. You watch for beginning infection, which for that matter may develop in the simpler cases if the cleansing is not complete. Fever, pain, swelling of the joint, all rapidly increasing, are the signs of beginning infection and suppuration and call for immediate action. It is in- dicated to open the joint and drain. (See page 423, Arthrotomy.) Bullet wounds produce similar lesions, although usually they are of the milder type. Hemarthrosis indicates injury to bone as well as soft parts. Sometimes these wounds occur with scarcely any injury to the joint structure, the bullet lodging in the epiphysis. In the milder cases, wherever the bullet may be, it is better merely to cleanse and immobilize, and at a later date, if necessary, the ball may be removed. If, however, the hemarthrosis is voluminous, it is better to open the joint at once and clean out the cavity and, by a happy chance, the bullet may be found and extracted. (See also gunshot wounds of joints in military practice, and compound dislocations.) GUNSHOT WOUND OF HAND. A pawnbroker, examining a revolver brought in for a loan and which was supposed not to be loaded, was shot through the hand. The 32 bullet passed between the heads of the third and fourth metacarpals, splintering the fourth in some degree. The tissues were powder- stained along the track of the bullet and the wound bled very freely. The wound of entrance in the palm was jagged; the wound of exit smooth. The wounds were cleansed and a slender forceps passed through the hand, a piece of gauze attached and pulled into place for through-and-through drainage by withdrawing the forceps. The Sli'i km h i \i WOUNDS FROM FOWLING-PIECE. [65 bleeding stopped, but later began again soaking the bandages. Syring- ing the wound with peroxide and packing with gauze served to check the bleeding for a few hours. This intermittent hemorrhage persisted for two days. The hand was soaked twice daily for a half hour in hot normal salt solution; the swelling ami pain rapidly subsided and after three or four days the wound began to heal without the least evidence of in- fection. The ring finger was stiff and painful for some time, but under massage and passive motion gradually regained its use. Injury to the tendons constitutes one of the chief complications of gunshot wounds of the hand. Free trimming away of the shattered tissues, free drainage and free use of hot normal salt solution seem best calculated to promote repair in this class of wounds. SU PERFICIAL WOUNDS FROM FOWLING-PIECE. A farm hand, charged with trespass, was brought to the county jail sorely wounded. Two charges of bird-shot had caught him on the fly and peppered his back, buttocks, and the posterior surfaces of thigh and calves. Evading his pursuers, aided by the darkness, he had reached his cabin exhausted and, without changing his bloody clothes, lay thus unattended for two days, when he was discovered and arrested. By this time infection had set in. His buttocks and calves, particu- larly, where the shot were thickest, were swollen and inflamed. Many of the shot had carried shreds of clothing into the tissue: each was a focus of suppuration; none had penetrated beyond the skin. The whole injured area was cleansed, first with soap and water, and then rubbed vigorously with peroxide of hydrogen; the more superficial of the shot were picked out, and finally the inflamed surfaces were smeared with Reclus' ointment and covered with sheets of gauze held in place by adhesive strips. The relief from pain was great. In three or four daily seances the shot were all picked out and the inflammation practi- cally gone. 166 GUNSHOT WOUNDS IN CIVIL PRACTICE. WOUNDS FROM TOY PISTOLS AND BLANK CARTRIDGES. Two things are noteworthy in connection with these wounds: first, the surprising power of penetration of cartridges supposed to be harm- less; and, second, the great danger of a tetanus infection. The "wad" may be buried put of sight in the tissues, it may entirely perforate the hand, or it may produce a superficial laceration. As a rule, the hemor- rhage is insignificant, which may in a measure account for the devel- opment of infection, since bleeding is nature's means of disinfection. These wounds often present the appearance of punctured wounds, which, more than others, are likely to furnish conditions favorable to the growth of the tetanus bacillus. It may be that the disposition of the wad is such that the wound is in a manner stopped up, so that oxygen cannot reach the recesses where the bacillus finds its lodgment. It is true that tetanus develops in only a small percentage of cases, but one can never foretell positively what such a wound may do. It is the duty of every doctor to warn his clientele of the danger of these "Fourth of July" injuries. Every case is to be treated as if lock-jaw is not merely a remote possibility, but a probability. Free cleansing and douching with peroxide of hydrogen is indicated. Luckett says (American Journal of Surgery, July, 1906): "These wounds should be freely incised, particularly if not seen on the first day of the injury, and thoroughly curetted with a small sharp spoon until all the small pieces of wad, the unburned grains of powder, and all the dirt have been removed. If the wad has entered a metacarpal space a counter-incision must be made for through-and-through drainage. Having cleaned the wound as thoroughly as can be done mechanically, we now resort to chemicals and irrigate with some mild antiseptic. After next drying the wound thoroughly, the entire cavity should be swabbed out with one of the following, named in order of choice: " 1. Pure carbolic acid followed by alcohol. "2. Twenty per cent, tincture of iodine (made by dissolving iodine crystals, 20 parts, in ether and alcohol, each 50 parts). WOUNDS FROM Toy PISTOLS. 107 "3. Plain tincture iodine. "The wound should now be packed with moist iodoform gauze. A wet dressing is then applied, to he changed daily. Permission should he obtained for a prophylactic injection of antitetanir serum. Ten CC. are intra-musi ularly injected in the buttocks or thigh, under thorough antiseptic precautions." Antitetanic powder may be applied to the wound, as advised by Calmette. Experiments conducted by Joseph McFarland, of Phila- delphia, corroborate Calmette's statements as to the prophylactic value of this substance. By its use McFarland was able to protect from in- fe< tion animals which he had inoculated with the tetanus bacillus. CHAPTER XIII. FRACTURES. Definitions. — A fracture is a solution of the continuity of bone due to traumatism. A simple fracture has a single line of solution and there is no lesion of the soft parts. A multiple fracture has more than one line of solution of continuity in the same bone or several bones. A comminuted fracture has so many lines of solution running into each other that the bone is in fragments or splinters. A complete fracture involves the whole thickness of the bone. It may be transverse, longitudinal, oblique, dentate or comminuted. In an incomplete fracture, the line of solution does not involve the whole thickness or extent of the bone. It may be a fissure, "a green stick," a depression or a separation of an apophysis. A subcutaneous fracture has no communication with the surface. An open or compound fracture has a communication with the surface, has an accompanying solution of continuity of the skin and the sub- jacent soft parts. A spontaneous fracture is produced by an insignificant traumatism and is usually pathological, due to disease of the bone. An ununited fracture is one in which bony union has not occurred at the usual time. Gunshot fractures are those produced by projectiles (see Gunshot Wounds). The symptoms, the diagnosis, the prognosis and treatment vary with the region involved, and with respect to these factors fractures may be divided as follows: Fractures of the skull. Fractures of the face. Fractures of the spine. 168 DIAGNOSIS 01 l R A' i I B I \l nil BASE. 169 Fra< hires of the thorax. I r.h lun-s of the extremities. FRACTURES OF THE SKULL. Fractures of the skull are important practically only from the point of view of their complications, which number three; infection, hemor- rhage, and injury to the brain. In a given case, one or all of these complications are possibilities, Although for the development of each, certain combinations of circum- stances are peculiarly favorable. With respect to these variations, fractures of the skull are of two classes: fracture of the base and fracture of the vault. Each has its special symptomatology and prognosis, though the one may merge into the other and the clinical picture be more or less blurred. Either may be fissured, fragmented, or compound, with or without depression. /;/ cither the immediate gravity depends upon the nature and extent of the injury to the brain, and fractures of the base are the more serious, merely because the more important areas of the brain are there. With regard to the remoter consequences also, fractures of the base are less favorable; hemorrhage and its resultant compilations are more to be feared; and infection is a more certain eventuality owing to the communications opened up between the cranial cavity on the one side and the ear, the nose, or the pharyngeal region on the other. The symptoms in either kind of fracture are such as arise from con- cussion, compression, or laceration of the brain and are general or focal, that is to say, emanating from certain cerebral areas. FRACTURES OF THE BASE. Fractures of the base of the skull are more frequently indirect, the force being transmitted through the spinal column from some part of the vault or the ramus of the jaw; occasionally direct by a thrust through the mouth, a blow on the root of the nose, or upon the mastoid process. Any <>r all of the fossae may be involved. Fracture through the mid- dle fossa is most frequent, and the most serious is fracture through the 170 FRACTURES. posterior fossa. These fractures are usually linear because the force is indirect and because there is only one determinable table instead of two, as in the vault. These fractures are nearly always compound, which adds to the gravity of the prognosis. The external meatus, the nasal cavities and the naso-pharynx are all prolific sources of meningeal infection. The diagnosis is usually by inference, often impossible. There are certain symptoms always suggestive of fracture at the base, but not to be relied upon exclusively. Ecchymosis in the tissues about the orbit, or hemorrhage into the sclerotic, appearing first some little time after the injury, and gradually progressive — fracture through the anterior fossa suggests itself. Per- sistent bleeding from the nose following head injury must be given due consideration. Bleeding from the external meatus, copious and per- sistent, suggests fracture through the middle fossa. Late ecchymosis over the mastoid or into the tissues of the back of the neck suggests fracture through the posterior fossa. The discoloration follows the posterior auricular artery. However, these hemorrhages must not be mistaken for local rupture of mucous membrane or other soft parts and their absence does not necessarily mean absence of fracture. The bleeding, if intra-cranial, may come from rupture of the middle meningeal, or the internal carotid, or the sinuses. Instead of the bleed- ing, or accompanying it, there may be escape of cerebrospinal fluid. Its presence is pathognomonic of fracture of the skull, and it must be distinguished from ordinary serum and the fluid of the middle ear by these characteristics: the flow begins at once and continues for several hours; the quantity is considerable, sometimes a tablespoonful in fifteen to twenty minutes; the flow is temporarily increased by the increase of intra-cranial pressure, sneezing, coughing, and vomiting; alkaline in reaction; contains only a trace of albumin and is rich in sodium chloride. Useful in definite diagnosis are the paralyses of the cranial nerves. Recall their origin, course, and functions. The facial, optic, and tri- facial nerves are especially likely to be involved. For example, the optic nerve will be involved if there is a fissure of the optic canal. Vision may be lost totally and immediately; even though total at first, ik v< TUBES OP tin VAT I i 171 me blindness may gradually pass away. It will be impossible for some time to say whether the recovery will In' permanent. Added to these nerve symptoms, bul QOt particularly helpful in the diagnosis of fracture, may lie those of concussion, compression, or laceration. All these conditions may exist with or without fracture. The treatment has two ends in view, the prevention of further irri- tation of the brain and the prevention of infection. Keep the patient absolutely quiet in hed with the head elevated, ap- ply ice-bags, and keep the bowels open. Whenever fracture of the base is even merely suspected, carefully wipe out the external meatus and pack lightly with sterile gauze. Do not syringe the meatus or at least only very gently, lest infection be forced through the fissure. Remove the gauze as often as it becomes soaked with blood, which may be at frequent intervals for several days. Spray the nose and throat with peroxide of hydrogen or a similar mild antiseptic. These regions cannot he sterilized, but bacterial activity may be minimized. Do not pack the nares except for persistent nasal hemorrhage, as the packing irritates the mucosa and unduly stimulates secretion, and this is undesirable. Again, such packing may excite a sneeze which by its explosive effect may carry infection through the fissure to the meninges. If packing is deemed necessary, pack with sterile gauze saturated with sterile vaseline. In the great majority of cases, active intervention is quite out of the question either for the relief of infection or for hemorrhage. But this is true merely because the technic is not definitely worked out. The principle of drainage for infection and removal of compressing clots applies with as much force here as in fractures of the vault (see craniectomy). FRACTURF.S OF THE VAULT. Fractures of the vault of the skull may he fissured, comminuted or compound, any one of which mav he complicated by concussion, compression, contusion, or intracranial hemorrhage. The symptoms belong to the brain complications rather than to the fracture itself. Simple, fissured fracture without depression is practically impossible 172 FRACTURES. of diagnosis. The diagnosis is easier if depression is present and yet certain injuries to the scalp simulate fracture with depression. A blow crushes the soft tissues and around the crushed area marked swelling ensues. The sensation to the examining finger is that of a depression of the bone. Do not be misled. Comminuted fracture of the skull even without depression is gener- ally diagnosed, and yet a hematoma may mask the fragmentation. Be on your guard in that matter. ^<^^^^^^^B^» The inner table is always ^ffy lllillfe* more injured than the outer _ ; (Figs, too, no). *% r ||| The prognosis is good and the treatment simple in fissured fracture without depression and without symptoms indicating compression. Put the patient to bed, keep the bowels open, limit the diet, and await developments. Un- t <^ f interrupted recovery usually follows, yet the exceptions to this rule are not infrequent and FlG i^lc7ST^4n1r? Ut ^ai?° m one must be on his guard for intra-cranial hemorrhage. Or later, there may develop symptoms which are explainable only on the hypothesis of contusion of the brain. If at any time symptoms arise indicating the occurrence of hemor- rhage, say from a ruptured middle meningeal, immediate intervention is indicated. Some surgeons go so far as to recommend trephining for every fracture of the skull and exploratory operation in every suspected case, but that seems at the present time too radical, especially for the general practitioner left to his own resource. If the fracture is comminuted or even only fissured, with depression, the chances are so great that there is an injury to the brain that even with no symptoms present, immediate operation is indicated. (See Urgent Craniectomy.) r.tMi'iM M) i k\( i i ri s 01 THE VAULT. 173 CUMI'iil \1> 1 K Mil Kl S OF Till. \ All. I'. Much more serious from every point of view are the compound fractures of whatever origin. The constant element of danger is in- fection. Add to this concussion, contusion, or laceration of the brain, and the outlook is grave indeed. The treatment is not so simple, hut its purpose is quite definite, viz.: to prevent infection. This is accomplished not by keeping the streptococci out of the wound — they are already in; not by destroying them with strong antiseptics, as these are too injurious to the brain tissues, but rather by removing the con- ditions favorable to bacterial growth. To this end operation is im- perative. As in gunshot frac- tures, enlarge the wound, re- move extraneous matter, elevate depressed fragments, check the hemorrhage and remove clots, trim away devitalized tissues and provide drainage (see Craniectomy). Careful attention to these details results in the starvation of the germs present, with the result that repair proceeds. Skill in diagnosis, prognosis, and treatment in fracture of the skull depends upon a clear understanding of the mode of causation and the tymptoms of contusion, compression, and concussion of the brain. Although presenting quite a diverse clinical picture, separately con- sidered, these three conditions are nevertheless of the same origin fundamentally. They are each merely a complex of symptoms express- ing, on the one hand, varying degrees of either functional depression or stimulation of the cortex of the brain or, on the other, of the deeper centers of the cerebrum and medulla. The cortex is the seat of consciousness and at the same time the most sensitive part of the brain; Fig. no. — Same; fracture inner table. Note greater comminution and depression. (MouUin.) 174 FRACTURES. therefore it is the first to be affected by conditions disturbing the circu- lation of the brain. The deeper centers, those governing respiration and circulation, are not so readily affected. The result is that loss of consciousness is the first phenomenon following a general disturbance of traumatic origin. This trauma may not be sufficient to reach the cardiac and respiratory centers at first or at all; or it may only stimulate them; or finally it may paralyze them as well as the cortex. It must likewise be constantly remembered that stimulation of these basal centers means retardation of pulse and respiration; depression of the same centers means ac- celeration of pulse and respiration, and acceleration is an indication of approaching failure. It is only by reference to these first principles that one may explain and reconcile the variations in the derangements of these functions of consciousness, circulation, and respiration in different cases. CONCUSSION. This is in all probability due to a molecular disturbance of the brain substance, and is accompanied by neither microscopic nor macroscopic change. The disturbance may be (a) moderate, (b) severe, or (c) profound. (a) The disturbance is moderate. Under these circumstances, the trauma depresses the cortex, but does not reach the deeper centers of the brain and medulla, so there is therefore only a fleeting loss of consciousness without any change whatever in the pulse and respiration. (b) The disturbance is severe. The force depresses the cortex, but only serves to stimulate the deeper centers, and, as before, there is loss of consciousness, but there is this time slowing of pulse and breathing. Very soon the normal rate returns and a little later consciousness is restored. (c) The disturbance is profound. The cortex is paralysed and pro- foundly depressed as are also the deeper centers. The result is loss of consciousness and this time rapid and weak pulse and shallow breath- ing which may terminate very shortly in death. In doubtful cases, l()N( I SSION. 175 then, the heart is the chief elemenl in prognosis. The pulse imme diaU'ly grows either worse or better. Therefore the symptoms of concussion arc distinctly fugacious. This is its chief criterion. If the symptoms once improve and later recede, one may be sure the primary concussion is complicated by compression or contusion. Added to these phenomena of concussion, though not particularly helpful in diagnosis or prognosis, are certain other occasional symp- toms, referable to the reflexes. In the severe cases this will usually be the picture: At the moment of injury, unconsciousness occurs, immediate and complete. The patient is more than unconscious, he is anesthetized. The face is pale and sunken and the whole body cool. The pulse is small, rapid, and irregular. The temperature is subnormal. The breathing is shallow and sometimes sighing. The urine and feces may be retained or pass involuntarily. Repeated vomiting is quite common, especially as consciousness begins to return. Following the return of conscious- ness, a stage of excitement occurs. The symptoms of this stage are those of meningeal irritation, and in uncomplicated cases rapidly subside. The treatment is quite definite. Disturb the patient as little as possible in getting him into bed. Lower the head at first and try to maintain the body heat with woolen blankets and hot-water bottles. Carefully stimulate the heart. To this end, apply a mustard draft over the heart and inject ether hypodermically or a 10 per cent, solu- tion of camphorated oil. Repeat these injections frequently, being guided by the pulse. Yon Bergmann recommends inhalations of ether for the very weak and failing pulse. Do not forget artificial respiration. In those severe cases where the respiration is dangerously low, it will sometimes tide the patient over the danger-line. In the subsequent stage of congestion, keep the head elevated and apply ice-caps if the dressings will permit. Keep the bowels open. If the excitement and restlessness are pronounced, morphine hypoder- mically is indicated (Von Bergmann). 176 FRACTURES. COMPRESSION. Any condition, traumatic, inflammatory, or neoplastic, which dimin- ishes brain room, may induce symptoms of compression of the brain. The symptoms and their course will vary according to the manner in which the pressure is produced. What is said here applies particularly to the pressure symptoms origi- nating in depressed fracture or traumatic hemorrhage, though much would apply equally well to the pressure of brain abscess or brain tumors, or meningeal exudates and similar conditions. Pressure symptoms have fundamentally the same origin as concus- sion symptoms, that is to say, they are an expression of depression or of stimulation of the cortex and the automatic centers. In both there may be initial stimulation and terminal paralysis. However, this depression or stimulation is produced differently in the two conditions, concussion and compression. In the first case, the disturbance of function is brought about by mechanical injury and in the second by interference with the blood supply. Sudden diminution in the circulation modifies the functional activity of the brain centers. The cortex, the most sensitive, is first affected, followed by loss of consciousness. The automatic centers are next affected, at first stimulated, though each reacts differently; thus the respiratory center is the first to be stimulated and by the presence of carbon dioxide which was its primal stimulus. The vaso-motor centers are next invaded, and finally the vagal and convulsive centers. In those cases where the circulation becomes gradually slower, the order in which these centers and areas are successively affected is as follows: the cortex, the corona radiata, the gray matter of the spinal cord, the pons, and finally the medulla. Now the symptoms origi- nating in these various areas as a result of pressure are of two kinds : (a) General or indirect. (b) Focal or direct. Each may manifest itself in two stages: (1) Stage of stimulation. (2) Stage of depression or paralysis. HI.I I MIW. ]'K()\I Till MIDDL1 M I NINGEAL. 177 It is the knowledge of these Eat ts which enables us t<> harmonize and reconcile the diverse statements of various observers regarding the character and cause of the symptoms of compression. It is in the kemorrhage arising from the middle meningeal artery that the emer- gency surgeon is chiefly interested. Traumatic compression suffi- ciently serious to require immediate operation in nine cases out of ten originates in: BLEEDING FROM THE MIDDLE MENINGEAL ARTERY. This may follow injury to the head with or without fracture. The fracture may or may not be diagnosed. In a typical case the concussion symptoms which supervened im- mediately upon the injury disappear after a half-hour. The patient regains consciousness, and the pulse and respiration approximate the normal. In the meantime, however, the blood from the torn meningeal is slowly oozing into the space between the dura and the skull, and the "free interval" is interrupted by headache, irritability, perhaps delir- ium (stimulation of the cortex). The epidural clot grows larger, the intracranial circulation is more impeded and complete loss of conscious- ness occurs (depression of the cortex). Coincident with this, the pulse grows slower and stronger, the respiration deep and stertorous (stimu- lation of automatic centers). A little later coma is profound, the respiration begins to fail, and the heart's action grows rapid, weak and irregular (depression of both cortex and automatic centers), and finally all the functions of the entire organ are suppressed a nd paralyzed, and death ends the scene. Along with these general symptoms there frequently occur at various stages certain focal symptoms, monospasms, convulsions; monoplegia or hemiplegia. I'sually at the time the decision to operate is made, this will be the condition of the patient: He lies inert, unconscious, the pulse full and bounding, the respiration deep and stertorous, the skin hot and perspiring, the pupils irregular, usually dilated on the side of compres- sion, partial or complete hemiplegia of the opposite side. 178 FRACTURES. Treatment. — With a definite diagnosis once made, there is no differ- ence of opinion as to the treatment. It is imperative to operate, and to do so without delay. Every additional hour adds to the certainty of a fatality. The nature of the injury and the focal symptoms point to the site of the clot or the branch of the meningeal most probably involved. By trephining, the clot is exposed, and removed, and the bleeding vessel discovered and ligated. (See Craniectomy.) The pressure symptoms of hemorrhage from injuries of the sinuses are identical with those from meningeal bleeding except that they develop much more slowly and are likely not to be so typical. Hemi- plegia is not always in the side opposite the clot. FRACTURES OF THE VERTEBRA. Fractures of the vertebra derive their chief importance from the accompanying injury to the spinal cord and are serious in proportion to the amount of injury to the cord, ligaments, and tendons. Aside from local pain and deformity, the symptoms are such as arise from compression or laceration of the cord and vary somewhat, depending on the particular portion of the cord involved. Fractures of the cervical vertebra are at once the most common and fatal. Frac- tures in the lumbo-dorsal region occur next in frequency. The break which usually involves the body of the vertebra, but may include the lamina or transverse or spinous processes, is generally due to forced flexion. Along with the fracture the ligaments are lacerated, the muscles torn, the vertebra displaced and the blood vessels opened. There may be present paraplegia and disturbances of the functions of bowel and bladder; and in addition to these symptoms there are certain others which are common to fractures of the vertebra wherever located, such as pain, tenderness to pressure and motion. Occasionally one will find deviations and angular deformities. (Fig. 111.) The prognosis in a well-defined case is always bad, although by no means always hopeless. The emergency treatment is limited generally to transportation and securing the proper bedding. The patient must be handled with the FRACTURE OF Till V I R rEBRA. '79 greatest care. Sometimes the least added pressure <>n die cord by the movements of the spine may produce immediate death. Tlu- bed must be uniformly soft and smooth. A water bed is ideal. If the symptoms of compression are urgent, it is necessary at once to make an effort to re- duce the fracture by simulta- neous traction and pressure. While the assistants pull on the head and feet, the doctor at- tempts, by pressure, to correct the deformity. There is some danger of a fatal asphyxia where the fracture is high, in making these manipulations, as the patient is turned on his face and the movements of the diaphragm may he interfered with. Lami- nectomy is not to be considered when the indications point to complete crushing of the cord. In other cases where the pressure symptoms are obvious, a laminectomy should be done without delay. (See Wounds of the Spine.) PlG. iii. — Fracture of vertebra. (Moullin.) FRACTURE OF THE NASAL BONK. Aside from gunshot fractures (see page 144), the bones of the face suffer occasionally from direct violence. The nasal bones may be fractured alone or in connection with the ethmoid. Bleeding is profuse and deformity apparent. On account of infection from either the outside or inside of the nasal cavity, in- flammation and necrosis may In- a sequela. Ad attempt should be made at once to elevate the depressed frag- ments by pressure within the nasal cavity. The reduction may be both difficult and painful. General anesthesia may be necessary. Check the hemorrhage by mopping the nasal cavity with a solution 180 FRACTURES. of adrenalin chloride, or pack temporarily with sterile gauze. Sub- sequently douche the nasal cavity frequently with glycothymoline or Seiler's solution to prevent infection. FRACTURE OF THE SUPERIOR MAXILLA. Fracture of the superior maxilla occurs alone or with fracture of the malar or other bones of the face. It may be accompanied by splintering of the bone, caving of the antrum, loosening of the teeth, and disfigurement generally. The alveolar process may be broken off. If this is the case, it may be replaced without great difficulty. Oftentimes little can be done to correct the deformity. The lower jaw can be used as a splint and very little force is needed to retain the fragments in position. If the fracture is compound, the fragments should be treated con- servatively. It is surprising how perfectly they may sometimes be re- paired. The vascularity of both bone and periosteum favors this result. With the jaw at rest, a liquid diet should be maintained and fre- quent cleansing with alkaline antiseptic fluids. Be on guard for frac- ture of the base of the skull. FRACTURE OF THE MALAR BONE. Fracture of the malar bone seldom follows the suture lines. The whole bone may be dislocated in a direction corresponding to the force. In this manner, the injury may be transmitted to the superior maxillary, its sinus and infra-orbital canal, to the nose, the orbit, and the base of the skull. Uncomplicated fractures of the malar bones require little treatment. Compounds fractures must be treated on general principles. It may be possible to replace a depressed fracture of the zygomatic process by pressure through the mouth. FRACTURE OF THE INFERIOR MAXILLA. Fractures of the inferior maxilla occur most frequently just in front of the mental foramen, and are usually compound, opening into the mouth. The deformity is determined chiefly by muscular action and the degree of obliquity. Ik \« li R] in I III LOWER I \\\ 1S1 The diagnosis is rarely difficult. Reduction, which is indicated by a correct alignment of tin- teeth, may be accomplished by bimanual manipulation with the fingers of one hand in the mouth. This is usually easily done, the chief diffi- culty being to retain the fragments in position. The prevention of infection is likewise important. (Fig. 112.) Oliver, of Indianapolis (Ind. Med. Journal, 1906), has described the mode of treatment most applicable in the emergencies of general practice. He recommends, as the result of his ex- perience, that in the ordinary case, when the patient retains the majority of his teeth, the upper jaw be used as a splint. This is his procedure: before attempt- ing reduction and without anesthesia, if possible, he begins by passing a loop of wire (soft iron wire, gauge 26 or 28) around the neck of the most available tooth behind the break in the lower jaw; a similar loop is thrown around the cor- responding tooth in the upper jaw. Fl ^ e ^^^^ ^^ Coming forward of the fracture the first solid tooth and its fellow above are both looped in the same manner. Next a similar loop is adjusted above and below on the opposite side of the jaw — on the sound side. Altogether six separate wires have been used. Bach loop is now twisted down tight with a pair of pliers, so that the teeth are firmly encircled and the free ends of the wires left projecting from the mouth (Fig. 113). Reduce the fracture as the next step. This is done by pressure and traction with the fingers inside and outside of the mouth. Immobilize. — This is accomplished by twisting firmly together by means of the pliers the corresponding upper and lower wires, which brings the lower jaw into intimate contact with the upper. Liquid diet sucked through the teeth. l82 FRACTURES. Antisepsis. — Direct the patient to fill his mouth with the antiseptic fluid and to churn it vigorously backward and forth between the teeth. This washing should be done frequently each day, and especially after each feeding. If necessary, as additional support, a plaster-of-Paris or Barton's bandage may be applied. Fig. 113. — Wiring the teeth for fracture of the lower jaw. Note the manner in which the wires encircle the upper and lower teeth before and behind the line of fracture. The upper wire is subsequently twisted with its corresponding wire below, so that the lower jaw is splinted against the upper. The wires are left for three weeks, or longer in the severe cases, and after their removal a bandage should be kept on for another week. The patient should be supplied with a small pair of wire cutters and directed how to use them in an emergency, such as serious vomiting which might result in asphyxia. As Oliver observes, this formula may be varied to suit the individual case. The many forms of splints need not be here considered. The FRACTURE OF Till. CLAVICLE. 183 cases of special difficulty in reducing and retaining, those which are compound and those in jaws practically edentulous, require wiring. This is an operation simple in theory, but more difficult in practice. The main points are to make the incision along the lower border ot the jaw, cutting to the hone and Letting the middle of the incsion fall over the line of fracture. The bone is carefully denuded of perios- teum. The sutures are not to come in contact with the buccal sur- faces. The bones are drilled; the sutures passed and tied, the peri- osteum drawn over the sutures, and the soft parts partially repaired. FRACTURE OF THE RIBS. Fractures of the ribs occur most frequently between the fifth and ninth, and are usually single and without displacement. If the vio- lence is sufficient to break a number of the ribs simultaneously, it may cave in the chest wall; and, by perforation of the lung, produce emphy- sema, hemoptysis, pneumothorax. Pain and crepitus point to the presence of fracture. Detect crepitus by laying the palm over the site of the pain or by the stethoscope. Slight displacements may be reduced by making pressure over the site of fracture during inspiration, or perhaps by compressing the chest from front to back between the two hands. Apply adhesive strips two inches wide over the injured side, beginning at the scapula, and fol- lowing the course of the ribs around to the sternum. Three or four such strips may be necessary, and they must be applied at the end of expiration. The pain will almost always be relieved by such immobilization of the chest wall. Those fractures which involve the viscera are consid- ered with injuries of the thorax. FRACTURE OF THE CLAVICLE. Fractures of the clavicle formerly occurred more frequently than any other, but are not now so frequent. One-half of the cases are in children. The break very much more often occurs in the middle third. Occasionally in the outer third, but rarely in the inner third. In the 1 84 FRACTURES. middle third, the inner fragment overrides the outer, the result of the action of the sterno-cleido-mastoid and the muscles that pass from the thorax to the humerus, and the weight of the shoulder (Fig. 114). The patient leans his head toward the injured side and supports the elbow, the position of greatest comfort. The nature of the accident, the pain, deformity, crepitus, and mobility determine the diagnosis. Reduction.— Seat the patient on a low stool; direct the assistant to stand behind and to grasp the patient's shoulders, steadying the sound one with one hand and lifting the injured one upward, backward, and Fig. 114. — Fracture of clavicle. Inner fragment lifted upward by sterno-mastoid. (Moullin.) Fig. 115. — Velpeau's bandage for fractured clavicle. {Stewart.) outward. At the same time the operator stands in front, helping move the shoulder; and, by pressure and manipulation of the clavicle between finger and thumb, molds the broken ends into place. The reduction is complete when the injured shoulder is as long as the sound one, measuring each from the sterno-clavicular joint to the tip of the acromion, landmarks which can always be defined. Feel along the injured clavicle for any irregularities. Apply the dressing. (1) If the patient is to be kept in bed for other reasons than the clavicular fracture, it will be sufficient to keep him on his back with a small pillow between his shoulders and with the hand lifted to the chest. (2) Any bandage or dressing which draws the shoulder upward, outward, and backward, and holds it in that position will serve. Of SAYKKS DRKSSINC. 185 the dressings, a number arc especially recommended. They need to be applied for three or four weeks (Fig. 115). In ordinary practice, the Sayre's dressing is excellent. The essen- tials are two adhesive strips three inches wide and long enough to go once and a half about the body, absorbent cotton, roller bandages. Begin by fixing the end of one adhesive strip loosely about the injured ami just below the armpit. The loose end carried around the body will pass over the lower ends of the scapuke. Before completing the turn about the lxxly, place layers of cotton wherever the cutaneous Fir,. 116. — Sayre's dressing. Fig. 117. — Sayre's dressing com- Fig. 118. — Anterior view. First stage. (Moullin.) pleted. Posterior view. (.Uiiii/lm.) (Moullin.) surfaces are to be in contact. The turn of the adhesive strip about the body is completed. This holds the shoulder in the backward and outward position (Fig. 116). The hand is drawn across the chest toward the sound shoulder and the second adhesive strip is applied. Fix one end over the sound shoulder and pass it across the back to the elbow (Fig. 117). It covers the point of the elbow and follows the arm across the chest to the starting-point (Fig. 118). It is designed to lift the shoulder upward. A few turns of roller bandage around the chest lend additional support and complete the dressing. Romer describes a method of dressing with adhesive strips which 1 86 FRACTURES. does not require the arm to be fixed to the side (Lancet, London, March 31, 1909). Three strips of Z. O. plaster, each an inch and a half in width, should be applied from a point immediately above the nipple over the clavicle to a point below angle of the scapula. The middle strip should cover the site of the fracture and should be first applied, the lateral ones overlapping it. The strips should be firmly applied Fig. 119. — Mayor's sling. First stage. (Lejars.) while the fragments are kept in apposition. The scapula may be steadied by a strip crossing its lower ang'e laterally. The arm is to be carried in a sling. Mayor's sling serves an excellent purpose here as well as in certain injuries to the arm. It is applied in this manner: Take a square of strong, unbleached muslin, or similar material, large enough to reach easily about the body; fold it into a triangle. mayor's sum;. 187 The dhow having been flexed to an acute angle and the hand carried toward the sound shoulder, the handage is carried across the flexed arm and around the chest, its upper level being just below the lever of the axilla (Fig. 119). The two points are fastened behind with a safety- pin or tied. PlG. i-'o. Mayor's sling. Second stage. The bandage is molded snugly to the arm. (Lejors.) Fig. 121. — Mayor's sling completed. 1 Ltjars.) Now turn the third point of the triangle upward between the flexed arm and the body, and carry it up <>vcr the shoulder of the injure. I side (Fig. 120). Mold the bandage well, so that it fits and supports the forearm snugly. The dressing is completed by hands « rossing over the shoulders and connecting the anterior and posterior parts of the bandage after the manner of suspenders (Fig. 1 2 1 ). 105 FRACTURES. FRACTURES OF THE EXTREMITIES. Fractures of the extremities are emergencies, often of the first- class; their reduction sometimes becomes equivalent to a major opera- tion. But it cannot be said that these cases are always treated well. As Senn says, "Bad results following fractures have been the tombstones that have marked the termination of an otherwise successful profes- sional career of many an ill-fated, unlucky, disappointed practitioner." Malpractice suits more frequently follow this class of cases, perhaps, than any other, which is an indication that somewhere there is a fault. Doubtless it is the fear of a damage suit that often makes a basis for it and in this way: The doctor, in order that he may have testimony as to his skill, treats the case in the stereotyped, and routine way; he gets a bad result. Had he used his better judgment, given his common sense rein and risked the reproach of being an innovator, the result would have been different. Every case must be studied and treated on its own merits, with due regard, of course, to certain general principles. To begin with, the prognosis should always be guarded in some degree. As King says, (St. Paul Medical Journal, August, 1906): "Optimism as to the final outcome on the part of the physician is a mistake. Take the patient into your confidence, let him anticipate the certainty of some permanent defect, so that in the end an imperfect result will not reflect so much upon your skill and will tend to minimize malpractice suits. And how very rarely indeed can the result be perfect. With the very best treatment, there will nearly always remain as the best outcome some slight weakness, or limitation of motion, or ache, or pain — at least a callus as a 'lasting memorial.' " The diagnosis of these fractures is usually easy in the large sense, as King says, but after all difficult as a whole, for no eye can see the injury wrought to the softer tissues. In many cases the position will indicate at once that there is a fracture, but one must endeavor to learn much more — the possible associated injuries to joints, muscles, blood vessels, and nerves. To be able to do this necessitates a fairly accurate knowledge of anatomy to begin with, aided by systematic examinations, and on this foundation skill grows with experience. [)I VC.NOSIS (IF I K VCT1 R] S. 189 The diagnosis of fracture in the bones of the extremities is based on several fai tors: (a) history of the case, (b) deformity, (c) abnormal mobility, (d) pain and loss of function, (e) crepitus, (f) X-ray examination. (a) It is essential to know how the accident occurred. Frequently in the absence of definite symptoms, the diagnosis must rest upon that. For example, in a case of a hip-joint injury in an elderly person pre- senting loss of function and some pain but no other symptoms, a diag- nosis of impacted fracture should be made if it is learned the patient fell striking the hip. (h) Deformity includes changes in the relations or dimensions of the hones and the appearance of the limb. The two limhs must al- ways be compared. It must be determined that there has been no previous injury to cause the deformity. When both ends of a bone are accessible to touch, it may be readily measured and compared with its opposite. In the case of the humerus, it is necessary to measure from the acromion; in the case of the femur, from the ilium. The position which the fragments assume may be due to the direction of the force or the action of the muscles. (c) Preternatural mobility implies movement in unnatural situations or in unnatural degree or direction. As one of the cardinal signs of fracture, it has hitherto been assigned too much importance. Its presence indicates fracture, but its absence indicates nothing. We all know that in impacted fracture, there is no abnormal mobility. In fractures of the bones of the tarsus and carpus, in epiphyseal fracture, in any fracture where the fragments are small or deeply placed, it may he impossible to discover movement without a manipulation which may be distinctly injurious. In the case of fractures near joints, it may he impossible to determine whether the movement is in the joint or near it. The fact is that in most cases where abnormal mobility is present, the fracture may be readily diagnosed without reference to this sign. (d) Crepitus is the almost constant accompaniment of abnormal mobility and is the grating produced by the friction of the two fragments. It is pathognomonic, but must not be sought for too vigorously. It is absent in impacted fracture, and to break up an impacted fracture, IQO FRACTURES. testing for crepitus, may be a calamity. Crepitus may sometimes be heard with the phonendoscope and not with the ear. (e) Pain and loss of function go together since the pain is usually the cause of the loss of function. Both are present in nearly all frac- tures, but often occur in as great degree with contusions. The amount of pain varies with the location, but is nearly always aggravated by movements or pressure. Taken in connection with the history of the case, it is a valuable diagnostic aid. The presence of pain may call for anesthesia before the diagnosis can be completed. Stimson has recently emphasized the significance of pain in the diag- nosis of fracture, and indicated the manner in which it may be inter- preted. Crepitus and abnormal mobility are, to his mind, of less im- portance than pain as a diagnostic aid (J. A. M. A., March 27, 1909). The search for pain in all doubtful cases should be systematic. Begin first with local pressure over the suspected area with the tip of the finger or with the rubber end of a lead-pencil. There are definite lines of tenderness to be discovered in many of the fractures about joints. For example ; in Colles' fracture this line can be plainly traced across the radius just above the wrist; in fracture of the external condyle of the humerus, along the external condylar ridge just above the elbow; and in fracture of the surgical neck of the humerus, along the front or outer side of the bone. Next test the character of pain elicited by cautious movement of the limb. Increased muscular tension thus produced awakens increased pain at the site of the fracture, and the patient may be able to indicate the exact location of the lesion. The effort on the part of the patient to produce certain movements is helpful. Finally, indirect pressure may be employed; thus, in transverse fracture of the tibia, pressure upward on the foot exaggerates the pain markedly, and in the same manner, pressure upward at the elbow, may assist in locating the fracture in the shaft of the humerus. Stimson notes the important exception, that in the case of fracture of the neck of the femur forcible pressure upward often fails to cause pain. In the case of fracture of one of the bones of the forearm or leg, squeezing the two bones together will generally help the patient to locate his trouble. PRINCIPLES OP TREATMENT < > I FRA< M RES. 101 (f) The X ray cannol be ordinarily available in general practice, although of the greatest assistance in cases of doubt. Without its use many fractures in the region of joints will be diagnosed as something else. Bloodgood particularly emphasizes its value (Progressive Medicine, Dec., iooo), believing that the doctor who neglects the aid of the Rontgen picture, when he is able to obtain it, will have much to regret. There is no danger that its employment will blunt the diag- nostic sense, unless, as is often done in hospitals, it is used to the ex- clusion of other aids. The X-ray has at least modified our notions as to what constitutes a perfect result in the treatment of a fracture. Wherever the X-ray picture is used to back up a claim of malpractice by reason of inaccurate apposition of fractured bone, we must insist that restoration of form and function constitutes a perfect result surgically, whatever discrepancies the Rontgen picture may reveal. The trkatmknt implies a reposition and an immobilization that the bones may unite in their normal relations. It has that objective, but has also another which is not necessarily a concomitant of the first. The bones must unite without deformity but there also must be res- toration of the limb's functions. Union in good position, then, is only one of the means to a larger end. It is better to say that the treat- ment includes reduction, immobilization, and mobilization. In making reduction, violence must be avoided. Gentle but per- sistent effort is always better than rude haste in overcoming the re- sistance of muscles and ligaments, which is usually the chief obstacle to reposition. The line of traction must be adapted to the muscular action. Traction must usually be accompanied by COuntertractioD and local manipulation of the broken ends. In making traction it should be made directly, if possible, on the bone involved, without the intervention of a joint. For example, in reducing the humerus the traction should be applied above the elbow- joint. Often an anesthesia is necessary to relax the muscles, and if anesthesia was necessary to complete the diagnosis, everything should have been prepared previously for the treatment so that only a single anesthesia is necessary for diagnosis, reduction, and dressing. In the cases of suspected fracture in the vicinity of a joint, it is not always best to hurry the reduction; often it is better to wail a day 192 FRACTURES. or so and try to reduce the swelling, for the swelling aggravates the difficulties which are always great in the differential diagnosis about the joint; and, if flexion is required, as in the case of certain fractures about the elbow, the pressure may shut off the circulation. So far as the shaft of the long bones are concerned, however, the formula should be immediate reduction and. fixation. That the reduc- tion has been complete is attested by the appearances of the limb, by the absence of any irregularities to the touch, and by the coincidence of its measurements with those of the sound limb. These comparative measurements should be a matter of routine practice. Warbasse says (J. A. M. A., March 13, 1909), " the sooner a fracture is reduced and held immovable, the less will be the swelling and the more satisfactory the result. There is a prevalent notion of waiting until the 'traumatic reaction has subsided.' This ancient phrase rolls off the tongue sonorously and sounds important, but is to be rever- ently laid aside. Traumatic reaction is going on all the time as long as the bones are out of place or so long as they are movable. If we can effect immobilization soon enough, the swelling will not come up." This is doubtless true in most cases, yet it is too be remembered that in spite of reduction of the bones, lacerated muscles and ruptured vessels may continue for some time, in some cases, to pour their exudate into the tissues to augment the swelling. This idea, however, pertains more to the mode of dressing and does not refute the doctrine of immediate reduction. Immobilization is a phase of treatment raising many questions in dispute. In what manner shall it be applied and for how long? Or, as Championmere insists, may it not in many cases be dispensed with entirely ? For he believes that absolute fixation of the fragments is not the condition most favorable to the processes of repair. A certain amount of movement is necessary to the vitality of the bone, and therefore movements and massage represent the chief elements of his treatment. That it is the best treatment for fractures about joints no one will deny, even though unwilling to dispense with fixation in other fractures of the long bones. As to the manner in which fixation is to be attained, let it be said briefly that the simplest effective dressing is the best. Its elaborateness i SI OB sim i\ is. tg j will depend upon the tendency for the displacement i<> recur, and this tendency must be measured by the degree of obliquity of the fracture and the action of the must Irs. Sometimes the temleiu \ to re< urreni e is an indication of imperfect coaptation. In one case, then, only a light retaining splint is necessary and in another it must indeed be firm and strong. At the present time there can be no question but that plaster of Paris is the dressing of choice. At any rale, it will render the best Service to the general practitioner who must rely on his own resources in fash- ioning splints. Ready-made splints are an abomination. There are other plastic materials that are often useful, and in lieu of all these materials the splint may he cut into forms to suit the case from hoards, etc., and applied well padded. (See page 45.) Walsham formulates the principles which must regulate the use of splints in any case. 1. The splints must he well padded. 2. Pressure must not he made over the points of bones. _:;. Strapping or bandages must not be put on too tightly. 4. Circular constriction of the limb must be avoided. 5. The splints, if possible, should reach beyond the joint above and below the fracture. 6. The patient should be seen within twenty-four hours after the splint is applied for the bandage may become too tight. 7. The splints should not be needlessly disturbed — that is to say, If the patient is comfortable and the limb in good condition. 8. Spasm of the muscles is to be overcome by Steady extension. 9. The part below the fracture should be bandaged, or at least raised, to prevent swelling and edema. The first immobilization will continue till there is no tendency to spontaneous recurrence of the displacement, which will vary in differ- ent cases. After this time a dressing must In' used which i-; easily (hanged, and daily massage must be instituted. Complete and con- tinuous fixation through a long period is distinctly bad practice and most especially whenever a joint is involved. Rossi has shown (Wiener Medical Presse, Jan., u)02) that the amount of new cartilage formation is proportional to the amount of IQ4 FRACTURES. movement permitted and is found in the greatest amount in fractures treated by massage, and is explained by the greater formation of new blood vessels and the consequent more active circulation and absorp- tion of effusion. First aid to those disabled with fractured limbs is in civil practice more frequently given by others than the doctor. It is desirable, how- ever, whenever possible, that he should direct the transportation and the preliminary treatment. The utmost care must be practised in liftmg and handling the broken limb, lest the injuries be augmented and a simple fracture converted into a compound. If fracture is merely suspected, it must be assumed to be present. The limb must never be lifted by the foot or hand but must be lifted as a whole, resting upon the palms of the hand. Two attendants are always better than one in handling a broken leg. If the deformity is quite obvious even to the unpractised, an effort should be made toward reduction before applying temporary splints, this with a view to preventing further injury to the soft parts. The limb is seized by an attendant at each end and gentle and steady traction made in the direction of its axis. If this does not succeed, the attendants must not persist in the effort. It must be left for the surgeon. If the fracture is compound, with severe hemorrhage, the clothing must be removed. Otherwise this is not necessary. In removing the trousers or a coat, for example, the sound limb is uncovered first and then, very gently, the injured one. It is better to cut the clothing or rip along a seam. A splint is next improvised from whatever may be first at hand, a thin board, laths, an umbrella, or the branch of a tree. The splint is padded, or the limb wrapped with whatever presents itself, a blanket or anything to prevent undue pressure, and then is fastened on the limb by a cord, or belt, or suspenders, etc., and finally the injured leg is bound to the sound leg, the injured arm to the side of the chest or carried in a sling. The limb thus temporarily immobilized, the patient is ready to be moved. FSACTTJR] "i i in -ii \i 1 OP mi nrui RUS. [95 To lift the patient with the greatest safety in the case of a broken leg, for example, one attendant standing on the sound side, places his arms under the body of the patient, who In the meantime locks his arms about the attendant's neck. A second attendant, standing on the same side, places one hand under the body, one under the sound liml>, while a third attendant, facing the others, supports the broken limb. At his word of command, all lift. This carefulness must not be relaxed. [f a litter is available, or one can be improvised, it is plated parallel with the patient, its feet at his head, so that without any inconvenience the patient may be laid upon it. FRACTURES OF THE HUMERUS. Certain points of anatomy apply to nearly all fractures of the arm, and are useful in diagnosis and reduction. Recall the relations of the humeral head to the acromial and coracoid processes; the great tuberosity; the internal and external condyles; the attachments of several muscles, particularly the deltoid, biceps, and triceps; the relations of the musculo-spiral nerve. Remember that in the normal relations a line dropped from the tip of the acromion to the external condyle will touch the greater tuberosity. The symptoms and treat- ment vary somewhat with the part of the humerus involved. Fracture of the Shaft of the Humerus. — Above the attachment of the deltoid there is not likely to be much deformity; below, the deformity will depend upon the degree of obliquity. Usually the displacement is not great. Pressure upward at the elbow will elicit pain. Reduction. — Seat the patient; the assistant standing on a chair lifts the shoulder with a towel passed under the axilla. Now flex the forearm at a right angle, holding ; t with one hand and the arm just above the elbow with the other. Make traction on the arm in the direction of the axis, gently rotating to disengage the fragments. It is a good indication, if there is much grating, that none of the soft parts are engaged. Reduction is complete when the acromion, tuberosity, and external condyle are in the same line and the injured arm the same length as the 196 FRACTURES. Fig. 122. — Testing the humerus for shortening. Measuring from the acromion to the external condyle. in nm (.tin's DRESSING. 197 other. (Fig. 122.) If slight rotation is particularly painful, think of an inclusion of the musculo spiral. If such a diagnosis is made, it will lie necessary to operate. A general anesthesia may be necessary to facilitate reduction. It will not alter the principle of procedure. The great difficulty is to maintain the reduction exact until the dressing has been applied. With the idea of insuring main- tenance of coaptation while the fixa- tion splint is benig adjusted, Lejars very highly recommends the appli- ance of Hennequin. It is equally applicable in some of the other fractures of the humerus, and is em- ployed in this manner (Fig. 123): The patient is seated; bandage the injured member from the wrist to about three inches above the elbow; protect the axilla with ab- sorbent cotton; flex the forearm at a right angle and maintain in that position in a sling. Pass a band under the axilla and fasten it to something (a hook in the wall), so that the shoulder is slightly lifted. That is the counter-extension. Another band crosses the forearm just below the bend of the elbow and to it is attached a weight, say of 2 K. G.; that is the extension. Give the apparatus a little time and it will effect a reduction as the muscles tire. Employ this interval to prepare the fixation dressing. Cut out sixteen strips of crinoline, each about one yard long, and wide enough to cover the arm at its thickest part. Lay these strips one upon the other, and fasten them together; and from the sheet thus formed, cut a deep scallop out of either end — at the lower end 45 to Method of securing extension and counter- extension and also fixation till plaster is applied. {Lejars.) 198 fractures. 50 cm. and at the upper end 15 to 20 cm. deep. Of the yokes thus formed, one will fit into the axilla and the other into the bend of the elbow, while the intermediate portion forms an internal splint for the arm. Soak the cloth in liquid plaster and apply it in the manner indicated, molding it carefully to the arm. The two upper bands overlap the shoulder and the two lower ones are wound spirally around the arm to the wrist. In this way the shoulder and wrist are immobilized. In the meantime the extension and counter-extension are not disturbed until the plaster split is fully hardened. The dressing may be further secured by a few turns about the chest. Other dressings recommended are the plaster roller from the wrist to shoulder; an internal splint with a shoulder cap and sling; or molded splints. Union requires from six to eight weeks; failure to unite is usually due to the interposition of the soft parts. The importance of the musculo-spiral nerve in this connection must never be forgotten. Fracture of the Upper End of the Humerus. — These injuries often offer the very greatest difficulties in diagnosis. Such cases for the most part present themselves with swollen, painful, and contused shoulders, perhaps deformed, and functionless. You ask yourself: is it only a severely bruised joint; is it a dislocation or a fracture of the surgical neck, or perhaps both; or is it an impacted fracture of the anatomical neck; are the soft parts implicated? Do not waste time in vague palpations but proceed at once to a systematic examination, under chloroform, if necessary. Begin by locating the apex of the acromion; if there is no depression beneath it; if the thumb cannot be pushed into a concavity but comes in contact as it should with the humeral head, you may conclude there is no dis- location. With the thumb still in front, close the fingers on the poste- rior aspect of the head of the humerus, and with it thus held firmly, attempt rotation of the arm. The humeral head rotates with diffi- culty in dislocation; it does not rotate at all if there is fracture, and besides, there is crepitation (Figs. 124, 125). A source of error: If the lower fragment overrides much, its rota- tion might be felt and mistaken for the humeral head. Abduct the DIAGNOSIS <>| PRACTURI M SHOULDER. 199 arm; easily done in fracture, with increase of deformity and pain. Pain is also produced by pressure upward at elbow and by local pressure over the front and outer side of humerus. Pig. 124. — Examining the shoulder. Rotating head of humerus. Examine the axillary spare and all the other aspects of the shoulder, comparing the two sides; and compare the other landmarks of the arm. 200 FRACTURES. Do not begin any treatment until the diagnosis is assured. How unfor- tunate it is to attempt reduction of a supposed dislocation by the ordi- nary method when it is complicated by fracture; or to treat as a con- tusion, a fracture with displacement! To consider briefly the more common findings of such examinations: i. Fracture of the surgical neck without overriding (Fig. 126) needs Fig. 125. — Examining the shoulder. Comparing the relations of the coracoid processes. only the simplest treatment: Brace the arm on the inside with a "V" shaped axillary pad, and with the forearm flex at a right angle; sup- port the whole extremity in a sling of the Mayor type. Additional protection may be afforded by a shoulder cap (Fig. 127). Begin mas- sage early. 2. Oblique Fracture of the Surgical Neck with Much Overriding. — These are difficult to reduce; difficult to maintain; likely to be mistaken for dislocation. lk'\( liKl M SHOULDEB Willi l>ISI.<>( ATION. 20I Reduction. — In making traction, draw downward ami outward at OTSl and thru in the axis of the limb. I >0 not slop until the arm is the correct length by measurement; until the subcoracoid projection has disappeared; the acromion, greater tuberosity and the external i ondyle are in the same straight line. Extension must be maintained while the dressing is applied or the displacement will certainly recur. The Hennequin apparatus described will he useful here and the plaster splints as well. Sometimes wiring is kecessary. 3. Fracture of the Surgical Neck with Dislocation. — This is a very serious injury; difficult of diagnosis; of had prognosis. Carrying out the systematic ex- amination described, you find the head displaced, hut the arm is not fixed in ahduction as in the ordinary Dislocation; it drops to the side. Again, the head does not rotate with the arm; there may be crepita- tion; from these and other confirmatory points the diagnosis is made. Reduction. — Anesthesia is necessary. Make a slow, gentle, hut persistent traction on the arm; this com- bined with manipulation of the head of tbe humerus in the axillary space may succeed in restoring the head to the glenoid fossa, for more than likely the head is still attached to the shaft by periosteum and muscular fibers. As the assistant makes the traction apply your thumbs to the head in axilla and, with the lingers braced by the shoulder, try to force the head into place. Once the dislocated head is reduced, reduce and treat the fracture by the ordinary means. Massage must he begun especially early. If these efforts fail, choice lies between operation and expectant treatment. Royster, of Raleigh, X. C. (Journal A. M. A., Aug. 10, igoj), re- views his own experience and the literature dealing with this condition, and concludes very Logically that operative treatment in the great major- ity ol cases is alone effective. The preferable incision begins at the acromion process, extends r PlG. i.!''. -Frac- ture of surgical neck of humerus. {Moullin.) FRACTURES. vertically downward as far as necessary, and aims to reach the bone by passing between the pectoralis major and the deltoid. The head, thus exposed, is to be reduced by manipulation, although occasionally a special hook or bone forceps may be necessary. Wiring will seldom be required except in the cases operated late. The dressing should be applied so as to maintain the arm in abduction. Royster believes in immediate operation, regarding such cases as emergencies, even as strangulated hernia or appendicitis. "Even in cases of doubt, it is preferable to expose the parts to view rather than to wait in the hope that nature and time will clear it up." Fracture of the greater tuberosity may occur as the result of either direct or indirect violence, such as a fall upon the hand with arm ex- tended. The displacement of the tuberosity may be upward, out- ward, and backward. Early disa- bility and swelling are prominent symptoms; crepitus may be absent. Pain is produced by local pres- sure. Taylor, of New York, as- serts (Annals of Surgery, Jan., 1908) that in uncomplicated cases with moderate displacement re- covery may be practically perfect without the use of splints, massage, or special movements (Fig. 128). Fractures of the Lower End of the Humerus. — Injuries about the elbow are always to be regarded seriously. They occur much more fre- quently in children and are usually due to falls upon the flexed elbow. Scudder insists that even in the apparently trivial cases the examina- tion should be made under anesthesia, for only by that means, as a rule, can the injury be exactly diagnosed. The diagnosis itself is chiefly a matter of applied anatomy. The Fig. 127. — Fracture of surgical neck. Axillary pad ; shoulder cap ; forearm supported in sling. {Scudder.) PRACT1 I'l \l LOWER END OF ill Ml Rl -. 203 landmarks ami tin- normal relations must be clearly in mind. Ob serve on the sound side die relations <>t" the interna] and external ion Byles, die olecranon, the head of the radius. It is uncertain at first whether it is a contusion, or dislocation, or fracture. Even when sure Pig. 1 28.— Fractures through head of humerus. Patient thrown from buggy alighting upon shoulder. This variety of fracture is mure common than formerly supposed. that the 1 ase is a fracture, yet it is to be determined whether it is supra- condylar, or ( ondylar, or some combination of the two. S. udder formulates a routine mode of procedure in making the Diagnosis. Observe the character of the swelling— whether general or Localized. Observe the carrying angle. 204 FRACTURES. Palpate the external and internal condyles. Palpate the olecranon process and head of the ulna. Rotate the head of the radius. Fig. 129. — Examining the elbow; locating the three cardinal points — the internal condyle, the tip of the olecranon and the external condyle. Note the relation of the three bony points in extension and flexion (Fig. 129). Determine the possible movements of the elbow-joint. Make measurements. Make pressure with the point of the finger to locate SI PB \ CONDI: I \\i FRACTURES. 205 a painful line which marks the fracture. If the X ray is used it should show both the lateral and antero posterior view. Certain forms of injury arc found most frequently: (1) Supra condylar fracture, (2) fracture of one of the condyles, (3) multiple fracture involving the jo : nt. (1) Supra-condylar Fracture. — The joint is not usually Involved, the plane of fracture extending commonly from above downward and forward. The displacement of the upper fragment, therefore, is downward and forward, and if union takes place in this position the flexion of the elbow is much abbreviated (Fig. 130). Reduction.— ( >ften the ordinary means, that is by traction and PlG. 130. — Supra -condylar fracture of humerus. Note obliquity. (Moullhi.) countertraction with the forearm Hexed, will not succeed. Try slow and progressive traction upon the extended forearm, aided by manipula- tion of the fragments at the site of fracture (Fig. 131). When reduction is complete, continue the traction but gently Ilex the elbow to an acute angle; if no displacement occurs, and if the swelling is not so great as to preclude flexion by reason oi the inter- ference with the brachial artery, proceed to apply the fixation dressing. The molded, posterior plaster splint, or trough, is recommended. Twelve to sixteen pieces of crinoline long enough to reach from the deltoid insertion to near the wrist, and wide enough to cover the arm, are quilted together and two oblique notches cut corresponding to the bend of the elbow. This piece of padding is now impregnated with liquid plaster and applied to the back of the arm and forearm, and 2o6 FRACTURES. well molded. The two notches permit a ready adjustment at the bend of the elbow. The support of the arm is not relaxed until the plaster has hardened. The gutter thus formed may be strengthened by a loosely applied roller which passes from the wrist across to the arm near the axilla, around it and back to the wrist again, and so on. The arm is thus fixed in acute flexion. A boy of twelve years was brought in from the country with an in- Fig. 131. — Supra-condyloid fracture of the humerus. Method of reduction before applying retentive splint. Countertraction on upper arm. Traction on condyles of humerus with right hand; backward pressure with thumb of left hand. Also illustrative of method of beginning acute flexion. (Scudder.) jury received the day before by being thrown from a horse. A diag- nosis of fracture about the elbow had been made, and with it the effort to fix the arm in forced flexion. The whole member was greatly swollen, edematous about the elbow with blebs in process of formation. The X-ray confirmed the diagnosis, showing epiphys- eal separation with fracture and separation of the internal condyle (Fig. 132). The dressing was removed, the arm fixed in extension; daily massage was instituted to remove the tumefaction, and after four days an effort was made to reduce the fragments and put the arm in forced flexion; but this only resulted in complete obliteration of the PRACTUR] «'l llll CONDYLES. 207 radial pulse. The arm was left in semiflexion and pronation, and massage was again instituted i'<>r a few days; gradual!] the swelling subsided, and after the end of a week more another effort was made to reduce under general anesthesia, with better results. After Fig. 13.?. — Supra-condylar fracture of humerus, lower fragment displaced upward and backward. a week of fixation in the correeted position the massage was begun again and continued for some weeks. Eventually the restoration of function was almost complete. (2) Fracture of the Condyles. — If the internal condyle is broken. 208 FRACTURES. swelling is marked over the inner side of the elbow. The condyle can be grasped between the fingers and crepitus elicited. The inner of the three bony points is displaced upward, which diminishes the carrying angle. The ulna is displaced upward in extension (Fig. 134). Fig. 133. — Fracture of external condyle of humerus in a child. The small mass near the joint line is the epiphysis of the radius. If the external condyle is broken the swelling is most noticeable externally. Although the external condyle is dislocated, its relations to the head of the radius are not changed. The fragments in either I\ I I RCONm LAB FRACT1 R] 5. 209 case are Likely to be easily reduced by pressure, bul the displacement immediately recurs when the pressure is removed (I'ig. 133). Reduction. ( Irasp the condyle between the finger and thumb of one hand and make pressure in the bend of the elbow with the other, and while the assistant slowly brings the forearm Into the position of acute flexion, manipulate the condyle into place. PlG. 134. — Frac- ture of internal con- dyle. (Moullm.) Fig. 13s. — Intercondylar fracture of humerus. (Monti in.) Treatment. — Scudder strongly recommends fixation in this position of acute flexion, maintaining it by passing an adhesive strip three inches wide about the wrist and upper arm, supporting the whole with a sling. He emphasizes the necessity of watching the circulation in the forearm and regulating the degree of flexion by the amount of swelling. (3) The intercondylar and multiple fractures involving the joint, as they do, require a very guarded prognosis (Fig. 135). By referring m 2IO FRACTURES. to the landmarks, the displacements are to be figured out and the fragments are to be manipulated until all the movements of the joint are restored. The forearm is then to be acutely flexed and fixed either by the adhesive strips, or plaster splints as before described. If the dis- placements cannot be held by this means the fracture must be treated by extension for a few days and then put up in acute flexion. Massage and passive motion must be very early begun in these cases and per- sisted in for a long time. FRACTURES OF THE FOREARM. Fracture of the shaft of the ulna and radius occurs more commonly in the middle third, both bones being broken or only one. If both are broken, the radius is likely to be broken at a higher level than the ulna. There is usually not much deformity if one bone is fractured; considerable if both are (Fig. 136). The diagnosis is to be made from the pain, deformity, mobility, and crepitation; supination is particularly painful if the radius is broken; lateral compression of the bones, even at some distance from the seat of fracture, may elicit much pain at the site of fracture. Reduction. — Flex the forearm at a right angle; direct the assistant to make countertraction from the arm; grasp the hand, place the arm in complete supination and make traction in the axis of the forearm, molding the fragments into place; the fingers, following the interosseous space down the front of the arm help to force the fragments apart. The preservation of the interosseous space is the essential thing. The extension and supination must be maintained until the dressing is applied. Whatever its form, the fixation must have one negative quality — it must not compress the forearm laterally or else the bones may be pressed toward each other and fusion occur. Anterior and posterior splints may be used, both wider than the forearm. The anterior must extend from the bend of the elbow to the base of the fingers; the posterior must extend from the elbow to the wrist. They may be shaped out of boards and well padded. The palm must be well padded. The splints are first secured with adhesive i k\n \ \<\ in mi: ioki \i-\i. 21 I ■trips and then with a roller bandage. The elbow is t<> be immobilized l>y suspension of forearm and hand in a sling (Fig. 137). ( 'arc- must be taken not to compress the bra< hial artery or the bony points. [nstead of the anterior and posterior splints a plaster cast mav be Pig. 136. — Fracture of tlu- shaft of ulna with separation of the epiphysis; fracture of the shaft of the rai llir NECK 01 mi FEMUR. 225 (d) Shortening is more frequently the accompaniment of impacted fracture. It is definitely determined by comparing with the sound side, measuring from the anterior superior spine (be sure the pelvis Pic. 156. — Impacted fracture of the anatomical neck of the femur. is not tilted) to the internal condyle and internal malleolus; also by determining the relation of the trochanter to Nelaton's line (Fig. 157). (c) Crepitation is proof incontestable but rarely available. One should make no effort to elicit this symptom, fearing to break up im- 15 226 FRACTURES. paction, which is an accident much to be deplored, according to the usually accepted view. Senn (Practical Surgery) says upon this point that it is better to be satisfied with the probable evidence of fracture. If the surgeon in his anxiety to obtain a perfect diagnosis moves the limb freely in all directions, he overcomes impaction, rup- rturing the cervical ligaments, demon-;; strating beyond all doubt the existence of the fracture and at the same time effectually destroying all hope of reunion. As Senn suggests, a useless limb is cer- tainly a high price to pay for a perfect diagnosis. The treatment resolves itself into two lines of procedure, depending upon whether or not the fracture is impacted. In either case the treatment should be modified by the age and constitution of the patient. Confinement on the back may be fatal in the aged, and it is impera- tive in such cases to give the patient more freedom. This imperfect immobilization may eventually result in an imperfect union, but one must be consoled by the reflection that a fatal attack of I57 .-Measurement of hypostatic pneumonia may have been lower extremity. Patient lying t J on the back looked at from above, preveilieu. ^oteZted aP &de S r:r d Hmbs In the case of undisturbed impaction, the treatment is of the simplest form. The patient is placed on a smooth mattress, the limb supported by sand bags or perhaps light extension applied, and systematic massage early instituted. In case there is much shortening with non-impaction and the patient's condition will permit, then the case must be treated on the same principles as fracture of the shaft. Senn advises prolonged immobilization in a plaster cast, which extends from the foot to the umbilicus, and is fenestrated for the ABDU< HON in FRACTURE or nil. FEMUR. 227 purpose of applying Lateral pressure, which he regards as essential to good union. J. B. Walker, of New York, is not in accord with the dictum that impacted fractures of the Deck of the femur should not be disturbed, and Whitman arees with him (Annals of Surgery, January, 1908). Unless the condition of the patient forbids, he proceeds gently to break up the impaction under anesthesia. The limb is reduced by extension and gradual abduction to an angle of forty-five degrees, in the mean- time supporting the upper end of the femur and rotating the leg inward. In this position, the limb is well covered with cotton batting, all the bony boints especially well protected and a flannel bandage smoothly applied. A plaster spica is now applied extending from the lower ribs to, and including, the foot. The plaster fits the pelvis snugly and is molded close to the trochanter and posterior aspect of the joint. It is also molded to the patella and condyles, and to the foot to prevent rotation. This dressing permits the patient to rise up in bed without much discomfort. Walker concludes from his experience that fracture of the neck of the femur occurs under fifty years more fre- quently than formerly believed; any injury of the hip followed by dis- ability should suggest fracture and calls for expert examination, aided by the X-ray wherever possible; that reduction of deformity and immobilization by plaster bandage in all suitable cases should be practised; that early gymnastic exercise is advisable; and that the weight should not be borne for three or four months. Whitman states that reduction under anesthesia by rotation and traction of the fragments, followed by fixation in abduction with a long spica plaster bandage, produces the best results. The advantage of abduction is that it makes the capsule tense and thus aligns the displaced fragments; that it directs the surface of the outer fragment toward that of the inner; that it relaxes the muscles that produce distortion by their traction; that it opposes the trochanter to the side of the pelvis and thus checks upward displacement. Repair in these fractures is slow and can hardly be completed within a year; thus prolonged after-treatment is necessary to restoration of function 1 J. A. M. A., Feb. 20, 1909). (2) Fracture of the Shaft of the Femur. — In this fracture the lower 228 FRACTURES. fragment is nearly always displaced forward and upward. If the fracture has been produced by direct force, it may be transverse, but this is the exception. The diagnosis is simple: shortening, eversion, loss of function. Manipulation is unnecessary and decidedly to be avoided, not only that the patient may be spared the pain, but also that the trauma may not be aggravated, the periosteum torn, the muscles bruised, the vessels injured. Reduction. — This must not be begun till all the dressings are quite ready. Lay the patient on the floor or on a hard mattress without pillows. One assistant grasps the thigh with both hands near the pelvis; the other assistant, the foot and lower third of the leg. As they make traction and countertraction the surgeon manipulates the fragments. The traction must be prolonged as these strong muscles relax only gradually. When the fracture is quite oblique and the pointed extremities are caught in the soft parts, a little patience will be required to free the fragments. To effect this, slight rotation and oscillation must be added to extension and abduction. How will one know that reduction is complete ? (i) These points must exactly correspond when the two limbs are placed side by side: the upper border of the two patellae, the lower border of the two internal malleoli, the two soles. (2) The limbs must be the same length by measurement from the anterior superior iliac spine to the inner malleolus. (3) The line dropped from the iliac spine to the malleolus must touch the inner border of the patelLe. Dressing. — Many forms of splints are described; many of them complex; all effective in some degree. Whatever the form employed, the limb must be frequently measured and the patient's general con- dition kept under close watch. Scudder highly recommends a modified Buck's extension (Treatment of Fractures, page 300, et seq.). Many are more successful with the plaster cast. Lejars recommends, as the simplest in emergency practice, the dressing of Tillaux. From a roll of adhesive plaster are cut eight or nine strips one and one-half inches wide, and long enough to extend TILT..\l\'s DRESSING FOB FRA< M B I 0] TEDS FEMUR. 229 from the level of fracture down the side of the limb, over the sole of the fooi after the manner of a stirrup, and up the opposite side of the leg to the level of the Fra< lure. Begin by applying one of the strips in the direction indicated. Next slip a strip transversely under the thigh, another under the calf, and a third under the ankle, and make one circular turn of each. Next apply a second longitudinal strip slightly overlapping the first; fol- low with another turn of each circular strip, and so on. In this manner the strips are given a firm attachment. Every point of contact of the adhesive must be perfectly smooth. Every longitudinal strip must extend the same distance as its fellows below the sole in order that the extension weight shall make uniform traction on all the components of the stirrup. A cord is fastened to the stirrup, passed through a pulley at the foot of the bed and a weight of five to ten pounds attached. If a pulley is not obtainable, a hole can be cut in the foot of the bed if it is wooden; or the cord may work over a broom handle attached to an iron bedstead. The weight must be increased in the case of the muscular or in the case of a very oblique fracture. A case will illustrate the difficulties which may attend reduction in these cases of fracture of middle of the shaft. A young man caught and crushed under a falling load of telegraph poles was brought to the City Hospital in full shock. It scarcely seemed possible for him to survive. It seemed certain that he must have had grave internal injuries though there was no direct evidence to that effect. The shock gradually subsided and no further evidence of visceral complication arising, attention was directed to his fractured femur, which was broken about the middle. Efforts at reduction were painless but wholly ineffectual in securing a coaptation. Continuous extension was ap- plied but after two days an X-ray examination showed the fragments still separated and overlapping. Later an open operation found the broken ends interlocked with muscular tissue. With some effort they were freed, coapted and wired. Some suppuration delayed repair, but he finally recovered with a good limb. (3) Supracondylar fractures derive their importance from the Ere 23° FRACTURES. quency with which the fragments involve the knee joint or the struc- tures in the popliteal space, and from the difficulty of maintaining coaptation. Both these characteristics depend upon the obliquity Fig. 158. — Separation of epiphysis of lower end of femur; below is shown the epiphysis of the tibia in its normal relation. of the fracture which usually extends from behind downward and forward. The complications must be treated on general principles. The fixation may be any of the means just described for fractures of the shaft. In this case as in any very oblique fracture, flexion of knee and hip seem specially indicated. FRACTURE in nil PATELLA. 231 Hennequin's apparatus, which Lejars describes, secures an effi- ■ent extension, combined \\ ith Sexion of the hip and knee and permits the patient to sit up. Downey, of ( rainesville, ( la., has thought out a device which involves the same principles as the Hennequin apparatus but is simpler ill application. As Downey remarks (Jour. Am. Med. Assn., Aug. 25, [906) the dressing aims to secure at once the position of the Esmarch, Smith, Hodgen, or Cabol apparatus; the extension of the Buck apparatus; the fixation of plaster of Paris. This is accomplished by means of a double angular plaster-ol-l'aris splint. The mode of application (briefly) is this: Secure countertraction by a padded sheet passed between the legs and brought well up against the perineum; traction, by grasping the leg above the ankle with one hand, under the knee with the other. A plaster cast is applied from the toes to just above the knee, which is well flexed. Now secure coaptation. Next apply the second section of the cast, beginning at the upper border of the first and carrying the roller in the ordinary manner up to the ensiform, all the while maintaining the traction with hip well flexed. Strengthen the outer side of the cast at the hip-joint by up-and- down folds of the roller or by metal splints. Split the splint if con- st fiction is feared. Fracture of the Patella. Fractures of the patella are comparable with those of the olecranon. They may be transverse, such are usually fractures resulting from indirect force; or they may be vertical, or oblique, or multiple (Figs. 159, 160, 161). There are two obstacles to osseous reunion: the action of tin 1 quadriceps extensor and the intervention of the patellar fascias, pre- venting exact coaptation. In spite of these unfavorable circumstances, there is generally some form of fibrous reunion unless the fragments are very widely separated (Fig. 162). The treatment of the present time is by one of two methods — mas- sage or suture. If the fracture is transverse, with very little separa- tion, and the conditions are not favorable for an aseptic operation, 232 FRACTURES. massage may be expected to give a good functional result. If the separation is considerable, massage will still give a better result than any splints. In any case suturing is the ideal form, although the ideal cannot always be attained. Again, every compound fracture should be im- Fig. 159. — Transverse fracture of the patella. mediately sutured. J. H. Ford, whose experience with these frac- tures has been large, describes his method of procedure in ordinary fracture (Ind. Medical Jour., July, 1907). In the non-operative cases he begins by elevating the limb for several days to relax the quadriceps. If there is effusion he bandages lightly FRACTURE OF TlIE PAT M.I.N. 233 with a flannel roller, or if the bemarthrosis is marked, a firm con- striction is practised or ice-bags applied. PlG. 160. — Transverse frac- ture of patella. (Moullin.) Fir,. 161. — Comminuted frac- ture of patella. (Moullin.) As soon as the acute symptoms have subsided, which is after three to five days, massage is instituted and daily applied. Begin with gentle constriction of the joint with the hands by an upward movement, and ending with more vigorous pres- sure of the sides of the patella and the joint. In the intervals the limb should be maintained on a posterior splint. After from four to six weeks of treatment, he immobilizes the joint in a plaster cast, preferably for two weeks more, and subsequently he recommends a morning and evening massage and flannel bandaging until the functions are practically restored. The operative treatment is by no means simple, yet by no means beyond the skill of anyone Nvho knoNvs how to secure asepsis and to apply a bone suture. Begin with a semilunar inci- sion, concave upward, well below the line of fracture and reaching to either border of the patella. Raise the cut*- SrS^rS^ neous flap and expose the patella. The articulation is carefully wiped out and freed of all fragments and clots. 234 FRACTURES. Fixing the upper fragment between the finger and thumb, two slight incisions are made in the periosteum at the points where the drill is expected to enter. Two tunnels are now drilled from -above, emerg- ing on the face of the fracture well outside the line of the cartilage. The sutures are drawn through these openings and the process is re- peated in the lower fragment, but great care must be used in securing Fig. 163. — Suture of patella. MethocTof drilling and passing sutures. (Labey.) a correspondence with the first two drill holes or the coaptation will be imperfect (Fig. 163). By traction on the sutures the fragments are brought together, and great care is necessary to avoid including shreds of fascia. The sutures are tied, twisted firmly, and pressed down upon the bone. The periosteum and fibrous coverings are next sutured with catgut (Fig. 164). SUTl'Ki OF nil PAT! l LA. *35 Ford prefers not to wire, but, after approximation, sutures the lateral fascia with No. 3 forty day chromicized catgut and the aponeurosis in front with No. 1. A No. 1 forty-day suture, 18 inches long, is then threaded on a Strong, half curved needle which is entered into the aponeurosis just above and on a line with the outer edge of the patella and follows the upper border of the patella to the inner side where it emerges; is re entered and carried down the inner side; again around the lower fragment, passing through the ligamentum patella Fig. 16.1. — Suture of patella. Completing repair by suture of periosteum and fibrous coverings. (Labey.) and emerging at its outer border. This retention suture is now tied tightly at this last point of emergence (Fig. 165). The skin wound is next repaired without drainage. The limb is subsequently immobil- ized for two weeks when massage is to be begun. Ford lays down these rules respecting the treatment of simple transverse fracture: (1) Operative treatment should never be undertaken except under the best conditions for maintaining asepsis. 236 FRACTURES. (2) Even under aseptic conditions not every case should be operated on, but only those in which the separation is at least one-half inch and the "reserve extension apparatus" is compromised by lateral tears. (3) Operative treatment fulfills all the indications in a degree which the non-operative treatment can only partially achieve. Fig. 165. — Fracture of patella. Circular suture. (Labey.) (4) Early massage favors complete restoration of function and should be used in all cases. (5) In operative treatment open arthrotomy should be practised. (6) Absorbable suture material applied only to the soft parts is sufficient in nearly every case. FRACTURES OF THE LEG. Fractures of the leg present many variations, but the prognosis and the difficulties of treatment depend chiefly upon whether the fracture is transverse or oblique. If transverse there is usually slight displacement, easily reduced and easily maintained; if oblique there may be much displacement which is difficult to reduce and hold, and often results in much loss of function. !'KA( I I Kl ()!■ 1111 III.. 237 Transverse fractures more commonly arc due to direct force and the lesion corresponds to the application of force. Oblique fractures are more commonly due to indirect force and the two bones give way at their point of least resistance, which in the case of the tibia is at the ■unction of the middle and lower third; in the case of the fibula in the upper third. In general, displacement is always favored if both bones are fractured. The diagnosis of these injuries usually offers but little difficulty. The deformity, loss of function, pain and crepitus, and preternatural mobility leave but little doubt except when the injury is at the upper end, and where the joint may be involved, or when PlO. 166. — Cloth cut to fit the limb ami gore] at the ankle in order to be more easily adjusted to the malleoli when it is soaked with plaster. (Lejars.) the fibula alone is fractured. A useful test for fracture of the fibula is compression of the two bones some distance from the suspected site; the pain occurs not at the point of pressure but at the point of fracture. Reduction. — The assistant grasps the leg at the knee, the surgeon the foot, seizing the foot with one hand and the heel with the other; or two assistants may make the necessary traction while the surgeon manipu- lates the fragments. What is the test of good coaptation? The crest of the tibia forms a continuous line without projections or depressions. This line pro- 2 3 8 FRACTURES. longed strikes the first metacarpal space. The internal surface of the tibia is smooth and uniform. With the foot at a right angle, a line dropped from the anterior superior iliac spine to the inner border of the great toe touches the inner border of the patella. Dressing. — This will vary somewhat, depending upon the situation and tendency to displacement. In the simple case of fracture of the Fig. 167. — Plaster splint applied and fixed with roller plaster bandage. Note manner of supporting limb and applying roller. (Lejars.) shaft of the tibia, following the counsel of Stimson (Fractures and Dis- location, page 381 et seq.), it is best to put the patient to bed with the limb in a Volkmann splint for about a week until the swelling has sub- sided, and then to encase it in plaster of Paris. Immediate applica- tion of the plaster of Paris is objectionable because it cannot be deter- mined from the first whether the swelling will increase or diminish. The two dressings may be combined by applying a plaster splint from the first. I'l \si i R SPLINT FOB mi LEG. 239 Lejaxs describes the construction of such a splint. He measures from the middle of the thigh down to the heel and up the sole to the toes, and this will be the length of the sixteen layers of crinoline from which the splint is to be made. Take the circumference of the thigh, the knee, the middle of the leg, the ankle, and transfer the measures to the crinoline which was cut wide enough in the first place to encircle the thigh. Connect the ends of these cross measurements with a chalk line and in this manner one forms a rough outline of the limb, and the bandage is cut accordingly. Some prefer to apply the material to the sound limb and mark it off in that way. Opposite the ankle a notch should be cut in the dressing, running toward the heel, that the dressing may be more readily fitted (Fig. 166). This is soaked with liquid plaster and applied while the ex- tension and counterextension are maintained and the foot fixed at a right angle. This tension must not be relaxed until the plaster has hardened. The dressing is com- pleted by applying a roller bandage (Fig. 167). Oblique fractures, which are hard to hold, are likely to be near the lower end, for the quadriceps extensor pulls the upper fragment forward, and the gastrocnemius pulls the lower fragment backward. The special form of dressing which Scudder recommends for this form of fracture is made by a combination of plaster ami adhesive strips. Fig. 168. — Plaster traction splint: a. Application of adhesive-plaster extension strips; (>, plaster bandage allowing exit of extension straps. Note space left below the sole to allow for effective traction and buckles to which the upper extension is attached. (Scudder.) 240 FRACTURES. The adhesive strips are applied as indicated (Fig. 168). A thick rod of sheet wadding is applied to the sole of the foot, and a plaster bandage applied from the toes to above the knee. A buckle looking upward is incorporated in the plaster just above the level of the knee. A slit is Fig. 169. -Fracture of the tubercle or anterior tuberosity of the tibia ; point of insertion of the ligamentum patellas. left in each side at the ankle for the lower extension strips to come through. When the plaster has hardened, the upper extension strips are fastened in the buckles and the lower extension strips pulled out through the slits and drawn tight around the foot piece after the wad- POTT S FRACTURE. 24] ning al the sole has been removed. The purpose of this arrangement is to maintain extension. Whatever form of dressing is used the limb must he watched to see that DO displacement occurs. While a simple fracture usually PlO. 1 70. — Pott's fracture. Fracture of the fibula and of the internal malleolus. firmly unites within six weeks, those which have been hard to keep reduced will remain weak much longer. As soon as there is sufficient union to prevent displacement, then massage should be begun and con- tinued till the limb's functions are restored. 16 242 FRACTURES. Pott's Fracture. — Fracture of the fibula with eversion and ab- duction has a character of its own. As Stimson remarks, the diagnosis can usually be made at a glance (Fig. 172). Three points of tenderness on pressure are constant and characteristic: one in the groove between Fig. 171. — Fracture of the shaft of the fibula. Too high for a Pott's. the tibia and external malleolus; another at the base of the internal malleolus; the third over the outer aspect of the fibula marking the point of fracture. Marked ecchymosis appears beneath the external malleolus and sometimes beneath the internal (Figs. 170, 171). I'ol I S 1 K All I R] . 243 Reduction. — Grasp the foot in one hand, the heel in the other, and while ihr leg is steadied by the assistant, draw the foot forward and inward. If this does not entirely succeed, the fragments may be pressed into place. With the foot at a right angle and the malleoli in their normal relations, the dressing is applied. This dressing, to quote Stimsoo further, is preferably a posterior and lateral plaster splint although the plaster cast may be used. The plaster splint may be made from twelve to thirteen Layers, cut from a four-inch plaster roller. The posterior splint should be long enough to extend from the toes along the sole and up the calf nearly to the knee (Fig. 173). The lateral one should begin just in front of the external malleolus, pass over the dorsum of the foot to the inner side, under the whole and up along the outer side of the leg to the same height as the posterior (Fig. 174). They are snugly molded and bound to the limb while still wet, with a roller bandage. In the meantime, till the plaster sets, the reduction must be main- tained. Dupuytren's splint is often of great service in this fracture, especially as a temporary dressing. It consists of internal lateral splint, well padded over the ankle and which extends from above the knee and projects beyond the foot. It is held in place by a bandage at the knee and above the ankle. The foot is then put in abduction at right angles to the leg and secured to the splint by a third bandage (Fig. 175). PlG. 173. — Pott's fracture. FRACTURE OF THE SCAPULA. Fracture of the neck of the scapula might be mistaken for fracture or dislocation of the humerus (Fig. 176). The head, however, can be 244 FRACTURES. Fig. 173. — Posterior splint applied. (Stimson.) Fig. 174. — Lateral splint applied. (Stimson.) Fig. 175. — Dupuytren's splint. Temporary dressing forjPott's fracture. I k M I I R] 01 l in. SCAP1 l \. 245 felt to rotate, which it would not do in dislocation. The deformity disappears on lifting the arm forcibly upward with the elbow Hexed, which docs not happen in a case of fracture of the humerus; the arm hangs vertically at the side and is mobile. There is no notching of the deltoid. In the case of fracture of the sur- gical neck of the humerus with over- riding, the arm is shortened. In case of fracture of the scapular neck, the arm is lengthened. Generally speaking, the diagnosis of any fracture of the scapula is to he made from crepitus, abnormal mobility, local tenderness, and more or less complete loss of certain functions. Begin the examination by inspection and measurement. Note any loss of contour; any lengthening or shortening of arm. To elicit crepitus, apply one hand to the body of scapula and with the other make traction on the arm. In thin subjects the lower end of the scapula may be readily grasped. Treatment. — The flexed elbow should be well supported by a sling, and the arm fixed at the side. Massage will relieve the pain and hasten repair. Mayor's sling furnishes an excellent dressing. Fig. 176.- Fracture of the neck of the scapula. FRACTURE OF Till: PELVIS. Fracture of the pelvis may be suspected from the character of the injury, which is usually a fall or a crush. The diagnosis is to be con- firmed by external palpation of the ilium, pubes, and ischium on each side, and by careful rectal and vaginal examination. Disturbance of normal relations, tenderness on pressure, crepitation perhaps, and difficulty in walking indicate fracture (Fig. 177). The treatment in uncomplicated cases is quite simple, rest in bed and some kind of pelvic immobilization such as adhesive strapping. 246 FRACTURES. represent the elements of relief. It is quite different if there are com- plications. If a catheter cannot be passed (and this should always be tried), it will be necessary to do an external urethrotomy for the ruptured urethra. If the catheter finds the bladder empty and ruptured, a lap- arotomy is imperative. If the exact complications cannot be deter- Fig. 177. — Fracture of the pelvis through the obturator foramen and dislocation at the sacroiliac joints. (Moullin.) mined and yet shock, pain, and increasing abdominal tension, with signs of sepsis, point to a lesion of bladder or rectum, the abdomen must be opened, and the visceral injury found and repaired. Following a variety of traumatisms there is often a condition now well recognized as relaxation of the sacro-iliac synchondrosis which simulates fracture and which may become quite chronic. It is re- lieved by adhesive strapping. COMPOUND FRACTURES. Every compound fracture, whether the skin wound be large or small, increases the danger over simple fractures, both with respect to function and even life. i Ki \l\li NT OF COMPOUND FRACTURES. 247 The outcome, as has so often been said, depends largely on the first treatment. The indications are various and depend upon the amount of fragmentation, the degree of destruction of the soft parts and the injury to the blood vessels. It is necessary to divide these injuries into several clinical groups. (Sec- I. e jars. Chirurgie d'Urgence, p. 1017 ct sec].) 1. Compound comminuted fracture with no injury to the vessels, with slight injury to the soft parts, and small skin wound is most commonly seen in oblique fractures of the tibia (Fig. 178). The break in the skin skin is slight and yet it is actual and must be regarded as infected. Fig. 178. — Compound fracture of tibia. (Moullin.) Do not be satisfied with merely washing the skin or applying a simple occlusive dressing. This may be sufficient in the case of gun- shot wounds; the circumstances may permit of no further treatment: and many cases will get well with nothing more, but that is significant of only one thing — that by good luck the wound was not inlet ted. Whether the wound is or is not infected, one can never tell. He must await the eventualities. Therefore, that chance may not enter in, one must exercise the same care as if he were certain the germs were there. A general anesthesia is usually not necessary. Begin by carefully ster- ilizing the surface about the wound. Scrub with soap and water, wa>h with ether and then with alcohol and finally with bichloride. Enlarge the wound sufficiently that it may be irrigated with hot sterile water or normal salt solution. Carefully clear out all debris with as little injury as possible to all the tissues concerned. When the 248 FRACTURES. cleaning is complete, if circumstances are favorable, the wound is sutured and drainage employed. Occasionally, it may be closed completely without drainage. Sometimes it must be left wide open, packed with sterile gauze and bandaged. Adjustment and Immobilization. — Reposition requires great care and it must be exact. Unless the fragments are extremely difficult to hold in place, requiring wiring, the limb may be immobilized with a plaster splint, leaving an opening sufficient for the inspection of the wound. Gangrene is little to be feared unless, indeed, the bandages are care- lessly applied, interfering with the circulation. Immobilization is the best method for relieving pain. Carry out a careful disinfection, a careful adjustment of the fragments, a careful immobilization in a good position, and one may confidently expect in such cases an excellent result. 2 . Compound Fracture with much Comminution and Great Destruction to the Soft Parts, Little Injury to the Blood Vessels. — A general anesthesia will be necessary. Prepare the field as before and flush out the wound cavity with hot sterilized water. Trim away the fragments of fascia and muscle, but in this do not be too radical. Such of these shreds as retain their blood supply can help later to fill the wound. Especially do not remove with too free a hand the fragments of the bone. Only such fragments as are completely isolated and deprived of their peri- osteum are to be extracted so that later they may not play the part of foreign bodies (Fig. 179). Lowery, of Carbondale, injects the cavities with a mixture of carbolic acid 95 per cent, and glycerine 5 per cent., following this with alcohol. A glass syringe is used, and the aim is to force the solutions into the deepest recesses of the wound (J. A. M. A., Oct. 31, 1909). The second step consists of reposition and adjustment, often with difficulty accomplished and many times requiring wiring or suturing. The wound may be sutured, but must be drained. More important even than accurate coaptation in these cases is continuous extension; for that reason the fixation dressing must be given special attention. If no fever arises, leave the dressing undisturbed for eight to ten days. The danger from infection is then passed and the immobilization and extension may be continued as long as necessary. TRKATMIA'T <>K < < >\l l'< >l \ I > I K.\( 11 K I S. 249 3. Compound Fracture, Obviously Infected. — You see the case per- haps some days after the injury. It has been neglected. Marked Inflammation is present. You are confronted by the possibilities of phlegmon or tetanus. These may develop with the greatest rapidity and continue uninterruptedly to death. How shall one act in the presence of these filthy or already infected or inflamed fractures? To amputate would have been in pre-antiseptic Fig. 179. — Compound fracture and dislocation at the wrist. Hand saved. (Scudder.) days the proper procedure, but not to-day and especially not in the recent case. Enlarge the wound freely. Remove the coarsest dirt by irrigation and then patiently and pirseveringly, wiping with sterile compresses while flushing, complete the toilet of the individual tissues, one at a time. The fragments of bone must be separated and the remotest nook of the wound sought out, that the cleansing may be complete. Do not spare time or patience. If the projecting fragment of bone is saturated with dirt, manifestly devitalized, resect it, not transversely, 250 FRACTURES. however, after the manner of an amputation, but following some type of plastic operation which will diminish, as much as possible, the loss of bone and consequent shortening of the limb. Finally the wound is flushed with peroxide of hydrogen and wrapped with sterile gauze saturated with the same solution. With the frag- ments coapted as much as may be by simple manoeuvres, though one cannot hope to achieve much in this respect, the drainage is applied and must be ample. The limb is put at rest, and with anxiety the out- come is awaited. The issue may be fortunate. General and local infection may be successfully combated and later the bone union may be secured. On the other hand, should general infection be imminent or gangrene ensue or the limb be from the first manifestly destroyed, there is no choice but to amputate. COMPOUND FRACTURE ABOUT THE ANKLE AND FOOT. Fractures of this variety are frequent; always serious; and the prog- nosis more or less uncertain, depending upon the degree of infection and destruction of the soft parts. Suppose a fracture of the inner malleolus: the^oft parts are widely separated, the joint cavity exposed, the astragalus dislocated. Such an injury must be as conservatively treated as an abdominal wound. Under no circumstances must the wound be explored with unclean fingers or without careful cleansing of the field. Only after all the preparations for definite treatment are made is the wound to be ex- amined. If transportation is necessary, a temporary splint is pro- vided, but at least do not cover the wound with a dirty handkerchief. If there is much hemorrhage, circular constriction of the leg about the knee will temporarily suffice. The first dressing will determine the future of the limb, perhaps even the life or death of the wounded. The whole foot and the lower half of the leg are most carefully disinfected and the fracture and joint cavity irrigated with hot sterile water, exposing every nook and corner in order to flush out foreign bodies, splinters of bone and clots of bl ( c TREATMENT OF COMPOUND FRA< I I RES. 25 1 In this case, merely chosen for example, the destruction of tissue is unusually light. After the cleansing, replace the parts, leave one or two drains in the partly sutured wound, bandage amply and place the limb at rest. The situation is less simple where there is much destruction of tissue, as in the case where the ankle is crushed. Begin with hot irrigations. Do not fear to enlarge the wound freely. It is of great importance that one be able to determine definitely the conditions in the wound and to see what he is doing. You may find large fragments deformed and overlapping. Try to replace them and often you will be thus enabled to restore the con- tour of the joint. To retain these fragments, wiring or nailing the fragments, if in a position to carry it out, will be an almost indispen- sable aid. Another case: The epiphyses are reduced to fragments of various sizes and forms. In irrigating, they flow away with the solution, so loosened are they. The rest hang by a mere shred. Reposition is here useless. The wreck is too great. You must proceed to do an atypical resection. Do your best to spare the malleoli or at least two processes which will serve to prevent lateral dislocation when the joint is healed. After this operation insert two drainage-tubes, one on either side ; and if there is considerable oozing, add an aseptic tamponade. The prognosis is worse if infection lias developed and there is fever, redness, and swelling in the limb. Amputation will be the measure of last resort and yet do not amputate until free opening has again been tried. Irrigate with peroxide. The removal of dead bone, etc., is followed by deep drainage but this must be done without delay. It is not union, or consolidation, or function of the limb which is the chief concern. It is infection against which all the forces of antisepsis are marshalled. Osteomyelitis or myelitis is the contingency feared. In such a case, do not employ a typical amputation or resection, but an atypical one, removing only such tissues as must be removed, and later when the infection has disappeared, the necessary operations may be done. CHAPTER XIV. INJURIES TO JOINTS. Dislocations; Compound Dislocations; Open Wounds; Contusions; Sprains. DISLOCATIONS. Shoulder-joint. — Of all the joints, the shoulder is by far the most frequently dislocated. Of these dislocations, there are several forms, and yet only one variety is likely to be met with by the general practi- tioner — the sub-coracoid. A clear conception of the conditions and of the manoeuvres necessary to a reduction presupposes a very definite notion of the anatomy of the joint. Recall the relation of the acromion and coracoid processes to the glenoid fossa, to the head of the humerus and to the capsular liga- ment; the relation of the long head of the biceps to the joint and the attachments and actions of the various muscles surrounding the joint, particularly the sub-scapularis, the spinati, the pectoralis major; and the relations of the axillary vessels and nerves. However simple a case may appear, do not begin any manoeuvre until a complete diagnosis has been made. Diagnosis. — Begin by inspection. The patient is in evident pain; his head is inclined to the injured side and he supports the injured member with the other hand; the shoulder is flattened, the rounded prominence of the deltoid has disappeared and the acromion projects; the elbow is abducted and the patient is unable to bring it down to the side. Palpation reveals the axis of the humerus pointing to the middle of the clavicle; the examining finger can be pushed under the acromion where the humeral head should be. The humeral head itself may be felt below or to the inside of the coracoid, and rotates with slight rotation of the arm. 252 ki.ih rnoN «'i 1 111 siloi ii'i B JOINT. 253 The fingers in the axillary spate feci the rounded head of the hu- merus projecting inward more noticeably when the arm is slightly Abducted. This question arises: "Is ii a case of simple dislocation, or is it complicated by a fracture of the upper end of the humerus, of the great tuberosity, or the rim of the glenoid fossa?" ''Have the arteries or nerves been injured?" You must test particularly for laceration of the circumflex nerve. Do this by pin pricks over the deltoid; if the skin is insensitive, forecast paralysis and atrophy of the deltoid, and thus anticipate and disarm censure. Reduction. — (Lcjars.) The method of Kocher seldom fails, if properlv applied, and if the various movements are modified to suit the individual ease. Its purpose is to put the head of the humerus in the position at which it left the capsule. Through the relaxed tear the head is then to be levered into the socket. Seat the patient in a chair facing a little to one side. Let a strong and able assistant, standing behind, seize the patient's shoulder firmly and make pressure downward and backward. Place yourself before the dislocation, and seizing (in the case of the left arm) the forearm at the el I iow with the left hand, and the wrist with the right hand, direct the patient to hold the head up and look straight ahead. First Stage: l-'lc.xion, Adduction. — The elbow is flexed and then gradually adducted until it touches the body, the wrist held firmly meanwhile. The elbow is now pushed backward beyond the axillary line — the first stage is not complete without this. Neglecting this part of the first manoeuvre is a frequent cause of failure. Do not get in too gnat a hurry. Remember that the larger part of the resistance is due to the muscles and that they yield only gradually. Too sudden and too violent traction on them augments the pain and their resistance. To pause a little now, gives them time to relax (Fig. 180). Second Stage: External Rotation.— Hold the elbow fast and flexed at a right angle, and now with your right hand, swing the forearm outward and backward until it lies in the transverse vertical plane of the body (Fig. iS 1 I. Its axis lies directly in front of you. Perform the manoeuvre cautiously and smoothly. Again pause until the mus< les are relaxed. Do not be alarmed by the snapping distinctly heard 254 INJURIES TO JOINTS. in the movement. One may follow the movement of the bulging head of the humerus with the eye. Occasionally reposition occurs at the' end of this movement, if it has been carried out methodically, or at J least at the beginning of the third stage. Fig.^i8o. — Reduction of shoulder. First stage : Flexation ; adduction; elbow a little posterior to the axillary line. Third Stage: Elevation. — Maintaining flexion and external rotation, next lift the elbow upward and forward — upward and forward exactly — do not permit the elbow to move outward. Abduction will spoil the R] in (i [ON 01 i hi sum LDEB rOINT. 255 manoeuvre (Fig. 182). Lift upward and forward till the arm reaches the horizontal — a sudden snap indicates that the head has slipped into the socket. Pig. 1 8 > . Reduction of shoulder. Second stage: External rotation until fore- arm stands at ri^'ht ai.Rle to body Fourth Stage: Inter/ml Rotation. — Proceed now rapidly to swing the forearm inward and across the chest until the hand rests on the oppo- site shoulder (Fig. 183). The movement is made rapidly hut with no great force. This latter holds good with respect to all the movements. 256 INJURIES TO JOINTS. It must be observed that the surgeon's hands do not change their hold at any stage of the reduction. If these manoeuvres fail, repeat them in the same order, using a little Fig. 182. — Reduction of shoulder. Third stage: Elevation while maintaining external rotation. more force in the second and third stages and pausing a little longer at the end of a stage. In the sub-clavicular form also this manoeuvre will succeed, but should be modified to this extent: prolong the second stage two or ki hi CTION OP mi SHOU1 in B JOIN r. 257 three minutes, using more force to obtain external rotation and the backward position of the elbow. In this wise, the muscles arc re- laxed more completely. Without changing the external outward ro- tation, the elbow is lilted upward and forward as before Pig. 183.— Reduction of shoulder. Fourth stage. Internal rotation. Not less efficient in certain cases of sub-coracoid dislocation is the method of Mothe, or traction in extreme abduction. It is also applicable in all other forms of inward and downward dislocation. In this procedure, COUnterextension is indispensable. A long towel *7 25 8 INJURIES TO JOINTS. will serve. It encircles the injured shoulder, passing under the arm- pit, and the two ends cross the back toward the sound side. While the assistant makes forcible counter-extension, the operator manipulates Fig. i 34. — Reduction of shoulder. Traction with high abduction. The axis of the humerus should be in line with the spine of scapula. Assistant steadies the shoulder. the arm. It is best that he stand on a stool or chair if not tall enough to make good traction upward. Now seize the arm above the elbow and the forearm near the wrist (Fig. 184). Flex the elbow. Next elevate the arm by extreme abduction until it is in line with the spine REDUC1 [ON 01 l Hi SHOULD! B JOINT. 259 of the scapula. The arm, you must observe, does not reach the horizontal merely, it is elevated beyond thai level. This is <>| the greatest importance. With the arm thus in extreme abduction, next nake strong traction in thai direction (Fig. [85). Assistance in trac- non may be necessary; or one may confide the traction to an assistant, 1S5 Reduction by high abduction and traction. Mote manner in which the assistant steadies the she irs.) while- with the thumbs, one pushes against the humeral head in the axillary space. If this docs not succeed, begin the second stage: Depress the arm rapidly and smoothly. Letting the point of the clliow pass in front of the chest, all the while maintaining traction. This method occasionally fails for these reasons: 260 INJURIES TO JOINTS. (i) Traction with high abduction is not long enough continued. The arm is depressed before the head has been sufficiently elevated by- traction. (2) The arm is lowered too slowly. Fig. 186. — Chipman's method of reducing dislocated shoulder. First stage. (International Journal of Surgery.) In neglected cases or in the very muscular, general anesthesia may be indispensable whatever the method, but force must then be em- ployed with still greater care, and it must be borne in mind, too, that incomplete anesthesia here is as dangerous as it is useless. The par- ri m < i ion or Till SHOl I Dl R JOINT. .:<>\ ■cular danger of this method is laceration of the axillary structures. If general anesthesia is strongly contraindicated, local anesthesia may be Employed, injecting the joint and the tendons near their lines of inser- tion. How long after the injury reduction may be attempted cannol ^^^r^ ^^^B ■ ;• * Imc. i S7. Cliipman's method of reducing dislocated shoulder. Second stage. {International Journal of Surgery.) he determined by any rule, hut by the conditions in the individual ease. Chipman, of New London, Connecticut, suggests a method which mii-l prove of value, especially to the doctor compelled to act without assistance. 262 INJURIES TO JOINTS. He describes his method thus (Int. Journal of Surgery, November, 1906): Stand facing your patient. Gradually raise the dislocated arm to a horizontal position and place it on your shoulder with forearm flexed on your back. Direct the patient to pass the well arm under your arm and grasp the wrist of the injured arm with the well hand. Thus the patient's arms encircle your body, the injured one passing over one shoulder, the sound passing under the other (Fig. 186). Second Stage. — Now direct the patient to sag downward, and the weight of the body drags the head of the humerus outward and up- Dislocation of shoulder. (Walsham.) ward, when you can easily return it to the glenoid cavity with your hands (Fig. 187). The dislocation is so easily and expeditiously re- duced that even the surgeon himself is surprised. There is the least possible additional injury, the least possible pain; there is no need of an assistant or an anesthetic. SUB-GLENOID DISLOCATION. This variety is always the result of forcible abduction of the humerus, the tear in the capsule falling below the glenoid cavity, and the head of the humerus remaining fixed there (Fig. 188). The diagnosis is to be made from the symptoms already described for the sub-coracoid form, the only difference being that the elbow ki mi i [( »N 0] -i B <•! i MOID DISLOCA flON. 263 is further from the chest, the flattening of the shoulder more pro- nounced, the luad of the humerus more readily felt in the axilla Eg. [89). Pig. 189.— Reduction of a subglenoid dislocation. Second stage. Gradual elevation with constant traction. The reduction may be affected by BLocher's method, but perhaps tin- best method is that of extreme abduction with traction, which has already been described. The patient may be seated, bul often must recline, for the weight of the pendent limb may be very painful. The 264 INJURIES TO JOINTS. injured member is grasped above the elbow with one hand, below the wrist with the other, flexed, slowly raised to form an obtuse angle with the chest. In this position strong traction and countertraction are to Fig. 190— Reduction of sub-glenoid dislocation. Third stage. Traction with high abduction and pressure on the humeral head. be made. Usually this succeeds, though it may help to press the head into place (Fig. 190). If traction and pressure are not sufficient to effect reduction after the muscles have been thoroughly relaxed, the arm is to be depressed as before described. \i i i R iki \ I \li N r OF SHOULDER DISLOCATION. 265 Sub spinous Dislocation. — In this case the shoulder is flattened in fronl and the examining linger finds a marked depression between the tip of the acromion process and the coracoid. The elbow is carried slightly forward and the arm rotated inward. The head of the hu- merus can he felt below the spine of the scapula. Reduction.- General anesthesia is usually necessary. Grasp the arm above the elbow; slightly abduct the arm; slightly increase the inward rotation (never rotate outward); make traction in a direction downward and forward. Pressure forward on the head is helpful. AFTER-TREATMENT OF SHOULDER DISLOCATIONS. The task in any form of dislocation does not end with reduction. There is still the duty to restore usefulness as completely as possible, and to that end the subsequent care must be minutely regulated. The inclination is to immobilize the joint too completely and too long, fearing a recurrence of the dislocation. This enforced rest combined with injury is liable to produce atrophy of the muscles, stiffness of the joint, and protracted loss of function. The indications for after- treatment arc vari ;us, depending upon clinical conditions. (A) An uncomplicated, easily reduced dislocation in a healthy strong adult: Begin by immobilizing "the shoulder, but take care that after three or four days of complete rest massage and passive motion shall be begun. The joint is cautiously put through all its motions, the deltoid, and pect ralis major, and the scapular muscles carefully massaged; a daily seance gradually prolonged. In the interval the arm is bandaged, but gradually the dressing is relaxed and, after a week, movement left quite free. In two weeks of such treatment the function may be entirely restored. (B) The case was complicated with injury to the soft parts, was with difficulty reduced, and only after a number of attempts; it is likely that the capsular ligament was extremely lacerated: Under such circumstances not only passive displacement, but actual dislocation is to In- feared. Immobilize the joint with a Mayor sling or Velpeau bandage and let it so remain a week. But this will not prevent massage over the shoulder after four or five days. Do 266 INJURIES TO JOINTS. not prolong the fixation, remembering that a dislocation accompanied by great violence furnishes the condition most favorable to adhesions and weakness, and against these evils we have no remedies but 'mas- sage and gymnastics, which must be early begun and long continued. DISLOCATION OF THE LOWER JAW. This accident, which may happen at most unexpected times, when yawning or laughing, for instance, might be confused with certain fractures of the inferior maxilla. The opened mouth, the loss of power to close it, are characteristic (Fig. 191). The reduction is usually easy. Both sides may be reduced simultaneously. Wrap the thumbs; you have to deal with the powerful muscles of mastica- tion, which, when the dislocation is reduced, are likely to close the jaws with much force. The thumbs, passed into the mouth, press downward and back- ward on the molar teeth; at the same time, the fingers hooked under Fig. 191.— Dislocation of jaw. {MouiUn.) the chin pull upward. In the mus- cular, considerable force is required. The jaws should be moved only slightly for several days. DISLOCATION OF THE ELBOW. Dislocation of the elbow, which occurs with considerable frequency, especially in children, nearly always assumes the form of backward displacement. Diagnosis.- — The elbow is increased in thickness antero-posteriorly. The flexure of the joint is depressed. Where the head of the radius should be there is a depression. The olecranon is abnormally promi- REDUCTION OF Till ELBOW-JOINT. 267 ni'iit. Compare the relation of the olecranon to the inner condylar lines f the knee. Gradual tK-xion of the hip with traction on thigh. kbulum into place. Continue traction t<> some extent, but rotate the pigh outward and at the same time abduct. All the other methods proposed are hut modifications of this (Fig. 200). 18 274 INJURIES TO JOINTS. ISCHIATIC DISLOCATION. Diagnostic points: Adduction, inward rotation, marked flexion of both knee and hip (Fig. 201). Fig. 200. — Reduction of hip. Third stage. External rotation. Hip strongly flexed. Reduction .— ^By the same method as the dorsum ilii. Do not begin the final movement of abduction and external rotation too soon. Sill IMIIIC MSI OCA HON. 275 SUB-PUBIC DISLOCATION. Diagnostic points: Compared with the ischiatic an opposite con- ation of affairs exists abduction, external rotation and extension. 1'he great trochanter cannot be located (Fig. 202). RlG. 201. — Dislocation of hip backward into the sciatic notch. Leg shortened, foot inverted. {Motdlin.) Fig. 202. — Forward dislocation: sub-pubic; extension, eversion. (Moullin.) Reduction. — Flexion is here illusory, and equally so, blind traction. Slightly lifting the extended limb, abduct it as far as possible; while abducting continue to lift. The head rolls down toward the obturator foramen, and finally the thigh stands vertically. Xow adduct and rotate inward. 276 INJURIES TO JOINTS. OBTURATOR DISLOCATION. Diagnostic points: The hip is flexed, abducted, and rotated out- ward (Fig. 203). Reduction. — Flexion of hip, traction on flexed thigh, adduction, inward rotation. DISLOCATION OF THE KNEE. This accident is infrequent, easy of diagnosis, and comparatively- easy to reduce. General anesthesia is frequently necessary. Two assistants are needed, one for traction on the leg and one for countertraction on the thigh, while pres- sure is applied at the joint. One must be concerned here with the con- dition of the blood vessels. Suppose there is no pulse at the ankle, the popliteal space' is evidently filled with blood. Under these circumstances apply a tourniquet, and, under rigid antisepsis, open up the space by a longitudinal incision, turn out the clotsJ ligate the torn vessels. Remove the tour-l niquet, complete the hemostasis, and sew: up the wound. The limb is bandaged in. cotton, elevated, and kept warm. Time; alone can tell whether or not the circulation will be restored and gangrene averted. DISLOCATION OF THE SEMILUNAR CARTILAGES. Fig. 203. — Downward disloca tion. Obturator. (Moullin.) This is an injury likely to be forgotten in making a diagnosis of disabilities of the knee. The internal semilunar cartilage is much more likely to be in J volved, the accident usually occurring in this manner: the individual attempts to turn suddenly while the knee is flexed. The cartilage, either as a whole or, more often, a part, projects to the outside or in- I'lsr.OCATION OF THE ANKLE-JOINT. 277 side of the joint circumference. There is a sudden painful locking of the joint. The patient himself is often able to relieve the condition by a little manipulation of the joint, combined with lateral pressure. The injury is a serious one, functionally, and demands prolonged rest, in the hope that union may occur. An elastic silk stocking for the knee gives support and tends to prevent recurrence of the trouble, but violent movements are almost sure to bring a return. If asepsis is assured, the joint may be opened and the cartilage sutured to the tibia — an operation to be advised by the general practitioner and yet scarcely ever necessary to be undertaken by him. DISLOCATION OF THE PATELLA. The difficulties in correcting the displacement of the patella are various, depending not only on the character of the dislocation, but also on the condition of the ligaments and muscles. In general, there is one method of treatment, viz.: Extend the leg completely and, holding it in extension, flex the thigh to a right angle. By this means the quadriceps extensor, in whose tendon of insertion the patella is lodged, is relaxed, permitting the bone to be manipulated into place. DISLOCATION OF THE ANKLE AND TARSUS. The diagnosis and correction of these injuries are more especially matters of anatomy. Whoever has clearly in mind the relations of the components of the foot, can determine the character of the disar- rangement with the minimum difficulty. If the diagnosis is wrongly made, correct reposition is lacking, and in consequence there persists a degree of deformity and loss of function. One must begin his task of diagnosing a serious injury to the foot by recalling the relations of the malleoli and astragalus, the os calcis, and the other tarsal bones, to each other. Inspect the foot; the heel, the sole, the borders, the malleoli, the 278 INJURIES TO JOINTS. tendo achillis — and compare each of these, point for point, with the sound side. Remember that the line of the tibial crest, prolonged, falls on the second toe. A dislocation of the ankle-joint assumes various forms. The other bones may be dislocated from the astragalus, which retains its normal relation to the malleoli. There may be solely a dislocation of the astragalus, which may take almost any position imaginable. Less often one finds displacement of the meta- tarsals and phalanges. It is scarcely possible to indicate an ex- act method of reducing such luxations. The surgeon's ingenuity must suggest the proper variations of traction combined with pressure. A type may be found in backward dislocations of the ankle (Fig. 204). The malleoli are carried forward, the heel is elongated, the foot shortened. There is a transverse fold in front of the ankle, ridged vertically by the stretched extensor tendons. Reduction. — The patient's foot projects over the end of the couch, an assistant steadying the flexed knee. Grasp the heel with one hand and the middle of the foot with the other (Fig. 205). Make traction at first to reflex the opposing muscles and then shove the foot forward and at the same time flex it. After-treatment. — The injured joint, carefully padded, must be fixed by a plaster splint. After eight to ten days, passive motion and massage must be begun. Fig. 204. — Backward disloca- tion of ankle. {Moullin.) COMPOUND DISLOCATIONS. These are accidents always to be dreaded, and yet they yield ex- cellent results under antiseptic methods. Before you is a joint wide open, the articular surfaces bare, perhaps protruding, and immediately you think of resection or amputation, COMPOUND DIS1 OCATIONS. 279 and yet you will do neither. Y<>u will proceed to do a most careful disinfection and to secure a complete reposition and immobilization. The one chief concern is disinfection. The same indications for treatment are present as in compound fracture into joints (sec page 249) and depend upon the degree of injury to the soft parts and whether the infection is or is not obvious. The skin about the wound is prepared as for a surgical operation, the wound is thoroughly Hushed out with sterile water, foreign bodies are removed, and replacement is effected. The next step will vary, depending upon the degree of confidence in having completely steril- ^ Fig. 205. — Reduction of dislocated ankle. The assistant steadies the flexed knee. {Heath.) ized the joint cavity. If the effort has been exacting in that regard, tightly suture the deep layers over the joint, close the superficial layers with interrupted sutures and apply drainage. If the articular structures were impregnated with dirt, one will still fear suppuration despite the greatest care in cleansing, and will close the wound less firmly and provide for free drainage. Remov- ing as many bacteria as posible, starving those that remain by re- moving their food supply devitalized tissue and blood serum — are the principles of treatment: cleansing and draining, the means; healing without inflammation or suppuration, the end. Dressing and After-care. Having provided for drainage, cover the wound with sterile gauze, envelop the limb in absorbent cotton and immobilize the joint with a plaster splint. 280 INJURIES TO JOINTS. As soon as the soft parts are healed and the danger of infection has passed, begin massage of the muscles and slight movement of the parts daily. But in spite of careful cleansing, infection may develop. On the third day, perhaps, a chill occurs, the fever mounts rapidly and there are all the local signs of inflammation and sepsis. Do not temporize, but immediately open the wound, douche thoroughly with peroxide or iodine water and leave the wound open. Immobilize. If the temperature does not fall and the local conditions do not improve in a few hours, proceed at once to do an arthrotomy (see page 376). The thorough drainage by this means obtained will usually control the situation. The drainage is gradually withdrawn and will not be necessary after about the tenth day. If, even then, the swelling and fever do not subside, there is nothing left to prevent a general in- fection but immediate amputation, and even that may be too late. The shoulder- joint rarely suffers a compound dislocation. Such an injury is especially serious for the reason that there are so many com- plications; the shoulder muscles are torn, the axillary vessels and the nerves of the brachial plexus lacerated. It must be treated on the general principles enumerated and the result is often surprisingly good. If traumatic aneurysm exists, the pectoralis muscles must be divided, the space exposed and the vessels ligated. The hip-joint is occasionally the site of a compound dislocation and nearly always the shock is fatal. Elbow. — This is a comparatively frequent accident and is treated on the general principles outlined. If the injuries are severe, a partial excision may be required to perfect drainage and insure a better joint. Amputation will be indicated only in old age, morbid constitutional disability, or extreme local destruction. The wrist should be treated conservatively. A loose carpal bone may require removal or partial resection. Amputation will be re- quired if healing is obviously out of the question. Compound dislocations of the knee-joint are very rare. If con- servatism fails, amputation is the only alternative. Ankle and Tarsus. — These dislocations are frequent and require WOUNDS m| | hi KM 1 JOINT. 281 much attention. Antiseptic foot baths serve an excellent purpose tlmuLih the primary cleansing must he especially vigorous. The larval bones may need t<> be sutured to be retained in place. Espe< tal Bare must be taken not to interfere with the circulation (see page 250, compound fractures). CONTUSIONS OF THE KNEE-JOINT. These are so frequent as to call for a special word. The aim is to avoid an acute synovitis, which may become suppurative. In milder rest in bed with some mild liniment and light massage will be sufficient, and the pain and stiffness will rapidly subside. In the severer cases, indicated by pain and swelling, more active measures must be instituted. Wrap the joint in absorbent cotton and apply a plaster bandage for two or three days. The uniform pressure will limit the effusion and hasten its absorption. After that you may begin hot sponging and very gentle passive motion with massage, applied at first only to the muscles moving the joint, and afterward, as the tenderness subsides, to the joint itself. PUNCTURE AND STAB WOUNDS OF THE KXKK-JOIXT. The treatment will depend largely on the instrument which in- flicted the wound and the appearance of the wound. If the wound is clean-cut, and the instrument presumably non-septic, content your- self with sterilizing the field of the wound, enveloping the knee in an antiseptic compress and putting the joint at rest, preferably in a plaster splint. You will anxiously watch the temperature. If it does not rise within three or four days, one may cease to fear infection, and such ■welling as appears is not significant. It is quite different when the temperature begins to rise and the local symptoms gradually increase, <>r if the wound is seen after some days of neglect and the symptoms of infection are fully developed. Under these circumstances, there must be no delay. Immediate operation is imperative; it is indicated to do an arthrotomv. disinfect and drain (see page 376). 252 INJURIES TO JOINTS. This treatment, early and properly applied, will save the joint. As infection subsides, the drainage is gradually withdrawn. There are cases, however, in which, unfortunately, even these strenuous measures fail. In spite of immediate recognition of the urgency, and immediate action, laying open the joint with the utmost freedom, followed by repeated irrigations — in spite of the utmost endeavor, the symptoms of grave general infection persist and it is necessary to amputate. This may save the patient's life — more often it will not. EXTENSIVE INCISED OR LACERATED WOUNDS OF THE KNEE-JOINT. In these cases, it is never sufficient merely to cleanse the skin and seal the wound with antiseptic dressings. The wound must be enlarged, thoroughly cleansed, and the joint cavity irrigated with sterile water or normal salt solution and wiped dry with sterile gauze. After the complete disinfection, the wound in the capsule is sutured and, perhaps, also the skin. More frequently, however, one will feel safer to leave drainage in the skin wound. The joint is immobil- ized, and if everything goes well, the drainage-tube is removed after forty-eight hours. SPRAINS. In general, these conditions are to be treated by firm bandaging for two or three days, to limit the swelling and hasten the absorption of the effusion; and then massage and slight passive motion are begun. It is better to give the joint functional rest until at least the greater part of the pain has subsided. The ankle-joint is more frequently sprained than any other, partly on account of its construction and partly on account of its function. The weight of the bodyWalls on the insecurely poised foot and the ankle gives way under the load. The ankle usually bends outward and the external lateral ligaments are subjected to great strain. They are undoubtedly often lacerated or the capsular ligament may be torn. The pain in the severe cases is immediate and intense; the MASSAGE 01 \ SPRAINED ANKLE. 283 patient may faint. If the joint is continued in use, the swelling is aggravated, hut in any event swelling rapidly ensues. Morphia may be necessary to relieve the pain, [fseen al once, the ankle is immobilized in plaster of Paris for a few days, or bandaged tightly with a flannel or ruhher bandage, or strapped with adhesive plaster, after which massage and passive motion are employed. The patient should walk with crutches at first. The joint will he stronger than if it was used before the pain and swelling had subsided, although excellent authorities advise walking from the first. If adhesive strips are used, in order to avoid circular constriction, apply them in this manner: cut the adhesive strips one-half inch wide and in two lengths, twelve and eighteen inches. (1) Begin with one of the long strips in front of the big toe, carry the strip back around the heel, keeping just above the contour of the sole, and bring the strip back across the dorsum of the foot to the starling-point. Overlap this with a similar strip. Both should he tightly drawn. (2) Begin with one of the shorter pieces above the ankle and carry it under the heel to the opposite side. The subsequent strips are applied alternately in this fashion, each overlapping the" one preceding, until the foot is practically covered. The whole is then enclosed in an ordinary roller bandage and the foot kept quiet. After two or three days, the patient may begin to move around a little, but the dressing must be left on till the pain ami swelling have subsided. It may be reinforced by additional strips placed over the loose ones. The manner of giving massage is also important. In the ease of a tender joint, begin by gently stroking the healthy tissues just above the joint in the direction of the blood and lymph currents, and grad- ually approach the joint. The movements are gradually made more vigorous, using the palmar surface of the hand. After a few minutes of this work, the joint will usually permit a direct manipulation and finally slighl passive movement i-- begun. CHAPTER XV. INJURY AND REPAIR OF TENDONS. There are three kinds of injuries to tendons which it is practical to consider as emergencies: dislocated tendons, subcutaneous rupture, and divided tendons. Dislocation of Tendons. — Dislocation is not a frequent injury, and yet it occurs and is to be considered as a possibility in making a diagno- sis of disturbances of function after certain joint accidents. Every sprain should be examined with this point in view. The tendons most frequently dislocated are those of the peronei muscles, especially the brevis. Following a severe wrench of the ankle, it is torn out of its sheath behind the external malleolus and carried forward onto the malleolus, where it can be felt and moved. It is easily replaced, but it is with more difficulty retained. The ankle must be immobilized at a right angle to relax the calcaneo-fibular ligament, and the tendon retained by pressure until the ruptured ten- don sheath or lateral ligament is healed, which will require about four weeks. It will sometimes be necessary to expose the tendon and re- pair the ruptured tissues. The long tendon of the biceps may be wrenched from its groove in the humerus and the loss of function and prominence of the head of the humerus may suggest dislocation of the humerus. As a rule, the tendon is easily replaced by a little manipulation, but the useful- ness of the arm will be impaired for a long time. The other tendons of ankle and wrist occasionally may suffer simi- larly, but not seriously. Subcutaneous Rupture. — Subcutaneous rupture is especially likely to occur with the tendon of the quadriceps extensor or triceps cubiti or the tendo achillis. A sudden violent effort is the usual cause. The pain, the loss of function, the gap between the ends of the rup- tured tendon, and the history of sudden muscular contraction point to the nature of the injury. 284 R1 I'M R] (H TENDONS. 28S There is only one logical treatment, viz.: l>y an incision to expose llu- tendon at Once and by some of the methods shortly to he des< rihed, reunite the parts by suture. It is the duty of the doctor to insist on nothing less (Fig. 206). But it must be remembered that the synovial sac is peculiarly susceptible to infection and the skin over the patella difficult to sterilize. FlG. 2o<>. -Repair of ruptured tendon of quadriceps extensor femoris. \. 287 riceps extensor in 1904. The history of one of the cases is typical. A man, 57 years old, slipped and fell with his left knee doubled under him. He could not lift his leg from the ground. Examination an hour later showed a gap 6 cm. wide between the upper border oi the patella and tin' retracted edge of the quadriceps tendon. Operation. A transverse incision was made across the front of the Pig. 209. Exposure of tendons by cnlar^in^ wound in aponeurosis. Suturing tendons. I I 'eau. ) knee and the ruptured tendon exposed. The rupture was complete fcccepl lor a few fibers on the outer edge. The joint was exposed, the clots wiped out. The edges of the tendon were then carefully coapted with interrupted catgut sutures. The leg was put up in plaster ol Paris splint for seven weeks. After that it was massaged daily and the splint definitely removed at the end of twelve weeks. The leu became as strong and flexible as before die ai cident. 205 INJURY AND REPAIR OF TENDONS. Divided Tendons. — These are found frequently, especially at the wrist. They must be immediately sutured for then it is relatively easy. Later they retract or acquire adhesions and it is difficult to approxi- mate the two ends, and one must have recourse to special manoeuvres. Use No. i or No. 2 silk or chromicized catgut. A small curved needle or a straight sewing needle will serve. Begin by carefully disinfecting the wound and securing complete ISP ccJ. 7?P Fig. 210. — Cross section showing relations of the various tendons at the wrist- joint. N. R., radial nerve; L.F.P., long flexor of the thumb; A.R., radial artery; G.P., palmaris longis; N.M., median nerve; L.F., flexors of the fingers; A.C., ulnar artery ; \N. C, ulnar nerve; C.P., ext. carp, ulnar; C.P.D., ext. min. dig., C.C.D., ext. com. digitorum; L.E.P., ext. long, pollicis; R, extensors carp. rad. ; M.P. ; supinator longus, extensor brev. pollicis. hemostasis. The lower ends of the divided tendons will usually be found near the lower lip of the wound (Fig. 207). Identify each and count them to be sure none have been overlooked. At the same time, see if a nerve has been divided. Look for the others of the divided ends. If they are not in sight, do not reach blindly for them with forceps, but attempt to bring them into view by "expression," and if this fails, boldly enlarge the wound. SI I I Kl u| || MioNS. 289 Expression. — Direct the assistant to grasp the member above the wound with both hands and the pressure may force the tendons into view. It" the extensor tendons are Involved, employ forced flexion with the pressure. (These muscular groups are more or less unified and the undivided tendons put on the stretch help to Drag the divided tendons into view (Fig. 208). If this method does not succeed, apply a roller bandage, beginning at the elbow joint in the case of the upper extremity; at the knee in the case of the leg or foot, and carry it down to within an inch of the wound. If this, too, fails, make a free incision observing this point; do not make the incision directly over the tendon for it may later acquire adhesions to the scar tissue, interfering with its free move- nent (Fig. 209). Generally with a little patience the tendon is found. It is often practical after incising the skin to make a diagonal incision of the deep fascia or two incisions at a right angle, creating a Bap which may be dissected up and the tendon group well exposed (Fig. 210). Fig. 211-One Suture of the Tendon. — (A) The tendon is round, tendon of medium . . . . , ... . , , size. (Veau.) as at the level of the wrist-joint. Seize the tendon with a dissecting forceps, being careful not to bruise it. Pass a suture through the whole thickness one-quarter inch from the end (Fig. 211), entering the super- ficial surface and emerging on the deep surface of the segment and carrying it then to the Other part; entering the deep surface and emerging on the superficial surface. The ends of the di- \ ided tendon are then coapted and the suture tied. The suture may be passed laterally instead ^\ anteroposteriorly. 19 i t»^j 212. — Method of introducing suture for divided tendon, i Mai 2 COMPRESSION OF NERVES. 295 Secondary Suture — It may be Found accessary to suture a nerve some time after the injury, and this operation will present difficulties. The ends may be separated or they may be imbedded in scar tissue. A knob often forms on the proximal stump. In Such a case, freshen the ends and pass the suture in the manner pictured (Fig. 224). If the two ends are attached by a fibrous cord, split the sear tissue longitudinally (Fig. 225), and transform the longitudinal fissure into a transverse one and suture (Fig. 226). If the ends cannot be approximated or bridged they may be sutured at different levels to a neighboring nerve in the manner described under Repair of Tendons. Warn the patient that it may be a long time before function is even partially restored. In the mean- time, muscular atrophy must be prevented by per- sistent use of electricity, and massage. CONTUSION AND COMPRKSSION OF NERVES. Fig. 223. — Suture of nerve through the sheath. {Veau.) Al F 1 1 ; . ...•(. of normal These injuries to nerves are by no means infrequent, following blows, gun- shot wounds, machinery accidents, frac- tures, and dislocations. The symptoms vary from slight ting- ling to complete loss of function. The loss of function is often a later develop- ment, due to a neuritis following the contusion, and is accompanied by neuralgia, muscular palsy and trophic alterations corresponding to the distri- bution of the nerve. Treatment. — The immediate indica tions are to restore the parts to their condition as much as possible, and to relieve the pain by —Secondary suture. Method coaptation, 1 1 •an.) 296 INJURY AND REPAIR OF NERVES. hypodermic injections of morphia or by phenacetine and codeine. The nerve must be put at rest by immobilizing the limb. Later, alteratives, electricity, and massage are useful. INJURIES TO INDIVIDUAL NERVES. Facial Nerve. — The facial is more frequently injured than any other cranial nerve: in fracture of the base of the skull; in the mastoid operation as it passes through the temporal bone; by shots and blows at its exit from the styloid foramen. Depending upon the distance of the lesion from the central origin of the nerve, there occur paralysis of the muscles of expression, dis- turbance of salivary secretion and the sense of taste, and paralysis of the palatal mus- cles. Injury to the facial nerve is often accompanied by injury to the abducens and auditory nerves. To Expose the Facial Nerve. — The incision begins behind the external auditory meatus and extends down- ward and forward to the angle of the lower jaw. Divide the integument, superficial fascia and the first layer of the deep fascia. This exposes the parotid gland, the sterno-cleido-mastoid and the mastoid process. The posterior auricular nerves and the vessels are to be avoided. Carefully dissect and draw forward the part of the gland exposed and the posterior belly of the digastric appears, just above which the nerve lies upon the styloid process. Optic Nerve. — The optic nerves are injured most frequently in con- Fig. 225. Fig. 226. The two ends of the nerve are connected by a fibrous cord which is split longitudinally and su- tured as indicated. (Veau.) EXAMINATION I'OK I1KAIN TRAUMA. 297 Lection with fracture of the base of the skull involving the anterior fossa, and especially when the fissure involves the optic foramen, for there the nerve is firmly attached t<> the hone. As a consequence of such injuries, there may he compression, lacera- tion, or extravasation into the nerve sheath. As a result of these in- juries, there are disturhanccs of vision of various degrees. In obscure trauma of the brain, the ophthalmoscopic examination of the fundus of the retina should never be neglected as a means of diagnosis. Motor ( huli Nerve. — The motor oculi nerve may be injured by wounds penetrating the orbit and by fractures of the base. Its func- tion may be disturbed by pressure following the rupture of the middle meningeal artery and often the only indication of this disturbance is a dilated pupil and drooping of the eyelid. Patheticus and Abduccns. — These nerves are often injured along with the third. Fifth Nerve. — The fifth nerve is rarely injured alone, but injury of single branches may occur. "The usual consequence of anesthesia of the trigeminals following cranial injury is so-called keratitis neuroparalytica." Auditory Nerve. — The auditory nerve is rarely injured without other serious lesions, and since traumatic disturbances of hearing may be due to injury to the labyrinth or tympanum also, a diagnosis of in- jury to the nerve trunk must be uncertain. The pneumo gastric may be divided or contused by bullet or stab wounds in the neck. The injury is not necessarily fatal, but may be followed by difficulty in respiration and deglutition or by pneumonia. When the symptoms point to injury an effort should be made to repair it. It is reached by the same operation as that for ligation of the com- mon carotid. The phrenic when divided gives rise to disturbances of the functions of the diaphragm, cough, difficult respiration. The recurrent laryngeal when divided gives rise to hoarseness and aphonia. If injured, an attempt should be made at repair. Laryngeal spasm may require a tracheotomy. Median Nerve. — The median nerve is likely to be divided by Stab- or gunshot wounds and may be exposed in any part of its course. 298 INJURY AND REPAIR OF NERVES. Injury to the median nerve results in impaired flexion of the hand and fingers and movements of the thumb. To Expose the Median Nerve. — (A) In the middle third of the arm (Fig. 227): Place the patient on the back with arms abducted to a right angle, the operator standing to the inner side of the arm. With the two hands define the biceps muscle. Along the inner border of the muscle, following the known line of the nerve (from the middle of the axilla to the middle of the bend of the elbow) make an incision two or three inches long, dividing the skin and connective tissue. Divide the deep fascia over the biceps and open the sheath Fig. 227. — Exposure of the median nerve^in the middle'third of the arm. B. Biceps. M. N. Median nerve. B. A. Brachial artery. {Schwartz.) of the muscle. Isolate the border of the muscle and with the retractor draw it gently aside. Do not use force or the nerve also will be dis- placed or the musculo-cutaneous may be exposed instead of the median. Now incise the deep layer of the muscle sheath exactly in the line that was occupied by the border of the muscle and the nerve is exposed lying a little to the inside of the vessels. (B) At bend of elbow (see Brachial Artery). (C) In the upper third of the forearm (Fig. 228) : The incision begins a little below the bend of the elbow, is two or three inches in length, and follows the line of the nerve, which lies in the middle line from l\ 11 kv rO nil i I \ \K NERVE. 299 the elbow to the wrist. Divide the skin and ligate the two superfii ial veins. Under the deep fascia define the external border of the pro- nai r radii tries and over this border incise the aponeurosis and retrai t the muscle. The nerve is immediately exposed, together with the ulnar artery, which crosses beneath it, running obliquely toward the inner border of the forearm. (D) At the wrist (Fig. 229). Make an incision two inches in length in the middle line, the middle of the incision corresponding to the Fig. 228. — Exposure of the'median nerve just below the elbow. The pronator radii teres (p. R. t.) drawn inward exposing the median nerve (m. n.), the ulnar artery (u. art.) being at outer side. (Schwartz.) :rease of the wrist. Divide first the skin and the fascia and then, very arefully, the anterior annular ligament, guarding the synovial sheath )f the flexor tendons. Retract the lips of the wound, and the nerve is iposed, easily distinguishable from the adjacent tendons by its ibrillated appearance. The Ulnar Nerve (Fig. 230). — The ulnar nerve may be divided any- vherc along its course, but is more likely to be contused in the ulnar groove. There also it may be dislocated by forcible flexion of the orearm. The loss of function of this nerve results in inability to extend lie distal phalanges, to adducl the fingers and to ilex the little finger. 3°° INJURY AND REPAIR OF NERVES. claw hand" appears as a result of atrophy of the Eventually the muscles. To Expose the Ulnar Nerve. — (A) In the arm: Make an incision two or three inches in length along the line of the nerve, which extends from the middle of the axilla to the internal condyle. Divide the skin and superficial and deep fascia. The brachial artery is about a finger's breadth to the outside of the line of incision. Draw the Med.N. Fig. 229. —Exposure of the median nerve at the wrist. (Schwartz.) Fig. 230. — Exposure of the ulnar nerve in the upper third of the arm. M. N. Median nerve. B. A. Brachial artery. U.N. Ulnar nerve. Tr. Triceps muscle. (Schwartz.) basilic vein to one side. Carefully divide the subjacent tissue be- neath which is the ulnar and median nerves and the brachial artery; the ulnar nerve is to the inside and in contact with the long head of the triceps. (B) At the elbow (Fig. 231): Place the patient on the back; abduct the arm; flex the forearm at a right angle; stand to the inner side of the arm and locate the inner condyle, the olecranon and the in- tervening gutter. Along the line of the gutter incise the skin and the INJURY TO MUSC1 LO SPIRAL NERVE 3 QI ksi ias for two or three inches, and the nerve will be exposed, accom- panied by the posterior ulnar recurrenl artery. (C) In the lower third of the forearm (Fig. 232): Following the linr of the nerve, from the internal condyle to the radial side of the pisiform, make an incision two inches long to the outside of the flexor carpi ulnaris, dividing the skin and superficial fascia. Retract inward the tendon of this flexor. Carefully incise the deep fascia and the nerve is exposed lying to the ulnar side of the ulnar artery. PlG. 231. — Exposure of the ulnar nerve at elbow. I. C. Internal condyle. E. C. U. Extensor carpi ulnaris. U. N. Ulnar nerve. Olec. Olecranon process. Trie. Triceps. (Schwartz.) Musctdo-spiral. — The musculo-spiral, more than any other nerve of the arm, is subject to injury from stab, contused, or gunshot wounds or to fracture of the humerus. Very characteristic, too, are the Symptoms resulting from its loss of function. The wrist and fingers cannot be extended and assume the attitude well known as the "drop wrist." In every fracture of the humerus, the stability of this nerve should be tested. The nerve may be explored in any part of its course, but is most easily reached at the outer side of the arm just above the elbow. 302 INJURY AND REPAIR OF NERVES. To Expose the Musculo-spiral. — In the lower third of the arm (Fig, 233) : The arm is abducted, the forearm extended and the hand supinated. Stand to the outside of the limb. In the line of the nerve, a line drawn along the middle of the external surface, beginning half-way between the shoulder and elbow and extending to a poinl one-half inch from the center of the bend of the elbow, make ar incision two or three inches in length through the skin and superficia fascia. Retract the cephalic vein. Divide the deep fascia along the border of the supinator longus and expose the muscle fully. Retract p IG 232 Exposure of the ulnar nerve at the wrist. U. A. Ulnar artery. U. N. Ulnar nerve. {Schwartz.) it to the outside. At the bottom of the wound is the nerve lying upoi the brachialis anticus. Circumflex. — In addition to such injuries as may be due to stab oi gunshot wounds, the circumflex is liable to be lacerated in violen wrenching or in dislocation of the shoulder-joint. The loss of power to abduct the arm through paralysis of the deltoic is the immediate result. The nerve may be exposed as it winds arounc the humerus just below its head. Operation. — The course of the nerve is in a line drawn from the innei end of the scapular spine to the point of insertion of the deltoid. Place the patient on the sound side, exposing the shoulder well b) rotating the arm inward a little and placing it in front of the trunk INJURY TO Till. ANTERIOR CRURAL NERVE. 303 Along the line indicated make an incision three or four inches long, corresponding at its outer end to the acromion process, but an inch or two from it. This incision divides the skin and superficial and deep fascia and exposes the posterior border of the deltoid. Bring into view and draw upward this border of the deltoid. Next locate the quadrilateral space, bounded above by the teres minor, below by teres major, posteriorly by the long head of the triceps, Sup. Long. Mus. Sp. Br. Ant. p u; 233 — Exposure of the musculo-spiral in its lower third. The supinator longus is exposed and the nerve found to its inner side lying upon the brachialis anticus. (Schwartz.) and anteriorly by the shaft of the humerus. By locating the tendons of these muscles define this space in which lie the nerve and the posterior circumflex artery (Fig. 234). The musculo-cutaneous is exposed in the same manner as the median in the upper third of the arm (Fig. 235). Anterior Crural. — The division of the anterior crural nerve means, among other things, loss of extension of the leg. To outline it locate the spine of the pubes and the anterior superior iliac spine, which points are connected by Poupart's ligament; under 3°4 INJURY AND REPAIR OP NERVES. this ligament a finger's breadth outside of its middle point the nerve passes (Fig. 236). To Expose the Anterior Crural. — Make an incision from this point downward in the axis of the thigh, about three inches in length, divid- ing the skin. Fig. 234. — Exposure of the circumflex nerve. D. Deltoid. T. M. Teres minor. Tr. Triceps. T. Maj. Teres major. C. A. Circumflex artery. C. N. Circumflex nerve. {Schwartz.) At the upper end of the wound expose the lower border of Poupart's ligament. Immediately below this line, open up the sheath of the psoas magnus, pass a grooved director under the sheath, and divide it to the same extent as the skin incision. Separating the lips of the sheath wound, the nerve is seen lying on the fibers of the muscle and is to be distinguished by its whiteness and its subdivisions. AN I I RIOB CRT RA1 M RVE. 305 Fig. 235. — Exposure of the musculo-cutaneous nerve in the middle third of arm. The biceps (B) drawn outward exposes the nerve (M. Cut. N.) lying to the outside of the median nerve (Med. N.) and the brachial artery, Br. Art. (Schwartz.) ' Fig. 236. — Anterior crural and external cutaneous nerves. (Labcy.) 3° 6 INJURY AND REPAIR OF NERVES. The Obturator. — If the obturator is divided, there follows loss of ab- duction of the thigh. To Expose the Obturator. — Abduct the thigh until the border of the ductor longus can be clearly defined, and along this line make an in- cision four or five inches long, beginning an inch below the fold of the groin, a little to the outside of the scrotal base. Divide the skin and superficial fascia, retracting to the outer side the internal saphenous Fig. -Exposure of the obturator nerve; separating the adductor longus from the pectineus. (Labey.) vein, but ligating its cross branches. (Fig. 237). Divide the deep fascia in the same line. Separate the adductor longus from the pectineus by blunt dissection. A fairly well-defined gutter indicates the line of separation. Retract the two muscles and at the bottom of the upper part of the wound you will see the obturator nerve, consisting of a couple of flattened cords. Now extend the thigh to relax the abductors and separate more widely the two muscles mentioned and the nerve may be completely exposed, EXPOSURE Oh' Till. SCIATIC M R\ I . 307 one branch lying upon the adductor brevis and the other passing under it (Fig. 238). Ilio-inguinal and Genito-crural. — These nerves are frequently wounded in hernia operations, and may give rise to an obstinate neu- ralgia of the testicle requiring removal of this organ. In such a case an effort should first be made to repair the nerve or resect it. The Sciatic Nerve. — The sciatic nerve may be injured in many ways and from the functional point of view, these injuries are always serious. Fig. 238. — Obturator exposed. (Labey.) It may mean loss of extension of the thigh and complete paralysis of the leg. It may be exposed at any part of its course down the back of the thigh. Exposure in the Middle of the Thigh. — Place the patient face down- ward or on the sound side. Along the line of the nerve (a straight line extending from a point midway between the ischial tuberosity and the great trochanter to the middle of the popliteal space), make an in- cision three or four inches long, dividing the tissues down to the deep 3 o8 INJURY AND REPAIR OF NERVES. fascia. Determine the interspace between the biceps and the internal hamstring, and over it divide the deep fascia and separate by blunt dissection the muscles of the space. Flex the leg so as to relax them. They are then to be retracted widely and in the fatty tissues of the interval the nerve is usually easily found. The External Popliteal, or Peroneal.- — This nerve, like others, is liable to injury in. fractures and wounds. When it is divided, "foot drop" occurs. The patient cannot walk without stubbing the great toe and to prevent this, the whole leg is raised (steppage gait). This nerve bears an important relation to the knee-joint and to the tendon of the biceps. To expose the peroneal behind the head of the fibula place the patient face downward or on the sound side. The line of the nerve corresponds to the tendon of the biceps, which may be palpated along the external border of the popliteal space, or the course of the nerve may be indicated by a line drawn from the tuberosity of the ischium to the head of the fibula. In this line, beginning at the neck of the fibula, make an in- cision upward three inches long, dividing the structures down to the deep fascia. Carefully divide the deep fascia over the tendon of the biceps and at once there comes into view the external popliteal, lying to the inner side of the tendon resting upon the external condyle of the femur above, and lower down winding about the neck of the fibula and disappearing in the peroneus longus. To Expose the Musculo-cutaneous .- — Place the patient upon his back, the knee flexed and rotated inward, and retained by a cushion placed under the thigh ; in this manner exposing the external aspect of the leg. The line of the nerve is drawn from the anterior border of the pero- neal head to the anterior border of the external malleolus. Along this Fig. 239. — Musculo-cutaneous nerve lying upon the peroneus brevis. (Labey.) EXP0SUR1 "I I in INT] RIOH TIBIAL M in I . 3°y line, in the middle <>i" the leg, make an incision three or four in< hes in length dividing the structures to the deep fascia. [ncise the aponeurosis of the peronei muscles, isolate the anterior honler of the peroneus longus and draw it backward. The muscle may be previously relaxed by rotating the foot outward. The nerve will be seen resting upon the peroneus brevis (Fig. 239). The Anterior Tibial Nerve. — The anterior tibial nerve is the continuation of the external popliteal nerve. The movements of flexion of the foot and extension of the toes depend upon this nerve. To Expose the Anterior Tibial Nerve. — (A) In the tipper third: Put the patient in the same position as for the musculo-cutaneous. The line of the nerve is drawn from the front of the peroneal head to the middle of the ankle- joint (Fig. 240). In the line of the nerve make an incision beginning three fingers' breadth below the articular line of the knee. Divide to the deep fascia; next divide that and then patiently Beari b Eor the intermuscular septum separat- ing the wide tibialis anticus from the narrow common extensor. It will aid greatly in the search to seize with a forceps each of the lips of the wound of the sheath and retract. This will help to develop the line of cleavage. _. , . . ., . ,. . 1- 1 1 Fig. 240. — Lines repre- Kemember that the tibialis anticus slightly renting the course (c) of the musculocutaneous; Overlaps the common extensor, SO that the iab) Anterior tibial nerves. intermuscular space slopes inward and back- ward. Retracting the muscles, the nerve will appear as a small rounded white cord lying in front of the vessels. (B) /// the lower third (see Anterior Tibial Artery). Posterior Tibial Nerve. — The posterior tibial nerve supplies the movements of the extension of the foot and flexion oi the toes and mav 310 INJURY AND REPAIR OF NERVES. be wounded in any part of its course, although in the region of the calf it is deeply situated. Behind the internal malleolus it is superficial and easily exposed. (A) To Expose Upper Third. — To expose the posterior tibial in the region of the calf is difficult (Fig. 241). Position. — Place the patient on his back with the thigh in abduction and external rotation, the knee flexed, and the foot lying upon its ex- ternal border and held in this position by an assistant. Standing to the outside of the limb the operator with this arrangement can see quite well the internal surface of the leg. Fig. 241. — Exposure of the post, tibial nerve. Gastrocnemius retracted; soleus exposed. (Labey.) Locate first the sharp internal border of the tibia, and a finger's breadth behind it make an incision four inches long, beginning at the level of the tuberosity. Divide the tissues down to the deep fascia, avoiding the internal saphenous vein, which lies close to the tibial border. Slightly retract the posterior lip, which will include the gastrocne- mius, and in this manner the soleus is exposed. Division of the soleus is the next step which must be carefully carried out. Divide it longi- tudinally, but further away from the tibia than the original incision. I XP0S1 K'l 01 I ill Wil RIOB M.R\ I $11 Cutting in this manner through the fibers of the sulcus, the yellow aponeurosis covering the nerve and vessels is exposed (Fig. 212). It is important to expose this landmark well. Make an opening in it Fie. 242. — Fibers of the soleus divided and retracted, exposing deeply situated the posterior tibial nerve and artery. (Labey.) an inch and a half from the internal border of the tibia, and beneath the opening is the nerve, lying to the outer side of the artery. (B) Behind the ankle (see Ligation of Posterior Tibial Artery). CHAPTER XVII. ABSCESS. An abscess is a circumscribed collection of the liquefied products of infective inflammation. There are two kinds of abscesses, differing in their etiology, clinical history, prognosis, and treatment. All these differences arise primarily in the nature of the infective agent. The acute abscess is due most generally to the activity of certain of the cocci. The chronic (or cold) abscess is nearly always due to the Bacillus tuberculosis. The chronic abscess may become infected secondarily with the germs of acute in- flammation, in which instance it takes on the character of the acute abscess. The content of the acute abscess is pus; that of the chronic abscess, though resembling pus, may be merely the liquefied caseated matter of the tubercle without any pus cells whatever. An acute abscess pre- sents all the cardinal symptoms of inflammation: constitutional dis- turbance, pain, heat, redness, swelling, all in greater or less degree, depending on the locality. A chronic abscess may present none of these symptoms except swelling, and where swelling is not perceptible the abscess is frequently unsuspected. An acute abscess is of very rapid development — the chronic of quite slow growth, as a rule. An acute abscess demands immediate evacuation by free incision and drainage. The chronic abscess very often permits only of aseptic puncture, followed by the injection of detergent remedies, and aseptic occlusion. Each occurs by choice in certain locations. The incision, the special dangers and details of treatment depend on the anatomy of the parts, so that the more common abscesses require individual consideration, and in that connection the general principles that under- lie the subject may be elaborated. The prevention of pus formation should be attempted in all acute 312 TRIM mini int where the tissues are sufficiently resistant to close when the trocar s withdrawn. At the end of the evacuation the fluid may need to be ■pirated. It may be discolored bv some blood from the puncture. Injection with some stimulating and antiseptic fluid should follow. Kthereai solution of iodoform has the advantage of distending the cavity >y gas formation and reaching all the diverticula; but it has the dis- ulvanlagc thai it is toxic. Inject 5 to ioc.c. of a 10 per cent, solution; cave the trocar in place, (losing its orifice with the finger. When the •avity becomes distended, remove the linger and the ether spurts out. 316 ABSCESS. Let all the gas escape. If one does not observe this rule there may be a slough. A solution of iodoform in glycerine may be employed; inject 3 to 10 grammes of a 10 per cent, solution, letting the surplus escape. Cam- phorated naphthol may be used in the same way. Bismuth paste in certain localities serves an excellent purpose. After the injection is completed seal the puncture with collodion. Several injections may be necessary for a cure. Constitutional treatment is of the greatest importance. ABSCESSES OF THE SCALP. These are found in three locations: 1 . Superficial — that is, above the aponeurosis of the occipito-f ron- talis. 2. Subaponeurotic — that is, between aponeurosis and the perios- teum. 3. Subperiosteal — between the periosteum and the bone. 1. Superficial abscess, due to staphylococci, is quite localized, and yet very painful on account of the resistance of the firm tissue. The lymph nodes behind the ear and in the back of the neck are enlarged and tender. The chief danger is in extension to the deeper layers; or the emissary veins may carry infection to the sinuses and produce thrombosis or pyemia. Evacuate immediately by free inci- sion, first shaving the scalp in the immediate vicinity of the abscess. Remembering the manner in which the occipital and temporal arteries converge toward the apex, the incision may be managed in such a way as to run parallel to the small vessels distributed to the area. The cavity must be kept open by a strip of rubber tissue or a small drainage-tube. A dressing of gauze, absorbent cotton and bandage complete the treatment. Change the dressing every day at first. 2. Subaponeurotic abscess is likely to follow wound infection. The streptococci follow the areolar tissues that separate the aponeurosis from the periosteum, and the spread of pus is limited only by the attach- ments of the aponeurosis. Septicemia, meningitis, and thrombosis are the actual dangers, and on these accounts immediate operation is demanded. n ii \i I i OF Tin PACE. 317 Make a free incision under antiseptic precautions; that is, after shaving and cleansing the part involved. Do not attempt irrigations, above all, in these cases, for the fluid percolating through the loose areolar tissues spreads the infection. Good drainage alone will suffice. The dressings must be changed frequently at first and must be firm enough to prevent movement of the occipito-frontalis muscle. If the abscess develops under the temporal fascia, it will not point toward the surface, owing to the extreme density of this fascia, but to- ward the mouth or neck through the ptergo-maxillary fossa. Even though there be no fluctuation (usually indeed, none can be detected), the diagnosis can, nevertheless, be certainly made from the presence of the edema, redness, and pain. Make a vertical incision an inch or so in front of the ear and with the center about the level of the eyebrow. It may be necessary to go through the substance of the muscle to the bone. A few small arteries will be divided and will require ligation. It may be necessary at the first dressing to pack the cavity with gauze to control slight but persistent bleeding. Drainage by means of tubes nay be employed subsequently. 3. Subperiosteal abscesses differ from the others in that they are likely to be the result of bone inflammation, tubercular or syphilitic. The abscesses are limited to the area of one bone as the periosteum along the line of the sutures is continuous with the dura mater. This furnishes an easy means of entrance into the cranial cavity for the infection and in that manner meningitis may result. For this reason, these abscesses, of whatever origin, should be evacuated at once and appropriate constitutional treatment instituted. ABSCESS AND FURUNCLE OF THE FACE. The danger in these conditions is that phlebitis beginning in the facial vein may spread to the cavernous sinus, so free is the communi- cation by numerous branches between these venous channels. Espe Bally to be feared are these furuncles beginning on the upper lip or median parts of the face. They may be fatal in a few days. Nearly always the staphylococcus pyogenes is the active causative agent and 318 ABSCESS. one need not usually be at a loss to trace the mode of entrance of the infection. Early incision is imperative in all such acute septic processes. The best form of local anesthesia in these conditions is by freezing with ethyl chloride spray. Hypodermic injections are best avoided here. The incision must be deep to be effective, and in making it two factors are to be borne in mind, the resulting scar and injury to the branches of the facial nerve. In severe cases even these points must be dis- regarded. Even more certain than free incision is central puncture with a fine thermo-cautery, followed by the Bier suction treatment. If it is a carbuncle of the diffuse type, accompanied by edema of the face and inflammation of the viens, crucial incision with curettement must be undertaken. The dressing of gauze may be held in place by adhesive strips. ABSCESS OF THE NASAL SEPTUM. Following a blow upon the nose, bleeding ensues and, two or three days later, obstruction. Looking into the child's nasal fossae, they are seen to be filled with a bright red, tender, fluctuating swelling, over the cartilaginous portion of the septum. The whole nose becomes hot, swollen, and painful. The treatment is evacuation by a free incision of the mucous mem- brane over the septum at the point of greatest fluctuation. To operate, apply a 4 per cent, solution of cocaine to the mucous membrane, and after waiting a minute or two, make an incision along the septal wall from above downward and forward with a slender, sharp bistoury. Douche the nasal fossa frequently with a mild, alkaline antiseptic. Recovery usually follows within a week, although in the neglected cases, necrosis of the cartilage may occur. ABSCESS OF THE EYELIDS. The loose connective tissues of the eyelids favor exudation and] edema. An abscess occurring here is usually due either to trauma- tism or to septic infection entering from the face or scalp or to periostitis of the margin of the orbit. Early treatment of contusions I>1S( hi OB ITIONS O] l Hi INI LED. 3 ' ') may prevent not only the unsightly discoloration ("black eye"), lint also a later al>s< ess. To prevent discolorations apply cooling or evaporating Lotions or wring a gauze compress out of ice water and apply to the lid, renewing the compress every two or three minutes. Do not allow the compress to cover the nose, else a< ute coryza may result. Apply in this manner for an hour and repeat every second or third hour for twenty-four hours. A solution of arnica (2 oz.), in water (1 pt.), may lie applied, or Ammonii Chloride, 1 Alcohol, 1 Aquae, 10 // discoloration appears, apply flannel cloths wrung out of hot water. for an hour at a time, three or four times daily, and follow with gentle- massage for five to ten minutes. Before applying the heat it is better to smear the lid with vaseline. Ointment of yellow oxide of mercury is excellent to use with massage. If an abscess appears make an inci- sion parallel with the muscle fibers. Apply antiseptic, absorbent dressings. ABSCESS OF THE LACHRYMAL GLAND. Abscess of the lachrymal gland is rare, yet doubtless is often over- looked. It is seen in infancy, usually traceable to some of the infectious diseases. The abscess breaks into the superior cul-de-sac and re- covery follows. ABSCESS OF THE EXTERNAL AUDITORY MEATUS. Abscess of the external meatus is extremely painful and alarming, but in fact not particularly dangerous. The meatus is closed by the swelling, but a stab with the point of the knife or, if it is more deeply situated, an incision in the direction of the long axis of the meatus, will cause a speedy disappearance of the symptoms, (lentle douching with an antiseptic solution, and, after drying, occlusion with absorbent cotton, will soon complete the cure. 320 ABSCESS. ABSCESS OF THE PAROTID GLAXD. An inflammation begins in the parotid gland, the result of local infection or secondary to an abdominal disease or injur} 7 (most fre- quently involving the pancreas, perhaps), and nearly always suppura- tion follows. The severe forms are dangerous; happily, however, the pus, even if left to take its own course, works its way to the surface or points at the pharynx. It may burrow down to the anterior medias- tinum. The special dangers are meningitis, septic poisoning, and thrombosis. When the swelling is great, pressure interferes with the venous current and, as a result, cerebral congestion, headache, and finally delirium ensue. The pus may open into the middle ear and infection by that route reaches the brain. Suppuration of the temporo-maxillary articulation may follow. Treatment. — If, when the swelling first appears, a probe be passed into Stenson's duct and the gland be pressed from the outside, a few drops of pus may be squeezed out and this may serve to head off a general suppuration. If the entire gland becomes involved, hot anti- septic poultices should be applied to hasten the localization of the pus. As soon as redness and edema indicate the most probable situation of the pus, an effort must be made to evacuate it. Several important structures are to be avoided; Stenson's duct (a fistula is likely to follow its division), the facial nerve, the carotid arteries, the temporo-' maxillary vein and other vessels of lesser importance may be wounded. If the anterior part of the gland is involved, the incision is made parallel with and below Stenson's duct. The skin and fascia are divided and retracted and an effort is made to burrow into the depths of the gland with a probe or grooved director. The pus follows the connective tissue lamina; instead of the lobules of the gland, and it is better, if possible, to avoid dividing the grandular substance. If the posterior and lower part of the gland is involved, the incision should be vertical, with its center a little above and anterior to the angle of the jaw. The temporo-maxillary vein will be seen, running parallel i to the incision near the surface of the gland. A drainage-tube must be left in the deeper abscesses. TR] \ I Ml N I "i I'l \ l \T. ABSi 321 l»l\ lAL ABSCESS. These painful affections are not to be neglected, for they may lift up the periosteum and result in necrosis of the jaw. Left to itself, the abscess may point in the mouth, less frequently on the face. It begins in the alveolar process from infection from a carious tooth. It makes its appearance at the junction of the cheek and the gum. In- spection and palpation make the diagnosis. A cotton tampon soaked in 2 per cent, cocaine solution is laid on the gum for five or ten minutes, but analgesia will not be complete. Lift the cheek away from the M.H. Pig. ^43. — Dental abscess. (Tt-JK.) j /I Fig. 244. — Submaxillary abscess in contact with inner surface of the inferior maxilla. M. H., Mylohyoid muscle. P., Platysma myoides. GLs.M., Submaxillary gland. (Veau.) gum as far as possible, and with a sharp-pointed bistoury, wrapped to within a half-inch of the point, make a horizontal incision and cut down to the bone. There is nothing to fear and without getting deep one may fail. The patient may resist further efforts or the field may be obscured by blood (Fig. 243). Order an antiseptic mouth-wash (peroxide or glyco-thymoline, etc.) to be used every half-hour at first and the pain will rapidly disappear. In more extensive subperiosteal abscess of the jaws, the same principle of procedure should be carried out. 322 ABSCESS. SUBMAXILLARY ABSCESS. Do not await fluctuation in acute inflammations in this locality. The pain, augmented by pressure, the brawny edema and diffuse redness are sufficient to demonstrate the presence of pus. The pus is not always easy to find, for it is deep, often subperiosteal and in con- tact with the internal surface of the jaw, and is generally due, in fact, to dental infection (Fig. 244) Fig. 245. — Incision of submaxillary abscess. Dotted line represents the facial artery. (Veau.) Local anesthesia is often sufficient. Locate the angle of the jaw. This is often difficult on account of the edema. A finger's breadth below, and following the body of the jaw, make a curved incision (Fig. 245) with slight downward convexity about three inches in length. Remember the point at which the facial artery crosses the body of! the jaw, just in front of the masseter. Do not cut deeper than the] skin, for this is dangerous ground. Now dissect with forceps andl grooved director the subjacent tissues, making haste slowly and re- ludwig's angina. 3*3 Dewing from time to time the analgesia or injections as the patient complains of pain. Can-)' the dissection upward and inward toward the inner surface of the jaw, and with patience the abscess will be located. As it is approached, the tissues will be found more and more edematous and idled with serum. Having once cut into it, enlarge the opening, always too small, by introducing and opening an artery forceps. Irrigate // ff I'n.. 246. — Phlegmon of the floor of the mouth. The tongue is pushed to the oppo- site side and the spread downward of the purulent collection opposed by the mylo- hyoid muscle. GSL, sublingual gland. AL, lingual artery. CW , salivary duct. GGL, genio-hyo-glossus. GY , genio-hyoid. MY., nyo-glossus. D, digastric. {Veau.) I"ir.. 247. — Incision for phlegmon of floor of mouth. (Veau.) with sterilized water, insert one or two small drains, dress with an- tiseptic gauze and absorbent cotton, and renew daily. The tempera turc will fall rapidly. After five or six days the drainage may be diminished and after ten days entirely removed. ABSCESS OF THE FLOOR OF THE MOUTH. (Ludwig's Angina.) This is a very grave, usually fatal condition, originating in strepto- coccic infection through the mucous membrane of the floor of the mouth. It more frequently occurs in adults, though childhood is not exempt. Its tenden< \ is 10 extend into the uei k, following the cellular 324 ABSCESS. planes, and if the patient does not die early from septicemia, gangrene may occur. In a very few hours after the infection begins, the floor of the mouth becomes brawny, the tongue is thrust up against the hard palate, and breathing and swallowing markedly interfered with. If anything is to do good, it must be done at once (Fig. 246). Try the antistreptococcic serum — if it does no good, it will at least do no harm. In the meantime, operate. Frequently a general anes- thesia is indispensable. Make v an incision a finger's breadth below the body of the jaw about three inches long so that it reaches beyond the median line (Fig. 247). If both sides are equally involved, make a bilateral incision. One may perhaps recognize the platysma, but MX Fig. 248. — Deep incision for phlegmon in floor of mouth. G.s.M., submaxillary gland. M.H., mylo-hyoid muscle. D, digastric muscle. (Veau.) the anterior belly of the digastric must be demonstrated and divided. Next expose the mylo-hyoid and divide completely (Fig. 248). Hav- ing now reached the sublingual space, you may find merely a serous exudate, characteristic of this form of infective inflammation. Do not stop until the mucous membrane of the mouth has been demonstrated, for otherwise one may mistake the submaxillary for the sublingual gland and not go deep enough. Douche thoroughly with peroxide, place two or three large drainage- tubes, pack with gauze saturated with peroxide, and apply absorbent cotton. Renew the dressings and flushing three or four times daily and the serum injections as well. Possibly the patient will go on rapidly to death from septicemia. He is almost certain to do so without the operation. The drainage may be diminished toward the tenth day. Several weeks will be required for a cure. TONSILLAH Ai-.sn ss. 325 ABSCESSES OF THE TONGUE. Abscesses of the tongue do not often occur, but when they do, may give rise to urgent conditions. They may develop suddenly with much pain, which may be variously reflected — to the ear, for example. The tongue may be so swollen as to fill the mouth and severely dis- turb respiration. The location of the abscess is to be determined by palpation. If it is at the base of the tongue and pointing toward the surface, it is to be evacuated by a median longitudinal incision from behind forward and deep enough to reach the pus. There is no danger of wounding important structures if the incision follows the middle line. Leave a strip of gauze in the wound for drainage. Prescribe frequent antiseptic mouth-washes. If the abscess lies under the tongue and points downward, the incision must be made along the floor of the mouth, if the mouth can be sufficiently opened and fluctuation de- tected. The ranine artery may be wounded. If the mouth cannot be opened it is best to operate from the outside, making a median vertical incision from the symphysis of the chin down, getting between the two genio-hyo-glossi muscles and following this crevice up to the under surface of the tongue. Drainage-tube, antiseptic absorbent dressing. TONSILLAR ABSCESS. "Ouinsy" is an acute suppuration in the tonsil or around the tonsil following acute infection of the gland. Often the suppuration occurs only on one side, though both tonsils are inflamed. At any rate the two tonsils do not suppurate simulta- neously. The temperature is high, the pain extreme, there is difficulty in Swallowing and perhaps in breathing. There may be edema of the glottis. Often there is difficulty in opening the jaws. After the ab- scess is well formed the soft palate is edematous and swollen. Pus begins to form about the third day after the attack. Previous to this an effort should be made to abort the abscess. Give calomel in small frequent doses and follow with a saline purge, and in the mean- time administer full doses of sodium salicylate. I'henacetine, two or 326 ABSCESS. three grains frequently, will make the patient more comfortable. Paint the tonsils and pharynx with argyrol once a day and use the peroxide spray (50 per cent, solution) every two or three hours. Ap- ply hot antiseptic fomentations or poultices externally. If these measures fail to relieve the symptoms after the third day, it is almost certain that pus has formed, even though fluctuation cannot be felt, and it is best to make an incision, but this must be free. The operation is sometimes difficult. A general anesthesia will be necessary if the jaws are locked. Open the mouth wide. A mouth gag is often necessary. Depress the tongue as much as possible. Swab the tonsil with a 10 per cent, solution of cocaine. With a sharp pointed bistoury (wrapped), make an incision in the soft palate just ex- ternal to, and parallel with, the anterior pillars and extending as low down as possible. If the pus flows freely, some of it may be swallowed, to pre- vent which bend the head down. Continue the spray and antiseptic mouth-washes for a few days. Whether pus is located or not, free incision gives great relief (Fig. 249). Fig. 249. — Tonsillar abscess. In- cision should extend as low as possi- ble. {Veau.) RETROPHARYNGEAL ABSCESS. These conditions are treacherous and dangerous because (most frequent in infants) they may be overlooked and, bursting into the pharynx, may produce suffocation. The pharynx is separated from the muscles covering the anterior surface of the bodies of the cervical vertebrae by a loose connective tissue. One or two lymphatic glands lie in front of the bodies of the upper two cervical vertebras en either side of the middle line. These receive lymph (and infection) from the nasal cavities and their acces- ft] I RO I'll \KN Net \l. \|.-( I SS. 327 sory sinuses, the naso pharynx, the Eustachian tube, the tympanum, ami Erom the tissues lying on the bodies of the adjacenl vertebrae. Septic conditions existing in any of these localities may be the sour< e of the inflammation of these Ij mph glands, which may end in suppuration. These glands empty by several chains of lymph vessels into the deep cervical glands. The suppuration begins <>n one side usually, but rapidly spreads toward the middle line, where the tissues are loosest. The ab may l>e behind the palate; it may be opposite the larynx; in either case almost out of sight. Usually, however, it is seated in the posterior wall of the pharynx, opposite the oral cavity. When situated there, ii rise to fewest symptoms, and for that reason its development is in- sidious, and in the infant unsuspected. The constitutional disturb- ance may be slight. Obstructed breathing and hoarseness and a feeling of tightness in the throat may first suggest the difficulty. Inspection and palpation, al- ways necessary, are not always easy and, in the case of infants, some- times dangerous. Still, only by touch, with the finger in the mouth, can the exact condition be determined. To prevent asphyxia or syncope, the main thing is to be rapid in the examination. To facili- tate this, the child must be prepared. It is seated on the assistant's lap with its face turned to the light, its arms and body encircled by a towel, its legs held firmly between the assistant's knees. Its mouth is forced open by pressing the cheeks between the teeth. The finger is passed to the back of the tongue and rapidly palpates the walls of the pharynx. It is not difficult to deter- mine the point of greatest swelling. Operation. — 1. Have already prepared a sharp-pointed bistoury wrapped with cotton close up to the point. The index linger in the mouth holds the tongue down and the bistoury is passed along the finger and plunged into the abscess in the middle line, that no blood vessels may be injured. This puncture is prolonged into an incision from above downward at least an inch; in fact, as low as possible, that chances of a recurrence may be diminished. The patient is imme- diately inclined forward in order that the pus may pour out of the mouth (Fig. 250). 328 ABSCESS. If syncope or spasm of the larynx occurs, do not lose your head, but proceed hastily to revive the patient by the ordinary means. Lower the patient's head, pull out the tongue, and employ artificial respiration. As after-treatment, direct frequent irrigations or gargling with sterilized water. A peroxide spray may be used with good effect. Recovery occurs within a few days. If the abscess recurs, or in the first place is situated too far down for oral puncture (which may sometimes be done by passing a curved Fig. 250. — Retropharyngeal abscess. (Veau.) director over the base of the tongue and then downward to the top of the abscess), or the jaws are locked, it will have to be reached from the side of the neck, an operation much more difficult in every way. Operation. — 2. Turn the patient slightly to one side, resting the neck upon a cushion to make its lateral aspect prominent; the sterno-mas- toid is the guide. Make an incision about two inches in length along the posterior border of the sterno-cleido-mastoid, which is exposed after the skin and fascia are divided. Ligate the veins; avoid the IBS< I ss in I hi (i i:\ [( \i <.l VNDS. superficial cervical nerves; pull the sterno cleido mastoid forward and locate the scalenus anticus. Stick t<> the scalenus anticus, follow its anterior surface inward, displacing forward by careful dissection with grooved director, the common sheath of the great vessels and pneumo- kastric. The connective (issue are rather loose; the dissection is not difficult. Be on the watch for the spinal accessory nerve, which lies or the deep surface of the sterno mastoid. Working inward in this manner reach the outer border of the longus colli which lies in the same Uane as the scalenus anticus, and upon which lies the pharynx and the Lbscess. After opening and emptying, a drain must be left. Employ the usual dressings and after-treatment. Sometimes the abscess lies further forward and it will be necessary to go in front of the sterno- cleidomastoid. After the skin and fascia are divided, the finger in the wound will be able to locate fluctation and that will he the best guide in the subsequent dissection. It may be necessary to ligate several small veins. Retract the anterior border of the sterno-mastoid and with it the sheath of the common carotid, the internal jugular and pneumogastric; draw forward the thyroid, the larynx and trachea. The fascias are divided by blunt dissection until the abscess cavity is Opened. ABSCESS OF THE GLANDS OF THE NECK. Acute suppuration of the lymph glands of the neck is quite frequent and originates in infective disorders of the areas drained by the glands. In treating these conditions, the source of the infection must not he overlooked. It is not always advisable to operate immediately, even ■hough suppuration is believed to be present, unless, of course, the inh < tion shows a tendency to become general. In the ordinary case, the pus may be \ cry deeply located or outside the i apsule of the gland. It is better under these circumstances to apply hot antiseptic poultices for twenty-four to forty-eight hours. The whole gland then becomes softened, the pus is easily evacuated and healing m i urs rapidly; whereas a dob suppurating gland cut into may remain enlarged and indurated. Free iin ision is always out oi the question as the many important structures of the neck have to In- borne in mind. Use local anesthesia. In making the in, ision it is usually best to 330 ABSCESS. follow the posterior border of the sterno-mastoid. Make an incision about two inches in length. When the muscle is reached, draw it forward with a retractor and with a grooved director search for the pus cavity; drain; use absorbent dressings. CHRONIC SUPPURATION OF THE CERVICAL GLANDS. There are various clinical manifestations of the tubercular processes, each of which demands a somewhat different treatment. It is as- sumed that the pus, gradually accumulating, has burst through the fascia and has begun to bulge the skin. It is best to operate at once. The most careful asepsis should be maintained. The pus is evacuated by free incision and the abscess cavity wiped out with iodoform gauze. A 10 per cent, solution of iodoform emulsion with glycerine is poured into the cavity (two or three drachms are sufficient) and the wound sutured and treated as an aseptic wound, provided there is no evidence of secondary infection. ABSCESS OF THE BREAST. Abscess of the breast may be either parenchymatous, originating in the substance of the gland; or submammary, originating in the areolar tissues separating the gland from the pectoralis major. In either case infection nearly always begins at the nipple and follows the lymph vessels downward. The first form is usually due to staphy- lococcic infection, the second to streptococcic. These conditions are preventable in the greater number of cases and for that reason the nipple should be given special care both before confinement and during the first weeks of lactation. Even when the breast becomes "caked" and tender and there is a little fever, antisepsis at the nipple and hot antiseptic poultices to the breast may prevent abscess formation. Continued rise in temperature, slight chills, edema and pain, more or less localized, indicate the for- mation of pus, and immediate operation is necessary. A general anesthesia is best for thoroughness, though the work may be done under local anesthesia. Aiisri SS < > I I hi BR] \si . 331 ruder rigid .isepsis, proceed to open up the cavity, and always re- Blember, the earlier the better. An incision an inch or so long should Begin near the nipple and radiate from it, as (he spoke from the hub )f a wheel. In this manner the least possible Dumber of the milk ducts and vessels are divided (Fig. 251). The first incision goes through the skin and fascia and then the ab- scess cavity is sought for by blunt dissection with a grooved director. Still there is nothing to fear in cutting boldly down to the abscess. Explore the cavity thoroughly for there may be pockets leading off -1 PlG. -'Si. — Abscess of the breast: incision. (Lejars.) from the main cavity. Do not neglect this point. If it extends deep, make a counteropening at the base, being guided by the director in- troduced through the first opening (Fig. 252). Pushing a forceps through the channel, it seizes a drainage-tube which is drawn into place as the forceps is withdrawn. Dress with antiseptic gauze, which should be changed twice daily at first, care being taken not to dis- turb the drainage tube. If the temperature rises again after the second or third day. you will lave to re explore. A new abscess is in process of formation. After five or six days replace the first drainage tube with a smaller one. The 332 ABSCESS. drainage-tube can be entirely dispensed with after ten days or two weeks. The submammary abscess develops without edema or redness be- cause it underlies the whole breast. The condition can scarcely be mistaken, for the marked elevation of the whole breast, along with the constitutional symptoms point to the nature of the trouble. Make a curved incision following the base of the breast at its lowest part, di- viding 'the skin and fascia. With a grooved director, dissect through Fig. 252. — Abscess of the breast. Manner of making counteropening. D, grooved director; P, its point; B, bistoury cutting down on to the point of director. (Lejars.) the areolar tissues between the gland and the chest wall, working toward the center of the breast. These deep tissues are likely to be infiltrated. In this manner the pus is evacuated and the subsequent treatment will be practically the same as that prescribed for the pre- ceding form. AXILLARY ABSCESS. Three chains of lymphatic glands are found in the axillary space. One lies along the anterior fold of the axilla and drains the anterior thoracic region; one lies on the posterior axillary wall and drains the Will AKV \l:-< I SS. 333 posterior thoracic region; one Lies alongside and externally is connc ted with the axillary vessels and drains the upper extremity. Axillary ftbscess usually results from inflammation <>f one or the other of these chains of glands, the infective agent having been carried to them from a distant point, such as the breast or hand, by the lymph vessels. The inflammation spreads from the glands to the adjacent areolar tissue and pus formation follows. Abscess may also form by exten- sion of pus formation from the base of the neck. The most frequent sources of infection, probably, are the breast and the sebaceous glands in the skin of the armpit. Abrasions and small Pig »S3. Cross section showing relations of axillary abscess. G. F. Pect. major. P.P. Feet, minor. G. D. Latiss, dorsi. S.SC. Subscapularis. G. D. Serratus mag- nus. (Veau.) boils in this locality must be treated with circumspection, lest they terminate finally in axillary abscess. The ordinary symptoms of in- flammation and pus formation, added to the painful abduction of the arm, indicate the nature of the trouble. It is imperative to evacuate the pus promptly for the reason that it pay burrow in various directions, usually upward toward the neck. Tin- axillary vessels may be eroded. The incision will depend upon the location of the pus thai is to say, whether it lies under the pectoralis major or in the loose areolar tissues 334 ABSCESS. of the center of the space. Acute abscess more often lies in the first locality (Fig. 253); tubercular abscess in the latter. (a) Acute Abscess (Fig. 254). —General anesthesia; place the patient on his back; abduct the arm as much as possible; and locate the border of the pectoralis major. Make an incision three inches in j length along this line, cutting toward the thorax; expose the muscle border well; dissect along the under surface of the pectoralis major with the grooved director. In this manner you keep in front of the Fig. 254. — Incision for acute axillary abscess. The blunt dissection should follow the anterior axillary wall. (Veau.) great vessels and nerves and will feel secure. When the pus once flows, enlarge the opening, and insert drainage-tubes. To avoid the axillary structures, you must keep these two points in mind: (1) Make the opening large enough to see what you are doing — a blind stab in this region is exceedingly dangerous; (2) stick to the pectoralis major — the pus is in contact with its deep surface. Wash out the cavity and place two drains; use a gauze and absorbent cotton dressing daily for a week, after which remove the tubes, though the external opening must not be allowed to close until the cavity isj eliminated. (b) Chronic Abscess. — Incision. Begin in the middle of the floor of the space and follow the middle line away from the arm toward the > PALM VB \i;s< i ss. 335 chest. In this direction alone Is -afeiy. In front arc the long thoracic vessels; la-hind are the subscapular vessels; to the outside arc the main axillary vessels and branches of the brachial plexus. The skin im is ion may occasionally divide a small artery, which will at first give some concern. It is best to divide the connective tissues layer by layer in the original line of incision. There is no danger if you keep in this line. Otherwise, the pus may be reached by Hilton's method. After the skin and fascia are divided, a dressing forcep is pushed up into the abscess cavity and the blades opened. Put in a drainage-tube; use absorbent dressings; maintain a careful asepsis throughout the process of repair. PALMAR ABSCESS. These are always serious conditions, not alone on account of sepsis, but because the hand may be left permanently crippled or useless as a result of the destruction of tissue and inflammatory adhesions. Immediate evacuation of pus is imperative. If the pus is limited to the connective tissues of the palm, has not reached the tendon sheaths, the incision should be made over, and parallel with, the in- terosseous space in the region of the greatest swelling. If the tendon sheaths are involved, the incision should be made in the long axis of the metacarpal bone (seePIilegnimi, page 362). Whether the condition is a diffuse inflammation (phlegmon) or an abscess will be determined by the history of the case. In the case of abscess, make a longitudinal incision. The palmar lurches are chiefly to be considered. Begin the incision just below a line drawn across the palm from the web of the thumb. Beginning Bearer the wrist, the superficial palmar arch or the deep arch as well may be divided. Cut toward the finger, making the incision suffi- ciently deep to go quite through the palmar fascia. Insert a drainage- tube. Use antiseptic dressings, changing the dressings daily. (See also Phlegmons.) POPLITEAL ABSCESS. Situated in the hollow back of the knee-joint in the superficial fa- cia are a few lymph glands which may suppurate following an infci li\e 336 ABSCESS. process in the foot or leg. Situated still deeper beneath the deep fascia are other glands which may similarly suppurate. These may be described, then, as superficial abscess and deep ab- scess of the popliteal space. The superficial abscess may be opened simply by a vertical incision over the point of greatest swelling. There are no important structures likely to be wounded by a superficial incision. It is quite different with a deep abscess. The situation of a number of important structures must be borne in mind. In the center of the lower half of the space lies the short saphenous vein; to the outer side lies the external popliteal nerve, and running vertically through the center of the space, and deeply located, are the popliteal vessels and internal popliteal nerve. The space is roofed over by the dense popliteal fascia which is the chief factor in determining the direction in which the suppuration extends; thus the pus is more likely to point up in the thigh or down in the leg than in the integuments of the space. A popliteal abscess may likewise be the result of the extension of a suppurative process in the thigh. These abscesses must be opened without delay for the reason that the joint may become involved, the vessels may slough, and there may be destruction of tissue. There may be permanent flexion of the leg due to scar tissue. Before opening a popliteal abscess the diagnosis must be confirmed. It has happened more than once that a popliteal aneurysm has been mistaken for an abscess and incised, a mistake serious indeed for both patient and operator. Acute inflammation of the bursae must not be mistaken for abscess. These bursa? are found in the boundaries of the space, separating the tendons from the protuberances of the femur, tibia, and fibula. Operation. — Either general or local anesthesia may be used. Make a vertical incision in the center of the space, dividing the skin, the superficial fascia, and the deep fascia successively. With the grooved director separate the fatty tissues filling the space; keep in the line of the original incision. The pus will usually be located before the depth of the vessels has been reached. Enlarge the opening in the con- nective tissues, irrigate, search for diverticula, insert a drainage-tube and pack lightly around the tube with aseptic gauze. Apply absorb- ISt'lllo \<\ (| \i \i:m i SS. 337 mi dressings ;m«l extend the leg <>n a posterior splint. This extension must be maintained until the healing is complete to prevent flexion. PLANTAR ABSCESS. The deep Fascia of the sole of the fool is especially developed. It extends as a broad, dense band from one end of the plantar arch to the other, from the os calcis to the base of the metatarsal bones. It is abroad hand divided into three portions: outer, middle, and inner. The central portion alone is of much surgical importance. Its ante- rior extremity is broken up into Eve slips, and each slip branches and forms an arch for a Ilexor tendon. The result of this arrangement is that here is a closed compartment between the fascia and the bones of the foot which is occupied by the muscles of the middle foot. Following an infection, pus forming in this compartment finds great difficulty in escaping. It burrows be- tween the metatarsal bones and makes its appearance on the dor- sum of the foot, follows the flexor tendons backward to the inner ankle, or may escape through the small aperture for the arteries into the subcutaneous fascia. On account of the denseness of the fascia, the pain in plantar ab- scess is extreme, and for relief of this pain and to prevent destruction of tissue, an early incision is imperative. The incision should be made over the most prominent part of the swelling, its direction correspond- \ ing to the long axis of the foot. The skin is divided and then the thick fatty tissues, until the white and firm plantar fascia is reached. After the fascia is divided, the dissection is completed with a grooved director until the pus cavity is located. In this manner no important structures are wounded. Wash out the cavity and insert a small drainage-tube. It is important that the cavity heal from the bottom. ISCHIO-RECTAL ABSCESS. The ischio-rectal fossa is a wedge shaped cavity, lying on either side of the rectum, between it and the pelvic wall. Its base is covered by the integument and its sharp edge is directed upward and corre- 33* ABSCESS. sponds to a line drawn from the pubes backward to the spine of the ischium — the line of attachment of the levator ani muscle, the "white line" of the pelvic fascia. The levator ani muscle forms its inner boundary. The obturator fascia covering the bony pelvic wall forms its outer boundary. The fossa is filled with fatty tissue which seems to form a packing and support for the rectum, but which at the same time forms a site of "lowered resistance" to infective agents. These infective agents gain access to the fatty tissues of the fossa through ulcerations or abrasions of the rectal mucous membrane or from similar conditions in the integument around the anal orifice. For the most part the bacteria follow the lymphatics which have their origin in these localities and which follow the branches of the inferior hemorrhoidal vessels through the fossa. The abscess may be second- ary to prostatic abscess. The symptoms of acute abscess here are the ordinary constitutional symptoms in marked degree, accompanied by intense throbbing pain in the region of the anus. The skin becomes brawny and indurated but no fluctation appears in many cases. The symptoms of chronic abscess differ only in degree, and are often so slight as to be entirely overlooked. Abscess of any kind in this locality, when diagnosed, should be evacuated without delay. If let alone it will eventually open into the rectum or through the skin if the patient shoul survived the general sepsis. But spontaneous evacuation is in every way to be avoided, if possible. A fistula is the inevitable sequel if the case is left to nature. This fistula, opening into the bowel whether the abscess formed near the roof of the fossa or near the floor, is very likely to be just above the external sphincter. There the bowel wall is thinnest, and the fascias of the levator ani act as an inclined plane along which the pus moves toward that part of the bowel. The examining finger in the rectum in the case of abscess will nearly always detect the threatened opening there and confirm the diagnosis. Operation. — General anesthesia; lithotomy position; antisepsis. The incision (Fig. 255), four or five inches in length, is made from I'l R] R1 ( I M. ABSCESS. before backward and inclined a little outward midway I etween the ischial tuberosity and the rectum. Remember that cutting too near the middle line, you may wound the rectum; too near the pelvi< wall, you may wound the internal pudic vessels. Some small hemor- rhage will follow the skin incision. It may be necessary to cut deeper along the same line and you may wound some of the branches of the inferior hemorrhoidal arteries, but that is not a serious matter. \\ ith a little patience, in this manner the pus is reached and it [tours out, extremely fetid and often mixed with shreds of connective tissue. Enlarge the wound so that it may be inspected and explore it with FiG.'asS- — Ischio-rec Incision. (Veau.) \ the finger. Irrigate vigorously. Being assured that all the minor cavities are opened up, introduce a large drainage-tube and pack around it with gauze. The dressing must be renewed daily at first. The tubes can be gradually withdrawn. It is absolutely necessary that the wound heal by granulation from the bottom and this may be a matter of weeks or even months. Of this the patient should always be forewarned. During this time the dressings must be carried out methodic ally. Often following incision and drainage there is a tendency to relapse because the primary focus of suppuration in the prostate has not been recognized and relieved. If a small opening is exposed high up in the cavity, through which pus drains, it indicates a perirectal abscess above the levator ani, dangerous because it may become a general pelvic cellulitis or peritoni- 34-0 ABSCESS. tis. Enlarge the opening by the introduction of a dressing forceps, irrigate and drain. These peri-rectal abscesses not involving the ischio-rectal fossa are difficult to diagnosticate, but when once determined they must be opened in the manner already indicated. Again, the ischio-rectal abscess may have, unfortunately, already opened through the rectal wall. Make the skin incision as before, and then an additional step is necessary. Push a grooved director up through the abscess cavity and through the rectal opening and then, following along the grooved director, cut through the entire thickness of the rectal and anal walls, holding one finger in the rectum to guide the knife. It will look like a very long wound, and yet it has the excel- lence of favoring recovery and of preventing a fistula. However, under the most favorable circumstances, it may require several months to heal (Lejars). PERI-ANAL ABSCESS. These are much less serious than those of the ischio-rectal region, both with regard to prognosis and treatment. However, if neglected, they are likely to result in a fistula; even if not properly incised they Fig."256. — Incision for peri-anal abscess. {Veau.) may so result. The peri-anal abscess is in the glands surrounding the anal margin and lies under the integument or mucous membrane. Local anesthesia is all that is necessary except for those who are timid, and with them general anesthesia is indispensable. PROSTATIC ABS4 I 34I Puncture the tumor at its apex. The pus is foul smelling. Irrigate; explore the cavity methodically with a grooved director. There is nearly always an ascending diverticulum on the anal side which com- municates with the rectum. Having located the apex of the cavity, push the point of the director through the mucous membrane; in other words, make a fistula if one does not already exist (Fig. 256). Divide all the tissues over the director, in this manner laying open the cavity and anal margin. Carefully wipe out the walls of the abscess and pack with iodoform gauze. As important as the operation is the after- treatment. This the doctor must attend to himself. The dressing must be made daily, washing and packing lightly. After each move- ment of the bowels, the wound must be washed and the packing re- placed, if possible. It is essential that the cavity granulate from the bottom. Repress excessive granulation with tincture iodine. PROSTATIC ABSCESS. The prostate gland, about the size and shape of a chestnut, lies at the base of the bladder, clasping but not quite encircling the first portion of the urethra. The upper surface of the urethra is covered by fibrous tissues which connect the upper surface of the two lateral halves of the prostate, so that the urethra apparently makes a tunnel through the prostate. The ejaculatory ducts empty into this portion of the urethra. The prostate is in contact with the second portion of the rectum one and one-half to two inches from the anal orifice. The apex rests against the triangular ligament, which separates it from the bulb of the urethra. Suppurative inflammation in the prostate originates from infection caught up by the lymphatics of the prostatic and membranous portions of the urethra. These infective agents arc the gonococci, staphylococci, streptococci, bacilli coli communis. As might be expected, gonorrhea is the most frequent cause, both lirectly and indirectly. The passage of sounds, perineal bruises, sex- ual excesses, and high living in one way <>r another favor the develop- ment of an inflammatory process which may result in abscess formation. 342 ABSCESS. The abscess may be limited to the gland substance or may develop in the connective tissue surrounding the gland. In this case it may be called a pelvic abscess. It may become an ischio-rectal abscess. Chronic prostatic abscess may be overlooked and unrecognized as the direct cause of many conditions: chronic urethral discharge; vesical and rectal irritation; rectal fistula; chronic inflammation of the prostatic adnexa (the ejaculatory ducts and seminal vesicles); sup- purating epididymitis and orchitis; nocturnal emissions. Any abscess of the prostate may open into the rectum, bladder, urethra, perineum, or suprapubic region. Finally there is, in the case of acute abscess, the imminent danger of the general involvement of the pelvic fascia, ending in septicemia. It is manifest that a prostatic abscess is a constant menace. Its evacuation must not be delayed. It cannot be denied that oftentimes spontaneous evacuation is followed by a complete cure, but the outlook is many times more favorable with immediate operation. Sometimes the only cure is in complete re- moval of the gland. Diagnosis. — There is usually a history of gonorrhea, recent or re- mote. Fever and a few chills; violent perineal pain, radiating to the. rectum and thighs; painful and difficult urination and defecation point to probable suppuration in the prostatic region. A little later perhaps the perineum is reddened, swollen, and infiltrated. Complete the diagnosis by introducing a well-oiled finger into the rectum, which will excite much pain. On the anterior wall of the rectum will be found a large unsymmetrical swelling, more or less clearly fluctuating, and which loses itself in a doughy tumor extending toward the sides of the rectum and the anus. Now must one operate even though there be some pus discharging through the urethra, having begun spon- taneously or following the passage of a catheter. Such drainage is quite insufficient. There are two methods of operation: (a) the rectal route when the abscess is about to burst into the rectum; (b) the perineal route, under all other conditions. In either condition general anesthesia is indispensable. The perineum and its vicinity are carefully sterilized and the patient placed in the lithotomy position for the perineal in- cision. PROSTA'l !«■ M'.SCI SS. 343 Rectal route: Place the patienl on the righl side, flex the left thigh ft) the abdomen and let the assistant hold up the left buttock. Dilate the anus and give the rectal mucosa a thorough lavage, washing with fcap and water and gauze, followed by an alkaline antiseptic solution. Retract the posterior wall of the rectum with a Sims' speculum. The anterior wall will thus he exposed to inspection. Locate by touch the thinnest part of the abscess wall, for the tumor will not be so conspicuous to sight as it is to the touch. Without hesitation push the point of the knife one-half inch into the tumor. This is to be done Fig. 257. — Prostatic abscess: patient in lithotomy position; incision between bulb and anus extending laterally to the ischial tuberosities. {Veau after 1'icrrc Duval.) by sight and not by touch. When the pus flows, enlarge the opening, cutting toward the anus. Make the opening at leastan inch in length. Favor the flow by slight pressure, and finally irrigate. You may be satisfied with that, leaving no drainage, but repeating the rectal Hush- ing several times daily at first. If the cavity is deep and if there is considerable oozing, it is better to pack very lightly with aseptic gauze, which will be expelled with the first movement of the bowels. Perineal route: An incision one inch in front of the anus, transverse, [lightly curved with convexity forward (big. 257). This incision di- vides the skin and superficial fascia- edematous, it may be. Separate 344 ABSCESS. the edges, of the wound and identify, if possible, the muscular layers composed of the transversus perinei, the sphincter ani and accelerator urinae, which, coming from the cardinal points, meet at the "central tendinous point of the perineum," which is to be next incised. If these structures are not recognizable, the bulb of the urethra covered by the accelerator urinae can at least be found. It is a prominence which the finger if not the eye will readily detect. Incise transversely Fig. 258. — Prostatic abscess. Showing relation of structures concerned in opera- tion; in front the bulb of the urethra, on either side the erectors of the penis, trans- versely the transversus perinei which is divided parallel with its fibers. (Veau after Pierre Duval.) through the middle of the transverse perinei (Fig. 258), or at least just behind the bulb. The transversus perinei artery will be divided. Now draw the bulb forward out of the way with a retractor and pull the posterior lip backward with an artery forceps. Make the third transverse incision through the layer now well ex- posed, viz.: the superficial layer of the triangular ligament, a dense, fibrous membrane. The abscess is now covered only by the deep layer of the triangular ligament, and this is best opened up with the grooved director, working forward in order to avoid the rectum, which ies immediately behind (Fig. 259). PROSTATIC VBS< .VI 5 As soon as the cavity is Located, enlarge the opening with the for< eps, irrigate gently, place a drainage tube and use an absorbent dressing, which is to be removed cai h morning and evening and after stool. Irrigation and Drainage of the Seminal Duct and Vesicle. — Purulent accumulations in the seminal vesicles demand relief on account oi the frequent urination and other symptoms which sometimes may be at- tributed to the prostate itself. Belfield, of Rush Medical College, accomplishes the relief of these conditions by drainage through the vas deferens. PlG. .'5'i. Prostatic abscess; showing relation to bladder and rectum and the muscular and fibrous layers to be divided. (Veau.) The vas deferens is caught between the lingers at the base of the S( rotum and brought up against the skin and held by a half-curved needle passed through the skin under the vas. A half-inch incision under local anesthesia is then made over the vas; it is exposed and opened by a longitudinal or transverse incision. The blunted needle of a hypodermic syringe is then passed into the canal and the solution injected. The liquid traverses the \as and the ampulla, and distends the seminal yesi< les. If necessary the vas may be stitched to the skin by a line silkworm 346 ABSCESS. gut suture, and a fistula thus established, through which daily in- jections may be made. By this means, too, the vas is made to serve as a drainage-tube for the ampulla. A fine silkworm-gut may be passed into the canal and left until the next injection. Belfield recommends the procedure for chronic gon- orrheal infections of the seminal canal; chronic pus infections in the elderly (often mistaken for enlarged prostate); for acute gonorrheal spermato-cystitis; and for the abortion of threatened epididymitis. VULVAR ABSCESS. The labia majora are composed of areolar and fatty tissues, bounded on one side by skin and on the other by mucous membrane. These integuments have many sebaceous follicles and are exposed to various forms of infection and traumatism. Along these sebaceous follicles and the lymphatics, agents of suppuration may travel to reach the areolar tissues, which are so prone to yield to the attack. The traumatisms of accident and brutality and excessive coitus then are the predisposing causes; the streptococci and gonococci, the specific agents of inflammation of the vulva, which may end in abscess. The suppuration takes on the diffuse rather than the cir- cumscribed form. The labium majus of the affected side is swollen, doughy, reddened, dry, and there are the other local and constitutional signs of suppuration. The skin, apparently more than the mucous membrane, is involved and the lesser labium, scarcely at all. In order to avoid general infection, or an ugly slough from spontaneous evacua- tion, the abscess must be incised immediately. The presence of pus can nearly always be determined by fluctuation. After careful anti- septic preparation, a vertical incision in the site of the greatest swelling, usually in the integument, will be sufficient. There are no vessels to fear. Ordinarily, a strip of iodoform gauze will furnish sufficient drainage. An absorbent dressing and rest will soon bring about a cure. VULVO-VAGINAL ABSCESS. (ABSCESS OF BAR- THOLIN'S GLAND.) Beneath the vaginal mucous membrane, near the junction of the lateral and posterior walls, between the lesser labium in front and the Vl'l VI) \ M.IWI. AHSCKSS. 347 liangular ligament behind, is Bartholin's gland, one on cadi side. The ■and is normally about the size of a small almond, and is about oneor ,,,<• and one half inches from the vulvar orifice. Its duct opens into the Elvar canal just external to the hymen or its remains, the carunculae myrtiformes. Its lymphatics empty into the superficial glands. Its relation of greatest surgical importance is with the venous plexus (the bulb of the vagina), which covers its upper half and which may he wounded by too free incision. As in the case of vulvar abscess, the cause of sup- puration is an infective agent, most frequently the gonococcus, which reaches the gland by way of the excretory duct. Excessive coitus is a predisposing cause. The symptoms at first are those of acute inflammation of the vulva or vagina; finally the symptoms become localized. On examination the vaginal orifice is found to be almost closed on account of the swell- ing, and the mucous membranes hot and dry. The examining finger detects on the affected side a well-defined body vary- ing in size, perhaps no larger than a chestnut, perhaps as large as a hen's egg. It is clearly circum- scribed. The labium ma jus is only slightly edematous ordinarily, the lower part more so. The abscess must be incised as soon as fluctua- tion is present in the slightest degree. Several serious consequences may attend delay. The inflammation may follow the vaginal areolar tissues into the pelvis; there may develop a phlebitis, or sloughing of the veins, or lymphangitis, or. what is more common, there may result a recto-vaginal fistula. Fig. 260. — Vulvovaginal abscess. Direction of incision. 348 ABSCESS. Operation. — Cleanse the parts carefully under local or general an- esthesia, incise the tumor in the direction of the long axis of the vagina from within outward (Fig. 260). Incise thoroughly, as this is the means of securing the drainage that will prevent a fistula. The in- cision must not be deep near the vaginal orifice for fear of wounding the bulb of the vestibule. A strip of gauze will favor healing from the bottom of the abscess. The region should be frequently douched. PELVIC ABSCESS. Separating the pelvic peritoneum from the organs of this region are loose areolar tissues which are prone to suppurate when attacked by infective agents. Pelvic cellulitis usually begins as a lymphangitis, following the ab- sorption of bacteria from some pelvic focus, usually the Fallopian tubes. A salpingitis is the most frequent cause of pelvic abscess. The ar- rangement of the fascia and organs is such that the inflammatory exudates gravitate to the cul-de-sac of Douglas. Left to its own course, the abscess may open into the vagina, rec- tum, or bladder; less frequently through the abdominal wall, saphen- ous opening, pelvic floor, obturator foramen, sacro-sciatic foramen, or into the peritoneal cavity. Diagnosis. — The history usually given points to an attack of pelvic cellulitis, following an abortion or complicated confinement, or some pelvic or abdominal traumatism. The temperature remains about ioo° with exacerbations reaching 103 or 104 . There are all the symptoms of septic aborption. On pelvic examination you are able to define a mass bulging down into the recto-uterine pouch. This taken with the fever and pain, and perhaps some edema of the vulva, points without doubt to the nature of the trouble. A colpotomy should be done as soon as possible. The instruments needed are a speculum, a vulsellum forceps, a long artery forceps or dressing forceps, curved scissors, a scalpel, an irriga- tor, drainage-tube, and iodoform gauze. General anesthesia is usu- ally necessary, though in the simpler cases local anesthesia will suffice. Lithotomy position; the thighs held well apart, the shoulders lowered, the pelvis slightly elevated. i\i [SION FOB I'l I \ n Al 349 .1 careful antisepsis: shave the vulva and disinfect the inner sur- kce of the thighs, and the pubic region as well. Disinfect the vagina, jfUbbing it with soap and water first and being careful to rea< h every part of the mucous membrane, using the finger wrapped with sterile gauze. Finally irrigate with i to 2000 bichloride or other antiseptic solution. Cover the outside parts with sterile towels. Now retract the posterior vaginal wall with a Sims' speculum. With the vulsellum force] >s seize the posterior lip of the cervix and pull the cervix forward (Fig. 261). You will now be able to see the site which is to be incised. Fir,. 261. — Incision of the vaginal mucous membrane for abscess in the posterior cul-de-sac. (Veau.) 'flu' tumor may be conspicuous, the edema and fluctuation well de- lined; or nothing but some edema may indicate the presence of the deeper seated inflammation. Do not attempt a mere puncture, how- ever well-defined the pus cavity may be. With a curved scissors or scalpel incise the mucous membrane of the vault of the vagina one inch behind the base of the cervix. Make an incision from side to side, but do not approach too near the vaginal walls else the arteries there may be wounded. Fnlarge the wound by stripping its edges 35° ABSCESS. back a little. The abscess wall is exposed and with a little puncture the pus will flow. However, it may be that the pus is higher up and separated from the mucous membrane by thick and edematous areolar tissues, and this must not be taken for the abscess. From it will flow a serous fluid which must be accepted as a proof of pus higher up. With the finger or an artery forceps follow the posterior wall of the uterus upward. Do not dissect backward. The rectum is there (Fig. 262). Follow the posterior wall of the uterus to avoid danger. There is always some hemorrhage, in nowise dangerous. It may be necessary to dissect upward for an inch; it will seem further than it really is. Fig. 262. — Showing the uterus pulled down, preparatory to opening the abscess in the^ posterior^ cul-de-sac. (Veau.) Fig. 263. — Showing relations of abscess in the posterior cul-de-sac. Dotted lines represent drainage tube. (Veau.) When once the cavity is opened into, enlarge the orifice and with the finger make careful search for a secondary cavity. It you irrigate, do not employ much pressure. Do not pack the cavity with gauze. In- troduce a long drainage-tube to the top of the cavity. Its lower end must not protrude at the vulva (Fig. 263). Pack the vagina lightly, changing the packing every day without disturbing the drainage-tube. You may wash out the vagina, but do not use much force. Replace the drainage-tube by a smaller one about the tenth day if the tempera- ture is normal. It is likely that it will be pushed out spontaneously, and if it cannot be reinstated and the temperature is normal, it is certain that it is no longer necessary. In the matter of drainage it may be preferable to follow the plan of ST BPHR1 NIC ABSC] SS. 35 1 Miller, of New Orleans, who employs both tube and gauze. A tube is introduced and plain gauze is packed around it. The gauze is doI all removed until after five days, after which the cavity is flushed through the tube. The tube is shortened as the cavity contracts, hut seldom entirely removed under ten or fifteen days in large abscesses (New Orleans Med. and Surg. Journal, Sept., 1906). Remember that the original cause of the suppuration has not been removed and after the abscess has healed a specialist had better take the case in hand. SUBPHRENIC ABSCESS. A localized peritonitis is possible only in those localities not occu- pied by coils of small intestine. The region immediately below the diaphragm is of this character, and it is practically shut off from the general peritoneal cavity by the transverse colon and its meso-colon. This space is subdivided by the falciform ligament into aright, occu- pied by the liver; and a left occupied by the stomach, pancreas, duode- num, and spleen. Guibal describes five subdivisions of the subphrenic space, in any of which pus may collect (Revue de Chirurgie, April, 1909). One is retro-peritoneal; four are peritoneal. The retro-peritoneal space contains the termination of the esophagus, the posterior border of the liver, the pancreas, duodenum, colon, and kidneys. Of the peritoneal spaces two lie between the liver and diaphragm and may be the seat of abscesses following lesions of the liver, gall- bladder and ducts, pylorus, stomach, and duodenum. The third or perisplenic space may be infected through the greater curvature of the stomach, the spleen or splenic flexure of the colon. The fourth space, or the posterior gastro-hepatic, may be infected through the posterior surface of the stomach, the pancreas, or liver. In effect, subphrenic abscess is a localized purulent peritonitis, and whatever part the various adjacent organs may play in its production, yet the most frequent cause of subphrenic suppuration is appendicitis. The pus forming around the appendix, or behind the cecum, follows the ascending and then the transverse colon to reach that region. 352 ABSCESS. Sometimes it is impossible to determine the original focus of inflam- mation. Usually, however, if the history of the case is sufficiently def- inite, one may arrive at a conclusion. For example, if we find a patient with subphrenic abscess and there has been a history of gastric discomfort, vomiting of blood, etc., one would decide upon perforating gastric or duodenal ulcer. If there has been a history of jaundice and symptoms pointing to the right hypochondrium, the liver, or its ducts, should be accused; if there has been a clear history of previous attacks of appendicitis one need not be in doubt as to the starting-point of the condition with which he has to deal. Diagnosis. — You will have, then, usually, a history of some visceral disturbance followed (very quickly in case of perforation of the stomach) by a chill, fever, malaise, pain in the upper abdominal pole. The symptoms, to be brief, are those of peritonitis anywhere. Suspecting from these symptoms an accumulation of pus in the region just below the diaphragm, proceed to a methodical examination by means of in- spection, percussion, and palpation. The quantity of pus may be so great, or so near the front, that the bulging of the anterior abdominal wall may settle the matter without further examination. In obscurer cases it will be necessary to recall the normal limits of dullness, or tympany of the various organs, in order to determine the nature and degree of their displacement. Remember, too, that in all cases follow- ing perforation the abscess cavity will contain gas which will be another source of confusion. But after all, in the typical cases, guided by the history, the symptoms of sepsis and the local signs, one can rarely go astray. Aseptic aspiration may be restorted to in the doubtful cases, and one need not hesitate to aspirate several times. But previous to aspiration the patient should be prepared and should be operated upon immediately if pus is found. The X-ray may be helpful in diagnosis, since it shows an abnormal conformation of the diaphragm, and that it is immobile on the affected side. The great majority of sufferers from this condition not operated upon die from sepsis. A general peritonitis may supervene. Left to itself, the pus may open into the alimentary tract, which is to be regarded as a complication rather than a cure, for such cases usually terminate fatally from slowly increasing sepsis. In rare instances DIAGNOSIS <>l- SUBPHRENIC VBSCESS. ;;; it may open through the abdominal wall. Most often, however, it extends toward the thorax, opening through the diaphragm into the lung to In- coughed up. Oftentimes the imminence of rupture into a bronchus may l>e predicated from increased pain in the shoulder of the affected side, increased cough and muco-purulent or sanguineous expectoration, and heightened temperature. The pleurisy nearly always present may be fibrous, serous, or purulent. An empyema, so originating, may even mask the primary condition. But whether the pus opens into a bronchus, or the digestive tube, or through the abdominal wall, the result of nature's drainage is too doubtful. It is imperative to operate as soon as a diagnosis is made, for even a latent case may fire up suddenly and march to rapid death. The prognosis, in fact, does not depend more upon the character and skillfulness of the operation than upon its timeliness. Operation. — The method of operation depends upon the location of the pus; it may be (A) near the anterior abdominal wall, or (B) it may be inaccessible from the front. (A) If the epigastric region is bulging, the incision should be over its greatest prominence or where the abscess seems to point. Redness and edema of the skin should be taken as an indication that the pus is well walled off and that there is no danger of the incision opening into the general peritoneal cavity, which is an accident always to be guarded against. One may cut directly through these tissues whether it be in the linea alba or the line of either border of the rectus. Once the cavity is opened and emptied, it is to be carefully wiped out, for there are usually collections in its deeper parts; and before drainage is inserted it should be cautiously irrigated with normal salt solution or peroxide of hydrogen. Moynihan recommends the "cigarette drain" which may be well saturated with boracic acid. A counter-opening in the loin may be required for efficient drainage. The cavity must (ill in by granulation which may require six or eight weeks. (B) i. If the abscess is behind the liver on the right side, an inci- sion along the costal margin is perhaps the best. Divide the muscles, or even resect the twelfth rib, and then, by blunt dissection, follow the under surface of the diaphragm until the abscess cavity is reached. 2 3 354 ABSCESS. If the abscess is retro-peritoneal it may be necessary to expose the upper pole of the kidney and to draw it downward and forward, exposing the renal fossa on the under surface of the liver, and thence work upward between the posterior margin of the liver and the diaphragm. Insert drainage-tubes packed about with iodoform gauze. 2. More often it is best to employ the transpleural route (Fig. 264), which will require resection of a rib or perhaps more than one. The incision exposes the eighth or ninth rib — right side; eighth or seventh — left side. (For technic of resection of rib, see page 441.) The Fig. 264. — Subphrenic abscess. Opening in the mid-axillary line. {Bryant.) center of the incision lies in the axillary line and about three and one- half inches of rib are to be removed. Now determine the condition of the pleura of which the cul-de-sac is exposed. In this region the pleura is easily stripped away from the chest wall, and so room may be made to open the diaphragm without opening the pleural cavity. If this can be done, evacuate and drain the abscess as described above. Ordinarily it will be necessary to open the pleural cavity, which is first to be aspirated if it contains serum; or opened and wiped out if it contains pus. If it is not purulent it is likely to become so unless steps are taken to prevent its infection by suturing the diaphragm to the upper lip of the opening in the chest wall. You are now ready to open the diaphragm and the pus cavity. In PSOAS ABSCESS. 355 pome rases a perforation will be found in the diaphragm, and this is to be merely enlarged; or, it' inconvenient for drainage, may he disre- garded and the incision made lower down. Drain. A single case will exemplify some of the characters and progn the disease. A farmer, thirty years of age, had suffered for several years with a severe affection of the stomach, of which no definite diag- nosis had been made. Though debilitated, he was yet able to do his work about the farm. Without warning he was suddenly seize with a violent hematemesis. The attack continued for some hours without relief and the total amount of blood vomited was appalling. But gradually the bleeding ceased, leaving the patient prostrate. A tardy convalescence followed, interrupted by an intermittent fever diagnosed as malaria. A month elapsed and he was brought to bed with a fresh access of "ague" — chills, fever, and exhausting sweats. At this time a consultation ex- posed the real character of the process. There was a vast accumu- lation of pus in the left side involving the abdomen and thorax. A constant irritating cough, a bloody sputum, severe pain in the left shoulder, and increased fever and dyspnea seemed to indicate the nearness of rupture into a bronchus. In fact this occurred within a few hours after our examination. A large amount of pus was coughed up and with temporary relief. An operation was refused. Indeed, it offered but little hope so late in the course of the disease. A week later he died. Had the perforation of the gastric ulcer been recog- nized, or even later the character of the sepsis been understood, an o] (oration would have saved his life. PSOAS ABSCESS. Psoas abscess is a term sometimes rather loosely applied to purulent collections in the iliac region. Properly speaking, it is a tubercular abscess having its origin in caries of the lower cervical, dorsal, or Lumbar vertebrae. It is necessary to recall the arrangement of certain muscles and fascias. The psoas muscle, a rounded fleshy mass, lying alongside the bodies of the lumbar vertebra?, extends across the pelvic brim, and passes in front of the hip-joint to be inserted into the lesser trochanter. 356 ABSCESS. The iliacus, its companion muscle, occupies the iliac fossa and con- verges below in a tendon which merges with that of the psoas. These muscles are covered by the iliac fascia which is so attached as to make the iliac fossa practically a closed compartment. The fascia is separated from the muscles by a loose areolar tissue in which suppuration may originate and which constitutes an iliac abscess. This fascia on its other side is separated from the perito- neum by another layer of connective tissue — the subperitoneal areolar tissue, which is liberally supplied with fatty tissue and constitutes a site of lowered resistance to germs originating in the pelvic viscera, the cecum, the sigmoid, and the appendix. Suppuration under this layer usually ends as a pelvic abscess. It is evident, therefore, that an iliac abscess beginning as such, and ab- scess in the subperitoneal tissues, are quite distinct from psoas abscess, except that all have common points of possible opening. The iliac fascia covers the muscles in the iliac fossa, but it also extends upward in such manner as to ensheath the psoas and separate it from the bodies of the vertebrae. In the case of caries, the products of decomposition may burst through the vertebral ligaments and the sheath, and thereafter follow the psoas muscle downward. The muscle itself may be decomposed in whole or part, and the accumulating pus may be directed by the tubu- lar sheath to its point of termination below Poupart's ligament to the outer side of the iliac vessels. Or, again, the abscess may burst through the sheath higher up and point in the loin (lumbar abscess) ; or may point just above Poupart's ligament in the gluteal region, the pelvis, the scrotum, or thigh. The diagnosis of psoas abscess rests upon the history of the case, which points to spinal trouble, and upon the presence of fluctuating swelling in the iliac fossa, or below Poupart's ligament. Usually the hip is flexed in some degree, as by that position the tension in the psoas is relieved. This flexion and some apparent stiffness in the joint might lead to a mistaken diagnosis of hip-joint disease. The swelling is to be distinguished, also, from a hernial tumor, by the fact that it is fluc- tuating and lies at the outer side of the iliac vessels. OPERATION I <>R PSOAS ABSCESS. 357 Treatment- As in all cases of tubercular abscess, secondary infec- tion and amyloid degeneration arc most to be dreaded. For that reason, spontaneous rupture and treatment by small incision and prolonged tubal drainage are equally dangerous. As early as possible an aseptic evaluation must be practised. 1 this may be accomplished by puncture and the subsequent injection of iodoform emulsion; this seems the advisable procedure, if the abscess is pointing in the region of Poupart's ligament, and it is likely that the destructive process in the vertebra is in abeyance. In general, most authorities recommend the operation of Treves, by the lumbar route. Operation. — Begin by locating the last rib, the crest of the ilium, and the outer border of the erector spina?. The incision, two and one-half inches long, with its center half way between these bony land- marks, follows the outer border of the erector spina? and exposes at first the lumbar fascia. Divide the first layer of the lumbar fascia and expose the erector spinas. Develop its outer border the whole length of the wound and retract the muscle inward, exposing the middle layer of the lumbar fascia. Divide this layer which exposes the quadratus lumborum. Divide the quadratus lumborum along the line of its attachment to the tips of the transverse processes, which exposes the deep or an- terior layer of the lumbar fascia. Divide this layer and finally the psoas magnus is exposed. Divide the attachment of the psoas magnus sufficiently to introduce the finger, which opens up the abscess cavity and determines the condition of the carious vertebra. The abscess cavity is to be treated by thorough irrigation with an antiseptic solution, wiped vigorously, or even curetted. The various layers are sutured without drainage and an antiseptic dressing applied. Previous to suturing, the cavity may be filled with iodoform emul- sion; or, as Walsham suggests, after tin- cavity is cleansed it may be packed with strips of iodoform gauze, which are to be changed on the third or fourth day. If at the end of a week no pus has appeared and the cavity is lined with healthy granulations, the wound may be closed by secondary suture. CHAPTER XVIII. PHLEGMON: ACUTE SPREADING INFECTIONS. The areolar tissues are less resistant than others. The streptococci in their mode of development tend to spread out so that, under favor- able circumstances, the streptococcic infection of the subcutaneous connective tissues becomes one of the most dangerous conditions, demanding immediate and radical surgical intervention. The rapid development of toxins makes death from septicemia to be feared; or, short of this, there may be great destruction of tissue and subsequent loss of function. Certain regions, owing to the opportunities for infection and the arrangement of the tissues, are more likely to be affected than others; but the general symptoms and the principles of treatment are the same. One peculiarity of this inflammation is that pus is often slow to form, so that when the engorged tissues are incised in the earlier stages, merely a serum exudes. It is innocent-looking, but it is toxic in the extreme. The point, then, is this — do not wait for pus formation and fluctua- tion, before evacuating these products. If pus has formed, immediately is none too soon to operate. In the case of superficial phlegmon of moderate severity, it will often be harmless to try to localize the process by the use of hot anti- septic poultices or baths, but the safest thing is free incision for drainage. The incision must reach the deepest layer of the affected tissues, as anything less is useless; it may even be harmful by introducing a new infection to tissues which were not previously involved. Slight injuries, with subsequent localized accumulations of pus, are often the source of an infection which attacks the connective tissues, reaching them by way of the lymphatics, and then what was a mere local and harmless infection at first, becomes a very dangerous diffuse phlegmon. 358 PANARIS. 359 These minor conditions, therefore, are emergencies from the point of view of prevention. A few examples will serve to emphasize tin- principles governing their treatment. PANARIS. This is an infection involving the tissues about the finger-nail. It may he limited to the epidermis, the dermis, the subcutaneous tissues, or the perisosteum, the last condition being usually called a felon. Panaris, Subcpidcnnic. — The appearance at first is almost that Fir.. 265. — Opening a purulent phlyctena or "run a round." (lYii/i.) of a blister, and all of the loosened tegument must be removed. No analgesia is necessary, as the epidermis is non-sensitive. Begin by pricking the phlyctena with the point of the bistoury, and then trim around its whole circumference with pointed scissors (Fig. 265). Carefully observe the denuded surface, and a small opening may be found, leading to a deeper cavity (button-hole abscess) which will require incision. Complete the treatment by a prolonged antiseptic bath and antiseptic dressing. 360 PHLEGMON: ACUTE SPREADING INFECTIONS. Panaris, Subungual. — In this form the pus accumulates under the nail and loosens it. It will be necessary to remove the part of the nail lying over the pus accumulation. A cure can be obtained only at that price. If it is confined to one side only, the skin is removed as described above, the sharp point of the scissors introduced under the nail, and enough of it resected to expose the suppurating surface. If both sides are involved, remove the nail completely. Panaris, Subcutaneous {Felon). — Incise as soon as pus is suspected. No harm can be done even if there is no pus, while a day's delay after pus has formed may make a great difference. Fig. 266. — Illustrating the situation of the pus in a felon; the dotted lines represent the limits of the incision. (Veau.) Under local anesthesia (Figs. 8, 9), make a longitudinal incision in the middle of the palmar surface where the pain is greatest (Fig. 266). Do not make a mere puncture, as the whole pus cavity must be exposed. Incise deliberately and let the first stroke cut long and deep enough, after which explore the cavity with a small probe. If there is a palmar prolongation, enlarge the opening, and if there is a dorsal prolongation, which is quite rare, make a counter-incision on the dorsum of the finger. Immerse the hand in an antiseptic or normal salt solution for an hour. A drainage-tube is unnecessary, if the incision is properly made. Dress with moist antiseptic gauze and give the hand a hot bath with each daily renewal of the dressing. After two to eight days, or when suppuration has ceased, employ a dry dressing. The dry dressing favors cicatrization, but the moist dressing best relieves pain. PI II U NT Tl NO SYNOVITIS. 361 SUPPURATIVE INFLAMMATION OF TENDON SHEATHS. Every neglected infection of the fingers or palm may become a phlegmon of the tendon sheaths. The great danger of these phlegmons is destruction or adhesion of the tendons, so that the finger remains permanently flexed or ex- tended, unsightly, and more or less useless. A threatened suppuration may often be prevented by a prolonged immersion in hot antiseptic or normal salt solution. This should be continued for an hour and used twice daily. The Bier treatment is excellent for this purpose. This treatment is to be applied after suppuration occurs, but not until the pus is evacuated. It shortens the incision required and the time of repair. As soon as pus is suspected, in- cise freely. Recall the anatomy of the parts (Fig. 267). The sheaths of the flexor tendons extend into the palm, whence the necessity of a palmar incision. The tendon sluaths of the thumb and of the little finger communicate with the common tendon sheaths in the palm, whence the additional gravity when they are involved. The com- mon sheaths extend from the palm under the annular ligament above to the wrist -joint, whence the neces- sity of incision in the fort-arm. There is in this incision an element of danger by reason of the median nerve, which lies on the middle oi the front of the wrist between the two common sheaths. The ulnar Fig. 267. — Diagram illustrating the arrangement of the synovial sheaths in the hand. Note that the sheath of the tendon of the little finger communicates with the sheath common to all the flexors of the fingers in the wrist and palm. Note also that the sheath of the flexors of the thumb extends into the wrist beyond the annular ligament. The median nerve passes under the annular ligament between these two common sheatns. (Veau.) 362 PHLEGMON: ACUTE SPREADING INFECTIONS. artery lies on the common sheath on the ulnar side. The incision must pass between the artery and the nerve. Phlegmons of the sheaths of the first, second, and third fingers are not likely to extend further than the middle of the palm, while, on the contrary, phlegmons of the sheaths of the thumb and little finger are likely to point above the wrist. Fig. 268. — Suppuration _of digital synovial sheath. Incisions. (Veau.) Fig. 269. — Opening into the upper part of the ulnar synovial sheath. (Veau.) Operation for Phlegmon of the Synovial Sheaths of the Flexor Ten- dons in the Fingers. — A general anesthesia is usually necessary, for the pain is great. Make an incision about an inch long in the middle of the palmar surface over the point of greatest swelling. Incise to the bone to be sure of opening the tendon sheath. The wound must be of uniform length in the superficial and deeper tissues (Fig. 268). If necessary, make a similar incision over each of the phalanges and in the palm, but avoid opening into the joints. If the sheath is dis- I>K \I\ At.r ()!• Ll.NAK SYNOVIA! -III \ I II. 363 tended with pus, a drainage tube is easily passed through from one incision to the other. When the pus has been Located, immerse the hand in a hot normal salt solution for an hour and repeat twite daily. This greatly favors the evacuation of pus and subsequent repair. Employ moist antiseptic dressings at first. Operation for Phlegmon of the Ulnar Synovial Sheath. — Continuous with the synovial sheath of the flexor tendon of the little finger, the ulnar synovial sheath is larger than the radial and its suppuration more serious. These phlegmons are usually consecutive to neglected infections of the little finger. Complete drainage is indispens- able. Begin by making an incision over the radial border of the mini- mal metacarpal (Fig, 269). Avoid wounding the palmar arch, which might require ligation; but, after all, this is not a serious accident and permits a freer incision. When the pus is reached, enlarge the incision so that the tendon may be seen the entire length of the wound. Superficially and deep, the incision must be of the same length. Next introduce a grooved director into this incision and push it through the synovial cavity until its point, passing under the annular ligament, can be felt beneath the skin of the wrist. Incise carefully over this point until it is exposed, keeping to the inside of the tendon of the palmaris longus to avoid the median nerve. When the point of the grooved director is fully exposed, enlarge the incision to an inch and a half. No artery of importance will be wounded. Pass a drainage-tube through from one incision to the other (Fig. 270). Operation for Phlegmon of the Synovial Sheath on the Radial Side. — Fir,. 270. — Drainage of phlegmon of the ulnar synovial sheath. (V«aw.) 364 phlegmon: acute spreading infections. The palmar incision may be made through the muscles of the thumb along the line of the metacarpal, but it is preferable to make it in the commissure between the thumb and index-finger. Make an incision two fingers' breadth in length. At the depth of one or two inches you will find the pus. Pass a grooved director along the sheath as in the preceding case. It emerges beneath the Fig. 271. — Drainage of the radial synovial sheath. (Veau.) Fig. 272. — Drainage completed. skin above the annular ligament. Locate and expose the point of the director; in incising keep to the outside to avoid the median nerve. The radial artery is in no danger, as it is too far to the outside (Fig. 271). In the same manner as before, pass a drainage-tube. Immerse the hand twice daily for an hour in hot normal salt solution, and employ a moist antiseptic dressing. The drainage-tube will probably be unnecessary after the eighth or tenth day (Fig. 272). <>n RATION I OB nil I <.\l<>\ <>l mi H'kl ARM. 365 SUBAPONEUR* ►TIC PHLEGMON OF THE FOREARM. By direct infection, <>r by extension of infection from the hand, the areolar tissues beneath tin- fascia of the forearm may become the site of a diffuse suppurative inflammation. If neglected, it follows the connective tissues into the intermuscular Spaces and finally all the soft parts are more or less involved. Free PlG. 273. — Incising the forearm for phlegmon. The grooved director search- ing for posterior prolongations of the pus formation. (Veou.) Fig. 274. — Note manner of fixing tubes in drainage for phlegmon of the forearm. ( 1 t'iIK.1 incision must he resorted to without delay. In the earlier stages no pus will he present, hut a straw-colored serum pours out along the line of incision. Operation —General Anesthesia. Over the site of the greatest swelling, make a free incision in the long axis of the member. This incision will traverse a thick, infiltrated layer to reach the aponeurosis, 366 phlegmon: acute spreading infections. which incise carefully, when, in most cases, the pus will pour out. Enlarge the opening sufficiently on the grooved director. Irrigate thoroughly with hot normal salt solution and mop out with sterile gauze. With a grooved director explore all the parts of the cavity for a diverticulum (Fig. 273). If necessary make a counter-opening. Tie such of the larger ves- sels as are divided and place several large drains (Fig. 274). Change the dressing twice daily, irrigating each time with hot normal salt solution. About the eighth day, smaller drains may replace those first em- 1 ployed and these are usually unnecessary after two weeks. Watch the temperature closely. If it rises, there is a retention of pus, the site is not sufficiently drained, or there is a new infection. DIFFUSE PHLEGMON OF THE ARM. All the soft parts are involved and infiltrated with serum. The arm is greatly swollen, edematous, and there are marked symptoms of septicemia. General anesthesia is indispensable. The freest kind of incision, even down to the bone from above downward, is essential. Three or four such openings are not too many. Irrigate freely with hot normal salt or bichloride solution. Moist antiseptic dressings should be used and at first should be changed several times daily. Incision with the Thermo-cautery, Lejars. — With the thermo-cautery make several large incisions in tfie axis of the member, each at least four fingers' breadth in length and about two fingers' breadth apart (Fig. 275). Under the skin will be found a thick layer, infiltrated with bloody serum. Cutting through this, the aponeurosis appears, which incise and thus expose the muscles. On the inner side avoid the vessels. If some of the large subcutane- ous vessels are opened and bleed too freely, tie them. Irrigate and dress with sterile gauze saturated with peroxide of half strength. Change the dressing and irrigate two or three times daily. Change to dry dressings when granulation is well under way. Later, skin SYMPTOMS OS rill i GMOM "i i m \i < k. grafting may be necessary. In the long time necessary for repair, passage and passive motion must be given the muscles. PHLEGMON OI THE NECK. An infection in the floor of the mouth may become diffuse and spread rapidly down the neck. The symptoms of sepsis will be Fir,. 275. — Incising a phlegmon of the arm with the cautery. (1 aggravated in the extreme and death may rapidly supervene, either from sepsis or asphyxia. The whole neck may be brawny and edem- atous, and the patient's condition is pitiable indeed. 3 68 phlegmon: acute spreading infections. Lejars recommends the thermo-cautery as offering the best hope of a cure, though seemingly brutal. Under general anesthesia several deep vertical incisions are made with the thermo-cautery with numerous punctures between (Fig. 276). Do not go too deep over the anterior border of the sterno-mastoid, for the great vessels are there. Fig. 276.— Manner of incising phlegmon of neck with the cautery. (Veau.) Pack each incision and puncture with gauze saturated with peroxide of hydrogen, and cover the whole with a similar dressing and absorbent cotton. The dressing must be kept saturated with the peroxide. In the meantime use the antistreptococcic serum. Watson Cheyne also urges the use of the serum, but does not use the thermo-cautery. His plan is to incise through the deep fascia in several places, enlarging the openings by blunt dissection. The wounds are to be freely sponged with undiluted carbolic acid, pow- dered with iodoform, and packed with strips of iodoform gauze. CHAPTER XIX. ACUTE OSTEOMYELITIS. This is an acute infection of great gravity, more often due to the staphylococcus or the streptococcus; but, in rare instances, the pneumo- coccus, bacillus coli communis, or tubercle bacillus may be the ex- citing cause. Usually the germ reaches the affected site through the blood current; at other times, leaving a primary focus which is perhaps unsuspected, it reaches its destination by way of the lymph channels or by continuity of tissue. For the germ to gain a foothold, there must be a lowered resistance or an impaired nutrition. The predisposing causes are found in certain constitutional states and in traumatism. The diagnosis is not always easy in the beginning, as the constitu- tional symptoms may be marked before the local signs are quite definite. Rheumatism does not have the symptoms of sepsis, though, indeed, the fever may be high. The pain is usually in the joint and usually in more than one joint. Arthritis likewise involves the joint, although it is to be remembered that an arthritis may be secondary to osteomyelitis and overshadow it clinically, but the history of the case will usually decide between arthritis and osteomyelitis. Erysipelas may be thought of when, after a little while, the skin becomes brawny and edematous, but in erysipelas the skin is so in- volved from the first. The symptoms may seem to suggest typhoid fever or other infectious fevers, but these may usually be ruled out by the absence of charac- teristic features. The symptoms of meningitis are often present, but by the time they arise, the local conditions point to the nature of the trouble. The general symptoms are those of sepsis; high fever beginning with a chill, rapid pulse, foul tongue, profound prostration, and finally delirium. 24 369 37° ACUTE OSTEOMYELITIS. \ Locally, the pain over the affected area is extreme, and the least! pressure tends to aggravate it. Gradually, as the inflammation spreads from the marrow through the bone to the periosteum, thej skin begins to swell, redden, become edematous, and finally shows fluctua- tion. In the virulent cases not operated upon, the patient dies within the first few days from septic infection. In the milder cases, even, large areas of the bone necrose. The treatment, then, must be prompt. It is an emergency. There is only one thing of any use to be done. The suppurating marrow must be evacuated and the medullary canal freely opened and cleaned out. Local applications, poultices, or even in- cisions through the periosteum are illusory. The bone must be trephined, its cavity opened up at its most accessi- ble part, and all the inflamed tissue scraped away. The whole extent of the canal may need to be opened, irrigated, drained, and treated with vigorous antisepsis. Mosetig-Moorhof's* iodoform- plombe or filling is applicable to such cases as these. It is prepared as follows: Equal parts of spermaceti and sesamoil are melted in an evaporating dish, then filtered into a Florentine flask and sterilized in a water-bath; forty grammes of finely powdered iodoform (not crystallized) are put into a sterile flask, and sixty grammes of the hot fat mixture are added, under * Surgery, Gynecology and Obstetrics, Vol. Ill, No. 4. Fig. 277. — Exposing the tibial crest, opening into the subperiosteal ab- scess. (Veau.) [ODO] OEM PLOMBE FOB BONE ABS< I SS. 371 constant agitation. This agitation must he continued without in- terruption, until the mass solidifies. The flask is closed with a sterile rubber stopper. Before using, the plombe is to be heated in water hath to a little above 50° C. The bone cavity is most carefully prepared for the reception of the filling. Everything must be removed down to sound bone. The laws of gravity must, of course, be observed in filling the cavity. If the cavity is large, it is advisable to fill it in several steps, letting the Fig. 278. — Trephining of the tibia: making the orifice. (Veau.) Fig. 279. — Enlarging the orifice and exposing the medullary canal. {Veau.) plombe solidify in one portion, before any is poured into another. The cavity must be dry before the mixture is poured in. This may be accomplished by sponging, by the application of adrenalin to oozing points, by hot air, etc. The course of healing after iodoform filling is aseptic as a rule. Sometimes the temperature rises within the first two or three days — so-called aseptic fever — which yields to a cathartic. The disposition of the sprouting granulations toward the solidified plombe varies between complete closure of the wound and healing by primary intention, and incomplete closure. In the first cases, absorp- tion of the plombe is effected through the steadily advancing granula- 37 2 ACUTE OSTEOMYELITIS. tions by vital phenomena; in the second, by partial displacement and I expansion. OSTEOMYELITIS OF THE UPPER END OF THE TIBIA. Here the disease occurs more frequently and here, fortunately, is most easily operated upon. General anesthesia; special instru- ments: a mallet, a gouge, a periosteal elevator or rugine, and curette. Begin by elevating the limb to empty the blood vessels. About thei middle of the thigh apply an Esmarch tube. Do not apply an Esmarch bandage, beginning at the toe and extending upward, for that only spreads infection. On the right side, the incision com- mences at the level of the tuberosity and extends to the middle of the leg, following the sharp crest of the tibia just to its inner side. However en- gorged the tissues may be, this first incision reaches to the bone (Fig. 277). Often by this first stroke, one opens into a pus cavity. Do not be beguiled by this into thinking the operation completed. This collection is to be evacuated and drained, of course, but there is another one in the central canal. Extend the incision to the limit of the loosened periosteum. With the rugine, expose the anterior surface of the bone. A fistulous opening leading to the medullary canal may possibly be found. In any event, proceed to trephine. At the upper end of the incision make an opening with the gouge down to the canal. The pus will be almost certain to flow, but it is often difficult to distinguish from the marrow. —Trephining of the tibia Tubes in place. (Veau.) "M EO-MYELITIS 01 i in i ic.i \. At the lower end of the Incision, make- another opening (Fig. 27.S). If again pus appears, ii is certain that the lowest limit of the suppura- tion has not been reached and you must lengthen the incision. Con linue to expose the canal until the full extent of inflammation has been exposed. It may require the removal of the whole anterior surface of the tibia, hut you are engaged in saving life, so that hone is a minor consideration. Chisel away, then, all the anterior wall between the two limits of suppuration (Fig. 279). Curette vigorously the medul lary canal down to firm and uninllamed hone, and especially ( urette the upper part, for there the suppuration is greatest. In the case of a child, the epiphyseal cartilage is quickly reached, and this one should try to avoid, since too free removal will end linear growth. Next irrigate with normal salt solution, mop out thoroughly with sterile gauze, and pack with sterile or iodoform gauze. This is an important part of the operation and it must be carried out thoroughly and methodically. Drainage must now be applied to the subperiosteal areas of suppura- tion, using rubber drains in the manner indicated (Fig. 280). If the operation has been delayed, the muscles of the tail" may be infiltrated with pus and will require drainage as in diffuse phlegmon. If there is serous effusion into the joint, it will require no especial treatment, for it will gradually be absorbed as the osteomyetitis is cured. If the joint is suppurating, it is quite different and another operation is required (see operation for Purulent Arthritis). Over the trephined area, apply a moist dressing and change daily. As the exudate becomes less abundant, change to a dry dressing and change the packing in the canal every other day. Smaller drains may be inserted about the tenth day, and are removed entirely when the suppuration shall have ceased. As Veau says, this intervention is only the first act of a prolonged and tedious process and this the family should understand beforehand. After several months, it may be necessary to remove some necrosed hone ; and, long after the S I EOM.YELITIS OF THE UPPER EXTREMITY OF THE FEMUR. Make the incision along the outer surface of the thigh over the great trochanter. Divide the aponeurosis of the gluteal muscle, trephine, and drain. CHAPTER XX. SEPTIC ARTHRITIS. Septic arthritis is acute purulent inflammation of the joints, due to the presence of an infective agent, more frequently the staphylo- coccus or the streptococcus. The infection may reach the joint through a wound, by way of the blood vessels or through the lymph channels. This purulent inflammation follows, then, direct injury, or is a se- quel to various infective diseases, such as typhoid fever, gonorrhea, scarlet fever, or osteomyelitis; but by no means are all the joint inflam- mations following these conditions purulent. Purulent inflammations are to be distinguished from non-septic inflammation both by the symptoms and the physical signs. The symptoms are those belonging to sepsis, for here it exists in a. high degree. The tongue is brown and the temperature is very high, the pulse is weak and rapid, there are the appearances of prostration and finally delirium ensues. The pain is extreme and aggravated by the least touch. With respect to the physical signs, there is marked swell- ing of the joint and the skin is red and edematous, not only over, but above and below the joint, and fluctuation is usually to be detected. Treatment. — This is an emergency of the first rank. It is an in- tervention designed to save the function of the joint; and sometimes even life is threatened. There is but one indication, once the diagnosis is made, viz.: — to open the joint by free incision and counter-incision, that every part of it may be reached and drained. The most careful antisepsis is to be observed. The limb is to be as carefully cleansed as if no pus was expected. Scrub the skin over the joint (the knee, for example), the upper third of the leg, and lower third of the thigh with soap and water and with ether and bichloride. Sterilized instruments are to be used; 376 AB rHROTOlfV <>l THE K\l I . 377 they arc simple, a scalpel a few artery Forceps, some rubber drains, and an irrigator. The whole aim is to secure ample drainage and subsequent antisepsis, and nature will take care of the rest. In cer- tain of the joints, however, mere incision may not be sufficient and excision must be added. Fig. 283. — Septic Arthritis. Incisions for drainage of the knee. (Veau.) Arthrolomy of the Knee. — Sepsis affecting the knee-joint causes the knee to become enlarged, globular in outline, painful, reddened, edematous, with constitutional symptoms of sepsis. The operation, Dnder general anesthesia, is very simple and without danger. The important thing is to open freely. Two incisions are to be made, one external and one internal (Fig. 283). 378 SEPTIC ARTHRITIS. External Incision. — Locate the lower border of the patella ; and, be- ginning a little below this line, make an incision parallel with the external border of the patella and ending about two fingers' breadth above its upper border, which will be near the upper limit of the syno- vial sac. This incision traverses the integument and beneath it the firm aponeurosis of the vastus externus. As the joint cavity is reached, very often the pus spurts out with great force. Fig. 284. — Drawing the transverse drain into place. (Veau.) Internal Incision. — On the inside, make an incision symmetrical with the first, but a little further removed from the internal border of the patella. The aponeurosis is here less firm, but the synovial cavity is deeper; the swelling is usually greater on the inner side. Some of the fleshy fibers of the vastus internus are always divided. The cavity is not so easily reached as on the outer side. Drainage. — Place a large transverse drain (Fig. 284). But in some cases this is not sufficient. The lateral diverticula of the synovial sac must be drained separately (Fig. 285). For this two counter- openings are required, one on each side. Into one of the incisions ARTHROTOMY OF Till KN1 I . 379 Fig. 285. — Cross section of knee-joint showing that the transverse tube drains the upper part; the two lateral tubes the inferior part of the synovial sac. (Veau.) Fir.. 28(1. Manner of making posterior counter opening for drainage of the knee. ( I , ■ 3 8o SEPTIC ARTHRITIS. at its lower part, introduce forceps, and push backward and downward through the synovial sac at the level of the interarticular line (Fig. 286). If it is an old arthritis, this is not difficult; but in the case of a recent effusion, the ligaments are tense, and the articular surfaces are in contact so that the passageway is quite narrow. When the forceps, pushed backward in this manner, bulges the skin, open the blades, and, between them, make an incision one or two inches Fig. 287. — Septic Arthritis. Drainage of the knee complete. (Veau.) long. Through this opening in the forceps, draw a drainage-tube into place. Repeat the manoeuvre on the opposite side. It is better to make the counter-opening on the external side first, as the ligaments there are less tense. The beginner is seldom success- ful in making the opening internally. He nearly always pushes the forceps backward at too high a level and the point engages in the tendon of the adductor magnus. It must be directed downward and back- AIMIIKoloUY OF THE KM I 3»1 ward (Fig. 287). When the joint is thus opened, irrigate freely with hot saline solution, reaching every recess of the joint and wiping with sterile gauze. Aim to clean the whole synovia. It the joint is putrid, finish the irrigation with peroxide. I><> nol suture the wounds. Em- ploy a moist antiseptic dressing. Immobilize the limb on a pos terior plaster splint. Subsequent Treatment. — Irrigate and dress twice daily for the first Fig. 288. — Puncture of the knee. (Lcjors.) few days. However, if the temperature falls almost to normal and the pain ceases, do not be in a hurry to change the first dressing. If the suppuration diminishes about the end of the first week, put in a smaller drain in the same manner as before, and employ dry dressings. Watch the temperature. A rise indicates a retention of pus and calls for new drainage. Endeavor to avoid permanent flexion of the leg, a matter of the greatest difficulty and of the greatest importance, for such flexion cannot be corre< ted. 3 82 SEPTIC ARTHRITIS. After the second week the lateral drains are removed; and, some days later, the transverse drain. After a month, if the inflammation is all gone, attempt passive motion; but it is almost a certainty that the joint will be stiff; still if it is stiffened in extension, there is no occasion for reproach. PUNCTURE OF THE KNEE-JOINT. Occasionally it is desirable to empty the knee-joint, as in the case of a voluminous hemarthrosis or serous exudation. The same careful ' AM Fig. 289. — Arthrotomy of the ankle. Trace of the incisions. (Veau.) asepsis is practised as for arthrotomy. Locate the upper external angle of the patella (Fig. 288). A little above and to the outside of this point, plunge the trocar directly into the joint. The structures here are quite resistant, but there are no vessels likely to be wounded. As the exudate flows out. gently compress the joint to empty it. With- draw the trocar with a quick movement, apply a sterile dressing, and bandage the knee in absorbent cotton. [NCISIONS FOB DRAINAGE <>l Wkl.i JOINT. 383 ARTHRt )T\ iMV < >F THE ANKLE JOINT. Tin's operation Is not so frequent!) required as for the knee. ( Iften local anesthesia will suffice. Make the first incision, two inches in Length, over the anterior border of the external malleolus and reaching a little below its tip (Fig. 2S9). in the upper part of the in< ision, one may cut freely down to the hone, but in the lower pari more 1 are must be used. Some small arteries may he divided if one goes too deep yj/. PlG. 290. — Septic Arthritis. Drainage of the ankle-joint. (Vcau.) In the middle of the incision, open the joint, enlarge the orifice, and mop out the cavity. Introduce an artery forceps and carry it through the joint cavity to the opposite side, and over its point make a counter-opening (Fig. 290). This opening should fall over the tip of the inner malleolus. As the forceps is withdrawn, it pulls a drainage-tube into place (I''i,L, r . 291). Dressing and subsequent care are the same as in the knee. 3§4 SEPTIC ARTHRITIS. ARTHROTOMY OF THE ELBOW-JOINT. Make a vertical incision three inches in length, with its center over the outer border of the apex of the olecranon, dividing some of the fibers of the triceps and anconeus (Fig. 292). Puncture the synovial cavity at the middle of the incision and enlarge the opening to corre- spond with the incision. Push a forceps transversely through the Fig. 291. — Septic Arthritis of ankle. Drainage placed. (Veau.) joint at the upper level of the olecranon. Over its point make the internal vertical incision. Cut carefully, for the ulnar nerve is here in close contact with the posterior surface of the inner condyle. Draw a drain into place with the forceps. The dressing and sub- sequent care is the same as that described for the knee. ARTHROTOMY OF THE WRIST. Make an external incision between the long extensors of the thumb and the extensors of the index-finger, lines which may always be ARTHROTOMY OF TIM IMP. 3»5 fctermined. Make a second incision on the ulnar side between the tendons of flexor and extensor carpi ulnaris. The two incisions may be connected by pushing through a grooved director. ARTHROTOMY OF THE SHOULDER. The joint may be opened by a vertical incision, beginning at the .nterior angle of the acromion process and cutting downward in the Fig. 292. — Septic Arthritis of elbow. Incisions for drainage. {Veau.) line of the bicipital groove, or the joint may be opened behind along the posterior border of the deltoid, splitting the tendons of the infraspinatus and teres minor. ARTHROTOMY OF THE HIP. The hip-joint, deeply set under a thick muscular mass, may be reached either from in front or behind. The aim of any procedure is to reach the articulation in such manner as to produce the least de- struction possible in these periarticular muscles; and, therefore, one must seek the intermuscular spaces, or split the various muscles in the direction of their fibers. 25 3 86 SEPTIC ARTHRITIS. The study of the anatomy of the region demonstrates that several pathways to the joint, complying with the above conditions, can be found. In front, the joint is covered by several muscles whose directions correspond to the axis of the thigh,— the pectineus, the iliopsoas, the rectus femoris, in direct contact with the capsule; the sartorius and the fascia lata more superficially placed. Behind, the joint lies under a group of muscles which are parallel to it when flexed at an angle of 45 °. These are arranged in two layers; ■ in the first, the g. maximus; in the second, the g. medius and the ob- turator internus and gemelli; while below and behind is the tendon of the obturator externus. anterior arthrotomy. — If one wishes to reach the joint from in front, he may pass (1) in between the fascia lata and the gluteus medius externally and the rectus and sartorius internally. (2) Between the rectus and sartorius externally and psoas internally. (3) Through the sheath of the psoas. In the first case, the outer end of the neck and the great trochanter is exposed. In the second, the inner end of the neck, and in the third, the head of the femur. Position. — On the back with legs extended. Operator stands at outside with assistant opposite, and second assistant moves the leg as directed. Incision. — (1) Incision begins above, and finger's breadth inside, of ant. sup. spine, and extends downward and inward parallel to sartorius, for four inches. Expose the internal border of sartorius, draw it outward. Below it will be exposed the rectus to be drawn outward also. The psoas is exposed and drawn inward to expose the capsule. (2) The incision begins directly over the ant. sup. spine, and descends nearly vertically, bisecting the angle between the sartorius and tensor fascia lata. The sartorius and rectus are drawn inward and the capsule exposed. (3) Finally, the incision, to follow the outer border of the psoas, may begin at the inner third of Poupart's ligament and extend downward and slightly inward. The psoas is exposed near its inner border and opened, avoiding the anterior crural nerve. IRTHROTOin 01 mi'- J87 ( )pen the ( 'apsule.- < >nce the capsule is exposed, whatever the route, the muscles are to be relaxed by flexion, abduction, and external rota- Inn which favors their retraction. The capsule thus freely exposed is incised to any extent necessary. Counter-opening in Capsule. — It may be advisable to make an in- ternal incision to secure complete drainage. Make an incision from the external border to the pubes downward and outward, exposing the span- between the pectineus and adductor longus. Avoid the obturator nerve. Next introduce a forceps into the opening already made in the capsule and let the point emerge at the second opening; and, on this point as a guide, the counter-opening is made. The force] >s is used to draw a large drainage -tube into place. CHAPTER XXI. FOREIGN BODIES. THE EYE. Foreign bodies lodged on the conjunctiva or cornea are painful, and may soon provoke a conjunctivitis, more or less severe. The offending particle may be concealed under the lid or be im- bedded in the cornea. The latter is especially likely to be the case with those who have to do with emery wheels. The patient's sensation is a very poor guide in locating the object; if it is on the cornea, he is likely to be certain it is under the upper lid. Begin by inspecting the eye under a good light and at various angles. Pull down the lower lid, instructing the patient to look upward. Evert the upper lid. This is done by grasping the eye-lashes between the thumb and fore-finger and pulling downward, at the same time making pressure upon the tarsal cartilage of the lid with a pencil, stylet, or the opposite thumb. Instruct the patient to look downward. Com- bined with this pressure, the eyelashes are now pulled upward and in this manner the lid is everted and exposed to inspection. The novice does better, perhaps, to stand behind the patient, but the special- ist, sits in front of the patient and turns the lid with one hand. If the foreign body is free, it is readily picked up with the point of the stylet wrapped with cotton, but if it is imbedded in the cornea, considerable curettement may be required to dislodge it. The in- strument must be sterile, otherwise corneal ulcer may follow the manip- ulation. In the case of nervous or sensitive individuals or when the conjunctiva is much congested, the manipulation must be preceded by j the instillation of a few drops of a 4 per cent, solution of cocaine, which should be fresh and must be sterile. Everything used must be sterile — hands, instruments, cotton, and solutions. Following the extraction, irrigate with normal salt solution and in- still two drops of 2 per cent, collargolum solution or 10 to 25 per cent. 388 FOREIGN BODE s in mi i \i\ 389 argyrol solution and direct the patient t>> wash 1 1 1 * - eye frequently with thoracic <»r normal salt solution; if there is much congestion, bandage the eye for one <>r two days. If tin- foreign body has penetrated to the anterior chamber, the iris, or the posterior chamber, the immediate treatment must be limited to such measure as will prevent infection — boracic irrigation and hand- age — until the case can be placed in the hands of a specialist or until Bpecial text-books can be carefully consulted. 1 1 may be necessary to employ the X-ray in diagnosis in these cases. The extraction may require a delicate operation or the use of the electro-magnet, and finally the removal of the globe may be necessary. Chemical irritants should be removed by free irrigation. For lime in the eye, a solution of sugar in vinegar is recommended, the sugar forming a soluble compound with the lime. A few drops are used, followed by free flushing with water. Afterward atropine, gr. 1 to the ounce is imperative. THE EAR. , The foreign bodies most frequently found in the ear are pebbles, shoe-buttons, peas, beans, pens, pieces of tooth-pick, pieces of cotton. etc., etc. Children may place these objects in their ears in play or innocent kperimentations or adults may meet with the accident, attempting to relieve an itching in the auditory canal. A tampon may be left in the ear by the doctor. The body usually lodges in the outer part of the canal, and only reaches the tympanic membrane after ill-advised efforts at extraction. The pain and discomfort are usually moderate; and, as a rule, there are no very urgent indications for intervention. But if the object rests against the drum, the pain is severe and may even produce mental disturbance. The first thing to do, then, is always to confirm the diagnosis. The iatient's belief in the matter must, under no circumstances, be ac- cepted as final. There is only one way to confirm the diagnosis; and 39° FOREIGN BODIES. that is by careful inspection of the whole canal, if the object is not seen in the outer portion. Draw the external ear upward and backward, and the tragus for- j ward. Under good illumination and with the aid of a head-mirror \ and otoscope, the drum is readily seen. If nothing can be seen, and provided there have been no blind efforts at extraction, it may be defi- nitely concluded that the patient is mistaken. If, on the other hand, you locate the object, do not hurriedly intro- duce a forceps into the ear seeking to grasp the object; unless, indeed, it is of such a nature that it may be easily seized, for you will almost always make matters worse, pushing it further into the canal. Re- Fig. 293. — Ear Forceps. member that however desirable it may be to empty the ear, there is, as a rule, no great urgency in the matter and you have plenty of time to take counsel with yourself (Fig. 293). In some cases, a small hooked instrument may be cautiously pushed past the object and withdrawn, pulling the object out, or a small blunt curette may be similarly employed. Usually a large syringe is the proper instrument. Throw a stream of warm, sterile water into the ear with the purpose of forcing the body out by the "vis a tergo." To inject the stream properly, lift the pinna upward and backward as in inspection, and direct the stream along the posterior superior wall, using moderate force. Use one syringeful after another, until the offending substance is washed away or the patient is tired out. FOR] ii. \ BODIl S in mi NOS1 , 39] If you have failed, instill into the car a few drops of glycerine or warm oil, lightly tampon, and dire< I the patient to sleep on the affe< ted hide, returning the next day for another trial. The chances are greatly in favor of ultimate success without injury to the ear. In the case of a live insect in the ear, till the ear with oil and sub- sequently the "cadaver" may be removed by irrigation. If "instrumentation" seems advisable, there must be no blind grasping for the object— it must be kept clearly in view. It has happened, in violation of this rule, that the middle ear has been in- vaded and the ossicles dragged out. Death has occurred from such manipulation, though the post-mortem showed that no foreign body had ever been present. In the case of children, instrumental extraction will, as a rule, re- quire an anesthetic. If the ear has become much inflamed or the body pushed through the drum, the case is one for the specialist. On the whole, the practitioner might adopt the rule, that if left in the ear, untouched, the foreign body is less likely to do harm than rude and maladroit efforts at removal. THE NOSE. The catalogue of bodies, recorded as lodged in the nose, is long. Naturally, children are more frequently the subject of these mishaps, although lunatics and hysterical women may intentionally plug the nose. Occasionally, a foreign body previously swallowed, may be coughed up and lodge in the posterior nares. Pledgets of cotton and pieces of gauze, which have been used as tampons, may be overlooked and a< t as foreign bodies. In the case of the irresponsible, the presence of a foreign body may not be suspected, so few are the symptoms, until there develops a profuse sero-mucous discharge. There may be frequent attacks of sneezing; and, if the body remains long, the mucous membranes be- come swollen and perhaps the skin of the affected side also. There may be headache or facial neuralgia. These foreign bodies should be removed as soon as possible, first having determined their nature, size, and situation. Begin by a careful examination of the anterior nares; and, if this is 392 FOREIGN BODIES. not sufficiently instructive, examine the posterior nares by hooking the finger up behind the soft palate. The examination and removal are often facilitated by the use of cocaine, and in the case of children, a few whiffs of chloroform may be necessary. Chloroform is also the effectual remedy for animate foreign bodies, such as insects and maggots. Used in this manner, it is not inhaled, but is shaken up with an equal amount of water and syringed into the nose before the two ingredients separate. Fig. 293a. — Angular forceps for foreign body in the nose. A body lying in the anterior nares is usually readily removed by a mouse- toothed forceps; or a curved probe or small curette may be necessary to dislodge it. An angular forceps is sometimes convenient (Fig. 293 a). In other cases, the obstruction may be removed by drawing a tampon through the nasal cavity from behind, as recom- mended by Sajous. If the body is lodged in the posterior nares, it is usually pushed backward into the pharynx, care being taken that it does not drop down into the larynx or esophagus. "In the case of infants, a small body may be removed by blowing forcibly into the mouth." (John J. Kyle.) PHARYNX AND ESOPHAGUS. Many diverse objects may lodge in these passageways, either through ineffectual efforts at swallowing or by inadvertently slipping TREATMENT "l FOREIGN BODIES IN Mil. I'HXKVW. 393 from the mouth. False teeth arc- often loosened and carried into the pharynx or esophagus during sleep. The point of Lodgment, the immediate effect, the dangers, and tin- difficulty of removal, depend upon the size and shape of the obje< t. The pharyngo esophageal canal is narrowest behind the larynx, opposite' the cricoid cartilage and the sixth cervical vertebra; at this point a Large body is likely to lodge. A second constriction lies two and three-quarter inches further down, behind the Left bronchus; and a third where the esophagus passes through the diaphragm. Larger bodies, then, are liable to lodge opposite the larynx. Sharp and pointed objects, such as needles and fishbones, may anchor at any point without refer- ence to the caliber of the conduit. The immediate effects of the lodgment of a foreign body vary from instant asphyxia to merely slight difficulty in swallowing. Later there may occur, even in the case of a slight obstruction, the dangerous conditions following infection — erosion of the walls, perforation of the bronchi or lungs, of the pericardium, the aorta, or carotids — one bas but to think of the numerous relations of the esophagus in the neck and thorax to understand how diverse the consequences of such spreading infection might be in various cases. Very naturally, the deeper down the object Fig. 294.— Horse-hair lodges, the greater the difficulty in locating and closed^' reaching it. Treatment. — Asphyxia, due to occlusion of the lower part of the pharynx involving the larynx, demands immediate action. The patient is Livid, gasping, and struggling. Run the finger into the throat over the epiglottis, where the body may be felt and hooked out. If you fail in this, do not waste time in these cases of extreme urgency, trying tentative measures, such as inversion, but do a //(/'Ki n, \ i ■. - - 1 ■ 1 1 5 r. i in RECTI \l. |oi t ra 1 1 ii hi made In the axis of the outlet if the body is long (a bottle for es ample) and firmly fixed (Fig. 298). The fingers or forceps may be used. If you are dealing with glass, (lie blades of the forceps must me t overed with rubber to prevent slipping. If the ends of the foreign body are pointed, and imbedded in the rectal wall SO that traction is Dangerous, great rare must be exercised. In some cases morcellation will be possible. If the coccyx cannot be retracted and serves as the direct impedi- ment, it will have to be resected. If the body has found its way up ; -to the left iliac region into the sigmoid, it may possibly be worked down into the rectum by external manipulation. Finally, in such a cast', laparotomy and opening the bowel may be the only means of relief. ( lombs, of Indianapolis, reports a case which illustrates the principles of treatment involved (J. A. M. A., Oct. 23, 1909). After a drinking bout and a drunken sleep in the woods, the patient awoke with a pain in his rectum and found it impossible to empty his bowel. He applied to a physician who discovered a beer glass in the rectum, inserted there during the victim's drunken stupor by brutal comrades. An attempt was made to remove the glass without preliminary divulsion of the sphincter. During traction with forceps the glass was broken and the attempt failed. Some hours later he was seen at the hospital by Combs who found the small end of the glass resting on the promontory, and the large >end imbedded in the hollow of the sacrum (Fig. 298), its broken t'dges buried in the soft tissues. By reason of the edema and swelling, divulsion was insufficient for removal, and consequently the contracted muscles were divided in the middle line posteriorly, when the glass, which was four inches long and seven inches in circumference at its large end. was readily removed. On account of the swelling and evident infec- tion, the incision was left to heal by granulation, and on discharge from the hospital the patient had a perfect control of the sphincter. Combs remarks that the shape, size, and nature of the foreign body, the edema and swelling, and the degree of traumatism will be the guiding indications for the course to pursue. It would certainly seem a rare instance in which amputation of the coccyx would be required. Ade- 402 FOREIGN BODIES. quate division of the muscles posteriorly with quick removal is advised in lieu of prolonged efforts at removal by traction, especially of an object with cutting edges from which fatal wounds may result. THE URETHRA. A piece of sound may be broken off in the urethra. Boys or the insane may lose various objects in the urethra, slate pencils, pipe stems, pieces of watch chain, etc. As a rule, the accident is not immediately disastrous, for generally the impediment to urination is not complete. The object should be removed as soon as possible and with as little irritation to the urethra as possible. Fig. 299. — Urethral forceps of Collin (a), Leroy d'Etiolles (b), and Hunter (c). It is necessary merely to enumerate some of the methods employed successfully in various cases, and each case must be treated on its own merits. Often the body may be easily reached and extracted with forceps (Fig. 299). In certain instances, it may be gradually worked forward by external pressure; or in urination the meatus may be pinched up and when the urethra is ballooned out by the pressure of the urine, sudden release may result in the body being washed out. In case the body is in the deeper part of the urethra, and considerable manipulation is necessary, pressure should be applied over the urethra on the bladder side of the foreign body, to prevent its being pushed FOREIGN BODIES IN THE Ck'l III kA. 403 deeper. A piece of hollow sound or catheter may sometimes be re- moved by passing a smaller sound down into its lumen; or the urethral speculum or a larger hollow sound may be passed down to, and over the body, which permits its more ready seizure by a forceps passed through the speculum. Dayat shaped a lead sheet into the form of a hollow sound and, passing it beyond the object in the urethra, closed its lower end by Fig. 300. — Extracting a pin from the urethra by " version." Protruding the point through the skin. (Bryant.) Fig. 301. — Point grasped with forceps. Its direction reversed and head brought out through the meatus. (Bryant.) pressure over the urethra and in removing the lead catheter the foreign body came out with it. In another case, a stick forced into the urethra could not be with- drawn on account of a hook on its lower end, but after being split into many pieces, its extraction was accomplished piecemeal. In the case of a pin lost in the urethra hea ' dow ward, its point may be driven through the skin and "version" accomplished and the head brought out through the meatus (Figs. 300, 301). 404 FOREIGN BODIES. In other cases it may be necessary to do an external urethrotomy, and finally the object may have to be pushed into the bladder and removed by suprapubic cystotomy. Hazzard describes a case in which a hat pin was lodged in the urethra, its head too high to manipulate. He bent the penis at a right angle to the direction of the pin and thus thrust its point through the skin, which enabled him to practice version (J. A. M. A., May 29, 1909). Hyde, of Kansas City, reports a shawl pin slipped, head first, down the urethra and into the bladder. The point could be felt at the peno- scrotal angle. An incision was made down to the urethra, the point was forced through the urethral wall into the incision, and the pin drawn out till the head reached the urethral floor; it was then reversed and delivered through the meatus without opening the urethra. The wound was closed by three deeply placed silkworm-gut sutures with prompt repair (J. A. M. A., March 13, 1909). CHAPTER XX11. BURNS, SCALDS, AND FROSTBITE. From the point of view of prognosis and treatment, burns are of three degrees: (i) Transient application of heat, something below the boiling- point, produces hyperemia. (2) A greater degree of heat or a longer application produces a more definite vaso-motor paralysis and there is exudation, particularly into the Malphighian layer, and the epidermis is lifted up in the form of blisters. (3) The albumen of the tissues and fluids is coagulated. This necrobiosis may be superficial or it may involve the deep structures as well. Symptoms. — Even in slight burns, pain is always a prominent symptom. In the severer burns, shock is always present in some degree, and as the shock disappears, reaction comes on, with rise of temperature, and the symptoms resolve themselves into some form of internal congestion, or systemic intoxication, characterized by hemoglobinuria or albuminuria, vomiting, or bloody diarrhea. After a few days the symptoms may be those of septic infection. The cause of death from burns falls into four groups: (a) Shock. This may be rapidly fatal, sometimes as late as twenty- four hours. Death may be due to cardiac paralysis, the result of over- heating of the blood. (b) Toxemia. The tox-albumens resulting from the chemical changes in the tissues find their way into the circulation and over- whelm the heart and kidneys, usually within the first two or three days. It has been demonstrated that these toxic substances arc hemolytic and cytotoxic for the parenchyma cells and are eliminated from the body by the kidneys and intestinal tract. 405 406 BURNS, SCALDS AND FROSTBITES. (c) Internal congestion and inflammation, involving the cerebral, thoracic, or abdominal structures. (d) Septic infection or its sequela. This may be fatal after the first few days or only after a prolonged struggle. Factors Determining the Prognosis. — (a) Area and depth of burn. (b) Age and general condition of patient. (c) Region. (d) Degree of infection. The rules for determining the prognosis can be formulated only in a general way with reference to these various factors, and yet keep- ing them in mind, a quite definite forecast may often be made in a given case. (a) It is the area rather than the depth of the burn which deter- mines the danger. An extensive superficial burn is more dangerous than a limited but deep one. It appears that under the effect of heat muscular tissue generates a poison much less toxic than that from the skin. Mere reddening of two-thirds of the cutaneous surface will almost inevitably result in death, while destruction of one-third of the skin will probably produce the same result, yet most burns of the first and second class commonly met in practice will recover. (b) The age and general condition involve the question of the ability to rally from shock and to resist infection. By reason of their lack of resistance to these forces, the young or the aged may succumb to even slight burns of the third degree. fc) Burns over the head are dangerous for the reason that menin- gitis may develop, and similarly burns of the thorax and abdomen are likely to result in lesions of their contained viscera. Burns about the face are often accompanied by corresponding injury to the air passages by inhalation of smoke or flames. (d) The most important factor, however, in the process of severe burns is infection. Such injuries, in fact, are infected wounds. The coagulated albumens of the destroyed tissues are not favorable soil for the development of the bacteria, but around the circumference of the burn are tissues of lowered vitality which are not only unable to resist the encroaching germ, but, more than that, actually nourish it. The serous exudates of superficial burns are likewise culture media, TKl \ I \li N l 01 BURNS. 407 Id thai in severe burns as well as in other wounds it may be said thai the patient's fate lies in the tir>t dressing. Treatment.- Slight burns of the first degree require protection, which may be furnished by vaseline; by gauze saturated in boracic ai id solution; by canon oil; by dusting powders of various kinds, boracic acid, dermatol, bicarbonate of soda, Hour. /// severe burns the indications are to combat the shock, to relieve the pain, and to prevent infection. In the matter of the local treat pent of these conditions, the final word has not yet been spoken. The most divergent opinions appear in current literature, and of these various lines of treatment perhaps none are wholly bad certainly, few are altogether good. Begin, then, by combating shock and relieving pain. These two conditions are usually relieved at once by frequent but small hypo- dermic doses of morphia, supplemented by subcutaneous or venous injections of salt solutions. If parts beneath the clothing are involved, use the greatest care in removing so that the skin will not be removed with it. To cut the clothing is safer than to attempt to undress the patient. Always remember that contact with the clothing may be the chief source of infection. Now, what will one do to prevent infection? This is the chief problem. If the burn is of large extent and depth as well and has been in contact manifestly with sources of infection, there is but one thing to do if the aseptic method is to be employed. Anesthetize the patient after the shock has passed and proceed to sterilize the parts. Scrub the uninjured skin around the wound with soap and water and then alcohol and bichloride. Next proceed to irrigate the burned area with normal salt solution, in the meantime carefully rubbing with sterile gauze to the end that every bit of foreign matter may be removed. In those parts that are merely blistered, the blebs are to be punctured and the serum washed away. It may be advisable, even, for the sake of thorough disinfection, to make no effort to spare the cuticle of the blisters in rubbing with the sterile gauze. .Not hurriedly, bu1 patiently complete this cleansing. It will prob 408 BURNS, SCALDS AND FROSTBITES. ably require from one-half to three-quarters of an hour, but it is time well spent. You have now now to deal with an aseptic wound. Next cover the area with plain sterilized or borated gauze and over this apply absorbent cotton and bandage snugly. If much cuticle has been removed, cover with sterile vaseline before applying the sterile gauze. The aid of a splint may be required to prevent deformity. If no fever arises the dressing need not be changed for eight or ten days. It may not be practical to institute the thorough disinfection which anesthesia alone permits, but one can at least cleanse the adjacent area as before described. Prick the blisters and irrigate the burnt area with normal salt solution, but in this case sterilization is not so much a certainty. Therefore, you must employ an antiseptic dressing. Whatever dressing you select should have these properties at least; it should be antiseptic, analgesic, and keratogenic. A number of substances possess these properties in various degrees and are otherwise more or less unobjectionable. Picric Acid. — This is employed in solutions of x or 2 per cent. A good solution is made by dissolving one and one-half drachms in three ounces of alcohol and adding some of this solution to two parts of water. After cleansing the surface apply strips of sterile gauze, soaked in the solution, cover with absorbent cotton and bandage. Change the dressing in three to four days, soaking it loose with the same solution. Turpentine. — This is an excellent domestic remedy, antiseptic and analgesic, but only to be employed in slight burns of the first degree. Cover the area with absorbent cotton and saturate with the turpentine, and bandage. ;4mto/.— This, too, renders excellent service. Use as an ointment mixed with sterile vaseline or zinc ointment in the proportion of eight to ten grains to the ounce and apply spread on sterile gauze. The Ointment cf Rectus. — This, perhaps better than any other ointment, meets all the indications. It is applied in a thin layer directly to the surface or spread on sterile gauze and the dressing com- pleted with cotton and bandage. Here is the formula of the ointment BURNS OF THE MOUTH. }0<> as modified by the author and prepared by the Pitman, Myers Co., and which should be ready lor instant use: ; — Hydrarg. Chlor. Corros., i part. At i.l t larbol., 30 parts, Aristol, 3° Acid Boric, 90 ' Salol, go ' Anti]>yrine, 150 ' Petrolatum, 576 ' Carron Oil. — This is an old and useful remedy, but, as ordinarily used, unqualifiedly to be condemned. It favors suppuration because it is in nowise antiseptic and perhaps may — indeed often does — carry infection. If the oil is sterilized and then applied to the surface which has been made as clean as possible, it is an efficient dressing. Granger, of Rochester, Minn., uses equal parts of lanolin and zinc ointment spread thickly on gauze, covering the ointment with the waxed paper sold by instrument dealers, and applying the dressing with the paper next to the burned surface. The dressing is next covered with a thin layer of cotton. He claims that it is soothing and easily removed. The frequency with which any dressing must be changed will depend on the pain or infection. If the secretions are excessive and, by dry- ing and stiffening the dressing, aggravate the pain, the dressings must be frequently changed. If there is infection, the rise of temperature will be the index. The same care must be exercised in changing the dressings as in treating any other wound. BURNS OF THE MOUTH. Burns of the mouth and air passages are not infrequent. These may be the result of taking hot substances into the mouth or the inhalation of hot gases in explosions. Pain and difficulty in swallow- ing are the most frequent symptoms. In addition there may be edema of the glottis or finally acute bronchitis may develop. Cold water and bits of ice give the most relief. The edema of the glottis may require tracheotomy. The various forms of inflammation, such as bronchitis or pneumonia, must be treated on general principles. 4IO BURNS, SCALDS AND FROSTBITES. ELECTRICAL BURNS AND SHOCKS. Electrical burns are painful out of all proportion to the size of the lesion and require two or three times as long as the ordinary burn for repair. Begin the treatment with hypodermics of morphia and strychnia (1/30). Cleanse the wound by the ordinary surgical methods and dress with sterile gauze, cotton, and bandage. The resuscitation of persons shocked by electricity is necessitated much more often than formerly by reason of the widespread use of the electric current. Spitzka has lately outlined the course to pursue in the treatment of such cases. He remarks, in the first place, that one cannot safely predict exactly what will happen in any case of shock by electricity, for many factors modify the action of the current: its nature, tension, intensity; the resistance and susceptibility of the individual; the duration, location, and area of contact. Broadly stated, the effect is the more severe, the greater the voltage, the greater the amperage, the longer the period of contact, the greater the area of contact, and the longer the path of the current through the body. Death by electrical contact would appear to be due to heart paraly- sis or to asphyxia, or a combination of both. In certain cases there is no paralysis of the heart, but only respiratory failure. The symptoms of electrical shock in cases which are not immedi- ately fatal, vary greatly in form and degree. I. Local signs: (a) Burns and superficial necroses. (b) Puncture and rupture of tissues. (c) Hemorrhages. (d) Edema and erythemas. II. General effects: (a) Loss of consciousness. (b) Paralysis and spasms of muscles. (c) Disturbances of respiration and circulation. (d) High temperature. Later there may develop disturbances of the bowels, kidneys, special sense organs, the central and peripheral nervous system. FK I AIM i \ I OF IK I I VIM.. 41 I The prognosis is good only in cases where there is some hear! tu tion and respiration and where treatment can be promptly applied. Treatment: If the stricken man is not out of the circuit, some 1 au tion must be exercised in accomplishing his relief. The rescuer should have on rubber gloves or have his hands wrapped in thick, dry, woolen material, to avoid shock from handling the victim. He may be freed by pulling at his clothing or using sticks of wood. If it is necessary to cut a wire, the nippers must have insulated handles and the eyes should be protected from the blinding Hash. Once freed, the patient should be laid with head elevated and arti- ficial respiration at once begun. This is more effectively done by compressing the chest with the hands applied flat against the sides of the lower part of the thorax. The tongue must be drawn forward so as not to obstruct the larynx. Massage over the heart and faradism help to stimulate its action. Arterial infusion of adrenalin has been proven by Crile and Dolly to have a direct effect. Other methods which have been suggested are lumbar puncture, venesection, and the high-tension shock of short duration (Jour. Med. Soc. New Jersey, Jan., 1909). FREEZING. The effects of very low temperature on the tissues are practically the same as those of heat. The ultimate effect is death of the tissues or gangrene. The treatment of patients overcome by cold must be circumspect. The main point is to go slow in warming the parts. The patient should never be brought directly from outdoors into a warm room. Sonnenburg advises that a cold bath, the temperature of the cold room, be used, and the temperature gradually raised until in two or three hours it reaches 8o° F. Where life seems extinct, artificial respi- ration should be practised, and sometimes the circulation may thus be re-established. Subsequently hot rectal enemata of whiskey or coffee may be employed. The limbs and other frozen parts should be covered with moist compresses for the first forty-eight hours and then dusted with boracic acid and encased in a thin layer of wool. 412 BURNS, SCALDS AND FROSTBITES. If the trouble is only local — a frozen ear or foot — begin by rubbing the part with snow or ice and then with cold water and finally apply cold compresses, gradually raising their temperature until the circu- lation is restored. Subsequently cooling lotions may be employed to allay the inflammation. PART 11. CHAPTER I. TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY. Tracheotomy is often performed in general practice as an operation of the greatest urgency, and one should be prepared to do it anywhere, at any time, and, if necessary, with a pen-knife. Yet it is not so simple a procedure as one might infer. To do it properly and quickly, re- quires coolness knowledge, and method. It is the measure of relief indicated in every case of laryngeal asphyxia, whether due to spasm of the larvnx, edema following burns, injuries, or disease such as diphtheria or cancer; or to the presence of foreign bodies. The essential equipment is a sharp pointed scalpel and a tracheotomy tube, and to these, as mere conveniences, may be added scissors, artery and dissecting forceps, tenacula, mouth-gag, and tongue forceps. The tracheotomy tube (Fig. 302) should be of simple construction, easy to introduce, and as large as the diameter of the trachea will admit, following table relative to the age of the patient and the diameter of the tube: Fig. 302. — Tracheotomy tube. Treves furnishes the AGE. Under 18 months, 1 J to 2 years, 2 to 4 years, 4 to 8 years, 8 to 12 years, 12 to 15 years, Adults, DIAMETER OF THE TUBE. 4 mm. 5 mm. 6 mm. 8 mm. 1 o mm. 12 mm. 1 2 to 1 5 mm. 413 414 TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY. Every practitioner should have tubes of various sizes in his "ar senal"; Senn recommends Trosseau's, while Lejars prefers those of Krishaber. Anesthesia is often unnecessary, owing to the condition of the patient. Otherwise a few whiffs of chloroform should suffice. It need scarcely be said that under these circumstances, free use of the anesthetic will only hasten the fatality. The preparation of the field, however desirable, the urgency of the symptoms will scarcely permit. Fig. 303. — Locating the cricoid cartilage. The little patient's arms should be pinioned to its sides with a towel or sheet, it should be placed on its back with a cushion under its shoulders to drop the head backward and bring the trachea into bolder relief. Operation. — Stand at the right side of the patient; locate the hyoid bone, the thyroid prominence, the cricoid cartilage,' and the sternal notch; and steady the trachea, holding the cricoid between the middle finger and the thumb of the left hand, while the index finger locates the middle line (Fig. 303). It is along the middle line that one must incise, and the aim is to OP] R \ I [ON FOB ik M in nin\n 415 divide the upper rings of the trachea and to avoid the thyroid isthmus (Fig. 3°4). Make the incision from the index finger downward exactly in the middle line for two inches (Fig. 305). Incise rapidly with a single sweep of the knife. The left index-finger in the upper angle of Un- wound hooks up the cricoid and still locates the middle line. Pay no attention to the bleeding, and without hesitation push the point of the bistoury through the upper ring and cut downward through the second and third if necessary. The air hisses through the opening. It is a moment of confusion, but one must keep cool. Insert the lube. Without changing its position, the left index finger presses the tracheal wound open and the right hand introduces the tube, horizontally at first, until the point is well in the trachea, and then carries the tube upward in a Curve until its break corresponds to the lumen of the trachea (Fig. 306). The patient's gasps expel blood and perhaps false membrane, which the attendants must avoid inhaling. The tapes at- tached to the tube are fastened behind the neck. Apply artificial respiration if the patient's condi- tion is not satisfactory. Let the air pass through FlG a warm, moist compress until the temperature of represent 3 the^thvruiii tin room can be regulated. isthmus. (Veau.) As Veau points out, the operation may fail for Several reasons, all within the control of the operator. The most frequent cause of failure is faulty introduction of the tube; it does not enter the tracheal canal, but is pushed down between the mucous membrane and the tracheal wall. These structures are loosely con- nected. The error is to be recognized by the absence of the charac- teristic sound of escaping air. The orifice is to be inspected, and, if too small, enlarged, before trying the second time to introduce the tube. Again, too much force in making the incision may result in wounding the posterior wall of the trachea. Excited operators have split the trachea its entire length, or wounded the vessels of the neck. There -Tracheo- 416 TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY. Fig. 305. — Tracheotomy. Incision. (Veau.) Fig. 306. — Introducing the tracheotomy tube. (Veau.) TRACHEOTOME FOK roREICN l'.«-DHS. | i 7 need be but little hemorrhage in the operation, if one but keeps in the middle line; and, as Senn says, that is the se< ret of success in performing the operation quickly and safely. The operation may be varied somewhat, depending, of course, upon the conditions. The cricoid may be divided if necessary. In other Rises, before cutting downward it may be ne< essary to draw downward the isthmus of the thyroid gland before enlarging the opening. In any case where time does not press, as when the tracheotomy is done preliminary to some other operation, the various steps may be carried out with more detail, the incision made by layers, vessels clamped, and the rings exposed, steadied with hoods, and incised. The tracheotomy may be done below the isthmus of the thyroid, but the higher operation is much the easier anatomically, although the principle is the same. Tracheotomy for foreign bodies differs in some respects from the ordinary technic. Westmoreland, of Atlanta, who has had a large experience with this class of cases has recently emphasized some of these points (Amer. Jour, of Surg., Nov., 1909). The incision should vary in length depending upon the size and character of the foreign body. If the opening is sufficiently large the foreign body is easily expelled by the respiratory effort; usually the opening is made too small and the trachea is injured by the forcible extraction of the body. In the young the thyroid isthmus is usually in the way ami should be divided between forceps and ligated. Even the thymus gland may intrude and is to be depressed with a narrow retractor, A tenaculum should not be employed lest it excite a troublesome bleeding. The incision in the trachea itself begins at the first ring. If asphyxia should occur in the course of the operation, the result of fixation of the objeel in the glottis, the operation should be rapidly finished, a tube or catheter passed into the trachea and the lung in- flated by blowing through the tube — a great help in artificial respira- tion which soon resuscitates the asphyxiated child. Tracheotomy lubes are not to be used. Once the trachea is opened the body may be coughed out which a lube would prevent. The 27 41 8 TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY. wound may be held open if necessary by silk threads passed through its edges. If the foreign body is expelled the trachea is to be sutured at once, employing a mattress suture of silk which is not to pass through the mucous membrane. Whether the tracheal wound is made air-tight or not is to be tested by filling the wound with' normal salt solution and obstructing the nose and mouth which will force some bubbles through if not tight. The fascia, muscles and isthmus, and finally the skin are repaired. The dressing is held in place by adhesive strips. If inflammation exists, even though the body is expelled, do no suturing; cover the wound loosely with bichloride gauze to keep out cold air and to absorb the discharges. Change frequently // the foreign body is not expelled the protective dressing is to be applied which will not prevent the escape of the object if it should be coughed up later, and under this treatment the inflammation will probably rapidly subside. After-treatment. — The success of tracheotomy rests largely on the care with which the after-treatment is conducted. There is no opera- tion, perhaps, in which care and skill are better rewarded and negligence and ignorance more severely punished. If the temperature of the room cannot be kept at close to 65 , the tube should be kept covered with a warm, moist compress. The wound must be kept clean. For the first few days, the inner tube must be removed and cleansed several times daily. This should be done rapidly, and the tube disinfected and oiled before being reintroduced. Morse (Post-operative Treatment, page 174) says, unless the cause of obstruction is a permanent one, it is often advisable to remove the tube after twenty-four to forty-eight hours; but the patient should be allowed to try breathing through the mouth before removing the tube, testing his capacity by stopping the cannula. In any event, he should be gradually accustomed to breathing through the mouth by plugging the canula. Morse advised that soup, milk, or broth should be given at first, if necessary through a nasal or esophageal tube, although this is not often required. Difficulty in swallowing is likely to occur on the third 0P1 RATION I OB ik \< in OTOMY. \ m »>r fourth day, l>ut encouragement will enable the patient to overcome this. Nutrient enemas art- rare I) necessary. Link, of [ndianapolis, relates an experience (Medical Record, March 2, 1907) which illustrates at once the value of the operation, the improvizatioD of instruments to meet an emergency, and one of the rarer forms of suffot ating edema. At midnight he was tailed to see a patient said io be choking to death and whom he supposed had an attack of asthma. lie found the patient, a man weighing 250 pounds, cyanosed and laboring for breath. One hour previously, it seems, his throat had been lanced for the eleventh time in the course of a ten days' attack of tonsillitis. A hurried examination found the pharynx too tightly swollen to pass a finger. How much laryngeal edema there might be could only be guessed. Thinking to intubate past the swollen pharynx, Link used the only thing available, the vaginal tip from a hard rubber syringe, bent at nearly a right angle. The attempt failed. While preparing for a local anesthesia to do a tracheotomy, the patient's neck was surrounded with iced cloths, but this seemed to aggravate the asphyxia; the patient became unconscious and ceased to breathe. The anesthesia was no longer necessary. All had fled but one woman, and while she held the patient's head, the doctor did a low tracheotomy. He says, kneeling in front of the patient, who was in a sitting posture, he incised the skin and deep fascia in the median line two inches above the sternal notch, working with his finger down to the bronchial rings. With the finger as a guide, the knife was introduced, the trachea stabbed and cut slightly upward. A closed hemostat was then introduced and opened. Very little blood was lost. A female silver catheter from his pocket case was introduced and held in place by the assistant, while the doctor performed artificial respiration. The patient soon began to breathe, but his convulsive movements threatened the loss of the small tube in the throat. The hard-rubber vaginal syringe tip was brought into use again, whittled and inserted. Tin- elbow shape fitted perfectly. In half an hour the patient asked to be put to bed, and breathing entirely through the tube, slept the Brsl sleep for several nights. 420 TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY. The edema declined as fast as it had arisen, and, within a few hours, the patient could breathe through the mouth when the tube was closed, and recovery was uneventful. LARYNGOTOMY. As an emergency operation, this is most frequently done in an adult for cancer, but one need not wait until the patient is asphyxiated for there is nothing gained thereby. Therefore one may operate deliber- ately, for there is not the extreme urgency as with the infant. Local anesthesia may be sufficient. Define as before the inferior border of the thyroid cartilage and the upper border of the cricoid, between which is the crico-thyroid membrane which is to be incised (Fig. 307). In the middle line over the space, make a vertical incision an inch long. Catch the bleeding points and retract the lips of the wound. Carefully incise the fascia until these cartilages are exposed. Now incise the crico-thyroid membrane transversely and open into the larynx (Fig. 308). Introduce the tube as in tracheotomy. Re- move and cleanse the inner tube on the first two days and the large tube on the third day. Of course, if the operation is for cancer, it is merely palliative and the patient will continue slowly to die. If the operation is for edema of the larynx, the cause must be treated and the proper time finally to with- draw the tube determined by the conditions. If the operation is for a foreign body, the wound may be sutured at once. Fig. 307. — Laryngotomy. Incision of crico-thyroid membrane. (Veau.) ESOPHAGOTOMY (Cervical Region). Position. — Place the patient on his back with shoulders elevated and the neck resting on a sand-bag with head turned to the right. Incision. — Begin opposite the upper border of the thyroid cartilage and continue downward along the anterior border of the left sterno- «>l-i km |. in i OH l SOPHAGOTOMY. .).' i mastoid for three or four inches, incising the skin, superficial fascia, and platysma. Ligate the veins and draw the sterno mastoid forward and the depressors of the byoid downward. The wound is thus enlarged and at the bottom is the layer of cervical fascia connecting the thyroid gland and the sheath of the large vessels. Incise it and again enlarge the wound by drawing forward the thyroid gland, trachea, and larynx, and backward, the greal vessels in their sheaths. At this stage, in the bottom of the wound are the inferior thyroid. Fig. 308.— Laryngotomy. Incision of the crico-thyroid membrane. (Veau.) which must be ligated, and the recurrent laryngeal nerve, which should he drawn forward. The esophagus now appears as a red tube. To steady the esoph- agus and define iis walls, an esophageal bougie may be inserted. The wall of the esophagus is raised with mouse-tooth forceps (Fig. 309) and incised along its lateral wall. A suture is passed through each li]> of the inri^ion, that they may he readily retracted while the foreign body i> located and removed, not always the easiest part of the task. The wound of the esophagus is repaired with sutures of catgut and 422 TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY. the rest of the wound lightly packed with gauze until all danger of in- fection is passed. As Bryant says, ordinarily the operation of cervical esophagotomy is not a perplexing procedure, but when the neck is short and fat, the vessels and thyroid gland enlarged, the detection and removal of the foreign body difficult, or the patient exhausted, the operation often taxes the patience and fortitude of the surgeon. After-treatment.— The patient must be kept in bed with shoulders raised. Nourishment should be given at first by enemata, and later, if neces- sary, by the esophageal tube. Nassau reports a case illustrating the subject (Annals of Surgery, Feb., 1908). A child swallowed a five-cent piece and thereafter could take only liquid foods. " X-ray" examination showed the coin lodged at the level of the suprasternal notch or just above. Removal was attempted with forceps but without success, although the coin could be felt. An esophagotomy was done. The operation was completed in fourteen minutes. No vessels require ligation. The esophagus was not sutured and the superficial wound was closed with drainage. There was no leakage and the child made an unevent- ful recovery. Nassau does not regard esophagotomy as a serious operation, but believes it should not be considered until efforts at ex- traction have failed. Fig. 309. — Esophagot omy. Final incision. {Bryant.) CHAPTER II. URGENT THORACOTOMY. REPAIR OF INJURY TO THE LUNGS. REPAIR OF INJURY TO THE PERICARDIUM; OF INJURY TO THE HEART. PUNCTURE OF THE PERICARDIUM. As has been indicated elsewhere (see Injuries of the Thorax), urgent Intervention for injuries of the thorax is a form of operative procedure at this present time with but a limited field. Whatever may be the apparent gravity of the case, it is far from being the rule to operate, for such operations require trained assistants, a special equipment, and a superior surgical skill. Of necessity, then, in general practice, the treatment must, generally speaking, be conservative: that is to say, ck;i using of the external wound with enlargement and trimming up if necessary, reunion and aseptic occlusion, firm bandaging of the thorax, and an absolute quiet in bed. These measures along with stimulation with caffein and camphorated oil and normal salt solution, represent the elements of treatment which are within the scope of all. But there are cases so manifestly fatal without operation that, as Lejars says, one cannot evade the question, "operate or let die?" Grave rupture of the lung indicated by an immediate flooding of the pleural cavity, followed by urgent symptoms of asphyxia and syncope, is the signal for immediate operation. Again, repeated attacks of secondary hemorrhage call for operation. URGENT THORACOTOMY. The technic of this operation can be exactly defined only in a gen- eral way and will need to be modified to suit the individual case. I. rjars insists that the opening must be large, that anything less will le a disappointment and the operation might as well not be undertaken. 423 424 URGENT THORACOTOMY. The operation may proceed in one of two ways: (i) by a permanent resection of the ribs necessary to be removed, or (2) by temporary resection with the formation of a thoracic flap. (1) Make a U-shaped incision forming a flap with its base posterior, and of which the two arms run parallel with the ribs and are wide enough apart to include at least three ribs. The incision reaches to the ribs. Rapidly dissect up this musculo- cutaneous flap, exposing the ribs and intercostal muscles. With the flap held out of the way, begin the resection of the ribs by incising the periosteum of the lowest rib along its middle line, the full length of the exposed part. Denude the rib with the rugine. Take special care in the denudation along the lower border that the artery and nerve re- moved with the periosteum are not wounded. Divide the inner and the outer end of the denuded segment. (See Operation for Empyema.) Resect the other ribs exposed in the same manner. Raise the musculo-pleural -flap. Begin by dividing the upper border; then the lower border; and finally the anterior border, catching each intercostal artery as cut. When this flap is lifted the lung is exposed. This procedure has the advantage that it can be rapidly carried out; the disadvantage, that it permanently sacrifices a part of the bony wall of the chest, but that is a small matter in the face of such emer- gencies. (2) A thoracic flap may be formed. Make the same "U "-shaped incision and expose the ribs as in the preceding operation. Each costal segment is then denuded of periosteum at either end sufficiently for the passage of the bone-cutting forceps. In this manner each rib is divided at each end. Next carefully divide the intercostal muscle parallel with, and above, the first segment, and lift the anterior end of this rib, and begin the separation of the pleura. Work along the front at first, dividing the intercostal muscles and arteries and ligating as necessary. The liberation of the flap along the lower border next follows and, as the musculo-osseous flap is more elevated, the separation of the pleura is more and more facilitated. Finally the flap is freed and turned back and the pleura is left bared. The pleura is next divided and the wounded lung is now freely exposed. TREA r\n \ I mi INJURIES TO mi ill ART. Wipe "ut the clots and seari h for the bleeding surface, [f necessary a hand may be slipped under the base of the lung pulling it forward for inspection. Repair the lung. The idea) method is by suture, employing a No. i or 2 silk thread and passing it through the parenchyma with a round curved needle. If this is not possible tamponade is the next resort. If a border is lacerated and projecting it may be ligated en masse and reset ted. Whether or qoI drainage is employed depends upon the amount of oozing and the probabilities of infection. If infection subsequently develops, the infected area is to be opened and drained as any other empyema. REPAIR OF INJURIES TO PERICARDIUM AND HEART. The general practitioner does not see many injuries to the heart. Gunshot wounds are. of course, usually immediately fatal; so that the form of cardiac injury most likely to present itself for treatment is a stab wound. Occasionally the heart is lacerated by a broken rib. The sudden death from cardiac wounds may occur in several ways. It may occur from syncope arising from the pressure of the Mood within the pericardium; or the heart may be unable to contract be- cause of its divided libers and cerebral anemia follows; or shock or pulmonary edema may be the immediate cause of death. Even if death does not immediately occur, hemorrhage and infection may later provoke a fatal issue (See Injuries to the Thorax, page 99). The treatment of traumatisms of the heart and pericardium has three ends in view; to combat shock, to control hemorrhage, and to prevent infection. Keep the patient absolutely quiet, lower the head, apply artificial heat, give morphine in small doses (1/8 gr.) hypodermically ; and, if there is an open wound in the chest, disinfect and dress asepti- cally, but do not operate merely to disinfect. If the In-art is injured sufficiently to bleed, operate. The sole in- dication, then, for operative treatment is hemorrhage. The patient will probably die even if operated upon, but he will 426 URGENT THORACOTOMY. most certainly die without the operation; so that it is our duty to give him the additional chance which intervention offers. If the wound seems likely to have reached the heart; if there is bleeding; if there is pain and precordial oppression; if there are fre- quent attacks of syncope; if there are signs of increase of fluids about Fig. 310. — Forming the costal flap. The three ribs in the flap are divided near the sternum, and the upper and lower ribs divided at the outer limit of the flap. The middle rib to be fractured by raising the flap. the heart; then one is justified in believing that the heart has been wounded sufficiently to produce hemorrhage and must prepare im- mediately for the operation. There must be no delay. It will depend upon the degree of urgency whether the time shall be taken for formal preparation of the field. However indispensable asepsis may be. OP] R \Tli)\ | OK Rl PAIB OB TIM III ART. \2~, yet hemostasis in such cases is the more urgent indication. Even in the mosl desperate i asesone must at least s< rub his hands and wash (lie Beld, for there is little use to check tin- hemorrhage it" the patient is to die later fnmi sepsis. While the anesthesia IS under way, the skin may he washed with soap and water followed by alcohol and bichloride solution; or Tr. iodine mav be used on the <\r\ skin. FlO. 311. — Costal Sap reflected. Pleura retracted. Edges of pericardial wound held in forceps and heart wound exposed. (lateral Anesthesia. — Ether should be employed if the patient's con- dition will permit. The opt ration proposes to make a thoracic flap, to open the peri- cardium and expose the heart, and to repair the injury. There is no operation that requires more decision, courage, and self-control. Incision- Begin in the third intercostal space just in front of the 428 URGENT THORACOTOMY. anterior axillary border and cut inward to the border of the sternum, abruptly curving there and following the sternal border downward to the sixth space; again abruptly curving and following that space outward (Fig. 310). These incisions expose the ribs and intercostal muscles. Fig. 312. — Heart supported in palm of hand preparatory to suturing. (After Lejars.) Formation of the Flap. — Divide the fourth, fifth, and sixth cartilages near the sternum and also the intercostal muscles, along the line of the original incision. At the lower outer angle of the incision, expose the sixth rib by SV I TKI OF WOUND OF llll HI U'T. 429 pulling the tissues upward. Incise the periosteum over its external surface and with the rugine free the rib of periosteum and divide it At the upper outer angle expose the fourth ril>, free it of periosteum, and with the costotome <»r a bone-cutting forceps, divide it in the same way. The flap is now attached only by the fifth rib which is t<> be fractured. Raise the sternal end of the flap with the left hand and press on the fifth rib with the right hand and with a little force the rib is broken in the line of section of the other two ribs. The flap is now gradually raised as its adhesions to the subjacent structures are freed, and the pleura is exposed. r?c Fig. 313. — Suture of wound of heart. Fig. 314. — Suture of heart completed. If there is a wound in the pleura, it may be enlarged and the pericar- dium may lie reached through it; otherwise proceed to the liberation and retraction of the pleura. With a grooved director, liberate the fibrous attachments of the triangularis sterni to the posterior surface of the sternum, which at the same time liberates the pleura. With the fingers, draw outward the free border of the pleura with its covering the triangularis sterni (Fig. 311). In this manner is the pericardium exposed. The assistant holds the pleura with a retractor. Incision of the Pericardium. — Enlarge the wound in the pericardium and in that manner expose the heart. Retract the edges of the peri- cardial wounds with forceps. Locate the wound in the heart. Slip 430 URGENT THORACOTOMY. the left hand under the apex and pass the first suture, and the heart may be thereafter steadied by traction on the threads of the first suture (Fig. 312). Suture the wound in the heart. Use either interrupted or continuous suture of catgut. There is no particular advantage in passing the suture in diastole. Pass them deeply, but not to the endocardium (Figs. 313, 314). Now wipe out the pericardium with sterile compresses and repair the pericardium by continuous catgut suture. Next, wipe out the adjacent portion of the pleural cavity, repair any part of the lung that may be injured and repair the pleura without drainage. Finally, replace the thoracic flaps, and suture. It is generally wise to excise the tissues along the mark of the wound. No drainage is to be employed except under these circumstances: if the case was operated on late and there is great probability of infection, it is better to leave drainage in the pleural wound, pro- jecting from the thorax at the lower angle of the skin wound; if there is much oozing, it is better to leave a wick of gauze in the pleural wound. A case of successful suture by Gibbon, of Jefferson Medical College, illustrates the subject (Jour. American Medical Assn., Feb. io 7 1906). Patient, aged 38, healthy colored man. Stab wound of chest, a few moments after which he fell unconscious. An hour later at the hos- pital his condition was very grave: unconscious, cyanosed, pupils dilated, skin cold and moist, respiration rapid and shallow. No pulse in the peripheral vessels and the heart sounds were distant, rapid, and irregular. Vigorous stimulation was employed with morphia and atropia, and his condition slightly improved. Operation about one and one- half hours after the injury. Only a small quantity of ether required. The fourth costal cartilage was found and divided and the entire cartilage and a part of the rib was removed. The pericardium was explored and a wound located which would only admit tip of index finger. This pericardial wound was enlarged and the sac 'emptied of clots and liquid blood. It began rapidly to fill again. Two fingers passed under the heart lifted it up into the pericardial opening and with rapid sponging, the wound was located. It was R] PAIS 01 WOUND "l I III III MM'. IS i situated in the right ventricle near the auriculo ventrii ular groove. It bleed freely, controlled by pressure; wasaboul three-fourths inch in length. The wound in the endocardium was about one half as Long. A traction suture of cbromicized catgut was passed through both edges and by that means the heart was held in position, while four other sutures were passed and no effort was made to avoid the en- docardium. A small gauze drainage was applied to the line of sutures and brought out through the pericardial wound which was not sutured. During the subsequent twelve hours there was enough oozing to require a change of dressing. His general condition was fairly good. The second day his condition was alarming; respirations 62. The gauze was found to be interfering with drainage and removed. The respirations fell to 38 in a short time. Large quantities of salt solution were given by rectum. Liquid food on second day. The dressings were changed every other day. Six days after the operation the skin wound was sutured almost com- pletely, the wound in the pericardium being practically healed. In six weeks he returned to work completely recovered, with heart's action regular and normal. Gibbon does not advise an osteo-plastic flap unless a pleural wound is demonstrated, believing it best to excise as much of the sternum or cartilage or rib as may be necessary to give free access. He em- phasizes the value of the traction suture, and advises the repair of the pericardial wound without drainage, but would always drain the external wound. Travers (Lancet, Sept., 1906) operated upon a case in which the patient was Impaled upon a spike fence. The right ventricle was torn, the spike penetrating the sternum to reach it. The wound in the heart was closed by twenty sutures. The patient did very well up to the eleventh day, when he died from heart failure, due to the pressure of a slowly forming clot. Travers notes that the suturing seemed to stimulate the flagging heart. Stewart, among the first in the United States to suture the heart 432 URGENT THORACOTOMY. successfully, turned the musculo-cutaneous flap to the left and the thoracic flap to the right, fracturing the cartilages near the base of the sternum. The pericardial wound was enlarged in the axis of the heart. The heart wound, produced by a stab with a long, rusty pen-knife, involved the thickness of the left anterior ventricular wall, ran parallel with the axis of the heart, and was about three-fourths of an inch in length, was larger than either the skin, pleural, or pericardial wound. The heart bled freely and continuously, and resembled a mere quivering mass of muscle. The wound was closed with a continuous silk suture, the pericardial cavity cleansed and the sac sutured with silk. A gauze drain was left at the lower angle. The pleural cavity was cleansed and irri- gated with salt solution. The thoracic flaps were sutured with silk- worm-gut and a gauze drain left also in the pleural cavity. During the operation, which lasted about forty-five minutes, twenty- four ounces of salt solution and adrenalin were injected, and strychnin and atrophia given hypodermically. Some infection followed, and by the eighth day, the temperature was 103 , pulse 150, and respiration 50. From that time, the symptoms of sepsis gradually declined until at the end of three weeks, these con- ditions were practically normal; at the end of the fifth week, the patient was out of bed. Stewart, discussing the operation (American Journal Med. Sciences, Sept., 1904), notes that the size of the heart wound cannot be predicated from the external wound; and concludes that the only safe procedure in doubtful cases is to enlarge the wound and ascertain if it penetrates the chest wall; and if there be symptoms of hemorrhage — of heart tamponade — operate. In all of these cases already mentioned, it was the ventricle which required repair. Peck, of New York, describes a case in which it was necessary to suture the auricle (Annals of Surgery, July, 1909). The patient, a colored girl twenty-four years of age, was brought to the hospital suffering from a stab wound over the third costal carti- lage at the left border of the sternum. Her condition was grave: no radial pulse; the heart sounds could not be heard; respiration faint and PUNCTVKK 01 mi PERICARDIUM. 433 ■hallow, and the extremities cold; operation begun about forty-six minutes after the receipt of the injury. A quadrangular Sap of the soft parts with base external was dissei ted lack. The third, fourth, fifth and sixth cartilages were divided at the sternal junction, and the third, fourth, and fifth ribs near the coSto chondral junction, and the flap turned out and the internal mammary ligated above and below. The pericardial wound was near the border of the sternum, a part of which was resected with rongeur foncps to give a better view. The tense pericardium was incised and the clots emptied out, whereupon the radial pulse could be felt. The bleeding seemed to come from the upper part of the cavity but She rapidly beating heart, churning the free blood, made it impossible to locate the wound until a transverse cut in the sac gave a better exposure. Lifting the heart forward and slightly rotating it to the left, a wound of the right auricle was brought into view. With each systole a tream of dark blood spouted two or three inches. Four sutures of chromicized catgut passed on a curved intestinal needle controlled the bleeding. The pericardium was cleansed, closed without drainage with continuous chromic catgut suture. The cartilaginous flap was carefully sutured with No. 3 chromicized gut and the soft parts with ratgut and silkworm-gut. No drainage was used. The operation asted sixty-five minutes, during which time 1900 C. of normal salt iolution was given intravenously. For the first six or seven days there were signs of mild pleurisy and the temperature ranged from 100 to 102.8, pulse 116 to 136; but, at the end of two weeks, these were practically normal, and at the end of another week, she was discharged, quite well. It will be observed that the incision and flap formation differed with lach operation, no one method can be insisted upon to the exclusion Df all others. PUNCTURE OF THE PERICARDIUM. Puncture of the pericardium — paracentesis pericardii — is indicated n those cases of hemo-pericardium and serous effusion in which :he accumulating fluids dangerously interfere with the functions of 28 434 URGENT THORACOTOMY. the heart. The physical signs and the symptoms point to the nature of the difficulty. It is not more frequently done because of the in- stinctive fear that one may wound the heart; indeed there are three structures which may be wounded with serious consequences; the heart, the pleura, and the internal mammary artery. The puncture may be made near the sternum to the inside of the internal mammary; it may be made to the outside of the internal Fig. 315. — Puncture of the pericardium and pericardiotomy; vertical lines, represent the anterior border of pleura and lung. The • represents sites of puncture. "^~, line of incision for, and portion of rib resected in, pericardiotomy. mammary, between it and the line of the lung. The latter is per- haps the better (Fig. 315). The point of entrance of the needle is in the fifth left intercostal space, 6 cm. from the sternal border. Use a small trocar or an aspirator. Cleanse the field thoroughly. Put the patient in a half reclining posi- tion on his bed and mark with the left index finger the site of the puncture. Direct the needle obliquely downward and inward and do not PURULENT PERICARDITIS. 435 penetrate deeper than 2.5 cm., holding the needle so as to regulate its progress. As the pericardium empties Itself, gradually elevate the trocar so as not to wound the heart. PURULENT PERICARDITIS. PERICARDIOTOMY. If the exploratory puncture demonstrates the presence of pus, the only rational treatment is drainage, unless the patient is moribund. To incise and empty the pericardium is the only procedure that offers any hope of permanent relief. Operation. — Begin by locating the attachment of the fifth costal cartilage and the middle of the sternum. Incision. — From the middle of the sternum horizontally outward over the center of the fifth cartilage on the left side, to the costo- chondral junction. Deepen the incision so as to divide all the soft parts down to the cartilage. Strip back the covering of the cartilage with the rugine (Fig. 315). Resect the cartilage at its sternal junction and, gently lifting up, grad- ually detach its coverings behind out to the junction of the rib. Here it may be fractured or permanently resected. Dividing their sternal attachments, retract the intercostal muscles with the arteries in the space opened up and thus expose the pleura. Detach the pleura by loosening the sternal attachments of the tri- angularis which allows the pleura to be drawn outward. This should be done with the finger passed under the sternum and hooked around the border of the pleural sac. The pericardial sac is now exposed. Incise the pericardium, first catching up a fold between two forceps, and- dividing it with scissors. If possible, the edges of the pericardial wound should be stitched to the margin of the skin wound. Insert gauze drainage: A rubber tube is too likely to irritate the heart. This operation is often followed by recovery without any impairment of the heart's action. CHAPTER III. EMPYEMA— PURULENT PLEURISY. Various bacteria may attack the pleura, most frequently they are the pneumococcus, the streptococcus, the staphylococcus, the bacillus tuberculosis, or the bacillus communi coli. The pneumococcus is usually present in the empyema of childhood. Be on your guard for empyema especially in whooping-cough. The clinical history and the prognosis vary in different forms of the disease and are directly dependent upon the form of the infection. But, whatever the pyogenic agent, when pus has once formed in the pleural cavity, it seeks for an outlet in various directions. It may rupture into a bronchus and escape by the mouth, and, under these circumstances, pneumothorax may ensue; it may perforate the chest wall, manifesting itself as an external abscess of various forms; it may open into the pericardium, esophagus, or stomach. In every case, the longer relief is delayed, the greater the probability that the lung will be permanently collapsed or bound down by ad- hesions. Finally, in some degree, there are always the evil results of sepsis. There is every reason, then, when pus is known to exist in the pleural cavity, to drain without delay. The diagnosis rests upon the history of the case (remembering that this history will vary with the form of infection), upon the pain, the constitutional symptoms which are those of sepsis generally, and upon the physical signs. These are: distention of the thorax accompanied perhaps by edema of the chest wall; flatness on percussion and evident displacement of neighboring organs; absence of the vesicular murmur, and the presence of bronchial breathing. Taylor, of Springfield (Illinois Med. Jour., 1907), attributes the most frequent source of error in diagnosis to a misconception of the position assumed by the exudate. Physicians are observed trying to establish a horizontal line for 43 6 I MM.OKATORY 1TNC II Ki; nr Till. I'l.KlKA. 437 tin' exudate with the patient in the sitting posture, under the impression that the fluid will follow the influence of gravity. But this is the exception rather than the rule. The dullness is usually higher pos- teriorly. The "S "-shaped line of Ellis, if present at all, is so variable from day to day as to be of minor importance. Taylor remarks further that the character of the fluid is often a matter of doubt. Chills and variable temperature point to pus, although he has seen patients Fig. 316. — Puncture of the pleura. (Lciars.) recovering from pneumonia who had none of these symptoms and yet carried around three pints of pus in the pleural cavity. Most of the signs and symptoms may occur as well with pleurisy with effusion, and it is only by exploratory puncture that the matter may be definitely determined. Exploratory puncture, then, is the court of final resort and must always be employed before deciding upon the form of treatment. 438 EMPYEMA PURULENT PLEURISY. PUNCTURE OF THE PLEURA. Let the patient lie on the sound side with his shoulders elevated and the arm of the affected side extended above the head, the effect of which is to widen the intercostal spaces. Locate, for example, a point in the axillary line and the sixth intercostal space. Freeze the skin with ethyl chloride or inject a little cocaine at the site of puncture. Press a finger into the intercostal space and locate the lower border of the rib. With the finger as guide enter the needle so as to avoid the rib and thrust it inward and slightly upward. One can readily determine whether it has reached the pleural cavity by the degree of resistance. Enough fluid, whether pus or serum, will escape through the aspirating needle to make its presence certain; but in order to draw off any quantity an aspirator, of which Potain's (Fig. 316) is the best type, must be at- tached. A serous pleuritic effusion is relieved by aspiration. Sometimes removal of even a small quantity will start absorption in a case of long standing. If the fluid- is pus, the subsequent fig. 317:— Empyema: course is quite different. ^avftytothLhestwai! As has be en said, every purulent pleurisy must and lung. (Veau.) ^ Q p enec i as soon as possible, must be opened freely and at its lower point. In the case of a child, it suffices usually to incise the intercostal space in order to perfect a cure. In the case of the adult, it is nec- essary to resect a rib for adequate drainage, and even then the patient may shortly die or retain a chronic sinus. These possibilities should always be explained before the operation, necessary but disagreeable, is undertaken. As a rule it is advisable, we will say, to resect a rib, although in the recent case, uncomplicated, obviously benign, a good result may be obtained by simple incision. Carsterls, of Detroit, has recently said he thinks we resect far too many ribs in these conditions. Site of the Incision. — The cavity must be opened where it will drain best in the recumbent position. The lowest level of the abscess can be determined only by exploratory puncture; any other method is useless. Having already confirmed the diagnosis by puncture, now at the begin- OP] B \ I [I ' v - I OB I M I * N I MA. 430 ■ng of the operation, make another exploratory puncture in the spa< e next lower. H" pus is found there, puncture again in the space below, and so on until no pus is found. The last puncture producing pus will In' tin' site of the incision. Anatomy (Fig. 517). — The aim will hi' to incise parallel with the rib. In going through the structures of the intercostal space, remember that the vessels and nerve lie in or near the groove in the lower border of the rib. Incising any space, therefore, keep close to the lower line of the space, keep near the upper border of the rib forming the lower boundary of the space. If a rib is to be resected, it should be denuded of its periosteum, which is loosely attached and on that account easily stripped off. EMPYEMA IN THE CASE OF A CHILD. In the case of a child, simple incision of the pleura will suffice. Under general anesthesia, if the condition of the patient will permit, make an incision three or four inches long, parallel with the ribs. The incision traverses the skin, and beneath it a cellular layer, often edematous. Next divide the muscles, letting the rib serve as a resist- I"ir,. 318. — Incision of the pleura without resection of a rib. (Schwartz.) ing plane. In front they are thin (pectoralis major); behind, thicker (latissmus dorsi and serratus magnus). Divide them at a single stroke and without concern. A small artery may need to be clamped. Having exposed the rib (Fig. 318), retract the upper lip of the wound and locate the upper border of the rib; below, it bounds the space about to be penetrated. Following this border, incise, layer by layer, the intercostal muscles. There is never any serious hemorrhage. As you approach the pleura, be prepared for a sudden spurt of pus, and, when 440 EMPYEMA — PURULENT PLEURISY. the pus flows, it is evident the pleura is opened. Enlarge the opening, using the left index finger as a guide. Incline the patient so that the cavity may be entirely emptied. Fix the drainage-tube (see further). Fig. 319. — Incision of the costal periosteum. (V euu.) EMPYEMA IN THE CASE OF AN ADULT. In the case of empyema in an adult, it is usually necessary to resect a rib. One needs a bone-cutting forceps or a costotome and a curved periosteal elevator or rugine in addition to the ordinary instruments. Local Anesthesia. — It is a grave error to give chloroform, for it is more Fig. 320. — Uncovering the posterior surface of the rib with rugine. {Schwartz.) than likely to hasten the patient's death. It is rare in such a case that any form of general anesthesia is safe, still it may be necessary with the excessively timorous. Having determined the site of incision by exploratory puncture, incise the skin and muscles as in the case of a child. The length of OPl B \i [ON l OB I \ll'\ I U \. 441 the incision will equal four fingers 1 breadth. When the rib is ex- posed, divide its periosteum in the middle line (Fig. 319). The denudation of the rib is an important step. With the nigine OT curved periosteal elevator, uncover the upper half of the external sur- Fi':. 321. — Section of the rib. (Schwartz.) face of the rib first and then the lower half, keeping very close to the rib as you reach the lower border, so as not to wound the intercostal vessels or nerve, which are closely attached to the periosteum and are removed with it. Finally, uncover the deep surface of the rib. Care- fully slip the elevator upward between the bone and its periosteum, Fig. 322. — Section of the rib. (Schwartz.) which is loosely attached (Fig. 320). Carry the elevator to one end of the section and then to the other and the part of the rib to be removed is thus entirely freed from its periosteal attachment. Divide the rib. Introduce one blade of a bone forceps or costotome under one end of the section to be removed and divide it (Fig. 321). 442 EMPYEMA PURULENT PLEURISY. Then divide the other end (Fig. 322). The bone removed should be two and one-half to three inches long. The stumps should not project beyond the limit of the flesh wound, else necrosis is favored. Incise the pleura. With the rib removed, the periosteum remains attached to the pleura and this periosteal layer is incised along its /* Fig. 323. — Rib removed, pleura incised. (Veau.) middle (Fig. 323), and the pleura is divided at the same time. Be on your guard, when making the incision, for a spurt of pus. Empty and drain the cavity. Incline the patient to one side and instruct him to cough. The pus pours out, often offensively fetid. Take plenty of time. Finally, wipe out the cavity with sterile gauze. Irrigation is usually inadvisable; but, if used, employ only warm, sterile Fig. 324. — Drainage of the pleural cavity. (Veau.) water, salt solution, or a weak solution of peroxide. The stronger antiseptics are dangerous. Do not suture the wound except to cover over the projecting end of the divided rib. The difficulty is to keep the wound open. Drainage must never be neglected. Employ two large and long l>K VINAG1 l I >K l \ll'\ l MA. 1 \ J libes placed in different directions and anchor with safety pins I ■24) <>r by a suture, else they may be lost in the abscess cavity. Dressing. — This is important. Pack moist sterile or boracic lauze all around the tubes, between the lips of the wound. Apply an ample dressing of absorbent COtton, which covers half the thorax, and hold all in place with a large flannel bandage maintained by suspenders. Let the patient occupy the half-sitting position, in- clined toward the affected side and supported by pillows at the bai k. Subsequent Care.- After a few hours, change the dressing, which is usually saturated, hut do not disturb the drains. Change the dressing twice daily until the discharge diminishes and about the third day withdraw, cleanse, and replace the tubes in the same place and to the tame depth; else look, for trouble, if you fail to accomplish this. Do not irrigate while making these dressings, unless the discharge has persisted undiminished for a week and continues fetid, when it is best to use a sterile wash of salt solution or dilute peroxide, which is to be injected under very slight pressure. The end results vary with the nature of the infection. (1) The metapneumonic pleurisy of children is usually cured. About the fifteenth day, smaller tubes may be used and are gradually to be shortened as granulation proceeds. In the fortunate case, the opening will close in something like two months. (2) In tubercular pleurisy with secondary infection, cure scarcely ever takes place. The patient will probably die in a few months of amyloid degeneration. Even if the patient does not die soon, the suppuration shows little tendency to yield. In these cases with per- sistent sinus, the bismuth paste injection often hastens a cure. (3) Streptococcic or staphylococcic pleurisy: The patient may go on to death or else recovers with persistent sinus. Keep the orifice open, for if the pus is allowed to accumulate, it will be necessary to operate kgain. Keep watch on the functions of the kidney and liver. Re- member the frequency of metastatic abscess, as of the brain, for example. After two to four months, the case may be referred to a specialist for a plastic operation. CHAPTER IV. URGENT CRANIECTOMY: TREPHINING. FRACTURE OF VAULT OF THE SKULL. There are two conditions which may accompany fracture of the skull, singly or together, either of which demands immediate relief. (See Fracture of the Skull.) (A) The depressed fragments have contused and lacerated the brain; consciousness was immediately lost and was not regained. Under these circumstances, the fragments must be elevated without delay. (B) Hemorrhage has occurred within the cranial cavity and the clot compresses the brain. In this case, there is a "free interval." The patient regains consciousness and, perhaps, for a time — two to twenty-four hours — appears not to be seriously injured, but little by little the signs of "compression" develop, namely, restlessness, dull- ness, stupor, coma; normal pulse at first, but which finally grows slow, full and bounding; and slow and stertorous breathing. Delay is dangerous. The clot must be removed and the hemorrhage checked. Nearly always it is the middle meningeal which is at fault. There is in consequence an extradural hematoma. Once in a while, however, the bleeding will be found to proceed from a ruptured sinus or from the pial arteries and there exists at the same time an injury to the brain substance. There is, in this case, an intradural or intracerebral hematoma. Whatever the form of compression, one is compelled to operate, but he must first get the anatomy of the middle meningeal artery clearly in mind. The middle meningeal, a branch of the internal maxillary, is the size of the radial, entering the cranial cavity at the base of the skull, through the foramen spinosum. It is embedded in the dura and grooves the inner sur- face of the skull. 444 TOPOGRAPHY OF Till: MIDDI.K Ml M\«.| \l . 445 Above the level of the zygoma, the artery divides. The posterior brant li the smaller, is directed upward and backward, and the anterior branch (Fig. 325), the more important, ascends vertically to the frontoparietal suture, which it follows upward, passing a little posterior to it. As it reaches this future, it gives off constantly a posterior branch. The anterior branch is accompanied by veins which occasionally assume the importance of a sinus. The directions for trephining over the middle meningeal are quite definite, but usually unnecessary to regard in emergency surgery, for it is a mistake not to follow the exterior indications and guides furnished by the traumatism. Still one should be able to locate these points readily. Two horizontal and two vertical lines arc employed to locate the paths of the two branches of the middle meningeal. Draw the first (A) from the inferior border of the orbit along the zygoma to the external meatus. Draw the second (B) from the upper border of the orbit backward, and parallel with the first, end- ing beyond the line of the mastoid. To locate the path of the anterior branch of the middle meningeal, draw a perpendic- ular line from A upward from a point cor- responding to the middle of zygoma; and where it cuts B is the point most advan- tageous for exposing the anterior branch. This vertical line is about tw'o inches in length or approximately equal to the length of the last two joints of the index finger. To locate the track of the posterior branch: from the apex of the mastoid, draw a second vertical line upward; its point of junction with B indicates the path of the posterior branch. These lines may be marked off on the skin by tincture of iodine. Operation. — Provide, besides the ordinary instruments, Rongeur forceps, a mallet and chisel, or a trephine. Carefully shave the half of the head corresponding to the traumatism or, even better, the whole head. Sterilize the field. Scrub with soap and water, followed by ether, which in turn is followed by bichloride solution. There must be no relaxation in the disinfection, whether exploration is to be extensive or not, for asepsis is the best means of preventing a hernia of the brain. General Anesthesia. — Often the sensibility is so benumbed, the patient so depressed, that anesthesia is both unnecessary and danger- ous. Chloroform is generally best for brain surgery, but ether is safer in these urgent cases with much shock. Incision. — The incision will vary with the conditions. We will Fig. 325. — Outline of the middle menin- geal artery. (Veau, after Cuneo.) 446 URGENT CRANIECTOMY: TREPHINING. suppose three circumstances: (a) there is an extensive skin wound; (b) there is a bullet wound; (c) there is no wound of the soft parts. (a) If there is an extensive and ragged skin wound, it is better to! enlarge it at once by crucial incision. This has the advantage of being; rapidly done, but has the disadvantage that it interferes with the blood supply of the flaps (Fig. 326). (b) If there is a bullet wound, make a " U " -shaped flap with the Fig. 326. — Depressed fracture of the skull. Crucial incision. (Veau.) bullet wound in the center, and which retains its attachment below the better to conserve the blood supply. (c) If there is no open wound, make the same sort of "U "-shaped flap with its pedicle downward, over the site of the contusion. Cut boldly to the bone if it is resistant. If the fragments are mobile under the scalp, proceed cautiously, but do not stop until on the pericranium. The incision will often traverse a zone which is con- tused and infiltrated, the various layers being indistinguishable. If possible, form the flaps first and then catch the bleeding points EXTRA! riON mi SKI I I \ \< u.mi 117 along tin- edges <•!" tlu- tlaps. In some cases it may be necessary to clamp a vessel In-fore tin- incisions are completed. As SOOD as the lume is reached, hurriedly strip back the flaps, in- eluding the periosteum. The site of the fracture is now ex] (Fig. 327). One of two conditions presents: (1) there are d< : ■ fragments which must be removed, or (2) there is a fissure without de- pression, but beneath the hone there is a clot to remove and a hemor- rhage to check. (1) The fragments are often superimposed in two layers and those Fig. 327. — Stripping back the periosteum to expose the field of fracture. (Veau.) of the internal table are usually the most extensive. In some cases the fragments are easily extracted, but in others the bony fragments are so wedged in that it is difficult to induce any instrument to pry them loose. Failing in this, notch the sound bone along the line of fracture with the chisel, and in this manner open up a way to introduce the elevator. Be careful not to further bruise the brain in extracting the fragments, employing only horizontal traction. Never wrench or twist the fragments (Fig. 328). The deeper fragments are usually adherent to the dura mater and, if so, require to be stripped loose before attempting extraction. 448 urgent craniectomy: trephining. (2) If there exists merely a, fissure, it will be necessary to trephine. At the possible site of the hemorrhage, create an orifice in the skull, either with the trephine or with mallet and chisel. Trephine.— (A) The ordinary Gait trephine may be employed. Begin by protruding its sharp point about 1/16 inch and boring it into the skull at the selected site. As soon as the cutting edge of the tre- phine has grooved the skull, retract the point, and proceed to deepen the groove by rapid half -rotations of the wrist. From time to time, test the groove with the point of a probe to be sure that one side is not Fig. 328. — Removal of the fragments. (Veau.) cutting faster than the other. If there is any difference, regulate the pressure accordingly. Diminished resistance and increased blood flow indicate penetration of the outer table. The inner table is more resistant, and, when it is reached, one must proceed more cautiously. When it is judged that section is complete, the trephine may be removed and gentle effort made to elevate the button. If the bone is completely divided, the button is easily removed. (B) Doyens' instrument is in less common use, but is simple and efficient. It consists of a brace, a perforator, and burrs of various sizes. TREPHINING Willi MALLEI VND CHISE1 i 19 Begin by attaching the perforator and drilling a shallow hole, Bteady- ktg the brace with the left hand. The instrument must always be lept perpendicular to the skull. Next replace the perforator with a burr and rapidly ream oul the opening begun by the perforator. As before, one recognizes the approach to the diploe and the inner table. Tin- burr pushes the dura before it without injury. A quadrilateral or circular Qap may be outlined by additional openings, and the chisel or |ongeur used to complete the section of the Qap. ((') The mallet and chisel may be used and, while not so efficient Pig. 329. — Removal of the clot. (Veau.) as the trephine, will serve the purpose. Begin by cutting a narrow groove in the skull, deepening it gradually until the inner table is bached and divided. The chief point to be emphasized is that the chisel is to be held quite obliquely to avoid concussion and unexpected penetration. Detach the dura malcr. Whatever the means employed, the dura is now exposed, and if the opening, which should have a diameter of at least two inches, needs to be enlarged, the dura should be deta< bed from the edge of bone and the chisel or rongeur employed. Enlarge so as to expose as nun h as possible of the middle meningeal artery. 29 45° URGENT CRANIECTOMY: TREPHINING. Treat the hemorrhage. Once the cranial cavity is well exposed, the next concern is the hemorrhage, (a) There is a clot to be re- moved; (b) a bleeding vessel to control. (a) The clot may be removed with the finger or with a dull curette. The amount of the accumulated blood may be astonishing, but one must work patiently. The clot must be removed to the last particle; remember that toward the base there is the greatest abundance. The white and resistant dura mater must be exposed in every direction (Fig- 3 2 9)- Fig. 330. — Ligation of the middle meningeal artery. (Veau.) (b) Next look for the bleeding vessel. A jet of blood may indicate the proper point at once, and the vessel is caught with forceps and a ligature passed with a needle (Fig. 330). If the bleeding point is too deep, the forceps may be left in position for twenty-four hours. More often, perhaps, the source of the hemorrhage cannot be definitely de- termined and as soon as the compress is removed, the blood wells up from the bottom of the cavity. Depressing the head, the change in the stream's direction may reveal its source which is liable to be the middle meningeal vein; it is to be caught up and ligated like the artery. If the blood comes from a sinus, pack the cavity with sterile gauze. The hemostasis must be complete. If there is only slight, yet persistent Mil B IKI \ I Ml N I 01 TRI I'lllMM.. 151 pozing, Leave a gauze tampon far twenty four hours. Suture the angles of the wound and apply a dry dressing. Another case, more rare: The dura mater is lacerated and the brain, more or less contused, is exposed. Catch the edges of the dura! wound with forceps and, raising the membrane, gently wipe out the bftrts with sterile gauze. A nnic slit in the dura may be repaired by catgut suture, but if there is loss of tissue, it is useless to attempt suture of this inelastic membrane. The hemorrhage must be eared for in the manner already described. Most trying are those cases presenting a subdural hematoma. Tre- phining is completed and the dura is exposed, but there is no clot. Instead, the dura, tense and darkened, bulges toward the orifice. Make a crucial incision in the dura, or raise a flap with its base above, and wipe out the exudate, usually diffused. Be very careful not to give additional injury to the contused brain tissue. Leave a strip of sterile gauze in the wound for drainage, removing it on the second day. After-trial mail. — Following the operation, it may be necessary to inject one or two quarts of salt solution in the first thirty-six hours. No alcoholic stimulants must be used. Keep the patient absolutely quiet, the head slightly elevated, and change the dressing as often as soiled. If sepsis occurs, open up the wound. If there is hernia cerebri, Treves advises a gauze pad saturated with alcohol held on under light pressure. Results. — The patient may die without regaining consciousness, owing to the shock of the traumatism, aggravated perhaps by the operation; for this reason, it is absolutely necessary to give as little chloroform and to do the operation as rapidly as possible. He may die the next day from persistent hemorrhage. He may die between the third and eighth day from septic meningitis, due to infection from the injury or the operation. Watch the course of the temperature in order to forecast sepsis. Finally, he may recover, and even then he may develop a Jacksonian epilepsy, delayed perhaps as long as ten years.* *It occasionally happens thai the hemorrhage occurs cm tin- si nothing t<> do but repeat tin- trephining on tin- opposite tide, f<>r the matter cannot be determined In-forehand. 452 URGENT craniectomy: trephining. FRACTURE OF THE BASE OF THE SKULL. It has already been said that the only way, as certainly as may be, to forestall infection in fracture of the base is to trephine and drain, leaving a permanent escape for microbes and their toxins. If there is evidence of compression originating at the base, the trephining is even more imperative. Cushing recommends drainage through the lower temporal region for the reason that very much more frequently the middle fossa is involved, the middle meningeal artery ruptured, and the tip of the middle cerebral lobe contused. Operation. — Make an incision from the middle of the zygoma di- rectly upward to the temporal ridge. Clamp the divided branches of the artery. Divide the temporal fascia and split the muscle in the same line and cut through to the bone. Strip back the two halves of the temporal by free use of the rugine. If there is a line of fracture, or some indication of pressure, trephine accordingly. Otherwise, aim to make the opening near the junction of the temporal with the great wing of the sphenoid. An extradural hemorrhage may be brought to light and a ruptured middle meningeal found. In other cases, the effusion will be reached only after the dura is divided. The escape of the bloody cerebrospinal fluid will be favored by passing a curved blunt dissector down under the temporal lobe. If the effusion is merely serous, the wound may be closed; if there is any persistence of oozing, a strip of rubber tissue should be left in the lower angle of the wound, extending into the cranial cavity under the temporal lobe. Vincent (Revue de Chirurgie, Aug., 1909) concludes that this inter- vention will reduce materially the sequelae so common to fracture of the base not treated by operation. TREPHINING THE SUBOCCIPITAL REGION. A case of Ford's illustrates this procedure: A man of fifty years fell from a street-car, striking upon his head. He was only slightly dazed; insisted he was not hurt and walked home. An hour later, his head began to pain severely and in the course of a couple of hours he began to grow drowsy and so gradually lapsed into unconsciousness. TREPHINING THE FRONTAL REGION. 453 He developed a divergent strabismus, but bis pupils remained normal and there were ao signs of paralysis. There were no marks about his head to indicate injury. After twenty-four hours, Ford was called in. He found the patient still unconscious and with the pulse and respiration of compression. He was removed to the hospital for operation. After the head was shaved, a flatness was noticed below the occipital protuberance, though there was no depression or evidence of contusion. It was decided, how- ever, to trephine over this point. A semilunar incision, convex up- ward, mapped out a flap with the base downward, and the skull was exposed. A stellated non-depressed fracture was found. A trephine button removed revealed the presence of a large clot. A large area of bone was removed with rongeur forceps and an immense subdural clot cleaned out of the posterior fossa. A strip of iodoform gauze was left for drainage. Uninterrupted recovery. We might add that in all cases of head injury followed by compres- sion symptoms, but in which there is no evidence of rupture of the middle meningeal artery nor any focal symptom, the suboccipital operation is preferable to the subtemporal. It will give easier and safer access and more efficient drainage. TREPHINING THE FRONTAL REGION. A case reported by Axtell, of Bellingham, Wash. (Northwest Medicine, Nov., 1908), illustrates the procedure: A laborer received a violent blow from a cable hook above the left eye. In spite of the severity of the injury, the man walked a mile to camp. Traveling by a logging train, by boat, and by street car, nine hours later he reached the hospital, showing no indication of collapse till he reached his destination. He had a marked depression over the left orbit, a swollen eyelid, and a protruding eyeball. A semicircular incision extending from the bridge of the nose to the external angular process exposed the shattered supraorbital ridge. The orbital plate of the frontal bone was broken into fragments and a large blood clot was found filling the upper and back portion of the socket, forcing the eye onto the cheek. 454 urgent craniectomy: trephining. Three lines of fracture extended from the supra-orbital ridge across the frontal, which was depressed in several places. The fragments of the orbital plate were removed; and, on removing the depressed por- tions of the frontal, the dura mater and subjacent portion of the brain were found mangled. The brain tissue was trimmed out, the dura adjusted, and the fragment of the supra-orbital ridge that remained at- tached to the pericranium was so turned and fastened that it covered the supra-orbital ridge that had been destroyed. This was retained in place by sutures passed through the skin flap which was drawn into place. The recovery was uninterrupted, and a year after there was nothing to indicate the injury but a puffiness of the upper lid. Trephining for Gunshot Wounds. — Every case of gunshot wound of the skull must be explored; though, of course, no trephining is necessary unless there is perforation or unless there are evidences of gunshot fracture without perforation. When it has been determined that there is perforation, raise a flap with the bullet wound in the center, as has been already described. The flap must be larger than the possible trephine opening in the skull. Enlarge the opening in the skull with trephine, chisel and mallet, or with rongeur forceps. Remove all fragments of bone and foreign matter, wipe out the dural and cerebral wounds with sterile gauze. Be patient and persistent in this cleansing. Do not explore the bullet track or attempt to remove the bullet unless, of course, it is within easy reach. CHAPTER V. MASTOID ABSCESS. The tympanum, and likewise its accessory cavities, are normally sterile, hut there are two highways by which infection may reach this site, the Eustachian tube and the external auditory canal. The Eustachian canal is the much more common route, the infection hr^t gaining a foothold in the mucous membrane of the naso-pharynx, so that an inflammation of the mucosa of the middle ear is often only a step further in the ordinary pharyngeal catarrhal process. Finally, the catarrhal inflammation may become a purulent one, in either case, running an acute or chronic course. Again, the pyo- genic germ will not long limit its operation to the tympanum; but eventually invades the pneumatic spaces adjacent, the antrum and mastoid cells; and then there may develop a mastoid abscess, a con- dition full of potential danger. The thin roof of the middle ear is the dividing line between the posterior and middle cerebral fossa?, and through it infection may reach the cerebellum or the middle lobe of the cerebrum: meningitis, epidural, cerebral, or cerebellar abscess is the immediate result. The mastoid cells are separated from the lateral sinus by a bony partition, so that through the small venous channels or by necrosis of the bony wall, infection may reach the sinus. Finally, general infection and sinus thrombosis may ensue, followed perhaps by metas- tatic abscess. These are the actual dangers of mastoid abscess and one can never tell how fast the pathological process may extend, aided by bone ero- sion or by the escape of the infectious matter through apertures in the bone or by the blood vessels and Lymphatics. Acute purulent mastoiditis, then, is an emergency, and every doctor should feel himself prepared to trephine the mastoid if it becomes his duty, and it is his duty if no one more .skilled is at hand. 455 456 MASTOID ABSCESS. 1v How shall one recognize this emergency? The pain, sleeplessness, prostration, fever, together with the history of the case, point with a great degree of probability to the nature of the trouble. Now, if the examination adds certain other signs to these symptoms, the indications for intervention are definite: (1) You find the upper and posterior quadrant of the ear drum (Shrapnell's membrane) bulging and perhaps the superior and poste- rior walls of the canal are swollen. (2) You find persistent tenderness over the mastoid process. (3) You may observe that a previously free discharge has suddenly diminished and this is an added warning that delay is dangerous. To repeat, the cardinal symptoms are pain, redness, swelling, bulg- ing of the drum, and fever. The first thing to do is a paracentesis. PARACENTESIS. Douche the auditory canal gently with warm, sterile water; co- cainize the canal with a 10 per cent, solution and wait five or ten minutes. With the otoscope, expose the drum and locate the bulging area. Puncture it with a small pointed bistoury making an incision three or four millimeters long, downward and forward. There is nothing to fear. Even if the drum has spontaneously ruptured, it is often an advantage to enlarge the opening. Usually a few drops of pus escape. Follow with irrigation. If, at the end of twenty-four hours, the symptoms have not subsided, proceed without further delay to trephine the mastoid. Operation. — The operation is easy and without much danger if one but knows the anatomy (Fig. 331). The sigmoid sinus is more shallow in children than adults. Recall the situation of the spine of Henle, the facial nerve, and the lateral sinus. The spine of Henle marks the upper limit of the external meatus; one-quarter inch above it is the middle cerebral fossa; the mastoid antrum is one-half inch posterior. Shave the temporo-parietal region and scrupulously prepare the field. General anesthesia is indispensable. Special instruments necessary are a Macewen seeker, a chisel (one centimeter wide), a small gouge, mallet, curette, curved periosteal elevator, and probe. EU i \u>>\ "i mi i \ii i'\i r i K) mi MASTOID PRO( i 5S. |" PlG. 331. — Landmarks of the mastoid. The square represents the area to be trephined the dotted lines the course of the lateral sinus. (Veau.) Fig. 332. — Incision for mastoid operation. (Veau.) 458 MASTOID ABSCESS. Incision (Fig. 332). — Begin at the apex of the mastoid and follow the curve of the external ear to the level of its attachment above. This incision reaches to the bone; and, when operating on children, be care- ful not to cut through the bone. Catch the bleeding vessels in the gaping wound. Rapidly denude the bone, an undertaking some- what difficult below where the sterno-mastoid is attached (Fig. 333). Introduce a sound into the external auditory canal to determine its direction. Expose the spine of Henle. Fig. 333. — Denuding the mastoid with the rugine. (Veau.) Trephine. Start the chisel vertically five millimeters behind the meatus; two or three slight blows of the mallet will be sufficient. In a child, a bistoury may be used. Make the second trace with the chisel horizontal and on a level with the spine of Henle. The third is parallel with the second, and finally the fourth, parallel with the first, completes the outline of chip. This fourth line of section is in the danger area, nearly over the lateral sinus. In making it, hold the chisel obliquely instead of vertically as in the first (Fig. 334). By slight and rapid blows, remove this chip. EXPOSING nil MASTOID CI LLS. If this does not expose the cells, deepen the opening carefully with the gouge. Pus will often be found at the first incision into the bony wall. p IG 334 — Outlining the chip of bone to be removed. 15. — Exposing-the lower mastoid cells. (I KM.) Introduce a seeker or blunt probe, which will locate the various cavities and canals leading to the cells of the mastoid and antrum. 460 MASTOID ABSCESS. Their coverings are then chipped off, or they may be merely curetted. Chisel below first (Fig. 335), and then, with the guide, locate the posterior limit of the cells and chisel off the bone lying over the point of the guide. A trough may be trephined downward toward the tip. Remember that posteriorly there is the lateral sinus (Fig. 336). Do not stop until all the cells are freely exposed. When the mastoid cells are thus opened up, it remains to expose the antrum (Fig. 337). It lies in the direction upward and forward at Fig. 336. — Exposing the posterior cells. The lateral sinus must be avoided. (Veau.) what seems a considerable depth, one to three centimeters. Locate the cavity with the guide, and enlarge freely. The mastoid cells and the antrum are now a single cavity. Carefully curette the necrosed bone and fungosities, but be very careful when curetting over the posterior wall, for the lateral sinus may be exposed. Throughout the operation, one may be disturbed by the hemorrhage, always con- siderable, and it will be necessary to sponge continually, for it is in- dispensable that one see what he is doing. Certain accidents may occur in the course of the operation. (1) The lateral sinus may be wounded, immediately recognized by the excessive hemorrhage; but do not be perturbed, for it is easy to in.I1 k\ TO mi PACT \l. M K\ i . I'm Irrest the bleeding. Pack the point or apply hot moist applications with sterile gauze and continue the operation. If you find thrombosis, it will he necessary to open the sinus. (2) The cranial cavity may he opened, hut neither is this j » ; 1 r t i < - ularly serious. However, you should avoid, if possible, an injury to the meninges, for there is danger of infection. Chisel discreetly, therefore, at the upper angle of the opening. If you do wound the dura, disinfect and tampon, hut do not attempt suture. If is scarcely possible at that depth in a cavity so narrow. Fig. 337. — The operation completed, the guide is in the antrum. (Veau.) The facial nerve may get in the way, and if wounded, that is indeed a serious matter, for you can do nothing to remedy it. It is deeply situated and if you follow the guide, you are scarcely likely to reach it with the gouge. It is almost certain to be injured if the mastoid is fractured in the course of the trephining, and this will happen if the mallet and chisel are recklessly used. Injur}- to the facial nerve is really the one danger of the operation. Close approach is indicated by twitching of the facial muscles. Dressing and Subsequent TrcatHicnt.—ParUiiUy suture the wound and pack with iodoform gauze. The dressings are as important as the operation. If neglected, a fistula may form or the suppuration may 462 MASTOID ABSCESS. recur. Instruct the patient that repair may require six to eight weeks, or longer. On the second day after the operation, remove the gauze and irrigate with warm sterile water, dry carefully and repack methodically so that all the diverticula are filled. They must not be allowed to close over. Granulation from the bottom is indispensable. Change the dressing every other day. Repress excessive granula- tion with tincture of iodine or nitrate of silver. Keep the patient in bed for one week; keep the bowels open, and regulate the diet. CHAPTER VI. GENERAL TECHNIC OF LAPAROTOMY. Since so many urgent conditions require a laparotomy, every do< tor .should be familiar with the general technic of the procedure without regard to any particular purpose for winch the abdomen may be opened. For the purpose of ready review, the various difficulties and their management and the after-treatment are briefly outlined. Preparation of the Patient. — Whenever possible, the patient should he under a preliminary treatment for two or three days in order that the bowels may be thoroughly cleansed, the field of operation sterilized with certainty, and the functions of the organs noted. In emergency work, these details cannot, of course, be so definitely regulated, but to omit any of them is a handicap. To have the bowels emptied by castor oil and enemata is the best prophylaxis against meteorism, which may be a source of embarrass- ment to the operator in the course of the operation, and a source of discomfort and perhaps danger to the patient subsequently. However urgent the operation may be, the sterilization of the field must be definite, even though the methods be abbreviated. To scrub with soap and water, shave, wash with alcohol or ether to remove the oils, and finally bathe with bichloride solution and cover with bichloride compresses until ready to make the incision is to realize a practical asepsis so far as the skin is concerned; or the sterilization may be even more rapidly accomplished by washing, shaving, and dry- ing the skin, and then painting with tincture of iodine. To have a definite knowledge of the patient's temperament, of the action of his circulation and respiratory organs and of his kidneys is to forestall many difficulties and dangers. At least a full stomach 463 464 GENERAL TECHNIC OF LAPAROTOMY. should be washed out, and the bladder emptied before the operation is begun. Incision. — The operator may stand on either side. It is preferable to stand to the patient's right and cut from above toward the pubes, supposing a median laparotomy. The skin and subcutaneous fatty tissues are divided first. Clamp the small vessels and gently sponge. In the case of abscess and chronic inflammation, the bleeding is likely to be rather free but never dangerous. The aponeurosis, when possible, should be divided in the linea alba, because the bleeding will be less and the access to the peritoneum readier. On either side of the middle .line the incision opens into the sheath of the rectus, whose inner border should be displaced to the outer side or its fibers split. The edges of this fascia should be caught with forceps in order to be more readily recognized in the course of repair. The peritoneum is now exposed, covered usually by fatty areolar tissue, more or less thick. Catch up a fold of it between two forceps and make a small opening with either knife or scissors, using caution not to cut into the bowel or omentum. The lips of the peritoneal wound are controlled with forceps which are to he left attached; and now enlarge the opening in either direction, using the finger as a guide and as a protection to the bowel. Approach- ing the pubes, guard against wounding the bladder, of which there is no danger if it has been previously emptied. In any event, it can be readily located by the sense of touch. Protect the Cut Surfaces. — When the peritoneum is opened to the necessary extent, apply two wide compresses of gauze, so as to com- pletely cover the incisions and attached forceps, tucking the edge of each compress under either side of the peritoneum. This is to diminish the chances of infection and to prevent bruising the peritoneum. In like manner, and for the same purpose, the parts that are to be dealt with are packed off from adjacent structures with large com- presses which are not only more efficient than small ones, but also are less likely to be lost within the peritoneal cavity. The surgeon or a ill MORRB M-\: l\ I tPAROTOlft . f>5 lesponsible assistant must always know how many compresses arc brought into use, and they must be accounted for before the cavity is closed. Management of Peritoneal Adhesions. The novice and even the mosl practised surgeon may experience the greatest difficulty in sepa rating adherent organs, their peritoneal surfaces glued together as the result of inflammation. In the ease of recent adhesions, they are soft and easily broken. In other cases, they consist of hands which need only be divided with scissors; but anally they may hind together Large anas of adjacent structures so as often to render them indistinguishable. Even here with a little patience one may often find a plane of cleavage, especially if the parietal peritoneum is involved. If the organ cannot be separated from the parietal peritoneum, a segment of this latter is to be cut out and left attached to the viscus concerned. In the case of the omentum it is to be ligated twice and cut between. In the case of the intestine, the greatest care must be used not to break through its wall. In general, intestinal adhesions discovered in the course of operation are not to be broken up except as they interfere with the work in hand or are likely to obstruct the bowel. If no plane of cleavage can be found, then the other organ involved must be deprived of its peritoneal coat to protect the gut. If the sur- face of the intestinal loop is left raw after the separation, the Lembert suture should be employed. If the bowel wall is torn through, it must be repaired by two rows of suture: a through -and -through and a Lem- bert suture. Hemorrhage. — The visceral blood supply is complex; to have its anatomy clearly in mind is a great advantage in hemorrhage from larger vessels. To locate the vessel at fault, to clamp it and ligate quickly, speeds the operation. Capillary oozing can generally be con- trolled by a few moments' application of hot compresses. A compress wet with alcohol will often promptly check free bleeding. If the oozing is persistent at the end of the operation and measures applied have failed to check it, the abdomen must not be closed without drainage. 3° 466 GENERAL TECHNIC OF LAPAROTOMY. To insure against recurrence of hemorrhage as well as to prevent infection and adhesions, all raw surfaces should be covered oven with a peritoneal coat. It is never desirable and seldom necessary! to leave a denuded area in the peritoneal cavity. Use of the Lembert .suture and of the 'free omentum enables one to obliterate them. Such : as must be left should be sprinkled with aristol. Drainage. — The old dictum, "When in doubt, drain," does not apply with such force to laparotomy as formerly. In fact, there are those bold enough to say, "When in doubt do not drain." Still it must be i admitted that, in spite of drawbacks, drainage is a real safeguard against infection. One should drain, then, when any septic process is present or is likely to develop, as in the case of perforating wounds of the intestine. Drainage must be employed whenever it is impossible to control bleeding from raw surfaces. If there is no infective process present in the peritoneal cavity, if there is no obvious reason for any to develop later, the abdomen is to be closed completely. The preferable method of draining the abdominal cavity is by rubber tubes. This is the only method available if pus is present. If the main object is to get rid of blood, then the tube should contain a wick of gauze which should rest upon the oozing surface that it may serve the double purpose of hemostasis and drainage. As soon as the oozing has ceased the gauze wick is to be withdrawn while the tube remains. The tubal drains are to be removed as soon as the danger of sepsis is passed. Repair of the Abdominal Wall. — Suppose the operation complete. The final inspection of ligatures and sutures is made, the cavity is wiped out, the compresses are removed and counted, the vessels in the abdominal wall that were clamped are ligated, if necessary, and repair of the abdominal wall is begun. The peritoneum, to which the forceps still remain attached, is pulled up into view. If the Trendelenburg position has been used, the table is now brought to the horizontal; the intestines are brought back into place, the omentum spread out over them, and a compress applied to protect the bowel while the peritoneum is repaired with a continuous \ii n; ril \ i \n \ r in I APAR0T01IY. l'>7 Wo. o catgut suture. The compress is withdrawn before the last two or three stit< hes arc passed. The aponeurosis and muscles are now repaired with continuous clironiit gut suture. The skin, finally, is to be repaired with interrupted silkworm-gut sutures, passing some of them deep enough to include the muscles and aponeurosis so as to obliterate any dead spaces. If coaptation is lot perfect, a few superficial catgul sutures may Ik- used a- accessary. One may close the skin simply by the continuous catgut or chromic gut suture or, as many prefer, by the subcuticular stitch. Of course, if drainage has been employed, the closure cannot be complete, though the suturing is to be carried close up to the tube. In case great haste is required, the abdomen may be closed by a feu- through -and-through sutures of silkworm-gut. After-treatment. — In the uncomplicated case, the after-treatment is simple. The patient is put to bed where he can get plenty of fresh air and hot-water bottles put to his feet. As he recovers from the anes- thetic, he is given water cautiously for the first twenty-four hours. After that, liquid nourishment should be given in small quantities at frequent intervals. The bowels should be moved on the second day by a light soapsuds enema. It is rare, however, that these patients do not have some complica- tion. If there was much shock or much hemorrhage, or if the anes- thesia was prolonged, give normal solution by one of the three methods, hot coffee by the rectum and whatever cardiac stimulant may seem in- dicated, strychnia, brandy, or camphorated oil. If the pain is severe, small doses of morphia hypodermic ally should be given until the patient is comfortable. If there is much nausea, try a glass of warm soda-water which will probably be thrown up, and thus washes out the stoach. If the nausea is quite severe,- wash out the stomach and put the patient in a half-sitting position. If the thirst is extreme along with vomiting, enemas of normal salt solution give the most relief. Sometimes 5—1 5 minims of aromatic spirits of ammonia, given hypodermic ally, tend to relieve the nausea, while acting as a diffusible stimulant. 468 GENERAL TECHNIC OF LAPAROTOMY. If there is much flatulence or meteorism, give minute doses of calomel and empty the bowel with soapsuds enema. If this does not give relief, the enema consisting of two ounces of Epsom salts and glycerin and one ounce of turpentine may be employed. A special line of treatment is required if postoperative ileus develops (see page 517). CHAPTER VII. LAPAROTOMY FOR TRAUMATISM. The indications for laparotomy following traumatism are as follows: i. Perforating gunshot wounds. 2. Perforating stab wounds likely to have wounded a viscus. 3. Contusions of the abdomen presenting symptoms of dangerous lesions of abdominal viscera or vessels; not always definite, but operate at once if you find these appearances following contusions: (a) The abdominal walls are resistant some distance from the in- jury; a progressive meteorism reaching the hepatic region; dullness over the iliac fossae or the flanks, indicating hemorrhage. (b) The pulse is weak and rapid, and growing worse. (c) The general condition of the patient is alarming, pallor, pain, excitement or delirium, subnormal temperature. But whether it be an open wound or a contusion, do not wait for the symptoms of peritonitis, for it will then likely be too late. The operation is delicate and dangerous in the hands of the unskilled, and yet the patient's life depends upon it. There is no time to send for a specialist unless he is right at hand, and, as Veau says, it is better for the patient to be operated on early by an inexperienced surgeon than to be operated on too late by the best surgeon in the land. It is an intervention in which one never knows what he is going to find. The steps of the operation are: (1) A laparotomy. (2) Search for the licmorrhage if there is blood in the abdomen. (3) Search for visceral injuries. General anesthesia is indispensable, and ether is preferable unless compelled to operate in close quarters by lamp light. Every precau- tion must be taken not to aggravate shock; the limbs should be wrapped and the chest protected. The whole anterior abdominal wall must be 469 47° LAPAROTOMY FOR TRAUMATISM. sterilized.- Be prepared for normal salt injections, often necessary throughout the operation. (i) Laparotomy Whatever be the site of the wound or contusion, make an incision in the middle line; below the umbilicus, usually; above, if the injury points to the epigastrium. The incision at first should be about three inches long. It may be necessary to extend it. Divide the skin and fatty tissues and catch up the bleeding vessels. Open the sheath of the rectus and look for the linea alba, but if not readily found, go through the muscle; it does not greatly matter. Divide the transversalis fascia and expose the subperitoneal fatty tissue. It may be quite thick. The peritoneum will probably not be recognized by its appearance, but rather by observing the tissues gone through. It is usually bulging. One may be able to see free blood in the cavity by reason of its transparency. Catch up the peritoneum with dis- secting forceps and incise the cone thus formed, with the cutting-edge of the scalpel turned away from the ab- dominal cavity, that the bowel may not be wounded (Fig. 338). Enlarge the small opening thus created, and direct the assistant to seize the lips of the peritoneal wound with forceps. Pay no attention to the blood which may pour out, but proceed rapidly to elongate the peritoneal wound with the scissors, protecting the bowel with the left index finger (Fig. 339). Remember the peri- toneum envelops the bladder, so do not open the peritoneum down to the pubes, although the skin wound should be carried thus far in order to give the best view (Fig. 340). Carefully catch up the lips of the peritoneal wound with forceps which may also serve as retractors; such control of the peritoneum will also facilitate its suturing at the end of the operation. It may now be necessary to push the anesthesia a little if there is much resistance. Fig. 338. — Incising the fold of peritoneum. (Guibe.) CONTKnl ill I III III \|o|.: I'll V.I 17' (2) Locate and check the hemorrhage. I>" nol be in a hurry to put ;i hand in the cavity bul observe closely, sponging gently. The character oi the Quids may be helpful in diagnosis. The examining finger may detect lesions, or the injured viscera may push up into the wound. Fig. 339. — Enlarging the peritoneal opening with the scissors on the index finder to guide. (Guibe.) The hemorrhage may come from the following: (a) omentum; (h) mesentery; (c) the vascular organs, liver, spleen, kidney; (d) the vessels of the posterior abdominal wall. (a) The great omentum should be gently lifted Out of the cavity. It may contain a hematoma and the divided vessels be hard to find. 472 LAPAROTOMY FOR TRAUMATISM. Tie them with No. 2 catgut. If the omentum is torn and lacerated, resect the injured portion (Fig. 414). It may be split; the large vessels opened must be tied; the small will be controlled by the continuous suture, which should reunite the edges of the wound. If the omentum Fig. 340. — Enlarging the opening toward the pubes, the bladder must not be wounded. (Guibe.) is detached from the greater curvature, the stomach should be exposed, and the omentum sutured thereto. (b) The hemorrhage from the mesentery may be arrested in the same manner, though one may not find it until in the course of in- specting the gut. Mesenteric wounds often exist without visceral injury. In suturing the tear, the needle must be passed close to the rREATMENT OF WOUNDS 01 mi INTESTINE. 173 gdges of the wound s<> thai qo vessel may be wounded or included in the tie. It its attachment to the bowel is disturbed for, say, more than three itches or it' it is accessary to tie a branch as large as the radial, the Integrity of the corresponding section of gut is compromised and it will be advisable to resect. If unable to d<> that, treat it as the doubt- ful bowel is treated in strangulated hernia (see page 539). (c) If the hemorrhage proceeds from a wound of the liver, spleen, or kidney, tampon methodically and firmly with sterile gauze. If the liver is ruptured extensively and tamponade has no effect, try deep suturing. If this does not succeed, the wound is probably be- yond surgical aid. If the spleen is extensively lacerated, remove it. (See page 482.) (d) If the vessels of the posterior abdominal wall are involved or the splenic, mesenteric, or renal, it will often be very difficult to find the starting-point of the hemorrhage, for it is in the midst of a great clot. Begin by applying a large compress to the suspected point and make firm pressure. Following this, rapidly wipe out all the clots and reapply the compress. Raise its edge gradually and as each bleeding point appears, clamp it. It will often be impossible to ligate at that depth and forceps are left attached. The forceps are to remain twenty-four to thirty-six hours. These must be removed without violence. (3) Wounds of the intestine: Do not forget that intestinal perfora- tions are often multiple, are usually so after gunshot wounds, so that it is absolutely necessary to inspect the whole intestine that no wound may be overlooked. (A) Examination of the Bowel. — The procedure must be methodical. Do not pick up first one segment and then another indiscriminately; in this way one part may be examined several times and another part not at all. Begin by picking up with forceps any part of the bowel that may present; these forceps will serve as a starting-point and landmark. It will not hurt the bowel with its pressure, as it includes in its hold only the serous and muscular coats (Fig. 341). Begin at this point, then, pulling up to view segment after segment, 474 LAPAROTOMY FOR TRAUMATISM. and as it is inspected, returning it to the cavity. The manucevre ma be attended with difficulty especially if one is compelled to operat late, when peritonitis has begun and the partially paralyzed bowe is greatly distended. If several folds of the bowel should escape an] there is difficulty in returning them, the procedure as described 01 page 116 will be helpful. Fig. 341. — Examining the bowel. (Veau.) Begin by lifting up the abdominal wall by means of the retractors. Cover the refractory mass with a wide compress and then tuck each border of the compress into the wound, gradually working it into the abdominal cavity. It will carry the bowel along. Then carefully withdraw the compress. Examining thus the small intestine, one of its fixed points will finally be reached, either the cecum or the duodenum; return then to the forceps and work in the other direction.* rliffir-ni? 6 ^f °* S un t hot . ^ ounds penetrating the abdomen from behind, the SotSngcaS 1118 the mJUneS "^ bC S-^ly increased, a fact illustrated^ On December 21 1907, a colored man was brought to the City Hospital with a fnc£:r Un i m t fe£ U £ the 5 Ullet enterin S the "g ht lumbar ^egronabo't Two inches from the middle line. Progressive abdominal distention and tendernTss with symptoms of hemorrhage pointed to a visceral injury. He was immldiSe y operated; he abdomen was opened below the umbilicus 7 The pelvis SSaUed considerable blood, but there was not the quantity expected. A Sematk exam mation of the intestine from the cecum to the d/odeno-jejunal j/nc ure reveakd i'i PAIH 01 i\ n sri\.\i. win \\> I, 475 Whenever a perforation is found, it must be repaired before looking further. (H) Repair of the Intestinal Wound. When an intestinal won no 1 is located, seize its edges with two forceps, including only the serous and muscular coats, draw the part outside the cavity and isolate it with compresses and then suture. (a) Non-perforating wounds are sufficiently repaired by two or three Lembert sutures. (I)) Small perforating wounds, such as bullet wounds, must be re- Fig. 342. — The inclusive suture passed; tied and Lembert suture passeil ; Lembert tied. paired by suture in two layers (Fig. 342). With fine silk, No. 1, make a suture which includes all three coats, serous, muscular and mucous (Fig. 343). If the wound is longer than two-thirds of an inch, use two such sutures, etc. These sutures are to be covered in and buried by the second layer, which involves only the serous coat no perforation. No opening in the posterior abdominal wall could be found be- low the level of the umbilicus. The incision was extended and the examining finger located a tear behind the stomach. At this time the patient's condition grew so bad it was necessary to cease the search and before the abdomen could be Completely closed, he died. The postmortem revealed a long tear in the transverse portion of the duodenum. Tlie bullet had struck the transverse process of a lumbar vertebra, had deflected to the left, wounding the ascending vena cava and the duodenum, and had lodged in the anterior abdominal wall. The Mood escaping from the vena cava had not emptied into the abdomen, but had followed the vein along the spine and had flooded the posterior mediastinum. 476 LAPAROTOMY FOR TRAUMATISM. (Lembert suture). In introducing them, begin at least one-half inch back of the first line and use either a continuous or interrupted suture (Fig- 344). Fig. 343. — The first layer of sutures include all coats. (Veau.) Fig. 344. — Applying sero- serous (Lembert) sutures. (Veau.) (c) Large Perforating Wounds. — If the wound is an incised one, suture without refreshing the edges, but if it is contused or lacerated (Fig. 345) it will be necessary for repair to trim away to the sound tissue; but take care not to diminish the caliber of the gut. Fig. 345. — Trimming away the bruised tissue. (Veau.) Fig. 346. — Transverse su- ture to prevent narrowing of the bowel. (Veau.) As before, beginning at one angle, introduce the first line of the suture, including all the coats, and using, if possible, a continuous suture (Fig. 346). AFTEE l'Ki\l\n\i hi LAPAROTOMY POB TRAUMATISM. 177 The second line of (Lembert or sero serous) sutures must begin and ml one half inch beyond the limits of the first and the needle must be btered far enough away from the first line that the peritoneal 3uri nay be well apposed and the first layer completely covered (Fig. 347). ((') Resection of the Gut. If the wound involves more than two- birds of the circumference or if then- is a contusion of the whole or i large part of the segment, it will be necessary to resect and do a ;ircular enterorrhaphy or some other form of anastomosis. If the ipenitor cannot undertake that, then the gut must he treated as in the gangrene of strangu- .aied hernia, making an artificial anus (see page 519). For resection of gut, see page 575. Drain the peritoneal cavity with a Micu- licz drain where there is oozing, and with a drainage-tube if infection is feared (see Chapter V on Drainage). Close the abdominal wall by three tiers of " "~aj? suture; the peritoneum with a continuous Fig. 347.— Applying Lembert suture of catgut, the muscles with chromicized catgut, and the skin with silkworm-gut. Apply a dry dressing. Subsequent Care. — Order complete rest and absence of food for forty- eight hours, not even excepting milk. To quench the thirst, let the patient suck a cloth saturated with water. Inject salt solution if there are signs of collapse. It will nearly always be expedient to give salt solution either by rectum or subcutaneously; in the worst cases by intravenous infusion. Change the dressing the following day. It will probably be satu- rated with bloody serum. On the second day remove the tampons and replace with smaller ones. On the fourth day remove the drain- age-tube, if employed, and replace with smaller one, which may be dispensed with after the eighth day. Prognosis. — The prognosis will depend upon the extent of the injuries and the skill of the operator. Death may occur from hemorrhage or peritonitis shortly after the operation, or about the eighth or tenth day if the suturing has been imperfectly done. 478 LAPAROTOMY FOR TRAUMATISM. Fecal abscess and fecal fistula may result, requiring a later operation, or which may eventually cure themselves. Complete recovery happily very often occurs and would be the rule if the doctor had the judgment or authority to operate within the first few hours after the traumatism. WOUNDS OF THE STOMACH. If the injury involved the upper pole of the abdomen, the stomach must be examined carefully. Extensive injuries are often overlooked. An escape of gas and bleeding may point to the situation of the lesion. Pick up the stomach with gauze to get a firmer hold, and examine the anterior surface systematically. Repair any wounds, as in the intestine by two rows of suture; the one including all the coats, the other only the serous and muscular. In the case of gunshot wounds, examine the posterior surface. To reach the posterior surface, Auvray insists upon a large incision in the gastro-colic omentum along the lower border of the stomach, for a large incision facilitates examination and does not compromise the vitality of any structure . If even then one cannot gain full access, he advises an exploratory gastrotomy (Revue de Chirurgie, Nov. 10, 1906). The posterior surface may be reached another way, by turning up the transverse colon and opening the transverse meso-colon. To prevent the spread of fluids which may escape from the stomach, the field must be carefully walled off with compresses as the explora- tion proceeds. If the wound can be felt but is impossible to be seen, then no attempt must be made to suture, but the cavity is to be thor- oughly drained. If there has been much loss of substance, it may be necessary to do a gastro-enterostomy. WOUNDS OF THE LIVER. If the nature of the abdominal injury leaves no doubt that the liver is wounded, it may be advisable to vary the procedure described from the first. A support under the back tilts the abdomen so that the intestine drops down toward the pelvic cavity, and at the same time the liver is bulged forward and made more accessible. I ki \ I \li \ I 01 WOUNDS 01 mi LIVER. The incision beginning al the ensiform cartilage may follow the festal arch, dividing, if accessary, the right rectus muscle. It may even be necessary, in order to reach the upper surface of tin- liver, to resect the u-nth, ninth, or eighth ribs. You may find on examination of the viscera that the liver lias been mmtused, and there Is evidently a hematoma formed beneath the cap- Kile. It is bettor not (<> disturb it unless the conditions seem to indicate continuation of oozing. There may be an open wound of any character or extent with great hemorrhage. One should attempt to catch up and ligate the bleeding points, employing a tine clip or artery forceps. The veins, as well as the arteries, will stand the strain of a ligature, hut may need to be dissected loose from the liver substance before the ligature can be applied. If the patient is not too weak, attempt repair by suture. It is a little difficult, but quite possible and certainly desirable. Employ a blunt-pointed needle and do not push it through boldly, but slowly, and as you push, gently oscillate the needle. In this manner, the point may slip by the vessels. Employ a large catgut suture, as a tine suture cuts through the soft tissue (Fig. 348). Van Buren Knott (Iowa Med. Journal, Oct., 1907) recommends inserting a strand of catgut parallel with the liver wound, tying the ends of the strand over small skeins of catgut to prevent tearing. Transverse interrupted sutures are then passed so as to include the parallel sutures first passed. Failing to suture, there is nothing left but the tamponade, and this, of course, is the only thing available in lacerated wounds. Wathen, of Louisville, even advises (Int. Jour. Surgery, July, 1906) that the average operator use the tampon from the first to save time and trouble. The gauze must be packed into the wound with firmness to prevent further hemorrhage, and its end brought to the external wound that it may be subsequently removed. Haynes, of New York (Annals of Surgery, July, 1907), describes a case illustrative of some of the difficulties of treatment and the sequela: of liver wounds. Patient, a man of twenty years, was brought to the Harlem Hospital 480 LAPAROTOMY FOR TRAUMATISM. with gunshot wound just below the tip of the ensiform cartilage. The bullet was found to have traversed the liver from before back- ward, and it was necessary to get at the wound of exit. From the median incision, a second incision was made transversely, dividing the right rectus and the seventh and sixth costal cartilages. The falciform ligament was also divided. With strong traction upon i^iji^w.^!..,^... .. ..' -.._' ' Fig. 348. — Suture of the liver. (Moynihan.) the costal arch, the posterior wound could be reached and felt but not seen, readily admitting two fingers. By the sense of touch, an iodoform wick was packed into this wound and a smaller one introduced into the anterior wound, and both brought out through the abdominal incision. This did not entirely SI ii K'i 01 w>i NDS "I Mil r\\< I'l IS. \Bl control the hemorrhage, and so the liver was forced u j > against the diaphragm and held by a large M ii ulicz tampon below the liver. The rectus was sutured. The peritoneum was repaired with the Falciform ligamenl included; the abdominal walls sutured above and below the gauze wicks. On the tenth day the tamponade was removed; and a few days later were removed the gauze wicks, for which rubber tubes were substituted, a discharge of bile and pus being present. At the end of the third week it became necessary to secure addi- tional drainage, and the ninth rib was resected in the axillary line, where, in the meantime, the bullet had been located; the costal and phrenic pleura were sutured, and the pleural cavity thus shut off. The diaphragm was opened, the pus drained out and a long tube passed from the anterior to the posterior abdominal wounds, and a smaller one left in the posterior wound. The progress of repair was slow but sure, five months elapsing before the cure was complete. It should be remarked that very rarely after gunshot wounds of the liver is there notable external hemorrhage. One must determine the degree of injury from the signs of internal hemorrhage and the evidences of peritoneal reaction which later develop. WOUNDS OF THE PANCREAS. Do not forget to examine the pancreas in wounds of the upper zone of the abdomen. Reach the pancreas from above the stomach, opening through the gastrodiepatic omentum. Carefully mop out the fluids, blood and pancreatic juice. Pack around the site with compresses and try to suture. Sometimes two or three deep sutures will coapt the wound surface and completely check the hemorrhage. If the tail is much crushed, resect it and suture the stump. Use gauze and tubal drainage. If the patient does not die, he may have a subphrenic abscess (Figs. 349, 350). WOIXDS OF THE SPLEEN. Any but the slightest wound of the spleen is universally and rapidly fatal from hemorrhage unless treated. One naturally thinks of sutur- LAPAROTOMY FOR TRAUMATISM. ing. If that and tamponade are not effective to stop the bleeding, it is indicated to try to remove the viscus. This is not difficult if there are no adhesions, though, if there are, failure is almost certain. Under such circumstances, as Moynihan suggests, the only thing left is to pack with gauze, soaked, if necessary, in adrenalin solution. Noetzel (Beitrage z. klin. Chirurg.) reviews his experience with six cases in which he removed the spleen for injury and concludes that splenectomy is the only safe way of securing hemostasis. Suturing and tamponing may arrest bleeding for a time, but there is danger that it will return. Fig. 349- Fig. 350. Figs. 349 and 350. — Method of suture of a wound in the pancreas. Two or three deep sutures of stout catgut or silk are passed, and the wound-surfaces drawn together. The wound-edges are then sutured with fine catgut sutures. (Moynihan.) Holliday, of Portsmouth, Virginia, reports a case illustrating the subject (Virginia Medical Semi-monthly Journal, January 11, 1907); patient, boy, age 15, was struck in left side by a flying pulley, fracturing his arm in several places and contusing the abdominal wall. His condition shortly became serious; temperature subnormal, absolute dullness on the left side, and marked rigidity. Immediate operation. The patient was almost eviscerated before the bleeding could be located, but which was finally found to proceed from the lacerated external surface of the spleen; a splenectomy was quickly done, and the abdomen closed without drainage. Convalescence was easy and uneventful. Splenectomy. — The operation following rupture generally finds the incision made in the middle line on account of the indications for hemorrhage. EXTRA-PI RITON] \l WOT M'S OF THE KIDNEY. 483 The spleen is broughl up into view and delivered from the abdom- inal cavity, avoiding any strain upon its pedicle, for the veins have extremely thin walls. Ligate and divide the pedicle. Transfix the pedicle with ;i -double ligature and tie each half separately, and finally tie the whole pedicle in a single ligature. The pedicle is next divided, the spleen removed, and its bed examined for any bleeding points. The under surface of the diaphragm is very likely to present some oozing. Fiske, of Brooklyn, describes a case which illustrates the variations in the procedure. (Annals of Surgery, Jan., 1908.) A man of twenty-five years was brought to the Kings County Hospital with a bullet wound in the left side corresponding to the spleen. The symptoms pointed to visceral injury and intra-abdominal hemorrhage. An incision was made over the outer border of the left rectus muscle from the costal arch to a point midway between the umbilicus and symphysis. The stomach and intestine were found to be uninjured. A perforation in the transverse meso-colon was re- paired, but the hemorrhage continued. A transverse incision was made and the spleen examined, revealing a rent which admitted two fingers. The spleen was pulled up into the wound, the pedicle clamped and ligated en masse. After removing the spleen, the vessels were ligated separately, the abdomen was flushed with saline solution, a small gauze drain left in contact with the stump, and the wound closed with through-and-through silkworm-gut sutures. The tem- perature subsequently did not rise above ioo°. The drain was permanently removed on the fifth day. The patient left the hospital at the end of the third week, entirely recovered. WOUNDS OF THE KIDNEY. If, while examining the viscera in the course of the laparotomy, you find a ruptured renal pelvis or a seriously lacerated kidney bleed- ing into the peritoneal cavity, remove the kidney. Make a longitu- dinal incision in its peritoneal covering, strip the organ out of its bed and, lifting toward the surface, free the pedicle. Ligate the ureter first and then, if possible, each of the vessels 484 LAPAROTOMY FOR TRAUMATISM. separately. If the oozing persists, leave a Miculicz drain or a rubber tube. Intra-peritoneal rupture without injury to other viscera is very rare. Extra-peritoneal wounds of the kidney do not, as a rule, require intervention. That the kidney has been involved will be suggested by pain, frequent micturition, and bloody urine. Rest in bed, morphia, and limited diet are the special indications. An abdominal binder may give relief. Eliot (American Journal Surgery, Nov., 1906) has observed twelve cases of subcutaneous rupture of the kidney. In seven cases there was not sufficient extravasation to make a perceptible tumor, and the diagnosis was made by the hematuria and the tenderness over the kidney and persistent rigidity for a number of days. In the remaining cases a well-defined tumor appeared in the ilio- costal space, becoming more sharply outlined as the rigidity dis- appeared. In five or six weeks, the tumor disappeared. In no instance was operation necessary. In such cases of extra-peritoneal rupture as require operation, the lumbar route should be chosen. Operation is indicated from the first if the violence was known to be great and a large tumor forms im- mediately. An operation is indicated at any time symptoms of sepsis appear. Morris Miller reports a case (Annals of Surgery, Feb., 1908) of a man who fell, striking his left side over the lower rib. He felt faint, and almost immediately passed a quart of blood by the urethra and later many clots. Miller saw him at the hospital an hour and a half later. There was no shock, but the side was rigid and tender, and an indistinct dull mass could be felt in the loin. An oblique lumbar incision revealed an extensive rupture of the kidney with much hemor- rhage. Wicks of gauze were placed in front and behind the kidney and the ruptured segments pressed together. The patient did well, the hemorrhage gradually ceased, though twice after the fifth day blood appeared in the urine. On the twelfth day the packing was all removed, and the opening finally healed. Gibbon, commenting on the case, remarks that hemorrhage severe enough to require operation REPAIR OP WOUNDS 01 CHI BLADDER. 485 noes not usually mean injur} sufficient to require nephrectomy. The question of nephrectomy must be decided when the kidnej is exposed. Stewart adds that the two early indications for operation arc a progressively increasing hematoma and constitutional symptoms Of hemorrhage. In several cases of moderate bleeding he had operated, and afterward been sorry he had interfered. WOUNDS OF THE BLADDER. Wounds of the Madder, if not previously suspected from the nature of the abdominal injuries, are inferred from the presence of urine in Fir,. 351. — Repair of ruptured bladder. Applying through and through sutures. Subse- quently Lembert sutures will he applied ami anally the parietal peritoneum will he repaired beginning at point of reflection onto the bladder. Peritoneum retained by forceps. ■ I the peritoneal cavity. Sometimes the rent is hard to locate. Inject the Madder with normal sail solution and observe its mode of entrance into the peritoneal cavity. 4 86- LAPAROTOMY FOR TRAUMATISM. The wound is to be repaired by two rows of sutures, the first, of catgut, involving all the coats except the mucosa; the second, of silk, includes the peritoneum alone after the manner of the Lembert suture. The stitches of both rows must be closely placed to seal the wound. The result may be tested by filling the bladder with normal salt solu- tion, and any defect repaired (Fig. 351). A catheter should be left in the bladder for drainage and the siphon- Fig. 352. — Van Hook's ureteral an- astomosis (Binnie.) Fig. 353. — Van Hook's ureteral anastomosis. (Binnie.) Fig. 354. — Anasto- mosis completed. (Binnie.) age kept up for two or three days. Subsequently, the bladder should be emptied by aseptic catheterization for a few days longer. The peritoneum should be drained for the first forty-eight hours. This mode of treatment applies to the intraperitoneal wounds of the bladder. The extraperitoneal wounds should be treated on the same principle, but often, under such circumstances, the operator must be content with suprapubic drainage of the bladder until the wound has healed. \\ VSTOMOSIS "I mi i RETER. l s 7 WOUNDS I »l THE URETER. If ii is discovered thai the ureter is wounded either by the trauma or in the course of the operation, an effort should be made at repair. Several methods are available. It" the injury does not amount to complete division, a few perforating sutures followed by Lembcrt sutures may succeed. Small wounds usually heal readily, but it is safer to use drainage. If the separation is complete, both ends of the torn ureter may be ligated, or the kidney may be removed, but naturally it is preferable, if possible, to establish an anastomosis. Under various circumstances, the proximal end may be anchored in the bladder or in the bowel, or the two ends may be brought together. Van Hook's termino-lateral anastomosis is generally applied. The technic may be briefly described in this wise: Ligate the distal portion one-quarter inch from the end and make a longitudinal slit double the diameter of the tube in length. Split the proximal end also for one-quarter inch, beginning at the free end. Pass the sutures. Employ a long catgut suture threaded on a needle at each end. One-eighth inch from the end of the proximal portion of the ureter, pass the two needles from without inward (Fig. 352). Carry the two needles through the split in the distal portion, into the lumen and let them emerge one-half inch below the end of the split (Fig. 353). Tighten the suture, which will have the effect of invaginating the upper segment in the lower (Fig. 354). Around the line of contact run a Lembert suture, and cover with omen turn or peritoneum. CHAPTER VIII. APPENDICITIS. APPENDICEAL ABSCESS. PURULENT PERITONITIS.* Inflammation of the appendix presupposes two factors, lowered resistance and a pathogenic germ. The lowered resistance of the appendicial tissue may find its origin in many diverse conditions involving its morphology, anatomy, and physiology. It is generally agreed that it is an organ undergoing a retrograde metamorphosis, or, at any rate, one adapting itself to new functions. There is a small facility for compensatory circulation if its main artery is blocked, and, in consequence, it is exposed to vicissitudes of nutrition. Owing to its varying position, it is brought into contact and may acquire connections, vascular and lymphatic, with other abdominal and pelvic organs and structures and, by this means, be the recipient of pathogenic bacteria that had not elsewhere found a favorable soil. The pathogenic organisms which, under favorable conditions, may here develop and produce various grades of destruction are the bacillus communis coli, the streptococci, staphylococci, and others less frequent. Whatever part of each of these causative agents may play in its devel- opment, the fact remains that appendicitis is one of the frequent and one of the most dangerous and treacherous diseases with which the general practitioner has to deal. Diagnosis. — The diagnosis is not difficult in the typical cases, but exceptionally may be extremely difficult, or even impossible, until the progress of the symptoms has been observed. A diagnosis should never be made from the mere presence of what *So important is this subject to the general practitioner, that he should be satis- fied to have and study no works Lss complete than the classic volumes of Deaver or Kelly. DIAGNOSIS "i M'l'i \i'l< Ml-. 489 L regarded as the cardinal symptoms; Dot until each symptom and ,j„ n has been weighed and accorded its proper significance, and all Eer possible conditions excluded, should it be decided definitely hat the case is or is not acute appendicitis. To discuss briefly the symptoms upon which one must rely: the kin in the milder catarrhal cases is limited usually to the right iliac fossa. In the ulcerative type, with sudden onset, or the perforate type, it is very likely at first to he general over the abdomen, hut after a lew hours, 'is rather definitely localized in the right side. In the gangrenous cases, it may be absent in one case or severe in another, depending upon the degree of active peritoneal inflammation. Rigidity of the right rectus abdominis and pelvic muscles is an important sign, and its degree is some index to the amount of peri- toneal involvement. Gastric disturbance, nausea, and vomiting are fairly constant occur- rences in the first stages of the attack, but last only a short time. T. B. Eastman (Ind. Med. Jour., Jan., 1907) has very strongly emphasized the frequent connection between the chronic forms of appendicitis and those appearances of gastric indigestion vaguely grouped as "stomach troubles." I Constipation is almost the rule, and Kelly adds further that it may amount to an actual obstruction. Only rarely does diarrhea appear with the attack, and if it does, may be regarded as indicating a grave form. Most rare of all is it for an attack even of the mildest type, to run its course without some aberration of bowel action. Tenderness on pressure is a symptom upon which alone the diagnosis is too often made. It is scarcely possible for it to be wholly absent, and yet it can by no means be relied upon to indicate the severity of the attack. Rosving (Central. Blatt. f. Chirurgie, October 26, 1907) states that pressure on the left McBurney point always elicits pain in appendicitis, but not in other cases. Robert Morris (Am. Jour. Surg., Jan. 25, 1908) adds something to this phase of the diagnosis. He claims that tenderness upon pressure over a point opposite the umbilicus in the line of the anterior superior spine of the ilium has a special significance and is due to involvement Of the lumbar ganglia. Thus Morris' point on the right side will be 49° APPENDICITIS. PURULENT PERITONITIS. tender in appendicitis. If that point on both sides is tender, the trouble is located in the pelvis. Tumor. — It is folly to wait for this sign to complete the diagnosis, for it means the certainty of a complicated pathology. It means peritoneal involvement with plastic exudates, or a pus formation, or both. Disturbance of Pulse and Temperature. — There is no other grave disease, perhaps, in which the pulse and temperature make such limited excursions. The temperature in the most serious cases may not reach 103 . Its elevation is in no wise significant. The pulse in the milder cases holds a certain ratio with the temperature. A temperature of 101 , for example, should be accompanied by a pulse rate of 90 to 100. Any marked disturbance of this ratio is extremely significant; whether it is a low temperature with a rapid pulse or a high temperature with a slow pulse, the outlook is ominous. H. O. Panzter, from extended clinical experience, insists that we must rely largely upon the rectal temperature in making a differential diagnosis, and that the temperature should be invariably taken by both mouth and rectum. The temperature by mouth in such cases may be very deceptive. Such, very briefly, are the principal symptoms and signs which, taken collectively, must serve to distinguish the disorder from accute intestinal obstruction, ovarian or tubal inflammation, cholecystitis, typhoid fever, pneumonia, and other acute diseases. There is not much danger at the present time, so prominently is the subject before the profession, that an appendicitis will be overlooked. Only too often is an innocent appendix held to be the cause of the illness in hand. Edmund Clark (personal communication) cites a number of instances, quite recently, where called to operate, he has found a lobar pneumonia and nothing more. Benneche (Med. Klin., Berlin, Feb. 14, 1909) emphasizes the danger in mistaking a lobar pneumonia for appendicitis, and states that pneumonia in the right upper lobe is most liable to give rise to appendicial symptoms. Such cases are likely to run an atypical course. It is an appendicitis, but what is its character? Is it mild or dangerous ? Is it a simple catarrhal trouble which will soon subside, VARU in s in \rn Mm 1 1 is. 49 J ar is it potentially ;i gangrenous pro< ess w ith general peritonitis ahead ? these are the questions which confound the doctor and upon their answer rest the prognosis and treatment. Four varieties are described. (i) Catarrhal appendicitis, in which the mucosa alone is involved, tlic predisposing causes arc easily relieved, and the pathogenic agent is of a low order of virility. Neither local nor constitutional symptoms are severe, and the attack very shortly subsides. (2) In the ulcerative type the process extends deeper and involves the muscular and perhaps the serous coat to some extent and there is produced a mild form of peritoneal inllammation. There is usually a diffused swelling of the whole appendix. (3) Perforative appendicitis, in which there is local destruction of all the coats and communication with the peritoneal cavity, is due to a sudden and virulent infection or an acute exacerbation of a slumber- ing process and begins abruptly with intense pain; and in a short time ends in peritoneal suppuration, local or general. (4) Gangrenous Appendicitis.- — This form beginning as such is the post treacherous, for often the symptoms are in no wise proportionate to the seriousness of the case. Death is impending, and yet neither the pain, pulse, nor temperature gives due warning. There is ab- solutely no way at this present time by which the doctor may recognize pis condition de >!<>:•<>. It may be imagined that such a condition arises from sudden interference with the blood current to the organ, while infection plays the lesser part. On the other hand, gangrene which ensues from virulent infection begins at once with the char- acteristic symptoms of appendicitis added to those of sepsis and peritonitis. It is from the point of view of these pathological variations that the most diverse opinions as to treatment have arisen. It is evident that nature, unaided, may be able to take care of the milder type. It is a clinical fact that nature by means of her own, may sometimes control and keep the inllammation within bounds, even in the more dangerous cases. By means of plastic- exudates, she walls off and limits the suppurating area and later provides a safe Beans of escape for the produi tS of Suppuration. But, unfortunately. 492 APPENDICITIS. PURULENT PERITONITIS. such a happy issue can never be depended upon. On the contrary, the suppuration is more likely to become diffuse and there presents the picture of purulent peritonitis and the imminent prospect of a fatality. In such a case one loses sight of the local symptoms. The abdomen is rigid, tympanitic and everywhere exceedingly tender. The temperature is high; the pulse rapid; the tongue coated, brown and fissured; and as the disease progresses, the symptoms of circulatory collapse appear. The temperature then becomes sub- normal, the pulse almost uncountable, and the features pinched and anxious, until finally a mild delirium with pleasant hallucinations ushers in the end. The infection may be so severe, the toxemia so profound, that the patient may die of septic peritonitis before pus has had time to form. Indeed, death may come from sepsis before the ordinary signs of in- flammation appear. Such may be the outcome of what appears to be the mildest case. It is this prospect and the attendant uncertainties which have led many doctors to regard appendicitis as an emergency to be operated upon as soon as the diagnosis is made. As Pfaff, of Indianapolis, puts it, the difference between the mortality of i per cent, in the very early operations, and that of 15 to 30 per cent, in the abscess stage, is so frightful that, in comparison, an occasional unnecessary operation is of no consequence at all. If we are to fulfill our obligations, we must act vigorously and to-day. This is undoubtedly a safe rule in the practice of the skilled operator, who has at his command all the facilities of the aseptic operating- room and trained assistants. The case is quite different with the general practitioner, remote from these accessories. Moreover, it is known that 80 to 85 per cent, of these cases recover without operation. Even for the relapsing form, Treves says that much may be done by medical means, diet, at- tention to the bowels, and by placing the patient under conditions more favorable to a state of peace within the abdomen. Whatever may be proper in hospital practice, it certainly cannot be imposed on the general practitioner that he operate at once. Even in connection with the skilled surgeon, it may be said that his technic I Kl \ I Ml \ I 01 M'l'l \l>l< II E. 10.} has not yet reached such a degree of perfection that an operation is always safer than the milder form <>i" appendii Itis unoperated. The doctor then will face his responsibility, a heavy one truly, mowing there is much t<> be accomplished by medical means and vet hoping thai he will have the judgment to recognize the failure of his art ami nature, and the will to resort not too late to more radical measures. Assume that the diagnosis is definitely made: assume that no sur- geon is within beck and call (for appendicitis is strictly a surgical disease), what will you do? It is evident at onee that this is a clinical hypothesis, and the question is to be resolved on a clinical basis. I. You see the case from the first. The attack begins mildly or with only moderate severity; there was perhaps a single attack of vomiting; the pain, abdominal tenderness and rigidity are not marked, and the patient's general condition is good. Under these circumstances, as Lejars says, it is perfectly legitimate to institute a medical treatment, in the meantime holding the case under the strictest surveillance. But this formula is null without the last provision. If the march of the disease cannot be watched, it is better to operate at onee. and this rule may as well be made to apply to any case in which delay might otherwise be counselled. You decide to try medical treatment, but in what form? Like many others herein involved, the question brings forth a varied response. Under these circumstances one may follow the plan of "immobili- zation." which Lejars and others so highly praise. But to be effective, it must be rigorously and consistently applied. Keep the patient absolutely quiet in bed. Give no purgatives — ami this means give neither calomel nor oil. Give no enemas. Sus- pend nourishment absolutely, relieving thirst by a few drops of water frequently given. Ice to the Abdomen. — Not a handful of ice in a little bag applied over the iliac fossa, but two or three large bags covering the whole abdomen below the umbilicus and refilled as the ice melts. Opium, in i >-grain doses in pill form every two hours for an adult; but it must not be pushed to the point of annulling all pain and sus- pending the functions of the kidney. 494 APPENDICITIS. PURULENT PERITONITIS. It is far from being the rule that the practitioner remote from the larger towns can have ice at his command. Likewise, opium in the hands of the inexperienced may be a two-edged tool. He must often, therefore, depend upon other modes of procedure, and for these, there is no lack of eminent authority. Under the circumstances in- dicated, begin with a single hypodermic of morphia if the pain is severe and with small doses of calomel (1/20-1/ 10 gr.) frequently repeated, until a grain or two is taken; follow at the end of three hours with a large dose of castor oil or larger doses of albolene until the bowels have moved freely. Give an immediate soapsuds enema. If the bowels are slow to move, supplement the internal remedies with enemas of normal salt solution. Give salol or carbonate of guaiacol every three hours. Apply hot fomentations to the abdomen, flannels wrung out of hot water and sprinkled with turpentine. Cover the hot flannels with several additional thicknesses and apply hot-water bottles filled with boiling water, and cover the whole to retain the heat. As the water cools, withdraw, one by one, the various layers so that the temperature may be maintained at the highest point of comfort. Hot kaolin cataplasms often render service. As Oschner commands, food must be withheld absolutely, and if there is much gastric disturbance or pain, the stomach should be washed out. Opium is contraindicated under this form of treatment, | for it is the purpose to cleanse the bowel. McGrath, of New York, probably expresses the prevailing opinion, summing the matter up in this wise (Medical Record, Feb. 1, 1908): "Only in the catarrhal cases can there be any question as to treat- ment once the diagnosis is made; whether it is better to operate without delay or seek to avail oneself of the advantage of an interval oper- ation. If sure of the character of the lesion, we may temporize; it will do no harm watching the patient carefully for any sign of danger. Many of these cases resolve without going on to suppuration or gan- grene, and therefore escape operation during the acute attack. Nature may be assisted in her efforts at spontaneous cure in these cases by en- joining complete rest, withholding all food and permitting only water to be taken, and by small repeated doses of calomel and sodium bicarbonate. An ice-bag may be applied over the region of the ap- TREATMENT OP APPENDICITIS. 495 ,)cnlit the sheath of the rectus and retrat 1 the edge of the rectus exposing the transversalis fascia. PlG. 357. Appendix and part of cecum delivered and walled oil with gauze. Divide the transversalis fascia, exposing the subperitoneal fat and pick up a fold of the peritoneum, and divide it, turning the cutting edge of the knife away from the abdomen (Fig. 356). Usually the ureal omentum will bulge into the wound after the peritoneal incision 5°o APPENDICITIS. PURULENT PERITONITIS. is enlarged. Replace the omentum and, if necessary, hold it with a gauze pad. Next introduce a finger and feel for the cecum, which will be rec- ognized by its bands, and pull it up into the wound until the base Fig. 3 5 8. — Peritoneal cuff turned back; appendix ligated and amputated. of the appendix can be seen. The appendix may be adherent, and the adhesions should be broken up very gently. Once the appendix is freed, it is to be brought up out of the wound and the cecum re- turned to the abdominal cavity and walled off with gauze pads (Fig- 357)- OP] R VTION li >R \ri'l Mi|« I \l \I;m I SS. 501 Tie off the meso appendix with catgut, and cut it away from the appendix close to its line of attachment. An incision Is now carried around the base of the appendix, dividing only the serous coat, which is stripped back toward the ce< urn, forming a peritonea] cuff (Fig. 358). The appendix is now ligated and 1 ut off, the mucous stump touched with carbolic arid and then with alcohol. J"he peritonea] cuff is drawn over the stump and sutured. The stump i^ now invaginated and buried with a row of Lembert sutures. The gauze pads are removed with the exception of one, which covers the cecum until the last stitches are placed in the peritoneum. Repair by separate lines of suture the peritoneum, transversalis, aponeurosis, and skin. Drainage is unnecessary. B. 'flic incision, four inches long, is a finger's breadth to the inside of the anterior superior iliac spine, with its middle corresponding to the spine (Fig. 359). / I ;9. — Appenilicial incision. (Veau.) Pig. 360. — The external oblique divided : the internal oblique exposed. (Vmw.) The first incision traverses the skin and superficial fascia, which are likely to lie very vascular in such a case. The external oblique appears, its fibers parallel with the incision. Divide it the whole length of the wound and catch the edges with forceps which will serve as retractors (Fig. 360). 5° 2 APPENDICITIS. PURULENT PERITONITIS. Next divide the internal oblique and transversalis muscles, whose fibers run transversely. The layer is thick, and several vessels will need to be caught (Fig. 361). Retract these layers and the transversalis fascia is exposed. This you divide, bringing into view the peritoneum. If you do not expect complications, make the primary incision shorter, and split each muscular layer in the direction of its fibers. Catch up a fold with the forceps, and divide its base with the scissors (Fig. 362). From the small orifice thus created, there flows a sero- Fig. 361. — The two oblique muscles incised, Fig. 362.— ^Showing the three muscular layers the transversalis exposed. (Veau.) and the peritoneum incised. (Veau.) or purulent fluid. Enlarge the peritoneal opening and hold back the intestine with compresses. Examine the cavity. It may be that the omentum, thickened and infiltrated, will cover the field, but do not dis- turb it. Follow with the index finger the wall of the fossa until the cecum is reached. Wiping out the cavity, you may be able to see the bands of the cecum, which are to be followed downward by sight and touch, for they lead to the appendix. Remove the appendix if possible. You may not be able to find it, but do not prolong the search and certainly do not break up adhesions in this search. OP] R VTION l OR M'l'l NDICIAL Ai;s< I SS. 503 Winn ii is Located, gently draw it to the surface. It is exceedingly friable and should nol be ruptured. Throw a catgul ligature about its base close up to the cecum and tie moderately tight (Fig. 363). Amputate the appendix, and if there is no bleeding cut the ligature short. Determine now the character <>f the suppuration, whether 1 ir cumscribed or diffuse t Fig. 36 | ). (a) It is Circumscribed. — Wipe out the cavity very carefully with sterile gauze. Do not irrigate. Place a drainage-tube upward toward the diaphragm (Fig. 365). Do not use violence. There a new col Fie.. 363. — Throwing a ligature around base of sloughing appendix. (Veau.) lection of pus may be found. Pass a second drainage-tube in the same manner down into the pelvic cavity. This is the most im- portant, for the fluids tend to collect there. Leave the third in the iliac fossa and (he fourth directed toward the middle of the abdomen. Sec ure each with a safety-pin. Suture up to the drainage-tubes, so that the opening will be only large enough to accommodate the tubes. If the patient is a female, after wiping out the cavity carefully, a counteropening may be made into the vagina in favorable cases, and with efficient drainage secured by that route, the abdomen may be completely closed. 5°4 APPENDICITIS. PURULENT PERITONITIS. In many cases even without such drainage, the abdomen may be closed after cleansing the cavity, but it cannot be advised in the emerg- ency work of general practice. (b) The Suppuration is Diffuse. — Hurriedly make an incision from the umbilicus downward for a couple of inches, which is sufficient. When the peritoneum is opened, the fingers can touch through the two openings. Fig. 364. — Diagram showing directions the pus may extend. B. Pelvic. C. Iliac. (Veau.) A. Sub-hepatic; If the pus seems to have reached into the left side, make a third incision over the left iliac fossa. Through these incisions irrigate the abdominal cavity with normal salt solution, using plenty, three of four quarts, and continue the irrigation until the fluid flows out clear. Unless it be complete, reaching every part of the cavity, irrigation had better be dispensed with. The additional incisions may even be unnecessary if the following treatment is pursued. SALINl I \i \i V FOR DIFFUSE SUPP1 R \ I l""-. 505 The patient is now put in the Fowler position and ,1 continuous rectal enema of normal salt solution arranged for. The purpose of this treatment, instituted by Murphy with such signal success, is to secure a constant saline lavage of the peritoneal cavity. In other words, the fluid passess from the bowel into the peritoneal cavity, accomplishes its healing mission, and drains out through the ab- dominal wound. The fluid should be maintained at a temperature of ioo° F., and should bi' allowed to flow into the rectum at the rate of one pint per ^1> "\ Fig. 365. — Placing a tube in the sub-hepatic space. (Vcau.) hour or thereabout. The patient's sensation should be consulted. If there is a feeling of tightness and distress, the flow should be lessened. After two or three quarts have been introduced, the flow should be shut off for an hour or two. The injections may be continued one to three days. Moynihan reviews his experiences with this treatment (Lancet, Aug. 17, 1907) and concludes that it has exceptional value. He insists upon attention to the details of administration and describes the methods found most useful. The largest quantity of the solution taken by any of his patients was sixteen pints for the first twenty- 506 APPENDICITIS. PURULENT PERITONITIS. four hours, and a total of twenty-nine pints in three days. He em- phasizes the character of improvement in the appearance of the patient, in his pulse and temperature, and in the action of kidneys and skin. The plan pursued by others aims to secure drainage by means of tubes passed in various directions into the intestinal mass and into the pelvic cavity. Under these circumstances, the enemas of normal salt solution should be used at intervals and the dressings changed on the second day. On the fifth day, the tubes should be removed, cleansed and replaced exactly as before. The patient must not strain while this change is being made and children may need to be given a few whiffs of chloroform. Cleanse the drainage-tubes every third day, gradually shortening them as granulation proceeds. If a new focus of infection forms, if the temperature reaches beyond ioi° in the evening for two or three evenings, no matter what it was in the morning, one may be sure of suppuration somewhere. It will be necessary to reoperate and reestablish drainage. Septic peritonitis, originating elsewhere than the appendix, ought to be similarly treated, but the results are so discouraging that the operation cannot be urged upon the general practitioner, however advisable it may be in hospital practice. The principle of treatment is the same. Make a median incision below the umbilicus and search for the cause. It may originate from a ruptured Fallopian tube, it may follow perforation of the stomach or duodenum, and the break must be located and repaired. It may follow the perforation of typhoid fever and for this condition, the operation will be done more and more as time goes by. The present status of this procedure is probably fairly stated in the Pennsylvania Medical Journal, Feb. i, 1908: Hayes, of Pittsburg, reports a series of thirty-eight cases with four- teen recoveries (36.8 per cent.). He operates under local anesthesia (cocaine 1/2 per cent.) and flushes the cavity with normal salt solution. He recommends that the perforated bowel be resected, regarding attempts at repair as futile. Mitchell, of Philadelphia, reporting on the experiences of the Pennsylvania Hospital, gives 23 per cent, of recoveries. He recom- OP] B \ I l"\ I OB l 1 I'll « > 1 1 > IM RPOB VI [ON. 507 mends opening through the outer border of the rectus muscle under ether anesthesia and with subsequent repair of the perforations. It too Dumerous, he advises packing off die injured portion oi the bowel from the general cavity by gauze compresses. Laplace remarks that usually the surgeon is not tailed until the patient is in full shock and a general peritonitis is already begun. He favors resection of the ulcer-bearing area of the ileum. Gerster, of New York, before the 1909 Congress at Budapest, sum- marizes the treatment of diffuse free progressive peritonitis thus: (1) Preliminary lavage of the stomach; (2) anesthesia by nitrous-oxid gas followed by ether; (3) rapid exposure of primary focus of infec- tion; ( () stoppage of viscera] leak by suture or tamponade; (5) gentle- ness and rapidity of procedure, avoidance of friction by wiping, etc.; (6) no irrigation; (7) soft rubber-tube drainage of right iliac fossa and, if necessary, of Douglas' pouch; (8) closure of external wound by three layers of suture; (9) for paralytic ileus repeated gastric lavage, low and high enemata, or systematic rectal lavage, enterotomy by stab done in intractable cases only; (10) rational administration of opiates; (11) withholding of all ingesta while vomiting is present; (1:) Murphy's proctoclysis; (13) Fowler's position; (14) early incision and drainage of secondary abscesses; (15) laxatives, calomel and salts, to be given only after cessation of vomiting; and (16) tampons used for walling off necrosed areas not to be disturbed without necessity till they become detached of themselves. CHAPTER IX. ACUTE INTESTINAL OBSTRUCTION. Acute occlusion of the intesinal canal is a condition always to be dreaded, for it begins suddenly and unexpectedly and, unless relieved, hurries to a fatal issue, due either to shock or sepsis. Perhaps, as Bloodgood says, the condition is not a frequent one, yet, none the less, it is an emergency whose character must be thoroughly understood. But for that matter its character is variable, depending upon the cause. To simplify the subject, the obstruction due to strangulated hernia is not considered here, for in such cases the cause of the obstruc- tion is quite obvious; nor need we consider postoperative ileus, for it has a pathology of its own; again the obstruction which may accompany appendicitis is in a class by itself. The acute obstruction to be studied includes those changes in the form or direction of the bowel or those accumulations within its lumen which completely and suddenly dam the fecal current. Whether it be a kink or twist in the gut; a volvulus or intussusception, an adhesive or constricting band, relict of a former peritonitis; an accumulation of gall-stones or a cancer: whatever the source of the obstruction, the danger arises, as has been said, from two sources — shock and sepsis. By far the lesser of these two evils is shock In many cases it may be absent, and even when it is the domi- nant feature early in the attack, it may gradually subside. The sympathetic plexuses seem able to regain their balance and adjust themselves to new conditions. For this reason attacks, which begin with collapse, often seem to improve in a short time. But such im- provement is deceptive, for sepsis pursues its insidious course, the bowel becomes more distended, its peritoneal coat more permeable, and so the intestinal bacteria find their way into the peritoneal cavity and their toxins into the blood. It is stercoremia, therefore, which is to be dreaded, for there is no way to measure its progress with any certainty. 508 DIAGNOSIS 01 \« i li OBS'l I'M l ion. 509 J. R. Eastman reports a case which illustrates the deceptive char- acter of many cases of obstrui tion. The patient had undergone, some lears before, three various abdominal operations. Tin- attack came on suddenly, and on the third day the vomiting became stercoraceous. In preparing for the operation, high enemas were given, followed by escape of flatus. The operation was deferred, as the patient continued apparently to improve, the bowels moving, gas escaping freely, and the patient feeling quite comfortable. Two days after, however, the fecal vomiting reappeared and with it all the ominous signs of ob- struction. At the operation, four inches of small intestine, adherent in an inflammatory mass, was found to be gangrenous. Resection, anastomosis, recovery. It is to be noted that the bowels had moved though the gut was strangulated and gangrenous, the gas and fecal matter undoubtedly passing the point of strangulation. | Indianapolis Medical Journal, July 15, 1909.) The group of symptoms constitutes a very definite clinical picture: (a) pain, (b) tympanites, (c) vomiting, (d) constipation, and (e) collapse. (a) The pain develops suddenly and severely, often following some violent exertion, and takes the form of paroxysmal colic. There is localized tenderness. (b) Tympanites is marked, the whole abdomen being distended, and often, on this account, the respiration and circulation are impaired. Peristalsis is exaggerated, and the violent movements of the bowel may often be noted through the abdominal wall. At the site of the greatest tenderness, a tumor may be found. (c) There is often at first a rumbling of the bowels and nausea, soon followed by an incessant and distressing vomiting, at first gastric and finally fecal. (d) Constipation is a constant feature, though at first there may be some movement from the lower bowel. In intussusception there is often all through the attack some discharge of bloody mucus and gas. This may be the case, too, in strangulation near the pylorus, but in such a case, the extreme distention of the stomach and the violence of its movements suggest the nature of the difficulty. (e) Collapse is imminent from the first, and is indicated by the 5IO ACUTE INTESTINAL OBSTRUCTION. weak, thready pulse, the rapid breathing, the pale, pinched features, and the anxious expression. These are the symptoms, whatever the form of the acute obstruc- tion, whether it be strangulation, intussusception, or volvulus, and very rarely can the form of the obstruction be definitely determined before the operation or postmortem. Certain factors make one of the conditions the most probable. If it is a child under ten years of age, it is almost certain to be intussus- ception; if there have been previous attacks of some form of peritonitis, strangulating bands of adhesion are likely to be present; if the patient is forty or fifty years of age, with a history of constipation, volvulus | suggests itself. In addition to noting the symptoms and history, a careful search must always be made by palpation for an abdominal tumor, and finally the investigation is terminated by rectal or vaginal examination. Treatment. — In the few hours that must elapse before one can fully make up his mind that it is a case of acute obstruction, there are certain things to do, but, more especially, certain things not to do. Do not give purgatives. This is an axiom scarcely necessary to re- peat. They can do no good and will most certainly do harm. Do not give large and repeated doses of morphine. It will help the patient to die easy, but in such a case, it is "not a remedy for the patient but a refuge for the doctor." It is doubtful even if it should be given at all. It is possible that minute doses may diminish the peris- talsis, quiet the vomiting to some extent, relieve the shock a little, and ease the pain measurably without masking the true conditions, but under the circumstances, it is an edged tool. Give no nourishment by mouth. The two measures likely to be of the greatest benefit are gastric lavage and rectal injections. The gastric lavage may in some measure diminish the vomiting; and, in case an anesthesia is necessary, it may prevent asphyxia from a gush of vomited matter. Rectal enemas are sometimes effective in relieving the obstruction, but if used, it must be with the strict proviso that the injection be done carefully. If roughly given, if the fluid is thrown into the bowel with too much force, even if there is no danger of rupturing the bowel, it TECHNK FOB RECTAL INJECTION. 511 at least irritates ii and defeats its own purpose. It is likely it" the con- dition has existed more than 2 1 hours the enemata will be of no avail. There is a definite modi- of procedure: put the patient crosswise in led iii the lithotomy position, with the pelvis turned slightly to the (ight side. Anoint the anal region well with vaseline, and also the rectal tube, which should be of soft rubber, three or four feet in length. In the case of an infant, a rubber catheter will serve. Guide the catheter with the left index finger, and as it enters the rectum direct it backward at first and then slightly to the left. Keep hold of the tube dose up to the rectum, the better to control it. Push the tube a little at a time, and if it meets with the obstruction, withdraw it slightly, and advance it with a boring movement. Any force may result in the tube merely coiling up in the rectum, in the meantime the doctor have- in^ the impression that it is ascending high in the bowel. Sometimes it is advantageous to let the injection How as soon as the first part of the tube is introduced, as by that means the rectum is dilated and Houston's valves are not so likely to intercept the tube. The tube must be introduced as high as possible without using force. In the great majority of cases it goes no higher than the sigmoid. Attach the fountain syringe, holding it low at first and gradually raising it to increase the pressure. It should not be raised much more than three feet above the patient's level. The quantity of fluid, either warm salt solution or oil, which may be injected, varies with the age, say one pint for the infant and four to six quarts for the adult. When the injection is completed, withdraw the tube rapidly, and lay the patient back in bed. The enema will be expelled sooner or later with severe colicky pains. If ineffective, it returns practically clear. If it has done good, it will be accompanied by flatus, and, at the last, there will be some hard lumps. The final evacuation may lot take place for some time, but the escape of gas is a good indication that the obstruction has been at least temporarily relieved. If this has not done good, the enema should be repeated with the patient in the knee-chest position. Lejars recommends the "electric bath" as efficacious in many cases, but this treatment is start civ applicable in general practice. Si 2 ACUTE INTESTINAL OBSTRUCTION. On the whole, the treatment is surgical; and the doctor must have it on his conscience that if the case is acute obstruction, delay is dan- gerous or even fatal. The point is to make the diagnosis quickly, and when that is made, there is only one thing to do, operate. The practitioner will hesitate between two procedures, median laparotomy and artificial anus. Median laparotomy is the ideal operation. It only is curative, for the cause of the obstruction is found and relieved; but it is delicate* and dangerous. These are the conditions which Veau formulates, under which alone the doctor must undertake it: (a) The operator must be experienced and resourceful, for it is often difficult to locate the cause and equally difficult to remove it, and the distended bowel is always a source of embarrassment. (b) The operation must be conducted fig. 3 66.— intussusception. w here there are the surgical accessories and capable assistants. (c) The diagnosis must have been perfected, so that the operator knows about what he will have to do. (d) The patient must be vigorous and able to stand a tedious and prolonged operation. These conditions are nearly always lacking when the doctor is thrown absolutely upon his own resources, so it may be laid down as a rule that the general practitioner must choose the second procedure. An artificial anus will usually save the patient's life and is within the skill of any doctor under almost any circumstance. After th patient has later regained his strength, the operation necessary tc complete a cure may be undertaken. It will not be an emergency operation, and the time and place may be chosen. To make a temporary artificial anus will be the proper procedure under the circumstances indicated. There is a single notable ex- ception: if the patient is a child with an undoubted attack of intussus- ception, and if the enemas have failed to give relief, it is imperative; to do a laparotomy (Fig. 366). I' ii ssi Si i PTION. 513 LAPAROTOMY FOR l\ II SSDSC1 PTION. A case reported by Estes (American Journal of Surgery, August, 1906) illustrates the subject and emphasizes the danger of expei tant treatment. A girl of three years in fair health, three days before had been seized with violent abdominal pains with straining and tenesmus. At first the passages were fecal and then mucous, tinged with blood. She had intervals of apparent ease when she would play with her toys and ask for something to eat. After three days' treatment by enemas and light laxatives, she developed signs of complete obstruction. The abdomen was distended, vomiting frequent and at last feculent; there- was persistent pain, rapid, weak pulse, and general weakness. At pis lime Estes was called and found a very pale, emaciated, weak, suffering baby, with pulse 130, and temperature 101 . She was vomiting every half-hour. No distinct tumor could be felt, but there was some thickening in the right iliac region. Through that night, while preparing for the operation next morning, she was given some krychnia and morphia and saline enemas, which produced an improvement. Operation — median incision. A hand passed into the right iliac fossae located the sausage-shaped tumor of an ileo-cecal intussuscep- tion. Turning the child to get the intestines out of the way, gentle milking motions were made and almost immediately the intussuscep- tion was reduced. Inspection showed a very much thickened and inflamed section of the ileum about six inches long. It was decided not to exsect the injured gut. The torn border of the mesentery was sutured, the peritoneal coat bathed with hot saline solution, dried, sprinkled with aristol and replaced, and the abdomen rapidly closed. The child made a rapid and uninterrupted recovery and has been quite well ever since. The principal steps in the operation are as follows: (1) Median laparotomy. Be careful in opening the peritoneum not to wound the distended bowel. Expect to find trouble in the management of the bowel. A skillful assistant is a great comfort in this matter. 33 5*4 ACUTE INTESTINAL OBSTRUCTION. (2) Search for the obstruction. The obstruction is usually easily- found in intussusception. After the abdomen is opened, proceed directly to the right iliac fossa, having no fear to introduce the whole hand, if gently done. In any case the cecum is first to be examined, for by its condition one can determine whether the obstruction is in the large or small intestine. The sausage-shaped tumor (in the case of intussusception) is pulled up into the wound and its topography carefully noted and its lt\ . \ \ \ Fig. 367. — Senn's method of performing taxis in reducing an invagination. integrity determined. If there are no adhesions, if there are no appearances of gangrene; in other words, if the accident is recent, try to reduce the bowel. (3) Disinvaginate, following the procedure of Senn, which has for its aim first to reduce the edema. This is to be accomplished by steady and uninterrupted manual compression of the tumor. As soon as the swelling is reduced, grasp the bowel below the tumor and press gently but firmly against the apex of the intussusceptum, at the same time making easy traction at the other end (Fig. 367). Re- member it is easy to tear the bowel or mesentery. RESECTION I l >\< INTUSS1 Si M'l tO! , 5IS Winn the bowel is reduced, examine again for gangrene. If ihcrc are points of disintegration, cover them in by Lembert sutures. li' the whole segment of the bowel is gangrenous, it must be reset ted; or it" doubtful, retained in the wound for further inspection. If the bow el is not impaired, wash and return; and the operal ion is 1 ompleted by the repair of the abdominal wall. If, as Scnn says, repealed attempts at reduction fail, one of two < ourses must be pursued: the establishment of an intestinal anastomosis or I'i<.. 368. — Intussusceptum exposed. (Gmbc.) I"ir.. 369. — Intussusceptum resected. (Guibe.) resection of the invaginated portion; but the latter, on account of the time required, must not be undertaken unless the invaginated parts are gangrenous. The anastomosis between the parts of the bowel above and below the invagination may be accomplished by suture or the Murphy button. The technic of resection of the invaginated portion is represented in Figures 368, 369, 370, and 371. A case reported by Edmund Clark, of Indianapolis, in a way typifies the condition and emphasizes the points which serve to distinguish intussusception from other forms of obstruction (Ind. Med. Jour., March, 1908). The patient, nine months old, previously well, began 5i6 ACUTE INTESTINAL OBSTRUCTION. to have fits of crying. In a few hours, it began to have frequent bowel movements which contained blood and mucus. A sausage-shaped tumor was discovered. On the second day the child was brought to Clark and its appearance was such as to suggest there was nothing serious the matter with it. But such appearances may be deceptive. An examination demonstrated the necessity for operation. By means of a median incision two and one-half inches long, the Fig. 370. — Anastomosis after resection. (Guibe.) Fig. 371. — Repair of the bowel and application of Lembert sutures over the site of anastomosis. (Guibe.) tumor in the- right iliac region was reached and delivered. Three feet of the ileum with its mesentery was found in the cecum. The mass was dark red. but not gangrenous. Though tightly constricted, it was disinvaginated without difficulty. The abdomen was closed without drainage; the whole operation lasted fifteen minutes. Re- covery was complete. The predisposing cause of such attacks is often acute indigestion. The pain, which is the first symptom, is often merely colicky at first, but later may be persistent. Vomiting is common but not nearly so severe as in other forms of obstruction, nor does it appear so early. s\ I1PT0MS "I POSTOPI K'A riVE ILEUS. 5"7 The temporary relief following the vomiting is characteristic of in- tussusception. The Dearer the duodenum the invagination is situated, the more severe the vomitus. Rigidity is not an early symptom. Distention is absent until late. Tenderness is also a late symptom ; indeed, in the early stages, pressure may give relief. The presence of a tumor is of great diagnostic value; it is usually movable, hard, and resistant. Its size gives no idea of the amount of bowel involved. Tenderness is a severe- and early symptom; thirst not marked. (lark says, regarding the indications for operation, that well- established lines of treatment, if simple and non-operative, die hard, so that medical treatment of such cases will only be given up after many more lives are sacrificed and many more cases successfully treated by laparotomy reported. POSTOPERATIVE ILEUS. The acute obstruction of the bowel which may — which too often does — follow laparotomy is one of the tragic accidents of surgery. An operation of comparative simplicity may terminate uneventfully; the patient rallies from the anesthetic, seems to feel well, and with the family is happy at the thought of danger passed. Twenty-four hours pass and it is noticed that the temperature falls to subnormal perhaps. and then begins slowly to rise. The pulse, at first 90 to 100 and of fair volume, slowly increases in rate while decreasing in force. The patient's mind, perfectly clear in the first instance, begins in a little while to be disturbed, and he grows anxious as to the outcome or per- haps calmly forecasts the end. In the meantime the tympanites has become marked, but no gas basses per rectum; and there is no sign of movement or peristalsis, in the distended gut. The pain is not severe, the chief distress is want of air; the patient complains that he cannot get a good breath; nausea develops, and finally continuous vomiting. If, now, the ordinary means of relief of gaseous distention fail and the symptoms do not in any re- spect improve, one may com hide that he has to deal with an intestinal paralysis. In simple tympanites the pain is colicky in its nature, there is little disturbance in pulse and temperature, the vomitus is more 518 ACUTE INTESTINAL OBSTRUCTION. nearly normal in character. But in spite of these distinguishing features, it may be impossible to say, during the first few hours, whether the obstruction is serious or not. In any event, certain measures should be employed: If there is much nausea or any evidence of gastric dilata- tion the stomach should be washed out and 1/20 grain calomel given every half-hour for at least ten doses. At the other end of the alimen- tary tube, the attempt at relief is begun with an ordinary soapsuds enema. If no flatus passes, a Watkin's enema is next to be tried, or one which consists of Magnesia sulphate, Glycerin, aa §ij Turpentine, 3j A large tube should be employed, but no effort made to introduce it high. Elevate the hips and inject the fluid slowly, and thus let it find its own way up the bowel. If gastric lavage and the persistent use of enemas fail to give any relief, if the judicious use of hypodermic in- jections of morphine and atropia, eserine, and strychnia are without effect to awaken the intestine or to sustain the patient's vitality, the only thing left which offers any hope is an enterostomy. This may be done under local anesthesia. The bowel through this opening is to be kept washed out with normal salt solution. By this means the toxemia may be kept under control until the patient's forces rally. But, after all, the chief treatment of postoperative intestinal paralysis is prophylactic and preventive. By washing out the stomach, by having the bowel well emptied with castor oil, by treating the exposed gut with scrupulous care, one may hope to reduce these accidents to the minimum. Slight traumatisms of the mesentery in the course of the operation, slight infections introduced in the clean cases are at the bottom of these surgical disasters. If they result from infections al- ready fixed upon the peritoneum before operation, the surgeon may have a balm for his conscience but no excuse to relax his precautions. In all operations in which there is a diffused peritonitis in order to prevent postoperative ileus, Heile injects 50 to 100 c.c. castor oil in a loop of the small intestine. The puncture of the gut is closed by a small silk suture. He claims excellent results. (Zeitblatt f. Chirurg., Leipsic, July 31, 1909.) CHAPTER X. ARTIFICIAL ANUS: TEMPORARY; PERMANENT. TEMPORARY ARTIFICIAL ANUS— ENTEROSTOM Y. An acute obstruction of the bowel may necessitate a temporary drainage through the abdominal wall. This will be the case when circumstances such as environment, lack of experience, assistance, or Equipment preclude a Laparotomy; or even when a laparotomy is done and it is found impossible at the time to remove the cause. F.nterostomy is therefore a life-saving operation which every practi- tioner must know how to perform. The operation proposes opening the abdomen, anchoring a loop of intestine in the abdominal wound and opening this loop to secure drainage. The incision will be made ordinarily in the right iliac fossa and the opening in the bowel made above the obstruction. For that matter, one need scarcely fear that he will open into the bowel below the constriction, for it is only the distended portion that will present. It is preferable to open the cecum, but if it is not available, whatever loop presents will do. No special instruments are required. It is a good idea to have several needles already threaded with silk No. o or No. i. Local anesthesia may suffice. Incision. — Begin by dividing the skin and fat along a line two fingers' breadth from the anterior superior iliac spine, parallel with the fibers of the external oblique — an incision about three inches long. whose central point corresponds to the anterior superior iliac spine ( Fig. 372). Catch up the two or three bleeding points. This first incision exposes the external oblique (Fig. 360) and the second divides that muscle in the same line. Catch up the edges of the divided muscle. In the same manner, the third incision divides the internal oblique and transversalis, and finally exposes a fibrous layer. 519 520 ARTIFICIAL ANUS: TEMPORARY; PERMANENT. the transversalis fascia, which is carefully divided in order to reach the peritoneum (Fig. 362). Pick up a fold of that membrane with the dis- secting forceps and incise it at its base, remembering that the distended bowel is in close contact (Fig. 356). A reddish fluid escapes as soon as the peritoneum is opened; seize each lip with forceps and enlarge the opening, but not to the full extent of the skin wound. Restrain the bulging gut with compresses. In- troduce the index finger and examine in various directions for a source Fig. 372. — Trace of incisions for artificial anus: on the right, temporary; on the left, permanent. (Veau.) Fig. 373. — Locating the cecum. (Veau.) of obstruction. Happily it may be found and relieved without loss of time. Usually, however, it will not be and one must not persist in his search or effort at relief. Attempt next to locate the cecum, pass- ing the index finger down into the iliac fossa, following the external wall (Fig. 373). If successful in locating it, pull it up into the wound with index finger and thumb and hold it with two artery forceps. It is easily identified by the appendices epiploicae and by its bands. If the ce- cum cannot be reached, employ any loop which presents. Anchor the bowel. The bowel is sutured to the abdominal wall MOD] ' II ANCHORING mi BOWEL. 521 in this manner: Commence al one angle, passing the needle through the parietal peritoneum of one side, through the serous and muscular PlG. ?74. — Attaching the bowel in the angle of the wound. {Veau.) Fie,. -575. — Attaching the bowel laterally. (Venn.) PlG. .<7<). Diagram showing disposition of suturs. ( 1 r «o«. 1 Pig. .W7- — Opening of the bowel with thermo- cautery. (Veau.) coats of the bowel, and through the peritoneum of the opposite side. Tic, hut do not cut the threads (Fig. 374). Now make on each side three or four " U " sutures one-half inch apart in this manner: the needle 522 ARTIFICIAL ANUS: TEMPORARY; PERMANENT. passes through the parietal peritoneum, the mucous and muscular | coats of the bowel, and out through the parietal peritoneum of the same side. Do the same on the opposite side (Fig. 375). Collect the loose ends of the sutures of the same kind in one forceps. In placing the sutures, do not let the protruding segment of bowel get folded or wrinkled. Suture the remaining angle in the same manner as the first and complete the repair of the peritoneal wound. The loop of bowel Fig. 378. — Temporary arti- ficial anus. (Veau.) Fig. 379. — Incisions for temporary and permanent artificial anus. (Veau.) may not occupy all of it and these peritoneal sutures are cut short at once. (The relative position of the sutures is represented in Fig. 376.) Now repair the superficial wound by interrupted sutures in two layers, one reuniting the muscles; the other, the skin. The opening left immediately over the anchored gut is about an inch in length. Cut the threads short. Open the bowel. This is reserved for the last, and here the long threads of the lateral bowel suture, left until this time, are used to pull the bowel well into view (Fig. 377). Incise it with the bistoury for about an inch, and there is an immediate escape of gas. Cut short all the sutures. The bowel will not immediately empty OPERATION FOR PERMANENT ARTIFICIAL ANUS. 523 ■self. It will require possibly twenty four hours, during which time the dressing should be changed every half-hour, after which time twi< i- daily is sufficient. Remove the cutaneous sutures on the sixth day, else later they will become septic. Apply ointments to the inflamed skin. When the bowel is once emptied, which may require as long as twenty-four hours, seek to locate the site of the obstruction and to de Fig. 380. — Opening the peritoneum. (Guide.) ermine its nature. See if an enema will find exit at the wound or if an injection at the wound will discharge per anum (Fig. 378). A month later when the patient has regained his strength, if the bowel has not become normal, send him to a specialist. PERMANENT ARTIFICIAL ANUS. This operation, palliative in the treatment of cancer of the rectum, pomes within the scope of every doctor. It may even be regarded as an emergency. There may come a time in the history of the case 5 2 4 ARTIFICIAL ANUS: TEMPORARY; PERMANENT. when the content of the bowel can no longer pass and the pain is un- bearable. Then the operation will give great relief. The patient! Fig. 381. — The sigmoid flexure drawn out through the incision. Note the appendices epiploic^. (Veau.) Fig. 382. — A forceps used to make an opening in the mesentery. (Veau.) suffers little pain after the operation, gains in weight, believes that he is going to get well, and so dies happy. [NCISIOIM KOK PKKMANKN1 ARTIFICIAL ANUS. 5 2 5 In this case, the opening is i<> be in the sigmoid; it may need to be large. The bowel is < ompletely divided transversely .ine lost ami a single anothesia will Serve both for the taxis and the operation. Chloroform is usually preferable to ether if il is e\|>e. led that taxis will succeed. It permits a greater relaxation. Technic of Taxis: Inguinal Hernia. — Elevate the hips, ilex and separate the thighs in order to relax the external ring. Grasp the tumor with the right hand (hernia on right side) so as to com- press it uniformly with the tips of the lingers and thumb. Seize the net k at the external ring between the thumb and forefinger of the left hand. While the right gently compresses the tumor, the left empties the gut by stripping in the direction of the external ring at first, and later along the inguinal canal. The sole aim of this first manoeuvre is to empty the gut. The manipulations must be made methodically, without interruption and without force. If compres- sion reveals the presence of a doughy mass, it is omentum, and as it probably occupies the lower part of the sac it will be better to com- press nearer the neck in order to deal more directly with the intestine. Sometimes, to make traction on the tumor while the fingers at the neck continue the kneading will start the bowel contents toward the abdominal cavity. If the tumor under these manipulations grows smaller and softer, it is some guarantee of success. When the bowel is sufficiently emptied, it then becomes reducible and its return to the abdominal cavity is announced by a gurgling or a marked sense of yielding. When the bowel is reduced, the omentum, if present, should be returned in the same manner. One should not persist if the mass is thick and adherent for there is risk of rupture of an omental vessel, which may be followed by hemorrhage, all the more grave because unperceived. After the hernia is reduced the patient must be put to bed and no food by mouth permitted for at least twenty-four hours. Before getting about, a truss must be fitted. If after ten or fifteen minutes of gentle effort the hernial tumor remains unchanged in size and hardness, it is a waste of time to prolong the procedure. It cannot be said too often that repeated at- 532 STRANGULATED HERNIA. tempts are injurious, becoming with each repetition more and more harmful and illusory. It may happen that after the hernia has been apparently reduced the symptoms of obstruction still persist, or even if at first relieved, appear again. The tympanites augments, the nausea and vomiting continue, and the signs of sepsis progress. It is evident that something is amiss. One of several things may have happened, but no time is to be wasted in conjecture, for only the operation which must follow will definitely clear up the doubt. Fig. 387. — Strangulated hernia reduced " en masse." (Moullin.) Fig. 388. — Incomplete reduc- tion of strangulated loop. Hernia in a diverticulum. (Moullin.) It may be that the hernial tumor has been reduced en masse. The hernial sac and its contents have been carried through the ex- ternal ring without having changed their relations and the constriction persists (Fig. 387). This can occur in recent hernia in which the sac is not adherent and is most common in the direct form of inguinal hernia. It may be that instead of entering the peritoneal cavity the herniated loop has entered a diverticulum of the sac near the neck and there becomes once more strangulated (Fig. 388). It may be that the neck of the sac has torn loose from the rest of the sac and has been reduced with the gut, the strangulation still being maintained (Fig. 389). OPERATION FOR STRANGULATED [NGUINA1 III KMA. 533 Again, a rent may be torn in the sa< and the gul escaping therefrom pushes up between the peritoneum and the abdominal wall (Fig. 300) • Finally the reduction may have been complete, bul the gut was gangrenous or ruptured and a general peritonitis follows, due to the escape of the intestinal contents; or the peritonitis may even be due to the infection from the septic fluids in the sac. Femoral and Umbilical Her- nia. — These forms of strangu- lated hernia require the same modes of procedure as the in- guinal but are likely to present more obstacles. In the case of femoral hernia, if complete, the pressure must be made down- ward toward the saphenous opening at first, and then up- ward along the femoral canal. In the case of umbilical hernia the pressure must be made toward the umbilical ring. Often the Trendelenburg posi- tion is helpful. The constant effort is first to empty the gut and then reduce it. In both these forms of hernia the gut may be enveloped by a mass of omentum which may not be reducible and thus gives rise to some doubt whether the gut has been reduced. Operation for Strangulated Hernia: Inguinal Hernia. — To re- peat, as soon as a hernia habitually reducible becomes painful and irreducible and is accompanied by the signs of beginning prostration, regard it as strangulated, and, aside from the exceptional cases in- dicated, operate at once. Do not wait for fecal vomiting for that is the last signal of exhausted nature — the precursor of death. Fig. 389. — Strangulated hernia reduced "en masse.' A. Upper end of the loop. B. Neck of the sac torn off and reduced with the bowel. C. Reduced loop still strangulated. D. Scrotal portion of sac. (Lejars.) 534 STRANGULATED HERNIA. General anesthesia is usually necessary, although in some cases of profound sepsis local anesthesia with cocaine or stovaine suffices, using Schleich's formula and injecting the various layers just before dividing. No special instruments are necessary. Surgical Anatomy. — The special points to be remembered are the situation of the abdominal rings, the relations of the external and internal oblique and transversalis muscles to the inguinal canal, and the location of the deep epigastric artery. The external ring in the aponeurosis of the external oblique lies just above the spine of the pubes. The internal ring in the trans- versalis fascia lies a half-inch above the middle of Poupart's ligament. The deep epigastric artery passing vertically between the two rings lies between the transversalis fascia and the peritoneum. The chief condition of operating well is to see and recognize what is to be divided. The coverings enumer- ated with such care by the text-books will not be distinguished, but there is little danger of cutting into the intes- tine, for before it can be reached the sac must be opened, and that is an- nounced by the escape of a character- istic sero-sanguinous fluid. The greatest injury to the bowel is at the site of constriction, which may be at the external ring, the internal ring, or the neck of the sac. The preparation of the field of operation must be painstaking. The pelvis must be shaved and scrubbed; the adjacent abdominal and inguinal regions and the scrotum must be thoroughly disinfected; and the penis after cleansing wrapped in a sterile compress. First Step. Incision. Exposure of the Sac. — Begin with a skin in- cision extending from the internal ring down to the spine of the pubes; if it is a scrotal hernia, down to the middle third of the scrotum (Fig. 391). Go directly through the skin and layers of fat to the aponeurosis Fig. 390. — Imperfect reduction by taxis. Hernia outside the ruptured sac. (Moullin.) EXPOSING THE SAC OF A STRANCULATKD IlKRMA. 535 of the external oblique, dividing the branches of the superficial epi- gastric artery. Expose the aponeurosis thoroughly and incise it from one ring to the other. It is easily recognized by the oblique direction of its fibers and its shiny look. The lips of this wound should be caught up with forceps, especially at the external ring, to serve later as a land- mark in beginning repair. Fig. 391. — Strangulated inguinal hernia; primary incision. Once the aponeurosis is opened the sac is exposed and the next effort is to isolate it preparatory to its incision. Separate it from the aponeurosis by careful blunt dissection around its whole circum- ference. Isolate the tumor up to the internal ring. If the sac is too intimately adherent to the aponeurosis it may be opened first. Second Step. Opening the Sac. — Catch a fold of the sac with dissect- ing forceps and cautiously divide the base of this fold with scissors or scalpel (Fig. 392). It may be one of the connective tissue coverings 536 STRANGULATED HERNIA. that is opened; divide it the full length of the wound and so proceed until finally the hernial sac itself is opened, which will be announced by a gush of bloody serum. Cautiously enlarge the opening till a finger can be introduced, and on it as a guide, split the sac close up to its neck (Fig. 393). When the constricting band is reached slip the finger under it, if possible, and divide it completely. If too tight for the finger, pass a grooved director as a guide. In some cases it may be better to use a herniotomy knife, but wherever possible avoid cut- ^^ t ^A> Fig. 392. — Opening the sac^of a strangulated hernia. As soon as the sac is opened a sero-sanguinous fluid escapes. (Guibe.) ting blindly. The constriction must be freely divided so that the intestine can be readily drawn down for inspection. This step is not complete till that is possible. It may happen that there is a second constricting band higher up; in such a case the forceps, which should always be attached to the lips of the incision in the sac, are useful in pulling it down so that what is to be divided can be seen. Third Step. Examination of the Intestine. — It is of the greatest im- portance that the site of the constriction be examined, for the chief lesions will be found there. Pull the gut down and observe the line of demarcation between the healthy and injured tissue (Fig. 394). TRl.ATUI \ I "I I III STH Wi.l I VII I' I OOP. 537 One of several conditions will be presenl and tlu- line of procedure will depend upon the one which is found. i. The intestine is sound; that is to say, it has a uniform, dark violet color, most marked at the site of the constriction where it is lustrous. There is no erosion of the serous covering. Douching Fn".. 393. ■ — Dividing the constricting fibers of the strangulated inguinal hernia. The 1 'arts should lie well exposed, (fiuibe.) the bowel with warm normal salt solution restores its tonicity, its rounded outline, and after a few minutes it assumes a redder color and is to be returned to the abdominal cavity. 2. The intestine is slightly injured; that is to say, there may be several small zones of erosion exposing the muscular or even the mucous layer. Bury these areas with a few Lembert sutures, repair any injuries to the mesentery, and reduce. If the intestinal loop is long. 538 STRANGULATED HERNIA. a methodical procedure may be required to prevent further injury to tissues already compromised. The posterior segment of the loop; should be reduced first, as it probably was the last to come down; in the meantime the anterior segment must be carefully supported. The least rudeness may result in a tear. 3. The intestine is doubtful; that is to say, it has a color mottled 1 Fig. 394. — Examination of the strangulated loop. (Veau.) and gray and purple. It does not recover its form under the douch- ing, but stays collapsed and flattened. Under these conditions it may not be possible to say whether it is gangrenous or not, but it should not be reduced. Treves, however, advises reduction under these circumstances, remarking (Operative Surgery, p. 534, Vol. II) that whatever theoret- ical objections to this procedure may exist, practice has shown that it may be safely carried out, assuming that this applies to a I ki \ I \n NT i»i QANGR] NOUS I OOP. 539 towel which is nol a< tually gangrenous, but in ;i condition whii h may be termed "doubtful." It is remarkable to whal extent these doubt ful intestines recover. The idea is that the peritoneal cavity is the most favorable site for re< overy. 1 1 tin.' operator is inexperienced and not certain that he can dis- tinguish between the bowel, possibly gangrenous, and that which has actually lust its viability, he must wait. Wrap the loop in moist gauze, and after tw elve hours examine again. It may be gangrenous or it may he viable, lustrous, reddened, rounded, and impels the belief that it will beeome normal. With that belief, reduce it slowly and carefully, breaking up the slight adhesions which have already formed. 4. The intestine is obviously gangrenous; that is to say, the serous coat has lost its luster, is blistered in spots, and can easily be stripped off with the lingers; its color is ashen or even black, sometimes mottled with white patches; there is a characteristic odor; the tissues are friable; and there may be perforations. In this case there is but one of two things to do: either anchor the gut in the wound and make an artificial anus, or resect the bowel. There can be no doubt that an enterectomy is the ideal procedure since it eliminates a source of danger and permits the radical cure of the hernia, but it is best not to undertake it unless skilled in intes- tinal suture (which for that matter every doctor should know thor- oughly how to do) for the time required may aggravate the shock and insure a fatality; but the first consideration is to save life. (See Enterectomy.) Allison, of Omaha (Jour. Minn. State Med. Assn., Jan., 1908), takes a different view: "We believe primary end-to-end anastomosis unjustifiable for, though we escape shock and peritonitis, there yet remains the danger of permanent obstruction due to circu- latory and septic changes, or a fatal paralysis due to distention and toxemia. Artificial anus offers the best way out. The two-stage operation is safer than the primary." If an artificial anus is considered safest, pull enough of the gut out to reach sound tissue. Pass a catgut suture through the abdominal wall — that is, through the aponeurosis and the parietal peritoneum — and then through the superficial coats of the bowel, then out through the abdominal wall again to make the letter "U." Employ four such 540 STRANGULATED HERNIA. sutures at the cardinal points. To the gangrenous loop apply a moist antiseptic dressing, changed hourly if the intestine was perforated. I If the intestine was not perforated, do not open it at once, but wait a few hours till adhesions form. It is then to be opened and the dressings must be frequently changed, for the discharge will be abundant. Later the fistula may gradually close of its own accord, more and more of the bowel contents passing by the rectum; or to cure the fistula a difficult operation may be necessary. (See Temporary Artificial Anus.) Fourth Step. Ligation and Amputation of the Sac. — In every case where the bowel may be returned to the peritoneal cavity, the treatment of the sac is of the greatest importance. After the intestine and omen- tum have been reduced proceed to dissect the sac, if this has not already been done, remembering that the structures of the cord may be very intimately connected with it and hard to separate. The separating of the cord from the sac is often facilitated by stripping with the finger wrapped with gauze. When the sac is completely isolated the neck is to be freed quite into the abdominal cavity, and then a finger is to be passed into the opening that any omental adhesions may be de- tected or any concealed hemorrhage. Next, the sac is to be twisted and then ligated, or simply ligated as high up as possible, and amputated. In freeing the neck at the internal ring the subperitoneal fat is usually seen; at this stage the bladder may be injured, and the point is that any fatty tissues at the inner side of the ring must not be in- cluded in the ligature, for this fat may conceal the bladder. In ligating the sac it is best to transfix it rather than use the circular ligature. If the sac has been split so high that the neck cannot be defined, then the upper end of the peritoneal wound should be repaired with a few stitches so as to reconstruct the neck and then ligate. Fifth Step. — This will depend upon the condition of the patient. If his condition is serious, it is sufficient rapidly to reunite the aponeuro- sis and repair the skin incision. If a little more time may be used, proceed to do the radical cure. Unless this is done recurrence is al- most certain, but the operator cannot be held responsible for that. In the urgent cases it is sufficient to have saved a life. M ii R iki \r\ii m I RNIOTOMY. 54 ■ Whether the radica] operation is attempted or not, employ drainage. rhe dressing must be carefully applied. Subsequent Treatment.— The patient must have no food for 24 hours. It m ay be oe< essary to employ salt salution freely. A Uttle ice may be ten to quench the thirst. At the end of 24 hours begin with small Lantities of milk. Change the dressings the second day or sooner .1 nuu h soiled. Remove the drain on the fifth. On the third or fourth E y give a laxative. Remove the sutures on the eighth or ninth. Peritonitis may supervene if the gangrenous areas have not been properly treated. POSSIBLE COMPLICATIONS IN THE OPERATION. In the operation just described, the ordinary difficulties are indicated. But there are others, rarer, which may arise to disconcert the casual operator not forewarned. The actual operation is always easier if one has in mind all the possibilities. There may be unexpected ad- hesions; there may be anomalies with respect to the sac or its con- tents, or there may be unsuspected conditions produced by attempts at taxis. Adhesions must be anticipated when the hernia is large and has been for a long time irreducible, and under these circumstances special precautions must be taken not to wound the bowel in opening the sac. The adhesions if recent and soft may be broken up with the finger or grooved director keeping in close contact with the sac so as to avoid the bowel. If the adhesions are old and the union between the bowel or omen- tum with the sac firm and fibrous, it will be necessary to divide them with scalpel or scissors, but this is a .procedure requiring patience and a delicate touch. If necessary, long, band-like adhesions may be divided between forceps and subsequently ligated. If, following the decortication, the raw surfaces ooze to any serious extent, apply hot, moist compresses for a moment, and either this will check the bleeding or at least reveal the site of the larger vessels to be caught up with forceps. Usually a few applications of the hot compresses will entirely suppress the oozing, or to a degree at least which will not contraindicate reduction, for when the bowel is do 542 STRANGULATED HERNIA. longer bent and the circulation no longer interfered with the oozing will cease. But it is chiefly injury to the bowel which is to be feared, not soj much because the rent may be difficult to repair as that some of the' septic contents of the bowel may escape. If the adhesions cannot be broken up the only thing left is to remove the source of the strangulation and leave the bowel outside. Occa- sionally it will be found that the source of strangulation is in some of the adhesions rather than the rings, or the neck of the sac; or, again, so much scar tissue in the bowel wall leaves it inert and paralyzed. All these difficulties are more likely to occur in the neglected cases. A hernia of the cecum or sigmoid may present difficulties depend- ing upon adhesions. It must be remembered that these two portions of the large intestine are not completely invested by peritoneum ; and, in consequence, it may come to pass that when they slide down through the inguinal canal a point is reached where a part of the bowel is out- side the hernial sac, and this surface acquires adhesions to the scrota] tissues. In such cases these adhesions cannot be divided for fear' of wounding important branches of the mesenteric arteries, so that to effect reduction a special procedure must be employed. In the first place, when, on opening the hernial sac, these parts of the large bowel are recognized, the neck of the hernia must be freely incised and the abdominal walls as well. In fact, one does what Lejars calls a hernio-laparotomy . Next the hernial sac is separated from the spermatic cord and then an effort is made to reduce the hernia en masse, returning, if possible, the bowel and the peritoneal prolongation at the same time. It will be a slow and tedious process. It is greatly aided by the Tren- delenburg position. If the attempt fails, an artificial anus is the last resort. Among the anomalies of the sac which may bother the operator are diverticula and double compartments. One may open into what appears to be the hernial sac and find it empty. In encysted hernia the processus vaginalis may be filled with fluid which surrounds the true hernial sac. A little study of the conditions will lead one to go ahead and find and open the true hernial sac. I I'l \ I Ml \ I m \ III K\l \ I 1 !> Ill U'l'l R. The hernial sac may push in between the peritoneum and the muscular layers, bulging toward the iliac fossa or the bladder. This is thf pro peritoneal hernia, and when ii becomes strangulated it is not likely a diagnosis will be made. Yet the presence of B tumor in the inguinal region and the signs of intestinal obstruction will demand an operation and again a hernio laparotomy is indicated. The site of strangulation is located and the bowel treated as in the ordinary form of strangulated hernia. In the interstitial form of hernia great difficulties may arise. The incision is likely to he quite different from the ordinary since it follows the long axis of the tumor. Once die hernial sac is exposed it must be freed from its adhesions to the muscles. The neck of the sac corresponds to the internal ring, and if that is the site of constriction it must he divided by cutting outward. The deep epigastric artery lies to the inner side. After the bowel is reduced and the sac ligated, the break in the abdominal wall must be sutured, repairing the opening in each layer separately. The contents of the hernial sac may be abnormal. At some time or other each of the abdominal organs except the pancreas have been found herniated. It is the bladder which most often gives rise to trouble. It may be in the sac and appear as a second "sac" when the hernial sac is opened. It presents as a rounded, reddish tumor, perhaps as large as a hen's egg. Such a tumor should never be opened on sus- picion, but a careful effort must be made to locate its limits by blunt dis- section. The fact that it leads down to, and behind, the pubes clears up any doubt. It is to be reduced in the same manner as the intestine. In other instances it is without the sac, lying to the inner side of its neck and is perhaps intimately connected thereto. It may be mistaken for a thickened portion of the sac or an adherent mass of fatty tissue. If it is opened into, the escape of urine and the evidence to the e\ ■mining finger of a large mucus lined cavity reveals the nature of the accident and imposes immediate repair. A large hernia, easily reducible, or one whose size diminishes, follow- ing urination or the use of the catheter suggests hernia of the bladder; 544 STRANGULATED HERNIA. but, unfortunately, these signs are not available in strangulation. In every herniotomy the danger of wounding the bladder must be kept in mind. Another point Lejars makes: One may expose a thin-walled trans- parent cyst at the inner side of the neck of the sac, and unwittingly open it only to find oneself working into the bladder. This trans- parent cyst, in nowise resembling the bladder, is due to a hernia of the mucosa of the bladder between the fibers of the muscularis. Following the separation of the bladder from the hernial sac the urine may be bloody for a day or two. This hematuria is of little moment and soon clears up. If the bladder is wounded its repair must precede everything else. As soon as the injury is discovered, pack around the site with sterile gauze, catch the edges of the wound with small forceps and suture, uniting the mucosa first with a continuous cat-gut suture, and the muscular coat with interrupted sutures, accurately applied; a third line connects the superficial tissues. The appendix may be found in the hernial sac, either inflamed or normal. If the latter, it is to be removed in the ordinary way unless time presses, in which case one must be satisfied with reducing it. If the symptoms of strangulation arise in consequence of an in- flamed and herniated appendix, they may differ somewhat from those ordinarily observed. There will be the same tendency to collapse, the vomiting, the tympanites; but constipation may not be complete, and the hernial tumor, in addition to being swollen and painful, may be reddened and edematous. No one should think of taxis under these circumstances: an im- mediate operation is indicated. Regarding these grave cases, Kelly says (Vermiform Appendix and its Diseases, p. 793) where there is suppuration in the sac it must be drained, and here as well as in the cases where there is gangrene in the appendix, resulting from strangu- lation, the utmost care must be observed in handling the diseased tissues in order to avoid inoculating the peritoneal cavity. If the dis- eased portion is found to extend up into the peritoneal cavity, the operator must at all hazards discover the upper limits of the infection and resect the bowel in its healthy portion. iki \i\ii \i 01 \ in RNIAT1 D APPENDIX. 545 Moreover, he must « 1 « > this with the hast possible manipulation ami tra< t it * r i upon the parts, preferably by enlarging the abdominal Opening in the direction of the inguinal canal while protecting the healths- regions and keeping the disease well isolated by abundant jgauze compresses. When infection extends still further up into the abdomen an even wider incision must be made, if necessary, in the form of an inverted ,|, in order to provide abundant drainage after removal of the disease. In such cases the cure of the hernia becomes a matter of secondary con- sideration to he taken up after recovery. McEwen (London Lancet, June 16, 1906) reports a case in which the patient, a man of 62, presented himself for an operation for strangu- lated hernia. Two weeks previously his hernia (of 12 years' standing) had begun to give him pain, which had gradually increased. A large pyriform tumor occupied the right inguinal region and the scrotum, which was much inflamed. The mass was dull on per- cussion, there was no impulse on coughing, and it was irreducible. On opening the sac the hernia was found to consist of the appendix, held in position by a pin protruding through its wall. There was no abscess formation, yet it was not deemed advisable after removal of the appendix to proceed with the radical cure. Regarding these unusual conditions, Lejars remarks that in be- ginning an operation for strangulated hernia we should expect every- thing and be surprised at nothing; laying aside for the moment all theoretical discussions and applying ourselves to the chief indication, not deeming our work complete until the bowel is properly reduced and lost to view in the abdominal cavity. Oliver, of Indianapolis (Ind. Med. Jour., March, 1908), reports a case in which the hernia had grown to remarkable proportions extend- ing as low as the knee. The mass had long been irreducible. The patient was a butcher of about 50 years of age. Following a heavy meal of "pigs' feet" and a lift, his hernia suddenly became painful and he experienced the sensation of something giving way; symptoms of strangulation in mild form gradually developed; taxis being out of the question, immediate operation was practised. On opening the hernial sac it developed that its content was the stomach in its entirety, 35 546 STRANGULATED HERNIA. but no gut was present. With great difficulty it was reduced. The pa- tient's condition did not permit of any further manipulation, and shortly afterward he succumbed. Oliver expresses the opinion that the stomach had been forced down into the sac by the strain, replacing the gut. Femoral Hernia.— Operation is even more urgent in the case of strangulated femoral hernia than in strangulated inguinal hernia. Gangrene is likely to develop earlier, and taxis is all the more ineffectual by reason of the anatomical arrangement. Especially must one be on his guard in the case of small hernia, for then the femoral ring is small and unyielding. It is essential to have the anatomy in mind to understand this and especially to operate without embarrassment. Surgical Anatomy. — Poupart's ligament stretches across the front of the pelvic region from the anterior superior spine of the ilium to the spine of the os pubis. The space between this band and the ramus of the pubis is occupied by several structures — from without inward, the iliacus and psoas muscles on their way to the lesser trochanter, the crural nerve, the femoral artery and vein, the femoral canal, and Gim- bernat's ligament. Gimbernat's ligament is a firm triangular fascia with its base directed outward and abutting the femoral canal. The femoral sheath, a prolongation of the iliac fascia, encloses the femoral vessels. In the thigh it fits closely about the vessels. In the groin the sheath is more capacious so that there is a space left between its inner wall and the femoral vein. This space constitutes the femoral canal. The femoral canal is, therefore, conical in shape with its base above and its apex below where the sheath gets in contact with the femoral vein. The circumference of the base constitutes the femoral ring which is bounded internally by the base of Gimbernat's ligament; above, by Poupart's ligament; below, by the ramus of the pubes; externally, by the femoral vein. The narrow orifice bounded by these structures is the usual site of strangulation of a hernia de- scending along this slender channel. It is Gimbernat's ligament whose sharp edge is most likely to shut off the circulation of a loop of intestine bulging past it and which is most likely to cut into or bruise the bowel in efforts at taxis (Fig. 395). OPERATION FOR STRANGULATED HUM'U III KM. \. 5 17 In other cases the hernia descending lower finds the direction id" least resistance toward the surface and bulges out through the saphenous opening and the < ribriform fascia. Operation, [f the operation is done early before complications, Pig. 395. Relations i i the neck of a femoral hernia under Poupart's ligament. {Moullin.) such as gangrene, have arisen, the operation for strangulated femoral hernia is simple and without special danger. Begin by disinfecting the whole held; the inner surface of the thigh, the groin, the abdomen, the genitals. The incision may be vertical, following the axis of the tumor, or 548 STRANGULATED HERNIA. oblique, below and parallel to Poupart's ligament; Lejars prefers the latter, claiming that it gives freer access to the femoral ring, facilitates the dissection of the sac and the procedures in the radical cure. The vertical incision is probably better for large and lobulated hernia which extend well below Poupart's ligament. But whatever, incision is employed must be of ample length. The incision traverses the skin, and then a fatty layer through which ramify a number of veins tributary to the long saphenous. Having divided this layer, the sac is exposed; or, at least, the fatty en- velope in which so often it is enclosed — a collection of fat which at times amounts to a veritable lipoma. The hernial sac lies immediately be- neath this fat — sometimes in thin subjects immediately beneath the. skin — and presents itself in divers aspects. Usually it looks like a tense and reddish cyst; often it is lobulated. Second Step. — Isolate the sac. Proceed to separate it from the ad- jacent tissues by blunt dissection, peeling it out with the fingers and disengaging it quite up to the neck. It is essential for the later steps of the operation that this be thoroughly done and is complete when Poupart's and Gimbernat's ligaments are well in view. This dissection of the sac takes less time than one might expect and is greatly facilitated if one is able to find a line of cleavage be tween the tissues. Sometimes bursa? intervene between the sac and adjacent tissues and favor a rapid separation. Third Step. — Open the sac; examine the contents. Once the hernia] tumor is well exposed up to the constricting ring, cautiously incise the sac. Caution is required because often it is difficult to know when one has penetrated the sac and an adherent intestine may be wounded. In this form of hernia the true sac may be covered by! I a cyst, which may be filled by bloody serum and thus simulate the appearances of the hernial sac. A moment's examination, however, shows that it is a small closed cavity without communication with the! abdomen. The layers are to be cautiously divided one by one unti. the sac is opened into and the opening enlarged. Catch up the lips of the wound of the sac and examine its contents Usually, in this form of strangulated hernia, one will see a small loop of intestine, darkened, tense, and tightly constricted. Occasional!) STRANG1 LATED I \ir.n [CA1 Hi RNIA. S \<> llong with the omentum there may be several loops of small intestine, or he < e< win, or the sigmoid flexure, [rrigate the < avity and its i ontents ,viih normal salt solution and prepare to relieve the constriction. Fourth Step- Relieve the constriction. The first effort should be to relieve the strangulation by stretching the offending fibers, t<> this aid introducing a finger, if possible, into the ring along the innci side >f the hernia. ( Oftentimes the pressure thus exerted will, with a little effort, streti h innc may dare take. When the condition of the patient im poses great baste ii must suffice to pass interrupted sutures through the whole thi< kness of the belly wall and draw the edges of the wound Ph -Umbilical hernia; repair of abdominal wall. {Mayo.) together SO that the peritoneal edges point out and the two serous surfaces are thus brought into contact. Before the last suture is tied the compress is removed; and finally a continuous suture will com- plete the reunion. 554 STRANGULATED HERNIA. If more time is available, after the sac is trimmed its edges are sutured as after a laparotomy. The sheaths of the recti muscles are opened up and the inner border of each muscle exposed. The two sides are then brought in contact and three tiers of sutures applied; one uniting the deep layer to its fellow of the opposite side; the second uniting the two muscles; the third uniting the two superficial layers of the sheath. Finally the excess of subcutaneous fat is trimmed away and the skin sutured. The usual dressing is used, held in place by a wide binder, and the after-treatment, already indicated, is instituted. Figs. 396 and 397 show the manner in which Mayo perfects the radical cure. Obturator Hernia. — A strangulated obturator hernia is rare, yet it is to be thought of and ruled out before opening the abdomen for in- testinal obstruction. Several points help to locate the trouble even when no marked tumor is present. The presence of pain over the region of the obturator foramen directs the attention to that point, and pressure made there projects a pain down the inner side of the thigh to the knee, along the course of the obturator nerve. In the female vaginal examination will reveal the tumor. In this form of strangulated hernia, taxis is useless and likely to be very harmful, and therefore must never be employed. A herniotomy must be done without delay, though in these cases it is a procedure by no means simple. Several anatomical points must be borne in mind. The hernia usually comes out through the upper part of the obturator membrane and is covered over by the pectineus muscle. It may work into the pectineus or it may lie on a lower level, working into the obturator externus. The pectineus is usually the chief guide to the hernia. The obturator vessels and nerve are usually found behind and to the outer side of the neck of the hernia, though one cannot count on that. The femoral vessels lie to the outer side. It is the obturator membrane which constitutes the constricting ring. The operation, chiefly as described by Treves, is as follows: The pelvis is elevated, the thigh flexed and adducted, the femoral artery located, and about a finger's breadth internal an incision is made from STRANG! I Ml D 0BT1 RATOH III KM A. 555 the spine of tin* pubes downward for three or f<>ur inches, [ncise the skin, the subcutaneous fal and the fascia lata, and expose the addut tor longus. Catch up the deep external pudic artery. Retract the adductor brevis and beneath thi> is the pectineus whose fibers are separated by blunt dissection; or, if necessary, divided in order to expose the sac 1 I' i.L,'. 308). PlG. .;'<*. — Obturator hernia. A. Hernial sac-obturator artery. B. Pectineus. C. Adductor longus. (Lejars.) \\ hen the sac is once in view, free it completely up to the neck. The obturator membrane is now to be nicked, observing first the course of the arteries. It is better, however, to open the sac at once, cleanse the contents, and endeavor to insinuate the finger alongside the bowel and stretch the Strangulating fibers; failing in this, to divide them, keeping in mind the possibility of a hemorrhage. If, in spite oi 556 STRANGULATED HERNIA. precaution, this occurs, tampon firmly against the obturator mem- brane, and when the tampons are removed one by one, the bleeding points may be recognized and clamped. Finally the intestine, if sound, is reduced, the sac dissected and ligated high up, and the ex- ternal wound sutured. Lejars remarks that one may find in the sac of a strangulated obturator hernia not only bowel and omentum, but also the tubes and ovaries, the bladder and the appendix; and that it is well to be fore- warned of these possibilities, which may greatly complicate an opera- tion at best never simple. Of strangulation of other forms of hernia— sciatic, lumbar, perineal, vaginal — it need only be said that they are too rare to be with profit considered here. CHAPTER XII. RADICAL CURE OF INGUINAL HERNIA. (JO PO T Ft p The radical cure of hernia may be attempted at the operation for strangulated hernia under the conditions defined. Hut aside from those emergency cases there arc others in which the family doctor will feel it his duty to recommend and to do the operation, ilis results will be excellent if he wisely chooses cases not beyond his skill. As Veau says, he should select only such as arc small, reducible, congenital. The large hernias are difficult to handle and recurrence will be almost certain. The irreducible hernias may have acquired ad- hesions that can scarcely be broken up without severe injury to the gut. With respect to age, the ideal case is a young man fifteen to twenty- five years old, who has well-developed ab- dominal walls, a well-defined external abdom- inal ring, and a hernia easily controlled by a truss. Under these favorable conditions, the hernia rarely recurs; but almost certainly it will recur if suppuration follows the operation, and there- fore absolute asepsis is the sine qua non of success. Surgical Anatomy. — The hernia, then, which the general practitioner should under- take to operate on is an external or oblique, which escapes from the abdominal cavity through the internal ring to the outside of the deep epigastric artery and follows the inguinal canal down to the externa] ring (Fig. 399). Beneath the skin will be found only a few insignificant vessels. The aponeurosis of the external oblique is easily distinguished. Strong ami resistant, and its fibers bounding the external ring are 557 Fig. 399. — Transverse vertical section of the in- guinal canal showing rela- tion of the hernial sac. GO, external oblique; PO, internal oblique; T, trans- versalis; Ft, transversals fascia; /', [uritoneum; TC, conjoined tendon ; I cremaster; . d, vas deferens in contact with the hernial sac represented in black. (\\-a:>.) 558 RADICAL CURE OF INGUINAL HERNIA. thickened to form the "pillars" of the ring. Behind it lies the cord, which includes the vas deferens and its accompanying vessels and nerves, all surrounded by a common sheath derived from the trans- versalis fascia, and in this case, it contains also the hernial sac. To reach the sac, the sheath must be divided and the elements of the cord separated from the sac. In the case of congenital inguinal hernia, the sac is very thin and, in spite of precautions, it is sometimes torn 01 one even fails to find it. Fig. 400. — The primary incision for hernia. (Veau.) The chief difficulty of the operation centers around the recognition and dissection of the sac. The posterior wall of the inguinal canal is formed by the conjoined tendon, the transversalis fascia, and the peritoneum. The purpose of the operation is to reconstruct the posterior wall and restore the obliquity of the canal, and the "Bassini" operation is the type the inexperienced operator can best imitate. Operation. — Prepare the field most scrupulously — abdomen, thigh, and scrotum. Employ general anesthesia, as a rule, although local and spinal anesthesia are available. |\i IM<>\ FOR IM.l l\ \l. Ill KM \. Begin bj locating the external ring, which is to l>c the first point of attai k. '/'/.'<• incision will extend from this orifice to a poinl just over the in lernaJ ring, which lies one-half inch above the middle of Poupart's liga- ment. The incision, then, beginning above (on the right) (Fig. 400), extends downward and forward to the spine of the pubes, where it bends a little to become more vertical and ends in the l>asc of the PlG. 401. — The external oblique exposed aivl the external ring developed. {Veau.) scrotum. However large the hernia may he, one need not extend the incision further, so lax and distensible are the scrotal tissues. Having divided the skin and subcutaneous tissues, catch up and Kate the small vessels. Next divide the fatty tissues layers by layer down to the aponeurosis of the external oblique, which lies deeper than one may expect. Now, with the grooved dire, tor, completely expose the pillars of the ring. Do not neglect this as it is a most important step in the oper- ation. The inner pillar is easily found, but the outer pillar is covered by the cord and a little patience is required to get it well exposed. 56o RADICAL CURE OF INGUINAL HERNIA. Catch up each pillar with forceps; these are not to be loosened until, at the end of the operation, they have served as a guide in the repair of the external ring (Fig. 401). Now comes the next step in the operation^ Carefully divide the aponeurosis in the line of the pillars and to the full extent of the skini wound. Unless one cuts deeply, there is nothing to fear. You have; now laid open the inguinal canal and have left to do the most difficult part of the operation. Fig. 402. — The external oblique divided, exposing the cord and hernial sac. (Veau.) To Find and to Dissect Out the Sac. — The cord is covered by the cre- master which also covers the hernial sac. You may begin the search; for the hernial sac without disturbing the position of the cord, but it is ! better to raise it up out of its bed. To do this follow along the external pillar and Poupart's ligament and you will find it easily disengaged ! by blunt dissection (Fig. 402). Slip the left index finger under and support the cord. The sac is enclosed in the fibrous sheath of the cord. Very gently incise this sheath, using a sharp bistoury (Fig. 403), and, the structures of the cord appear. Rolling them between the finger and thumb, you can recognize the vas deferens by its form and con- sistency. You can see the distended veins. You will see a whitish transparent membrane. Catch up a fold of it with the forceps and divide its base, and if it is the sac, you will open into a serous cavity (Fig. 404). Enlarge the orifice sufficiently to introduce a finger and, EXPOSING I III III KM \l SAC 5 6l Fig. 403. — Dividing the fibrous coverings of the sac. (I eau.) Pio. 404. Incising tlu- hernial sac. il tan 1 36 562 RADICAL CURE OF INGUINAL HERNIA. with that as a guide, dissect the sac from its associated structures (Fig. 405). It is often a difficult task, for the veins and vas deferens are glued to the sac, especially in the congenital hernia. Sometimes pressing and stripping the tissues back with a gauze compress facilitates ] the manoeuvre. It is important that the sac be isolated quite to the internal ring (Fig. 406) ; otherwise when the ligature is applied there will be formed Fig. 405. -The index finger introduced into the sac which is being separated from the other„structures of the cord. {Guibe.) a peritoneal diverticulum, the starting-point later of another hernia. Do not carry the dissection further than the internal ring for fear of wounding the bladder. Assure yourself now that the sac is empty by passing a finger up into the abdominal cavity. Now transfix the neck of the sac with a needle carrying a catgut ligature (Fig. 407) and tie in the manner in- dicated in figure (Fig. 408). If the ligature merely encircles the neck, it is too likely to slip off. Do not cut off the ends of the ligature I>|n>i i ||\(. \\|> i|i. VTING I Hi SAC. 563 Pig. 400. -The sew separated from the cord; the cord in the bottom <>f the wound, on either side the lips of the external oblique. "^_( Vain.) » 8l 1 1 Pio. 107. Ligation "f the neck of the >vu\ (l 564 RADICAL CURE OF INGUINAL HERNIA. until through dealing with the sack. Amputate the sac within one-half inch of the ligature and, if everything is all right, cut the threads and the stump disappears in the cavity. Sellenings proposes to dispense with the dissection of the sac. After it is exposed, incised, and emp- tied, he obliterates it by passing a purse string around its neck at the internal ring and suturing the rest of its length (Amer. Jour. Surgery, March, 1909). Suture of the Abdominal Walls. — This is the next step. Draw the cord down out of the way for the moment and expose the shelving Fig. 408. — Illustrating method of ligating the sac. (Veau.) Fig. 409. — The cord drawn to one side while the posterior wall of the canal is restored by suture of the conjoined tendon to the shelving edge of Poupart's ligament. (Veau.) inner edge of Poupart's ligament, which is to be sutured to the free border of the conjoined tendon. In other words, the internal oblique and transversalis are to be sutured jointly to Poupart's ligament. Through this shelving edge near the pubis pass a chromic catgut suture on a curved needle and carry it through the corresponding part of the conjoined tendon (Fig. 409), and apply three or four such sutures (Fig. 410). In this manner reconstruct the posterior wall of the inguinal canal. Place the cord back in position upon this line of sutures. Now draw the edges of the divided aponeurosis into position by means of the forceps attached to the pillars at the beginning of the operation. Begin the repair by a chromic catgut suture at the upper end of the wound (Fig. 411) and pass six or eight in this manner. i i i ri \\i. i . i ■ i SSING 01 mi WOUND. 565 The last will rejoin the pillars and restore the external ring, and when these are all tied the anterior wall of the (anal is thus recon Btructed. There is little danger of making the external ring too small for the cord (Fig. 1 12). Complete the hemostasis. A scrotal hematoma may develop unless one is very particular about the oozing. Complete the operation by suture of the skin wound with silkworm- gut, leaving in it a small drainage-tube if you fear infection or oozing; otherwise this is not necessary; still it does no harm. Cover the wound with a strip of moist gauze, fix it with collodion, and then apply the ordinary gauze and cotton dressing. A double spica bandage will greatly diminish the chance of infection. If drainage was employed, remove the tube in two or three days under strictest asepsis. Otherwise do not disturb the dressing, but watch the tempera- ture. If the temperature runs up to j oi° on the third day, open up the wmi nd by removing one or two sutures, and if there is any pus, drain. Delay in this is likely to result in ex- tensive suppuration, and a recurrence of the hernia is thus assured. If everything goes well, remove the stitches on the eighth day, but keep the patient in bed for three weeks. A truss is not necessary. Rilus Eastman, of Indianapolis, recommends a modification of the final suturing especially applicable in the case of children. His method aims at the closure of all the layers by a single tier of easily removable non-buried sutures. The method described (Annals of Surgery, Jan., 1906) consists in the reduction of the sac by the ordinary proced- ure. A I'agenstecher celloidin linen suture bearing a needle on each end is then first passed through Poupart's ligament from without in- ward one inch from its free margin. It is next passed through the outer border of the obliquus exlernus and transversalis muscles and brought back through I'oupart's ligament about 1/3 inch nearer the margin than at its first point of passage. The needle now external to. Fir, 410. — Posterior wall-repair complete. (Veau.) 5 66 RADICAL CURE OF INGUINAL HERNIA. and above Poupart's ligament is made to overlap the free margin of the ligament and the aponeurosis of the external oblique by carrying the thread through in the form of a simple running mattress suture. Fig. 411. -Reconstructing the anterior wall by repair of the external oblique. Forceps still attached indicate the position of the ring (Veau.) The needle is next passed through the superficial fascia, panniculus adiposus, and skin, emerging about 1/8 inch from the skin wound margin upon the side opposite Poupart's ligament. When traction is Fig. 412. — External oblique repaired. (Veau.) made upon the two ends of the suture no kinks or curls remain, and the suture is tied up as a simple loop. Five or six such sutures are re- quired to coapt the wound from the internal ring to the pubes. When union is complete they are easily clipped and removed. CHAPTER XIII. RADICAL CURE OF FEMORAL HERNIA. Aside from the cases of strangulated hernia, the general practitioner should not undertake the operation for the radical cure of femoral hernia without due consideration and without warning the patient that relapse is possible and even frequent. The operation is not more difficult than that for inguinal hernia, but a cure is much less certain. As with inguinal hernia, he should select only such cases as are small and reducible. Surgical Anatomy. — The sac of a femoral hernia is generally thick and imbedded in adipose tissue originating in the extra-peritoneal layer. (See Strangulated Femoral Hernia.) The relations at the neck are of the greatest importance. To the outside is the femoral vein in direct contact, easily perforated by a care- less needle and producing a hemorrhage that can be arrested only by ligature of the vein. To the inside is Gimbernat's ligament, sharp- edged and tense, the chief structure to be dealt with in strangulation. Above is Poupart's ligament, separating the femoral from the inguinal canal, and below is the ramus of the pubes, thinly covered by the pectineus and its fascia. These boundaries are unaccommodating structures in the matter of repair, and for this reason relapse is frequent. Operation. — The anesthesia and preparation are the same as for inguinal hernia. The incision, parallel with, and a finger's breadth below Poupart's ligament, begins (on the left side) at the spine of the pubis and is usually about four inches in length (Fig. 413). Incise in the same manner the fatty tissues, layer by layer, until the easily distinguishable coverings of the hernia are reached. The line af cleavage between them and the fatty tissues is followed and the aeck, lying high and deep, is exposed. Where the coverings seem 567 5 68 RADICAL CURE OF FEMORAL HERNIA. thinnest, catch up a fold with the dissecting forceps and incise the base. It may be that the incision will only open into another fatty layer. Divide the next layer in the same manner, and so proceed until you have opened the sac; secure its edges with forceps and pass an index finger into the cavity. If omentum is found it must be resected (pig. 414). Be sure there is no adherent bowel. • Now dissect the sac, proceeding slowly and methodically until the femoral ring is reached. Introduce a finger to be sure the bowel is Fig. 413. — Incision for femoral hernia. (Veau.) protected, and transfix and ligate the neck of the sac as in inguinal hernia. Again recall the relations of the femoral ring (Fig. 415). Obliteration of the Femoral Ring. — Retract the upper angle of the wound so that you can see, and with the edge of the bistoury held] horizontally, divide Gimbernat's ligament freely (Fig. 416). Poupart's ligament can now be approximated to the pectineus. Protect the; femoral vein with a retractor and pass the first suture adjoining it, using a strong curved needle and No. 2 or No. 3 catgut. The needle enters the pectineal fascia, grazes the bone, comes out a little higher, and then passes up to the posterior surface of the liga- < [.OS! K'l "I I III II \1< iK A I RING. 569 mi-lit and forward through it (Fig. 117). Place four sutures in this manner before tying (Fig. |i*). Tie them successively from without inward. It is this line of suture alone that will be effii ient, bul suture the fascia if you wish, and finally the skin. The subsequent treatment is the same as in inguinal hernia. Such is the method which Watt recommends, and which has the (great merit that it is anatomical. Bul there are many differences of opinion as to the best method of closing the femoral ring, and as to the advisability of even closing it at all. PlG. J14. — Resection of the omentum. (Guibc.) Ochsner enunciates the principle, applying it to the radical cure of femoral hernia, that circular openings in any part of the body, will certainly close unless kept open by a mucous or serous lining. Wherever, therefore, the femoral ring is well defined, he is content with high ligation of the sac and dissection of all the fat and simple closure of the wound. With a technic thus reduced to the simplest terms, he obtains excellent results. Unfortunately, the femoral ring cannot always be defined as a circular opening, and especially after the operation for strangulated hernia. Coley in the main agrees with Ochsner, but lays somewhat more 57° RADICAL CURE OF FEMORAL HERNIA. stress on the closure of the femoral canal. His method, described briefly in Progressive Medicine (June, 1907), is as follows: An oblique incision is made 1/4 to 1/2 inch below Poupart's liga- ment and parallel with it, almost identical with incision made for in- Fig. 415. — The neck of the sac ligated and cut off. Above, Poupart's ligament; below, the ramus of the pubes; internally, Gimbernat's liga- ment. (Veau.) Fig. 416. — Femoral hernia; incision of Gimbernat's ligament. (Veau.) Fig. 417. — Suturing Poupart's liga- ment to the pectineal fascia. ( Veau.) Fig. 418. — Suture of Poupart's ligament and pectineal fascia completed. (Veau.) guinal hernia, only slightly lower and a little shorter. The sac with the mass of extra-peritoneal fat that almost always surrounds it, is then freed well up into the femoral opening. The masses of fat are care- fully removed; the sac itself, by gentle traction, is brought down well CL0S1 RE 01 I III II \K'K Al. KIN<;. 57' beyond its ne< k to a point where it widens into the general peritoneal cavitv. It is always opened before ligature, to make sure it is empty. Il" omentum is present, this is tied off and removed, the sac is trans A ■'///', PlG. 419. — Closure of femoral ring. Sutures passed through Poupart's liga- ment and the pectineal fascia. (Bintlte.) FlG. 420. — Suture of femoral ring com- pleted, by passing sutures through the plica falciformis and pectineal fascia, 1 Binnie.) fixed, resected, and reduced. With a curved Hagedorn needle threaded with kangaroo tendon of medium size, the suture is placed, passing the needle first through the inner part of Poupart's ligament, then downward through the fascia lata overlying the femoral vein, and Fig. 421. — Roux's operation for closure of the femoral ring. {Binnie.) finally upward, emerging through the roof of the canal 1/4 inch distant from the point of entrance. On tying this suture the floor of the canal is brought into apposition with the roof and the femoral 57 2 RADICAL CURE OF FEMORAL HERNIA. opening is completely obliterated. The skin and superficial fascia are closed with uninterrupted catgut suture. The first change in dressing is made in a week, and the patient is allowed to go home at the end of two and a half weeks. Another method is represented in Figs 419 and 420. In Roux's operation, Poupart's ligament is brought down to the pubes by a metal or ivory steeple (Fig. 421). ( ilAI'TKR XIV. ENTERECTOMY. INTESTINAL ANASTOMOSIS. Resection of a segment of the small intestine may be a necessary fart of several emergency operations. It may be required following gunshot or other lacerating wounds of the intestine; it may be neces- sary in certain wounds of the mesentery and in the gangrene of strangu- lated hernia. Large wounds of the gut, those which carry away more than one- lr.ll' the circumference, require resection, for any form of repair is likely to result in stricture. In the case of multiple perforations, it is safer to (teect than to attempt separate repair of the orifices. A small wound of the omentum near the intestinal border may require an extensive resection, for an inch of mesentery at that level may contain the blood supply of two feet of intestine. Resection of the bowel, implies anastomosis, and this may assume one of three forms: it may be end-to-end — termino-terminal, termino- latrral, or latero-lateral. The end-to-end anastomosis is preferable following resection. The method employed may be either by suturing — circular enteror- rhaphy — or by the Murphy button or some of the other mechanical devices, such as Robson's bone bobbin or Frank's decalcified bone coupler. With the great majority of surgeons, suturing is the method of choice, although the casual operator may not yet be ready to dis- card the mechanical device. Moynihan, in his great work on abdominal operations, sums the matter up in this wise: "The use of mechanical appliances is no longer necessary; these have played their part — a most important part. 1 gratefully admit in the development of surgical work, and it is now time thai their surgical use should be abandoned. They have been useful, nay, indispensable steps in the march of progress. To Murphy above all other surgeons for his instrument is one oi the most in 573 574 ENTERECTOMY. INTESTINAL ANASTOMOSIS. genious mechanical contrivances ever invented — we should gratefully acknowledge the debt we owe. The weightiest argument against all mechanical aids to anastomosis is this — they are unnecessary. By their aid we do not accomplish anything which cannot be accomplished with equal rapidity and greater safety by simple suture. We have nothing to gain from their use and we risk much by leaving something behind which may be and has been the direct cause of danger and of death. The day of mechanical aids is over. The buttons and the bobbins, the elastic ligatures and the forceps of many forms have no more than a historical interest." Technic of Resection. — The first essential of this procedure is that all the impaired gut be removed. Otherwise subsequent slough and perforation are almost a certainty. There is a limit, of course, to the length of the segment which may be safely removed, but in the ordinary operation one need not fear to^remove too much. Cases are on record in which as much as ten feet of the small intestine have been removed with recovery. As Moynihan said, it is not so much a ques- tion of how much is removed as how much is left to carry on the in- testinal functions. A second requisite in resection is that the blood supply of the bowel be left unimpaired. Lack of precaution in this respect may nullify an otherwise careful operation. The integrity of a given part of bowel is absolutely dependent upon the condition of the vessels which arise from the last arterial arch to supply it. It must be remembered that the vasa intestini tenuis break up into a number of freely anastomosing arches, but the terminal branches anastomose but little. It is this character of the circula- tion which determines the mode of section of the mesentery. The third principle constantly to be borne in mind is that the peri- toneum is to be completely protected from contamination by the bowel contents. It is true of all the hollow viscera that their contents are more or less septic, always sufficiently so to produce peritonitis. The bowel, then, must always be temporarily constricted beyond the limits of the section. This is ordinarily done by means of intestinal clamps or by elastic ligature or by gauze strips passed through a button-hole in the mesentery. Not only must the intestinal contents be restrained, but also the RESK< I IMS in I III 'I I . 575 field of operation must be shut <>iT from the peritoneal cavity :i m I from jontact with the resl of the viscera by means of sterile compr< The larger and more deeply placed of these are iml to be removed Until the i-iin rea< hing poinl " B " leave the needle, still threaded, hut wrap it in gauze and Lay it aside for the moment. Now begin the perforating suture at the mesenteric margin. The two leaves of the mesentery separate here to encircle the dowels, PlG. 434. — End-to-end anastomosis; the first part of the sero-serous or Lembert suture applied. Beginning the inclusive suture. (Binnie.) leaving a part of the surface bare. The stitch must be passed so as to bring the mesentery in contact with this bare area. Proceed in this manner: Pass the needle through the bowel wall [beginning with the right side) about 1/6 inch from the cut edge, enter ing the mucus, emerging from the serous coat just where the mesentery rcu< In s the bowel. Carry the needle over and across to the left side, pass it through into the lumen, reversing the first puncture. Pass it next from within out. perforating the wall near the mesenteric juncture, and finally perforate the right bowel wall again, passing from without inward. The knot is tied within the lumen of the gut at the original point of entrance. The edges of the mesentery being thus brought 37 578 ENTERECTOMY. INTESTINAL ANASTOMOSIS. together, the suture is carried continuously around the whole circum- ference of the gut (Fig. 425). The punctures are 1/10 to 1/12 inch apart and the work is facilitated by keeping the thread taut, which at ! once tightens it sufficiently and brings into view the site of the next punc- : ture. The end of the suture is knotted, the thread left long at the beginning and thus the perforating suture is completed. Remove the 1 clamps. A Fig. 425. — -End-to-end anastomosis; the first part of the Lembert suture buried by the inclusive suture which will be completed before resuming the Lembert A B. (Binnie.) It remains to complete the sero-serous suture which was temporarily abandoned. It is carried from the convex border on around to the mesenteric border, and when that point is reached the perforating suture is completely buried. Knot with the thread left long in the be- ginning and held with forceps, and thus the sero-serous suture is com- pleted (Fig. 426). Finally suture the rent in the mesentery. This must never be neglected, else it may be the site of a strangulated hernia. The line of suture is to be carefully wiped, the compresses re- moved, and the loop returned to the abdominal cavity. \\ OTOBIOSIS B\ Ml K I'l ( \ i:i I l<>\. 579 (hi By the Murphy button (Fig. .127). The bowel is resected as de- scribed above. Begin by passing a purse string suture around the towel near its cut edge, involving all the layers. The chief concern is t.> get control of the mesentery whore its layers separate. To do this A l'n;. 436. — End-to-end anasto- mosis completed. A and B to be knotted. (Minnie.) A P B Fig. 427. — Murphy button. Fig. 428. — Purse- striiiK' suture (b) run- ning over edge of bowel and closing space be- tween mesentery (c) at (a). (Shwart.) Fig. 429. — Anastomosis with Murphy button completed. {limine after DaCosta.) pass the needle through one layer, on into the lumen of the bowel; out again through the bowel wall and through the other layer of mesen- tery (Fig. 428). When the suture is puckered the intermesenteric space is obliterated. 5 8o ENTERECTOMY. INTESTINAL ANASTOMOSIS. Now grasp one half of the button with forceps and introduce it into the end of the gut so that when the purse-string suture is tightened it will fall into the groove in the button. Adjust the other half of the button in the same manner. The male half is pressed firmly into the female half, noting that all the Fig. 430. — Lateral anastomosis facili- tated by use of clamps. Continuous su- ture for both layers. (Binnie.) Fig 431. — Lateral anastomosis; first row of Lembert sutures applied. (Binnie.) edges are turned in. Strengthen the union by a few Lembert sutures. Repair the rent in the mesentery and the anastomosis is complete (Fig. 429). It may be expected that the button will pass about the tenth day. Lateral Anastomosis. — Proceed as before, bringing out of the ab- dominal cavity the loops to be anastomosed and pack with sterile ' rECHNK 01 LATERAJ W \- rOMOSIS. 58l compresses. F.ach loop is clamped and the two clamps laid side by side so as to bring about 5 inches of the bowel walls in contact I Fig. 430). Pi is-. -Lateral anastomosis; irst part of the through and through uture applied. (Binnie.) Fin. 433.— Lateral anastomosis. in^' last of the Lembert sutures. Inter- rupted in this ease, use the continuous instead. (Binnie.) The first line of suture is to be applied nearer the convex than he mesenteric border and should be about 3 inches in length. Unite 582 ENTERECTOMY. INTESTINAL ANASTOMOSIS. the opposed surfaces then by a sero-serous suture. The line of-- suture runs toward the operator, and when the line has reached, say 3 inches, the needle is left, still threaded, and temporarily laid aside. The next step consists in making the openings which are to afford the means of communication between the two loops. A straight incision about 1/4 inch from and parallel with this line of suture lays open the bowel down to the mucosa. Section of these superficial coats leave exposed an ellipse of mucous membrane, and this ellipse should be trimmed out with the scissors. The other loop is opened in the same way. The adjoining edges are now to be coapted by continuous per- Fig. 434. — Cross-section of lateral anastomosis. (Binnie.) f orating suture (Fig. 431). As this suture progresses the opposite angle of the wound is reached, but without interruption it continues to draw together the more widely separated borders (Fig. 432). When it has reached the point of beginning, the terminal thread is knotted with the first which was left long, and so the perforating suture is finished. Remove the clamps, wipe the bowel, and now return to the sero-serous suture and continue with that until the per- forating sutures are completely buried or, in other words, until the sero-serous suture has traveled completely around the bowel and the terminal thread knotted with the primary suture. If preferred, this sero-serous suture may be an interrupted instead of a continuous stitch (Fig. 433), but the continuous suture is more fECHNIC O] fERMINO-LATERA] \n VSTOMOSIS. 583 tepidly passed and is in every respei 1 as set ure. The main thing to l>c attained, however, is thai the serous surfaces be brought into contacl ■trough the whole circumference of the bowel. Fig. 434 >hnws the appearance of the bowel on cross section after such an anastomosis. This method may l>c modified in many ways. Fn;. 435. — Tcrmino-lateral anastomosis. Clamps and continuous suture employed. (Binnie.) Fig. 436. — Termino-lateral anastomosis completed. (Binnie.) hut exemplifies really the fundamental principles involved in any anas- tomosis of the digestive tube. It is purposely stated in its simplest terms and shorn of detail. The technic of the termino-lateral form of anastomosis does not differ in any essential detail from that just described for the latero- latrral form (Figs. 435 and 436). CHAPTER XV. IMPERFORATE ANUS. A correspondent addresses the editor of the Journal of the American Medical Association (September 8, 1906) to this effect: "Mrs. B., a perfectly healthy woman of twenty-eight years of age, after a normal pregnancy, gave birth to a fine eight-pound boy, well nourished. and healthy looking, and perfect in every way except there was no anus nor sign of any. A small amount of meconium was being passed through the urethra. The next morning a local surgeon was called in counsel and an incision was made through the floor of the pelvis and dissected up along the coccyx, but no rectum was found nor trace of a gut until the sigmoid flexure was reached in the free peritoneal cavity. A large opening in the sigmoid was followed by a discharge of feces. No attempt was made to stitch the gut to the wall or the integument. The opening was not closed in any way and no dressing applied, except that the nurse was directed to keep the site of the operation sponged with a saturated solution of boracic acid after each evacuation of the bowels. The child nursed well after the operation and has continued to do so. It sleeps nearly all the time, but has had no elevation of temperature; the passages come free and the urine is passed normally. Can you suggest any means of treat- ment that will permit the child to grow up with at least a slight control of bowel movement?" That is the question which occurs to every doctor compelled to deal with these cases, which are fortunately rare. The little being's life rests upon the doctor's readiness to act; and if it survives, whether or not it carries a life-long disability depends largely upon his skill. It usually happens in the course of such cases that no meconium passes within a reasonable time after the baby's birth. It grows restless, perhaps vomits, and for the first time it is suspected that there is some abnormality about the rectum or anus, which an examination . 584 OP] RA1 l« >N FOR IMI'I RFORAT1 WTS. 5»S [aerifies, it is imperative to relieve the condition at once and if no Specialist is within reach, the doctor musl undertake it. He may ind it quite easy or he may find it impossible. In the first instan. i', the anus and return may be both fully devel oped, but in passing a finger or probe into the orifice, a thin bulging tembrane can be Felt, apparently almost ready to hurst when the infant cries. A sharp-pointed bistoury, wrapped and introduced along the finger or a grooved director, easily punctures the membrane, ■allowed by a free passage of meconium; and thereafter the bowel PlG. 437.— Incision for imperforate anus. (Veau.) readily empties itself. The mother is directed to dilate the opening daily with her little finger, and that, with an occasional stretching with a bougie, is sufficient. In another case there may be no depression where the anus should be. The median raphe extends unbroken from the scrotum to the coccyx. The anus is absent and it may be practically impossible to tell how high up in the pelvic cavity the rectal cul-de-sac may be; and yet it is one's duty to hunt for it through the perineum. Operation. — Put the patient on its back with thighs Hexed and pelvis elevated in short, in the lithotomy position. Employ a light chloroform anesthesia, not that there is any danger if the anesthesia S 86 IMPERFORATE ANUS. is carefully conducted, unless, indeed, the operation has been too long delayed, but that a little straining on the patient's part may help to locate the bowel. Make a median incision from the base of the scrotum or from near the posterior vaginal wall to the coccyx, which must be exposed (Fig. 437). A number of eventualities may present: (1) One may find immediately beneath the skin some of the fibers of the external sphincter, a favorable indication. Split these fibers by blunt dissection. Free incision may spoil their usefulness. Be- Fig. 438. — Retention suture. (Veau.) neath the muscular layer appears the lobiilated fatty tissue peculiar to the new-born, which is to be next divided. Here one must go slowly, keeping in the middle line and all the time working toward the coccyx. The danger is in front. If toward the hollow of the sacrum, a fluctuating pouch is felt or a brownish rounded tumor is seen, one breathes easy, knowing that the imperforate gut is within reach. But do not be in a hurry to open the gut. It is first to be secured by passing a suture on each side of the middle line or by catching the bowel wall with forceps. The suture should not per- forate the bowel. Making gentle traction on the bowel, proceed to free it by careful blunt dissection. Do not use knife or scissors to divide what seem DIM R \ l |d\ I i IR IMIM khi|; \ I I Wis. 587 to be fibrous bands, for it is possible thej contain the blood supply of the bowel; and, if divided, dangerous bleeding may occur or the tissues be« ome gangrenous. As the pouch is freed, it is gradually pulled down into the wound; and if they were Dot passed before, two sutures are now passed with Which eventually to fasten the gut to the skin opening (Fig. 438). Now is the time to open the pouch and let the meconium flow out. It may require several minutes for the bowel to empty itself. Evert the mucous membrane, enlarging the bowel wound a little if ne< cssan T Fig. 439. — Mucocutaneous suture. (Veau.) Suture the mucous membrane directly to the skin; no other tissues should intervene (Fig. 439). Irrigate thoroughly and apply a gauze dressing, which is changed as often as soiled. The functional result is often surprisingly good. Broncho-pneumonia may develop when the operation has been too long delayed and septic absorption has begun. (2) The pouch cannot be drawn down. In that case when the bowel is opened the discharge will have to flow over the raw surfaces of the flesh wound which will need to be kept open with bougies. Infection is a constant danger, not to speak of lack of control of bowel movement. Belter than to leave the wound in this condition, the coccyx and a part of the sacrum may be removed and the gut brought out poste- 588 IMPERFORATE ANUS. riorly. Still better, open the peritoneal cavity, find and draw down a loop of the sigmoid to fasten in the wound. (3) The pouch cannot be found. Obtain more room by resecting the coccyx, follow the sacrum a little higher, open the peritoneal cavity and search for the cul-de-sac; if possible, draw it down into the wound and suture. If all these measures fail, there is nothing to do but make an artificial anus in the inguinal region. Indeed, there are those who advise this from the first with the idea that later the operation for the construction of a normal anal orifice can be better undertaken. Tuttle says (Diseases of the Anus, Rectum, and Pelvic Colon) that where there is no evidence that the rectal pouch can be easily reached, and where the child is in an enfeebled condition with distended ab- domen, fecal vomiting, and nausea in progress, one should not hesitate to choose the abdominal route, perform an inguinal colotomy at once and thus afford an immediate exit to the intestinal contents, and an escape for the gases which are causing the distention and the consti- tutional disturbance. To this same volume the reader is referred for a full discussion of these problems, and for consideration of those other forms of imper- fect development in which the anus has abnormal openings. Such cases are not strictly emergencies, for usually there is a partial means of escape for the bowel contents. CHAPTER XVI. TORSION OF THE PEDICLE OF OVARIAN OR UTERINE TUMORS; OF THE SPERMATIC CORD; OF THE PEDI- CLE OF THE SPLEEN; OF THE OMENTUM. Torsion of the pedicle <>f an ovarian or uterine tumor may be either chronic or acute; in the one ease developing so slowly as to produce no symptoms or even no effed upon the tumor unless merely to in- hibit its growth, for in the adhesions are new sources of nutrition; in the second case developing suddenly and producing a train of symptoms that demand immediate relief. The acute cases alone, then, are to be regarded as emergencies. ( 'ysts of Ih c ovary, especially those which are spherical, non-adherent, and connected l>y a long pedicle, are most liable to this accident. Kelly finds two causes for this rotation. The first of these is in the effort of a large cyst to accommodate its convex surface to ihe con- cavity of the distended anterior abdominal wall. The second cause is found in contractions of the anterior abdominal wall, which act upon the part of the tumor nearest the middle line. The effect of the force thus applied is to rotate the tumor. In the case of smaller tumors lying in the pelvic cavity it is likely that unusual movement in the intestine or readjustments of the pelvic viscera may produce the same effect. Kelly quotes Kiistner to the effect that tumors of the right side, as a rule, rotate from left to right, while left ovarian tumors rotate from right to left. The diagnosis of acute torsion is not difficult if an ovarian cyst is known to be present. If such a tumor was previously unsuspected the certain diagnosis may be impossible, especially if the caseisseen late and general peritonitis is developing. The symptoms, as a rule, arise without warning. There are severe colicky pain, vomiting, marked constipation, and the appearances "\ collapse. Abdominal rigidity and tension rapidly increase. This is 5 8 9 590 TORSION OF THE PEDICLE OE OVARIAN OR UTERINE TUMORS. ' true of the more urgent cases. In general, the severity of the symp- toms vary with the degree of torsion. Appendicitis and acute intestinal obstruction present the greatest difficulties in differential diagnosis which it is desirable to make, not to determine the advisability of operating, but to determine before- hand the kind of operation one is to undertake. Ranzi (Berliner klin. Wochenschrift, Jan. 6, 1908) reports four cases of torsion of ovarian cyst which were not differentiated from appendicitis, except in one case, before the operation, and in this case by the pains in urin- ating. In three of the cases there had evidently been mild attacks of torsion which had subsided and which had been diagnosed as catarrhal appendicitis. The treatment is operative, and, as has been indicated, the operation must often begin as an exploratory laparotomy, for though the symp- toms indicate the seriousness of the case they may not reveal its char- acter. Delay is dangerous in these cases, and seldom will one regret having operated early, for nearly always the lesions found exceed the expectation. The appearances once the abdomen is opened will depend upon the size of the tumor, the degree of torsion, and the time of intervention. Usually the tumor will be found enveloped in loops of intestine bound together by soft adhesions (Fig. 440). These adhesions are to be carefully separated, and one must proceed with prudence for the cyst may be filled with pus and its walls may be friable. The intestines, detached, are to be held out of the way with compresses and the tumor thus brought into view. Its nature may be -at once apparent in spite of the fact that it is discolored, dark red, or even black. If it is a cyst not quite so large, it may resemble a dilated cecum. Its attachments are carefully broken up, and gradually working toward its base the pedicle is finally defined. An effort is now made to lift the tumor out of the abdominal cavity, and there need be no hesitancy in enlarging the abdominal incision if necessary. Usually it is to be lifted out with the two hands applied to its base. Occasionally only after its pedicle is untwisted is it possible to deliver it. Next the pedicle is tied near its point of implantation, divided, rORSION "I I I I k'l\l FIBROIDS. 591 and thus the tumor is removed. It' there are no evidences of infection tin- abdomen is t<> be 1 losed without drainage. Tumors springing from the uterus are much less likely to become twisted. Yet, in the case of large non-pedunculated fibroids, the Fig. 440. — Torsion of the pedicle of an ovarian cyst. {Montgomery.) uterus itself may be rotated and give rise to symptoms which demand ■elief. In such a case the intervention may be quite complex. In some instances a myomectomy may be sufficient. The uterine wall is incised over the long axis of the tumor, which is exposed and 592 TORSION OF THE PEDICLE OF OVARIAN OR UTERINE TUMORS. peeled out, and the hemorrhage checked by suture of the uterine wound. The uterus may still tend to rotate and may require fixation. In still other instances, hysterectomy, either supra-vaginal or complete, may be the procedure necessary for relief. This will be the case when the condition of the uterine wall after removal of the tumor would preclude repair. Harsha reports to the Chicago Medical Society (Annals of Surgery, Nov., 1905) a case of torsion of the pedicle of an ovarian cyst in a woman of thirty-three, who for several years at intervals had had attacks of intestinal obstruction, accompanied by pain and vomiting, lasting for three or four days. Her last attack began suddenly with pain, vomiting, constipation, tenesmus, accompanied by the symptoms of shock. At the end of four days the abdomen was opened. A cyst, the size of an orange, with twisted pedicle was removed. There was neither peritonitis nor gangrene. There had been no further indications of obstruction. In a second case the cyst was as large as a fetal head and black to within an inch of its implantation. Ochsner, commenting on these cases, says that symptoms of ob- struction are not uncommon in such cases and that the history is often that of volvulus. He cites a case in which the abdomen had been opened by a prac- titioner who believed he was dealing with intestinal obstruction. Having opened the abdomen, however, he discovered a large black tumor. Disconcerted, he stopped his operation, hurriedly trans- ported the patient to the Augustana Hospital where Ochsner com- pleted the work. The doctor performing an emergency laparotomy must not have his mind too definitely fixed on one diagnosis. Expecting one thing, he must still have in view the possibility of having to deal with one or-more of a variety of conditions, and so will not be taken completely unaware. John Cahill and Sir William Bennett give the history of a case which well exemplifies the difficulties of diagnosis, the occasional complexity of treatment, and the dangers of delay (London Lancet, Dec. 8, 1906). The patient, aged seventeen, was suddenly seized with abdominal pain. There was some tenderness and resistance over the right iliac n »rsk '•-■ "i i in SPi km \ 1 1' < <>ki». 59 5 fossa. The temperature was 98. 8°, the pulse 90. Bowels were emptied by enemata, but the pain continued. < >n the third day the pemperature ran up to 101 8° and the pulse to 120. An operation was still refused until at the end of a week the patient' Condition had become very grave. An operation for appendicitis was then performed and the appendix found adherent and filled with pus, in addition to other evidences of chronic disease. Further examination revealed a dark, firm mass occupying the upper part of pelvic cavity ami intimately adherent to the bladder and uterus. Exposed by extending the incision, it proved to he an ovarian cyst the si/e of a cocoanut with a thick pedicle twisted upon itself for three- fourths of a turn. Its walls were thin and blackish, and its contents mainly decomposed blood. The cyst was removed and the patient recovered. Dr. Cahill, commenting on the case, remarked that the situation of the cyst was unusual in that it was wedged between the bladder and uterus, whereas one expects to find such a tumor in Douglas' pouch. Sir William Bennett says that although cases not infrequently operated upon for appendicitis prove to be cases of torsion, yet the to.xistence of the two conditions must be very rare. He suggests that in this case the appendicitis, by aggravating the intestinal peris- talsis, had displaced the tumor with consequent torsion of its pedicle. Angus (British Medical Journal, Jan. 27, 1906) reports an attack in a child of six, beginning with pain, vomiting, and abdominal dis- tention. By the rectum a mass was palpable in the cul-de-sac. A diagnosis of appendicitis with abscess formation was made. Opera- tion. The appendix was inflamed at the end where it was attached to a dark cystic swelling in Douglas' pouch. It was the right ovary darkly congested, large as a duck's egg, and with twisted pedicle. Its contents showed it to be an ovarian dermoid. TORSION OF THE SPERMATIC CORD. Malformations and imperfect descent predispose to rotations of tin- testicle- — an accident rare yet none the less to be borne in mind as a possibility. The exciting cause is usually to be found in trauma. A heavy lift or strain may produce it. 38 594 TORSION OF THE PEDICLE OF OVARIAN OR UTERINE TUMORS. It is readily comprehended that an incompletely descended testicle shifting backward and forth through the external ring could be forcibly rotated. The rotation may occur in two ways: either the testicle with its tunica vaginalis may be turned or the testicle alone may rotate. The spermatic vessels, nerves, and the vas deferens are all involved in the resulting torsion. The symptoms range from moderately severe to grave. Pain, nausea, vomiting, constipation, and tympanites signalize the attack, and soon the signs of local inflammation appear. In the more serious cases the pain begins abruptly and persists It usually radiates from the inguinal region and lower part of the abdomen, and may be intense or even produce shock. The con stipation is usually relieved by enemata. The presence of a painful tumor in the inguinal region together with the symptoms point to strangulated hernia and torsion of the sper matic cord equally, and the differential diagnosis may be a matter of difficulty. The pain is much more intense and sudden in its onset; than epididymitis. The cord, in torsion, can be felt tender and swollen; it cannot be felt in strangulated hernia. Of course in strangulated hernia the constipation is absolute. Once the diagnosis is assured, an effort to untwist the cord should be made and occasionally it will succeed. It is recorded of patients, 1 who, having had several attacks, learn to give themselves relief. If manipulation fails it is imperative to operate without delay, for there is danger of gangrene of the testicle. An incision extending from near the external ring follows the cord down toward the base of the scrotum. Layer by layer the tissues are divided until the tunica vaginalis is reached. The tissues are often edematous, reddened, and swollen. The tunica presents itself as a thin-walled sac. Open it and drain away the' serum and the testicle will be found, possibly deformed, perhaps difficult to recognize, and above it is the twisted cord. Seize the testicle and rotate it from right to left in order to relieve the torsion and restore the circulation. The further procedure will depend upon the integrity of the testicle. If its violet color fades, if the congestion diminishes, it is almost certain the testicle will recover, TORSION OP I hi PI I M SP] EEN, 595 and it is therefore to be preserved. If ii is bla< I. or mottled or ilaky, remove it by tying the i "r diagnosis <»f the condition generally, that amenorrhea, followed later by pain and ir regular uterine bleeding, should always put one on his guard. From the history, then, and from the physical examination one must diagnose the condition. I >n the signs of progressive internal hemor- rhage tin- decision to operate immediately is based, and one should Scarcely ever deem it too late, for even in the face of the most mcnat ing conditions, we must hold bravely to the last resource in which, even in the desperate cases, there is often safety and life. Operation. As Lejars says, the operation is moving and dramatic, hut presents no especial difficulties if one but keeps cool and knows what is to he done. Instruments. — The instruments necessary are scalpel, scissors, artery forceps, two Long clamp forceps, two retractors, and curved needles. General Anesthesia. — General anesthesia is necessary and must be closely watched. A continual hypodermoclysis is an excellent means of combating the combined effects of shock and anesthesia. It should not be begun, however, until the hemorrhage has been controlled. Antisepsis. — It is scarcely necessary to say that it is of little use to save the patient from hemorrhage to die a few days later from sepsis. The peritoneal cavity, under the conditions assumed, is a dangerous culture medium. The Trendelenburg position is almost indispensable, and if necessary, may be improvised. Incision. — A median incision extending from the umbilicus toward the pubes is made. Do not wound the bladder, which may be pushed upward and forward. This, however, is not particularly serious unless tlu- wound should be overlooked. Waste no time. As soon as the peritoneum is opened, catch its edges with artery forceps and enlarge the orifice upward and downward. Do not try to sponge out the cavity. Without regarding the clots, which will roll out and which mask the viscera, plunge a hand into the pelvic cavity and locate the uterus, which is easily recognized. To one side, a thick, doughy or 600 RUPTURE AND HEMORRHAGE OF TUBAL PREGNANCY. friable mass will be felt. Slip your fingers under it, break the adhesions, and enucleate it. This will empty the retro-uterine pouch — the cul- de-sac of Douglas. Feel with finger and thumb for the pedicle and, if possible, pull the entire mass up into the wound and clamp. If the mass is not adherent, a single clamp enclosing the broad ligament from the outer side and passing under to include the tube will suffice (Fig. 442). If there is too much adhesion, clamp on either side of the Fig. 442-- -Forceps applied to the tubo-ovarian pedicle. Trendelenburg position. (Veau.) pedicle. When the clamps are placed, the chief end of the operation has been attained. Do not waste time trying to catch the bleeding points, but ligate en masse. Ligate the pedicle. With a blunt, curved needle armed with No. 3 catgut, transfix the pedicle close to the cornu of the uterus, between it and the forceps (Fig. 443). Ligate and then carry the ligature around the lower segment of the pedicle and tie again, directing the assistant to pull up on the clamp, and finally carry the ligature around the entire LIGATION 0] mi i'i i » I « I i • 601 mass ami tic a third time. Preserve the ends of the Ligature. Ri tin- tumor and lift up the Stump by means of the threads l<> sec if there is any bleeding (Fig. 111). This ligature stands between the patient and death. If two damps have been used, it will be accessary to ■gate "en chaine." Now clean out the dots, mop out the blood, and lower the pelvisto drain the upper part of the abdominal eavity. The quantity of Mood is often enormous. If the patient is very weak, do not prolong the Fig. 443. — First ligature applied. (Vcau.) task of cleansing it all out; yet in the long run, it is better to take the time to cleanse out the fossa and wipe the intestine and omentum, lor then the abdomen may be dosed without drainage. Drainage. If there is oozing, apply a gauze drain at the site ot the tumor, and insert three or four drainage-tubes into different parts of the 1 avity to carry out the blood left behind. Do not forget to fix the drains, lest they be lost in the abdomen. Suture the wound partially, unless able to dispense with drainage, 602 RUPTURE AND HEMORRHAGE OF TUBAL PREGNANCY. in which case suture completely. Apply a dry dressing of gauze and absorbent cotton. Inject salt solution. After twelve hours, change the dressing, which will probably be saturated; thereafter change daily. About the seventh day the tubes may be shortened, and about the fifteenth day, or often sooner, altogether removed. Interstitial tubal pregnancy (Fig. 445) may occasionally be met with and present complications. A case described by O. G. Pfaff, of Fig. 444. — Ligation and division of the tubo-ovarian pedicle. {Veau.) Indianapolis (Western Clinical Recorder, March, 1903) illustrates the subject. On opening the abdomen a large reddish bag presented, which seemed to develop from the right wall of the uterus, involving the right tube. In order to minimize the hemorrhage as well as to secure the tumor, the upper portion of the broad ligament was clamped and another clamp placed to the left of the tumor passing obliquely across the fundus and including the uterine artery. The sac was now in- cised at its summit and the fetus, membranes, and placenta turned out. HYSTERECTOBTV FOB 111 MORRB M.I . (>oi No ligatures were required. The sac was partially sutured, a drainage tube fastened in its cavity and broughl oul through the lower angle of the abdominal wound. The drainage-tube was removed on the fifth day, and recovery was complete. Fig. ovarian pregnancy. (Montgomery.) Hunt (British Medical Journal, Sept. 29, 1906) reports a similar base operated on after rupture, and the hemorrhage was only controlled after hysterectomy. In some cases, perhaps, as Lejars indicates, ex- cision of a " V "-shaped section from the region of the cornua with sub- sequent suture will succeed. CHAPTER XVIII. CESAREAN SECTION. Cesarean section, designed primarily as an operation to save the babe after the mother's death, is to-day of far broader application. Without considering its exact indications, which for that matter the whole profession is not yet agreed upon, it may be stated broadly that it is the method of choice when the child cannot otherwise be de- livered alive. Unfortunately at the present time it is usually what it should not be, viz., an emergency operation. The Technic of Operation. First Stage: Laparotomy. — Incise the abdominal wall. The incision extends in the middle line to within 2 inches of the pubes and should be at least 4 inches in length. If the uterus is to be brought out of the abdominal wound it will require to be longer. The peritoneum is to be exposed and opened up in the usual manner. The abdominal walls are often quite thin. As soon as the peritoneum is opened the uterus pushes into view. Correct any lateral deviation. Hurriedly wall off the uterus with sterile com- presses, or deliver the uterus, protect with sterile compresses and suture the upper angle of the peritoneal wound. Second Stage: Incision of the Uterus. — Keep exactly in the middle line. Make a small incision in the uterus at the level of the lower end of the abdominal wound that you may not later encroach upon the lower segment of the uterus. The peritoneum and superficial muscular layers are divided with the bistoury, the deeper muscular fibers separated with the fingers. Make a small opening in the mucous membrane. Through this wound slip a finger into the uterus and on it as a guide divide the uterine wall with scissors toward the summit; the incision should be 6 or 7 inches long. If the placenta is attached over the median line, cut through it also. It makes no difference if the work is done rapidly. Third Stage: Deliver the Child. — Slip the hand into the uterus. Grasp the feet, delivering the breech first. Clamp the cord in two places and cut between. 604 < ESAR] W SEI l K)N. 605 Fourth Stage: Remove the Membranes. As booh as the i nil I K I III KA. <;0() R 11 j >i 11 re- of the urethra, therefore, is always ;i serious injury, and in order that its dangers may It ob> iated, promptness <>i re< ognition and intervention is imperative. The symptoms of injury to the urethra arc definite though varying in degree ami an-: retention of urine, hemorrhage from the urethra, and perineal tumor. These symptoms, together with the history of the ease, readily make the diagnosis, hut only by a careful study of each, recalling at the Same time the anatomy of the urethra, may one decide upon the location of the injury. (a) Retention of urine accompanies in some degree all traumatic ruptures, though one should not make a diagnosis from this symptom alone for retention may follow a mere contusion — an interstitial rupture, without any solution of the continuity of the canal and without obstruction. It has its origin in "shock," perhaps, with temporary paralysis of the bladder musculature. In such a case, there is gradual development of a perineal tumor from the contusion, but, on the other hand, the bladder slowly fills and rises out of the pelvis. In a few hours, the urine begins to dribble; a little later micturition becomes voluntary though painful, and gradually the function is restored to the normal. In actual rupture, the retention is complete and continuous. (b) Hemorrhage from the urethra is indicative of rupture, but its amount in nowise points to the degree of urethral destruction. No inference may be drawn from it as to the severity of the lesion. In fact, the slighter the hemorrhage, the worse the outlook if the other Symptoms are aggravated. For instance, if the mucous membrane alone is torn, the hemorrhage is immediate, perhaps voluminous, and yet the lesion is of minor importance. On the other hand, if the rupture is complete, the blood pours out into the lacerated tissues oi the perineum, and only a few drops may find their way through the occluded canal. Therefore, one must never conclude that because the hemorrhage from the meatus is slight, the injury is slight. (c) Perineal Tumor. — There is always swelling in some degree follow- ing contusions of the perineum whether the urethra is injured or not. The perineal and scrotal tissues are ecchymosed and the scrotum 39 610 RUPTURE OP THE URETHRA. especially is likely to be engorged with exudates. If the urethra is ruptured the bladder empties itself into the bruised perineal tissues, the ecchymosis rapidly becomes an edema gradually thickening and expanding. At first perhaps an ovoid swelling in the middle of the per- ineum, it gradually spreads until the scrotum, the pelvis, and finally the abdominal walls are infiltrated, thickened or edematous to a marked degree. But do not forget that the absence of a perineal tumor does not always mean that the injury is slight. If the rupture is situated behind the anterior layer of the triangular ligament and if this is not torn, the transudates cannot reach the perineum, for this tendinous band limits the forward movement of the urine; and so, taking the direction of least resistance, it percolates through the cellular tissues of the pelvic cavity and passes up along the side of the bladder to the abdominal wall. Since, however, the anterior layer of the tri- angular ligament is nearly always torn to some extent, perineal swelling is nearly always present. Slight swelling will give no feeling of se- curity that the injury is slight. It is obviously essential that one must have clearly in mind the anatomy of the urethra. THE ANATOMY OF THE URETHRA. Stretched across the anterior segment of the pelvic outlet, between the rami of the pubes, is the triangular ligament, dense and fibrous, and arranged in two layers, separated by a one-half inch space. In contact with the deep or pelvic surface of the triangular ligament, is the apex of the prostate gland. In contact with the superficial or per- ineal surface is the bulb of the urethra, the knobbed posterior ex- tremity of the corpus spongiosum. The urethra traverses the prostate, perforates and bridges the space between the two layers of the tri- angular ligament and then tunnels the bulb, runs the length of the corpus spongiosum, and emerges at the glans penis, the anterior knobbed extremity of the corpus spongiosum. The part of the urethra anterior to the triangular ligament consists, then, of two portions, the penile and bulbous; the deep urethra of two, the prostatic and membranous, which later is the part which bridges the one-half inch space between the lwo layers of the triangular ligament. The clinical manifestations of rupture depend upon whether the bulbous or mem- TREATM1 \ I "i C0NT1 SION 01 im I Rl [BRA. 'hi ■ranous portion is involved and in a minor degree upon whether the lupture is partial or i omplete. (Sec Fig. 469). CON 1 1 SION OS THE B1 LBOl S POB l i<>\. [njury to the bulbous portion is by far the more frequent; il is the form which the practitioner will nearly always find. It remains for him in decide whether the injury is a contusion or rupture, for the prog nosis and treatment are quite different in the two degrees of injury. It' the < ase is one of 1 ontusion, it is likely the hemorrhage was abundant ; die patienl complains of pain and inability to pass water; then- is no perineal tumor though the tissues may be much bruised. After a few hours he begins to pass water after painful effort. The urethral Heeding may persist, hut the bladder keeps well emptied. Treatment.- — The treatment is very simple. Keep the patient quiet, relieve the pain if necessary with small doses of morphia, and give some urinary antiseptic such as urotropin. Do not pass a catheter. Why should you? The bladder empties ■Self; there is no perineal inlitration; and to do so would only increase the risk of infection. The normal micturition will return in a few davs in the cases of mild contusion, and perhaps in a week the patient will be well. If, however, in such a case, after a few days micturi Ion should become more painful and finally impossible, due to urethral swelling or spasm, catheterization is indicated. Try a ■Urge, soft, aseptic catheter first; try to carry it gently along the upper wall of the urethra. You may fail and be forced to fall back on a catheter of small size, but in no case must violence be used or the attempts prolonged. The catheter may be left in if the introduction was diftic ult, but it must be kept under constant surveillance, and at the first appearance of a perineal tumor, indicative of infiltration, operation is imperative. If a catheter of small size has to be employed, it may not fill the urethra and there may be some dribbling of urine, Which favors infection. In such a case the catheter remaining in the bladder may keep it empty by siphonage. ( ontusion, with the formation of a large hematoma in the perineum, might simulate rupture, but the presence of a distended bladder dem- onstrates that the perineal tumor is not infiltrated urine. In su< h 612 RUPTURE OF THE URETHRA. a case again, an attempt should be made to pass a catheter if the urine does not begin to flow after three or four hours. If successful, the size of catheter may be increased from day to day. It must be borne in mind in making the first attempt that too per- sistent effort may result in rupture of the already contused urethra, or insure infection. In case of failure, you may follow the recommendation of Lejars, and proceed to drain the bladder by suprapubic puncture and it may be, after a day or two when the swelling has subsided, a catheter can be passed and drainage secured in that manner as before, but hold your- self ready to operate at the first sign of infiltration. This line of treatment can only be recommended to those who are sure they can distinguish between hematoma following contusion and infiltration following rupture. In case of doubt, always treat the case as one of rupture. RUPTURE OF THE BULBOUS PORTION. Urethral hemorrhage, rapidly increasing perineal tumor obviously due to infiltrating urine, and retention of urine following injury point at once to some destruction of the urethral wall. There is no use of wasting time attempting to pass a catheter; prepare at once for an external urethrotomy. Even if you succeed in passing a catheter, it will not prevent extravasation in the end, as Reginald Harrison and others have pointed out. Nor is there need to wait for additional symptoms. The indications for operation are un- mistakable. Delay merely exposes the patient to all the risks of infection. The end in view is to furnish a free outlet for the urine and if possible to repair the ruptured canal. Operation for External Urethrotomy. — Provide for the operation soft rubber catheters of various sizes; a grooved staff or steel sound; small, curved needles, silk No. o, and three or four sizes of catgut. General anesthesia is indispensable. Place the patient in the lithot- omy position with the perineum exposed to a good light. The entire field must be disinfected with extreme care. As soon as the patient is anesthetized, an effort may be made to pass a catheter, and, if successful, the operation will be greatly facili- til'l K \ i t( IN I OB Rl l* l i Rl "l I •■■' I H8 \- ''i ^ jated. Otherwise pass the guide as deepl) as possible without usin^ i'<.r. e, and let it be held in position by an assistant who also supports the si rotum. The median incision extends from the base of the s< rotum to within an inch of the anus. Divide the skin and fascia, when you may rra. h an area filled with clots and Lacerated tissues, the site of the bulb and its muscular coverings (Fig. 446). You may not be able to recognize the hull) it' the destruction has been great, but after wiping out the clots Pic. 446. — Incision exposing the bulb of the urethra. (Duval.) and debris, a cavity is exposed (Fig. 447). Expose the point of the guide, and you have thus located the opening into the distal half of the urethra. Determine the nature of the urethral tear, whether partial or complete. The subsequent procedure will depend largely upon the type of injury present. (a) If you find rupture of the lower wall only, the remnant of the upper wall, a mere band perhaps, will be a great help in the next step, which is to locate tin- orifice of the urethra on the farther side of the fear. The search lor this opening must be patient and minute. Let 6 14 RUPTURE OF THE URETHRA. the point of a probe or grooved director follow the remnant of the upper wall backward and it may haply engage in the orifice and pass on into the bladder; if it does not, every bit of the mangled tissue must be examined. Another manoeuvre may be tried: if you have a soft-rubber catheter in the urethra, pull it down into the wound and endeavor to engage its point in the hidden orifice. Once the orifice is found and the cath- eter carried into the bladder, try to suture the urethral wound over the Fig. 447. — The muscular and erectile-tissue of the bulb divided, exposing the urethra. (Duval.) catheter. Place lateral sutures of fine silk or catgut, beginning at the upper wall and suturing toward the lower where the separation, is greatest. If possible, pass the suture through the outer coats only. (b) If the rupture is complete and the two ends are widely separated, the difficulties are aggravated. There is no trace of the upper wall left to assist in the slightest degree in locating the orifice of the prox- imal segment of the urethra. "With the point of the grooved director, every small orifice, every depression, every fringed tubercle must be examined in the hope that it represents the opening." HIM R \ I |o\ I ok' |.M I'll I' R] I UK A. 6is [f you find something which looks like mucosa and the lumen <>i tin- i anal, introduce the poinl of your i atheter ami if it is in the ri^ht track, it will glide into tin- bladder. "A good light, patient e, perseverani e, ami an a< i urate knowledge ol Be anatomical relations of the injured parts often lead to success in the most difficull cases." (Senn's Practical Surgery.) Fig. 448. — Soft catheter passed into the bladder after repair of the upper wall. (Duval.) Pressure on the bladder may sometimes help by forcing a drop or two of urine through and thus exposing the urethral opening. Some- times bleeding from the ruptured artery of the bulb will serve as a guide to the hidden opening. The incision may be extended backward with a view to exposing the ■anal, but this is often unsatisfactory and care must be taken not to wound the anal sphincter. If, by any of these means, the orifice is finally located and the cath- 6i6 RUPTURE OF THE URETHRA. eter passed into the bladder, it remains to adjust and suture the divided ends. The ideal way consists in making an end-to-end anastomosis, passing the sutures through the outer coats only. Occasionally you will be satisfied if, by passing sutures through all the coats, you can approximate, in some degree, the two ends, favoring by that much the ultimate restoration of the canal and minimizing the stricture formation (Fig. 448). " In twenty-nine reported cases of rupture of the urethra treated by Fig. 449. — Repair of the muscular layers. (Duval.) immediate suture, all are announced as successful. These results are astonishing and commend repetition." (Bryant's Operative Surgery.) After suture of the urethral tear, the perineal wound may be short- ened a little by one or two sutures, but ample space must be left for drainage. A wound unnecessarily large is much less dangerous than one too small (Fig. 449) . Pack the wound with iodoform gauze. The catheter should be left in the bladder for three to four days, when it is removed and a steel sound passed thereafter every two or three days until repair is complete. SI i-k \i'i BK - YSTOTOMY. 61 7 (c) What arc you to « 1 < > in case patient search fails to locate the bladder end of the t<»rn 1 anal and you arc unable, therefore, to pass the catheter Into the bladder and to suture . Two procedures are re< om mended: (1) Park the wound with iodoform gauze and empty the bladder as necessary by suprapubic puncture. Perhaps al a later examina- tion the opening may be found, or, as will nearly always happen, the Madder is sufficiently drained after a day or two, through the perineal wound. (2) Do a suprapubic cystotomy and "retrograde catheterization." Where the general condition of the patient and other circumstances permit, this procedure is the better, since it assures drainage and facilitates primary repair by definitely locating the bladder end of the torn urethra in the perineal wound. It is necessarily a delicate operation and should not be undertaken by the wholly inexperienced. To perform suprapubic cystotomy and retrograde catheterization, begin by carefully disinfecting the abdominal wall. Make an incision two and one-half inches long in the middle line, beginning at the pubes and cutting through the skin and subcutaneous tissues and the fascias. Retract the lips of the wound widely. You may not be able to distinguish the peritoneal covering of the bladder, for it may be above the upper level of the wound. In any event, it must be pushed up out of the way. Next locate the bladder, which is easily felt if it is distended; but if it is not, follow- the posterior surface of the pubes. Transfix the anterior wall by a suture on each side of the proposed line of incision, and lift the bladder upward to the abdominal wound and open it by a free incision. A small incision is a nuisance, while a large incision renders the subsequent steps easier and is easily sutured at the end of the operation. With the bladder opened, the next step is to pass the catheter. If possible locate the urethral orifice in the badder and pass the catheter by sight, but you will usually have to depend upon touch for this procedure. Introduce the left index and middle fingers into the bladder and touch the bast'. \ow draw the lingers forward in the middle line and the neck of tin- Madder will be recognized by its relation to the 6l8 RUPTURE OF THE URETHRA. prostate, and the urethral opening feels like a pimple on the base of the gland. The catheter is now slipped along the finger resting on the orifice. Once engaged, it is pushed on through the urethra until its point emerges in the perineal wound. Couple it onto the soft catheter in the anterior part of the urethra and retract it through the abdominal wound, and by this means the catheter in front is drawn into place and should be left in the bladder after the urethra and perineal wounds are sutured, as before described. We must now provide for the drainage of the bladder through the suprapubic wound. Employ a medium-size catheter and let it reach almost to the bottom of the bladder and anchor it in place with a safety-pin. Suture the bladder wound tightly about the tube. Repair the abdominal wall, leaving enough room for light gauze packing about the tube. "Many elaborate methods of suprapubic drainage are described, but this tube connected to a long rubber tube by means of a glass coupler and terminating beneath the bed in a bottle filled one-quarter full of bichloride solution, will meet all the requirements of the case." (Taylor, G. U. and Venereal Disease.) The tube may be replaced by a smaller one after two or three days. As soon as possible, the wound is allowed to fill up by granulation and the drain is entirely removed. RUPTURE OF THE MEMBRANOUS URETHRA. This accident is rare except in connection with fractures of the pelvis. Under any circumstances, it is even more dangerous than rupture in front of the triangular ligament, for the extravasated urine may easily spread up into the pelvic cavity and induce cellulitis and general in- fection. Examination per rectum will often reveal the edema, no signs of which appear in the perineum. Nothing but free incision and drainage through the perineum is of any use. Finally the pendulous portion of the urethra may be ruptured, some- times in coitus,* and the hemorrhage may be quite alarming to the pa- tient; there may also be retention of urine. Usually catheterization will be sufficient. CHAPTER XX. ACUTE RETENTION, CATHETERIZATION, SUPRAPUBIC PUNCTURE, CYSTOTOMY, URINARY INFILTRATION. Every acute retention of urine demands immediate relief. It must be relieved aot only on account of |>aiu and discomfort, but more especially to avoid damage to the bladder or urethra and the evil effects of sepsis. This rule applies equally to the cases due to temporary Insufficiency of the Madder musculature and to those duo to urethral obstructions. Urethral obstruction may assume various forms. In general prac- tice, it will usually originate in one of three ways: spasm of the urethra, enlargement of the prostate gland, or stricture. Very many more times than we suspect in those cases regarded as simple retention from Bpasm, the real and predisposing cause is organic. In every case before instituting measures for relief, it is wise to make minute inquiry into the patient's history with respect to this function. At least one should be suspicious of the presence of stricture and on his guard. It is true that in a particular case certain circumstances tend to make one or the other of the causes of retention the more probable. Thus if the patient is in a febrile attack or has suffered some slight trauma of the urethra or has undergone an operation on a region ad- joining the urinary tract, one thinks of retention from urethral spasm. If the patient is known to have a sexual history, has been a votary at the shrine of Bacchus and Venus, the logical inference is organic stricture. If the afflicted one is elderly, one thinks of enlarged prostate, though mere age does not rule out other causes of obstruction. One may be past the hey-day of life and yet strictured, paying late the price of pleasures long since fled. But after all, whether the predisposing cause is temporary or per- manent, the actual exciting cause is usually congestion. This i> a practical point constantly to he borne in mind, for it is congestion 619 620 CATHETERIZATION . which makes urethral instrumentation potent to produce trouble, and which makes strict asepsis an absolute necessity. CATHETERIZATION. The first measure of relief to be tried in actual retention, if opium and a prolonged warm bath are not practical, is catheterization. To meet the possible indications every practitioner should be armed. A certain equipment is indispensable. A cylindrical metal case capped at one end is most convenient in which to keep and carry these instruments. The most essential are soft -rubber catheters of various sizes, flexible bougies with olivary and Fig. 450. — Conical. Fig. 451. — Olivary. Fig. 452. — Cylindrical. (Stewart.) \_E.HTZ.VSQNS Fig. 453. — Elbowed flexible catheter. ■ m Fig. 454. — Mercier double elbowed flexible catheter. conical tips, gum catheters with single and double elbows or armed with stylets, filiform bougies (Figs. 450, 451, 452, 453, 454). Sterilization of these instruments may be a problem, except as to the rubber catheters, which may without injury be disinfected by boiling. The other instruments are best sterilized by formaldehyde vapor and should be prepared before leaving the office and carried wrapped in sterile cloths. Without the special sterilizer, one must boil these instruments, risking eventual injury. They may be fairly well cleaned by rubbing with an antiseptic ointment or by immersion in a 1-20 carbolic or CATHETERIZATION, ' i 2 i i [ooo bichloride solution. Previous to its introduction, anoinl the catheter with sterile vaseline <>r similar Lubricant. Position of Patient. -The patient should lie up«>n a table high enough thai the operator does not need t<> stoop. The pelvis should be elevated and the thighs flexed and abducted. Begin by thoroughly cleansing ihc field: cleanse the penis, the foreskin on both sides, the glands and the meatus, wiping each part with a separate compress. If possible, irrigate the urethra with boric add or normal salt solution. Whatever condition may be suspected in an unexplored urethra, make the first attempt at relief with a large catheter, seventeen or eighteen French, which, as is well known, excites less resistance than one of smaller size. Standing at the patient's left side, hold the penis between the linger and thumb of the left hand, elongating it, while managing the catheter with the right. Usually it is best to hold the instrument parallel with the groin as its beak enters the meatus, gradually bringing the handle to the middle line of the abdomen as the instrument penetrates. As the catheter progresses it may be helped along by giving it a slightly boring motion. Proceeding thus gently but steadily, always avoiding force, the bladder may be reached. If not, a smaller catheter is to be tried, and so on until one is found that will enter. If all these efforts fail and it becomes evident that a prac- tically impermeable stricture is present, resort must be had to filiform bougies, which may be bent into various shapes, bayonet shape, or corkscrew form, and kept so by a thick collodion coating. A filiform bougie is passed until it engages, and then various back and forth, side to side, movements are imparted with the hope of finding a passageway through the scar tissue. The point may engage in lacunae or in false passages, and often it is useful to leave the bougie in situ. A half-dozen may be left in the urethra to occupy the false passages, until happily one finally passes into the urethral canal. Once a bougie is introduced into the bladder, it should be fastened and left until the second day, when often it may be replaced by a soft catheter or a larger bougie. In the meantime, the urine trickles past the stricture drop by drop, until, in a short time, the distention is relieved. If the retention is known from the first to be due to stricture, the 622 CATHETERIZATION. procedure may vary somewhat. Valentine and Townsend have defined the technic of emergency dilatation of urethral stricture in such a satisfactory manner (American Journal of Surgery, May, 1907) that it is transposed for present use practically in its entirety. The hyperesthesia of the urethra, often so great an obstacle in catheterization, is greatly relieved by filling the urethra with a thirty - Fig. 455. — Lubricating the urethra. (Am. Jour. Surgery.) three per cent, solution of malaleuca sempervirens in sterile oil and holding it for three to five minutes. Local or general anesthesia is undesirable. No lubricant is used for filiforms, but the urethra is to be filled with ten per cent, suspension of iodoform in glycerin, injecting with a sterile glass syringe of one -ounce capacity. The penis is held in the left hand, the index finger and thumb pressing the meatus open. The M« »l » I ■ HI l\s| R riNG A I II II "I'M B II • 623 tip of the syringe is inserted and the contents slowly injected until it can be fell thai the urethra is full (Fig. 455). When the injection is complete the finger and thumb compress the meatus to prevent the escape of any of the fluid to make the fingers or penis slippery. The filiform is to be inserted. A straight bougie, 5 French, is in- serted as far as it will go without force (Fig. 456). A smaller one is then passed alongside the firsl and the procedure continued with Pig. jsfj. — Inserting a filiform. {American Journal Surgery.) smaller straight bougies until a No. 1 has been inserted as far as possible. This is then left in place and from three to six more intro- duced, each one being left at the point of arrest. When as many fdiforms as will pass the meatus without stretching it are thus inserted, the one first introduced may be urged slightly for- ward. If its point is free but cannot progress, it may be withdrawn and an angular filiform inserted in its place. It should be gently rotated to the right and left as obstruction is met with. If it makes 624 CATHETERIZATION. no progress, it may be left in place and another of the straight filiforms withdrawn to be replaced by a bayonet filiform. The bayonet fili- form is to be pressed forward and then withdrawn slightly and again advanced in a different direction, hoping to find the lumen. If this fails, the corkscrew filiform is to be tried, removing some of the straight filiforms if necessary to have more room. When the corkscrew's tip reaches the face of the stricture, it is to Fig. 457. — Kollmann filiform guides. (American Journal Surgery.) be rotated, trying first the right spiral and then the left. If the second one fails, leave it in place and try each of the straight ones again, push- ing it gently forward, and if it fails to enter, withdrawing it. After all the straight ones are tested and removed, try the corkscrew that re- mains in the urethra and then the one tried first. If all these manoeuvres have, failed, an attempt may be made with the Kollmann guide (Fig. 457). A straight or curved guide is to be Fig. 458. — Valentine-Townsend filiform carrier. {American Journal Surgery.) used, depending upon the location of the stricture. It is passed up to, and pressed firmly against the face of the stricture, while a straight filiform is introduced and lightly pushed up against the stricture, chang- ing the position of the guide from time to time. If this attempt with the Kollmann guide fails, a metal sound as large as will pass to the stric- ture by its own weight is introduced and held against the stricture for five minutes or more and quickly withdrawn and the urethra refilled MODI "I \\< BORING \ I [LIFORM BOl GIE. with the iodoform glycerin solution and all the manoeuvres with the liliiorms repeated, often with the result that the first inserted will traverse the stricture and enter the bladder smoothly. The urethroscope is sometimes useful in locating the orifice, but even then the aliform may be difficult to enter, manifesting the "per vcrsity of things inanimate;" although the shortest urethroscope tube be used, the filiform will cling to its sides or will sway to and fro, touching every point of the exposed region except the orifice. Under the tin umstances, the Valentine-Townsend filiform carrier (Fig. 458) is to be recom- mended and its use is thus described: After the urethroscopic tube is in- serted, the urethral mucosa dried, and the light in place, the carrier, armed with a filiform, is inserted. The lowermost ring containing the filiform's tip is pressed against the face of the stricture at the point where its lumen is visible. Once fixed by slight pressure, the filiform is very slowly projected into the exposed lumen. If it fails to traverse the stric- ture, an angular and then a corkscrew filiform are tried as before described. Whenever a filiform reaches the bladder, the fact is announced by the ease with which the instrument can be moved to and fro, and by the increased desire to urinate when the filiform touches the bladder walls, urine trickle by the filiform. The filiform must be fastened in place: No effort must be made at this time to pass a larger instrument. Valentine and Townsend recom- mend the following method of holding the filiform in place: Two pieces of sterile cord six inches long are used, one tied about the bougie in front of the meatus so that the knot corresponds to the dorsum of the penis, and the other tied so thai the knot corresponds 40 Fig. 459. — Cord attached to in- strument in urethra. {American Journal Surgery.) A few drops of 626 CATHETERIZATION. to the insertion of the frenum (Fig. 459). "Take the cords projecting from one side of the glans and pass them through one of the four holes of a common pearl shirt button, draw the button upon the two joined cords until it rests exactly at the post, coronary sulcus. Tie a Fig. 460. — Attaching button to cord. (American Journal of Surgery.) knot in each cord at that point to fasten the button in place" (Fig. 460). Proceed in the same manner on the opposite side. A cord passing over the penis connects the two buttons; another passing under the penis is threaded on to the two buttons and tied, care being taben not to disturb the position of the two buttons (Fig. 461). Finally a cord twelve inches long is fastened into the remaining Fig. 461. — Uniting cords attached to button, lateral holes. (American Journal of Surgery.) hole of each button, and carried backward to be attached to the pubic hairs after Guyon's method (Fig. 462). "The penis is then to be dressed, covering it with an aseptic garment. "Three layers of sterile gauze ten inches square are folded to form a triangle. This is passed under the penis with the base toward the scrotal angle. The apex is tied to the instrument at its projection RI I I \ ["ION I'M rO EN] \K'.l l' PROSTATE 627 prom tin- meatus. The two angles at the base are carried in front of t In- penis, one above the other, and their points arc attached to the pubic hairs by the extremities of the cords left after lying in the instrument " (Fig. 1.63). A pad of cotton should cover the genitals, and the whole be covered by a towel, to be changed as often as soiled. Pig. \<<2. Cords attached to pubic hairs. (American Jour, of Surgery.) Fig. 463. — Penis dressed. (American Journal of Surgery. I " While it is better that the patient with a filiform fixed in his bladder remains in bed, there are circumstances in which it is imperative that he be allowed to go about and attend to his occupation. Protected against the dangers of retention as above, this is permissible unless he be engaged at hard labor." /;/ the rase of retention due to enlarged prostate, the mode of procedure is quite different if the primary effort at passing a soft catheter tails. The prostatic catheter with long curve may be tried, passing is as 628 PUNCTURE OF THE BLADDER. deeply as possible before depressing the handle between the thighs, pulling the penis upward, elongating it to facilitate the movement of the sound. Once the point is in the perineal region, the handle is to be depressed rapidly, at the same time pushing the sound on, hoping in this manner to carry it over the prostatic projection. No force must be employed. Often the Mercier elbowed or double-elbowed catheter will surmount the difficulty (see Figs. 453 and 454). Sometimes a- large gum elastic catheter armed with a stylet may be useful. The catheter is introduced to the obstruction, the stylet slightly withdrawn, which serves to tilt the end of the catheter and permits it to be pushed on into the bladder. In these cases of chronic enlargement of the prostrate frequent catheterization may be required. As Stewart (Surgery, page 653) says, if it becomes difficult, if there is marked irritability of the bladder, if the residual urine steadily increases in quantity, or if there is stone or persistent cystitis, catheterization must be abandoned and operation advised. PUNCTURE OF THE BLADDER. When catheterization has failed and relief is imperative, supra- pubic puncture is the next resort. It is in nowise dangerous if aseptic, except possibly in those long strictured or long troubled with enlarged prostate, when the peritoneal covering of the bladder may approach the pubes. Begin with a careful disinfection. Shave and scrub the abdomen and pubes. Select for puncture the point immediately above the pubes in the middle line exactly. The instrument, which may be an aspirator or simply a trocar, is to be entered at the point indicated, without fear of going too deep, and pushed backward and slightly downward until resistance ceases. Withdraw the stylet and the urine follows in a steady stream. A rubber tube may be attached to the trocar. The bladder should not be emptied rapidly, but slowly, interrupting the flow from time to time. When the bladder is emptied, the trocar is to be withdrawn with a rapid movement, and the opening covered with a sterile compress, or, if quite small, with collodion. i JfSTOTOMY. 629 Aseptic puncture may be pra< tised e or t\\ u e a day for a number nf days without serious consequences, and at the end of this time the congestion oi the urethra may I"' relieved and the urinary function restored. It", however, at this time the urethral obstruction cannot be overcome, then one must proceed to establish permanent drainage. Permanent drainage is indicated from the first if distance precludes two or three daily visits, for there is no use to relieve the patient by puncture and then leave him to the danger and pain of a new retention, certain to oc cur. Again, if the urethra has been lacerated by rough attempts at Catheterization, and if to the symptoms of retention are added those of sepsis and the signs of beginning infiltration, it is imperative to es- tablish permanent drainage of the bladder. Under these circumstances the puncture may be performed with a large trocar, and after the bladder is emptied a catheter can be passed through the cannula into the bladder as far as possible and the cannula gently withdrawn. The catheter must be fixed in position, and this can readily be done by threads attached to the skin with collodion. To the catheter a long rubber tube should be attached, ending below in a vessel con- taining an antiseptic solution. By this means a siphonage is estab- lished and the bladder kept constantly emptied and prevesical in- filtration avoided. CYSTOTOMY. Permanent drainage through the suprapubic puncture is often alone available, though by no means ideal. Whenever possible, the bladder is to be opened formally and the drainage established by that means, nor is the operation beyond the skill of the general practitioner. No special equipment is necessary: scalpel, scissors, artery forceps, dissecting forceps, small curved needles. Local anesthesia may be employed in case of necessity, though, of course, general anesthesia is desirable. The region is to be carefully prepared. Operation. — Begin with an incision three inches long commencing at the pubes and extending upward in the middle line (Fig. 464). Divide the skin and fat down to the aponeurosis. Divide the aponeu- 630 CYSTOTOMY. rosis and expose the prevesical fat (Figs. 465-466). Draw this fatty tissue upward, and with it the vesical peritoneum, exposing the blad- der. The bladder appears dark and globular, marked by large veins. In fat subjects it may seem deeply situated in spite of its distention, but one need not fear to get into something else. Fig. 464. — Cystotomy. Primary incision exposing linea alba. It is helpful in controlling the bladder and later on in suturing next to pass a suture on either side of the proposed line of incision. The sutures should pass through only the superficial tissues and be parallel to the bladder incision. Next proceed to open the bladder in the middle line, making the puncture at the level of the pubes with the cutting edge of the bistoury turned upward, prolonging the in- I VS1 \IN . 631 cision from a half-inch to an inch. If the sutures have not been passed, catch up the edges of the vesical wound with forceps while the urine Sows out. The bleeding, often considerable al first, is not a matter for concern and ceases spontaneously as the emptied bladder 1 ontracts. Fig. 465. — Partial incision of the deep layer of the sheath of the recti, exposing the prevesical fat. When the bladder is emptied, douche it thoroughly with warm sterile water and explore its cavity for possible calculi. It remains to suture the edges of the bladder wound to those of the skin wound (Fig. 467). If the traction sutures mentioned were passed, they may now be used to draw the bladder up into close contact 632 CYSTOTOMY. with the abdominal wall, passing them through the entire thickness, and tying them on the outside. The mucous membrane is now brought in contact with the skin and sutured with catgut (Fig. 468). If the condition of the vesical walls does not permit the careful coaptation described, then four or Fig. 466. — Cystotomy. Recti separated, prevesical fat exposed-. five sutures may be employed, passing through all the layers of the bladder and abdominal walls, bringing them into contact. In this case a catheter must be introduced and siphonage instituted. In the first case, where the skin and mucosa are exactly coapted, it is not necessary to leave a catheter in the bladder. The skin wound is, of course, sutured above. and gauze should be packed around the catheter. The after-history will depend upon the condition present, but the ultimate aim will be to restore the urethral functions. SYMPTOMS <>r l\l il.i B \ I [ON. 633 [NFILTRATH ».\ < >F URINE. Sometimes it happens that Following a retention, partial or com- plete, the urethra gives way and the urine percolates through the adjoining tissues. Under these circumstances, the urine is nearly always septic, the patient debilitated, and the conditions are thus ripe lor a rapid fatality. Fig. 467. — Cystotomy. Bladder fixed to the abdominal wall, sutures passing through the recti; bladder opened. Shortly after the rupture of the urethral wall, the perineal tissues become edematous, and the scrotum and penis markedly swollen. The infiltration soon involves the pubic and hypogastric regions. The symptoms are those of sepsis: rigors, fever, pulse rapid and weak, tongue dry, anxious fades, profound depression generally, the symptoms depending in degree upon the duration of the accident, 634 INFILTRATION OF URINE. Fig. 468. — Cystotomy. Sutures connecting the edges of the bladder wound and the skin. Repair of the abdominal wall. I Ki \i Ml \ I i 'I INFILTRATION. tin' rapidity of the urine'.- spread and its septii ity. Diffuse phlegmon and gangrene may rapidly ensue. The rupture usually OCCUTS in fronl of the triangular ligament — tin- deep perinea] fascia and so the urine moves forward toward the scrotum and pubes, which is tin- direction of least resistance [Fig. I'.,;). Fig. 469. — Rupture of the urethra in front of the deep perineal fascia and at point of entrance to the bulb; showing the direction which the infiltrating urine may take into penis and scrotum, perineum and suprapubic region. (Veau after Hartmann.) The treatment has two ends in view: to relieve the burdened tissues and to open up a passage to the point of rupture. To relieve the engorged tissues, a series of parallel incisions are to be made, extending beyond the limits of apparent infiltration, for the deeper tissues are always more widely involved than the superficial. The incisions should be deep enough to reach the deep fascia. The bleeding is not likely to be serious, but any bleeding points may be caught up, and if the oozing still persists, the incisions may be packed with iodoform Rauze. 6 3 6 INFILTRATION OF URINE. To expose the urethra, put the patient in the lithotomy position and make an incision in the middle line, beginning at the base of the scrotum and terminating in front of the rectum (Fig. 470). There is no guide but the middle line, for the tissues, thickened and infiltrated, are unrecognizable. There is nothing to do but continue to cut, keeping in the middle line, until rewarded by a spurt of urine. All the incisions are to be thoroughly irrigated with hot normal salt solution, the tissues gently squeezed and the dead tissues removed. A compress saturated with peroxide is next applied, this covered with absorbent cotton, and the whole retained by a T-bandage. Fig. 470. — Perineal incision for infiltration of urine. {Veau.) r Ordinarily drainage is unnecessary, for the open wounds give free escape to the fluids. Often one is surprised at the completeness of the repair. At first the urine flows out through the breach in the perineum, but after a little while a catheter may be passed and fastened in the bladder and the perineal wound allowed to heal. Lejars prefers the thermo-cautery to the bistoury, both because the hemorrhage is less and because it exercises a salutary action upon the tissues about to become gangrenous, but Veau believes the knife to be better, because it does not seal the mouths of interstitial drains. If, in the course of intervention, an abscess cavity extending up DRAINAGE FOB [NFILTRATION. 637 toward the pubes is found, a drainage tube musl I"- passed as bigb as possible and fastened in position (Fig. 471). Sometimes it happens that the urethral rupture occurs behind the perinea] fascia, and again taking the direction of least resistance, the prine may pass up along the side <>f the bladder t<> the deep layer- oi the abdominal wall; or it may pass downward and backward into the Fig. 471.— Infiltration of urine; placing drain. (Veau.) ■chio-rectal fossae. This condition is all the more dangerous for the reason that the external manifestations are often delayed and in consequence the true condition is not suspected until too late. But whenever a zone of infiltration is found, wherever it may be, incise it and reach the urethra if possible. In the infra-pelvic in- filtrations it may be necessary to open and drain through the bladder. CHAPTER XXI. SUTURE AND LIGATION OF ARTERIES. In emergency surgery the suture of a divided vessel is occasionally applicable, but the doctor will usually prefer ligation, which will nearly always suffice. To suture a vessel, the blood current must be under temporary con- trol by means of a clamp protected with rubber, that the tunica interna may not be injured. The vessel wall is seized with a fine forceps. The silk sutures are placed one-sixteenth of an inch apart in a longitudinal wound, and only the outer coats are pierced. If an end-to-end anastomosis is required, three sutures are recom- mended by Murphy and the proximal end is invaginated in the distal, the sutures being passed first through the proximal and finally through the distal end from within outward and tied. The indications for arterial suture are as follows: i. Where ligation might bring about serious nutritional change. 2. In all wounds of large vessels. 3. Operative wounds where a part of the vessel must be sacrificed. LIGATION OF ARTERIES. It is a rule almost without exception that a divided artery must be exposed and both ends tied. Occasionally, in the case of secondary hemorrhage, it will be im- possible to secure the artery at the site of the hemorrhage and ligation at some point in the course of the artery above the lesion will then be imperative. So that though only rarely to be used in emergency sur- gery, yet the technic of special ligations should be kept in mind. General rules for all ligations may be formulated: 1. Put the patient in some position best to expose the artery and its landmarks. 638 Gl M R \l. Rl LES 1 OB I I'M EON. 639 2. Outline Ihe course of the vessel, using aniline if necessary. 3. Tie the vessel, bul avoid tying mar the origin of a large branch, if possible. i. I .it the middle of the -kin incision correspond t<> the point of ligation and let its length depend upon the depth of the vessel. 5. Let tin- first incision include the skin and superficial fascia; the incision in each succeeding layer should be the same length as the first. 6. Each structure must be identified as exposed. Fig. 472. — Ligation of an artery. A. opening the sheath; B, passing the ligature; C, tying the ligature. (Moullin.) 7. The sheath of the vessel is to be recognized by its position, pul- sation, and feel to the examining finger. 8. The sheath is pinched up in the form of a cone, the base of jrhich is incised with edge of the scalpel turned away from he vessel. 9. Through this small opening the vessel is gently detached and the aneurysm needle passed, beginning usually on the side in relation with the vein and keeping it in close contact with the artery (Fi.u- 47-.)- 10. After the needle is threaded and withdrawn, be assured that Other structures will be included in the ligature. 640 SUTURE AND LIGATION OF ARTERIES. 11. Draw the knot tightly enough to occlude the lumen of the vessel, but not tightly enough to crush the inner coat. 12. The subsequent treatment is that of an ordinary wound. THE COMMON CAROTID (Fig. 473) • The line of the artery corresponds to the anterior border of the sterno- mastoid. The incision should be three inches long in this line, the middle of the incision corresponding to the cricoid cartilage. Divide the skin, :2)esccnd.eiiS \noni nerve r-~0mo-7iyold s \ muscte ' Carctid "" '.artery Inb-jm '/ . vein 'fintT border of JSiermg Mastoid Muscle Fig. 473. — -Ligation of the common carotid and facial arteries. (Moullin.) fascia, platysma; catch the bleeding veins, and divide the deep fascia along the sterno-mastoid, exposing the sheath upon which lies the de- scendens hypoglossi and the omo-hyoid. Just above the omo-hyoid, open the sheath from the inner side so as to avoid the internal jugular. Pass the needle from outside, also to avoid the internal jugular. LIGATION 01 I in SUBCLAVIAN. 6 | I EXTERNAL CAR< 'III*. Line. Continuation of the common carotid. Incision. From the angle of the jaw to the thyroid cartilage, divid ing the skin, fast ia, and platysma. Ligate divided veins. Divide the deep fascia, exposing the sterno mastoid, which is to be ^tr acted. Locate the posterior belly of the digastric, the hypoglossal ftrve, and the tip of the cornu of the hyoid. Expose the artery opposite the cornu; pass the ligature between the juperior thyroid and the lingual arteries, avoiding the decendens hypo glossi and the superior laryngeal nerve behind. The operation pre supposes patience and a thorough knowledge of the anatomy. Through this same incision the superior thyroid, the lingual, the facial, the occipital, and the ascending pharyngeal arteries may be tied at their origin. LINGUAL (Beneath the Hyoglossus). Position. — Place the patient on his back, turn the head to the oppo- site side and raise the chin (Fig. 474). Incision. — Curved, its center just over the greater cornu of the hyoid, extending from the symphysis of the chin to the angle of the jaw. Divide the skin, superficial fascia, platysma and deep fascia. Ligate the numerous veins which may be divided. Locate the lower border of the submaxillary gland and divide its fascia, thus exposing it, and lift it upward out of the way. Develop the mylo-hyoid; also the two bellies of the digastric and draw them down firmly. In the bottom of the wound is the hyoglos- sus muscle. Identify the hypoglossal nerve with the lingual vein, which cross the hyoglossus. Incise the hyoglossus below, and parallel with, the hypoglossal nerve. Incising carefully, the artery bulges into the wound. Ligate the artery on the proximal side of the dorsalis linguae. SUBCLAVIAN (Third Portion). Position. Plate the patient on his back with shoulders raised, head turned to opposite side, and angle of shoulder depressed (Fig. 474). Incision. — From the posterior border of the sterno-mastoid, over the 41 642 SUTURE AND LIGATION OF ARTERIES. clavicle, to the anterior border of the trapezius, drawing the skin down first to prevent wounding the external jugular. Relax the skin. The incision now lies one-half inch above the clavicle. If more room is needed, partially divide the trapezius and sterno-mastoid. Divide the deep fascia and ligate veins. If the transversalis colli or the suprascapular arteries present, draw them to one side. Fig. 474. — Ligation of the subclavian and lingual arteries. (Moullin.) Now identify the scalenus anticus muscle — a very important step,! as it is the guide to the artery. Follow the external border of the, muscle down to the first rib and there the pulsations of the artery will be felt. Identify the lowest cord of the brachial plexus, which, as well as the pleura and the subclavian vein, must be avoided in passing the ligature. LIGATION "I I III UK \< III \l .. THE AXILLARY (Third Portion). Position. Patient supine, shoulders raised, arm at a right angle; ■perator between arm and body (Fig. .175). Incision. -Along the line of junction of the middle and anterior third of the floor of the spa< e. I >i\ ide the skin and fascia and expose the inner border of the coraco- jrachialis. Draw the coraco-brachialis, the median and musculo- cutaneous nerves outward, the ulnar and internal cutaneous nerves in- ward. Avoid the basilic and axillary veins. f*TtTe/>-Tnrtte&ia7t* mutclf ? /n'K.\! 645 ;inu TIBIAL (Lower Third). Position. Same as above. /;/< ision. Lot ate the lend on of the tibialis anti< us; along its external border divide the skin for three inches. Find the septum between Fir.. 480. — Ligation of the posterior tibial artery. The gastrocnemius retracted; the soleus divided. (Moullin.) the tibialis and the extensor proprius hallucis. In this space lies the artery with the nerve to the front and outer side. Pass the liga- ture from without inward. DORSALIS PEDIS. Position. — Patient on back with foot extended and resting on heel. Incision. — Two inches long beginning at the middle of the lower border of the annular ligament. Expose and separate the tendons of the extensor proprius hallucis and extensor longus digitorum; the artery is seen lying upon the tarsal ligaments. The nerve lies to the fibular side. Pass the ligature from without inward. POSTERIOR TIBIAL (Middle Third). Position. — Patient on back; leg and thigh Hexed; thigh rotated out- ward so (hat leg lies on its outer side (Fig. 480). Incision. — Four inches long, along the line three-fourths inch be- 6 4 8 SUTURE AND LIGATION OF ARTERIES. hind the internal border of the tibia. Expose and divide the deep' fascia. Expose and develop the inner border of the gastrocnemius; re-i tract and thus expose the soleus attached to the inner border of the tibia. Divide the soleus vertically, and at the bottom of the wound is seen the yellow fibrous aponeurosis which covers the vessels and deeper layer of muscles. Divide the aponeurosis about one and one-half inches from the internal border of the tibia and expose the artery. Draw the nerve to the outer side and pass the ligature from without inward. Fig. 481.— Ligation of the posterior tibial behind the ankle. (Moullin.) POSTERIOR TIBIAL (At the Ankle). Position.— Turn the foot on its outer surface (Fig. 481). Incision.— Curved, three inches long, with center midway between malleolus and the inner tuberosity of the os calcis. Divide the fascia and the internal annular ligament cautiously. The artery is just be- neath the ligament. Separate the veins and pass the ligature from without inward. CHAPTER XXII. SOME PRACTICAL AMPUTATIONS. The primary aim of an amputation is to conserve the life or health of the patient; the secondary aim is to conserve, as much as possible, the function of the member. The first requires that as much as m ■< es sary be removed; the second, that no more than necessary be removed. The good surgeon will always adjust and harmonize these two prin- ciples and they will determine the time and technic of the particular operation. The time element is of especial concern in traumatism and gangrene, for if the operation is done too early, too much may be removed in one case and too little in the other. In traumatism, tissue that at first sight seemed beyond remedy may survive; in gangrene, tissue that seemed viable may be left, only to necessitate another dangerous operation; so that following traumatism it is better not to operate until the limit of the devitalized tissue has been definitely determined; and in the case of gangrene, until the line of demarcation has definitely formed. The technic is principally concerned with conservation of function, and looks to the formation of a good stump. "A stump to be service- able, should be sound, unirritable, with good circulation and abundant leverage" (Bryant, Operative Surgery). To produce a stump with these qualities requires prevision of the flaps, particularly their shape, length, and vascularity. Upon their shape will depend the position which the cicatrix will take; upon their length, the comfortable ad- justment of skin and bone; upon their vascularity, the prompt repair, proper nutrition, and subsequent freedom from disease. The cicatrix should fall where it will be least subject to pressure and friction wherever that may be done without the sacrifice of useful tissues. In determining the position of the cicatrix, one must then consider the occupation of the patient and the possibility of an arti- ficial limb being worn. 649 650 SOME PRACTICAL AMPUTATIONS. In the case of the leg, for example, the greatest tension might fall on the end of the stump, and a scar there be some source of annoyance; in the case of an arm, more pressure might fall on the side, from arti- ficial appliances, and an end scar would therefore be more satisfactory. Nerves likely to be pinched up in the cicatrix should always be resected. The ends of severed tendons should likewise be resected, but not so high that their empty sheaths may be left to favor the lodgment of infection. That the stump may be sound and uniform in its outline, it is neces- sary that the different degrees of contractility of the various groups of divided muscles be known and their division accomplished accordingly, so that finally their ends may occupy the same level. The bones must also be sawed squarely and care taken that the division is not com- pleted by fracture. The periosteum also must not be too roughly handled. The technic is concerned also with the prevention of hemorrhage. This is best secured by first elevating the limb for several minutes and then applying an Esmarch tube above the site of the operation. After the section of the limb is completed and the large vessels se- cured and ligated, the tube must be removed and each bleeding point ligated separately. The tube has the disadvantage that there is nearly always a temporary vasomotor paralysis due to the pressure, and on that account the oozing is considerable. The occasional surgeon will be called upon to do amputations under two entirely different circumstances, and his mode of procedure will be quite different in the two cases. In one case, he will attempt the typical amputation of the text-book; in the other, his sole guide will be the preservation of tissue: he will do an atypical amputation. (A) The soft parts are more extensively destroyed than the bone. This is nearly always the case in traumatism and always the case in gangrene. The site of amputation will depend upon the limit of the sound skin; the rule is to remove none of the healthy soft parts; the line of incision should follow the line of demarcation, and having fashioned the flap following this indication, divide the bone high enough to accommodate the flaps, and no higher. (See also Injuries to the Extremities.) wiim I \ I Ion i»l FINGERS. 651 (H) In case the bone is more extensively destroyed than the soft parts, as in tuberculosis, sarcoma, etc., one bas more option; he can fashion the flaps in any manner desired, for usually nun h tli.it is bealthy will bave in lie removed. Tin- position of tin- i i< atru 1 an be determined and such is the typical amputation. FINGER AMPUTATIONS. Practical anatomical points (Jacobson, Operative Surgery): "The three creases in front almost correspond to the joints. The lower crease is just above the joint; the middle is opposite the joint; the highest, nearly 3/4 of an inch distal to the metacarpophalangeal joint. "The prominence of the knuckles is formed by the higher of the two bones; by the head of the metacarpal bone, the bead of the first phalanx, the head of the second phalanx for the three joints respectively. Fig. 482. — Typical amputation of finger; palmar flap, dorsal scar. (Farabeuf.) "The joint in each case is below, or distal to, the prominence; the metacarpophalangeal joint is about 1/3 inch below the knuckle; the second joint, 1/6 inch below the knuckle; the terminal joint 1/12 inch beyond the knuckle. "In the distal and intcrphalangeal, the joint is concave from side to side and presents a concavity toward the finger tips. In the meta- carpophalangeal joint, the convexity is toward the finger tip. "From the readiness with which the tendons conduct infection, care should be taken to keep even so small an amputation as that of a finger strictly sterile, and in amputating through damaged parts the flaps should not be too closely united with sutures." It is a rule with but few exceptions to save as much of the finger as possible, and it will almost always happen in removing part of a finger that an atypical amputation will be indicated. Let the scar fall where 652 SOME PRACTICAL AMPUTATIONS. it will, making a dorsal or a lateral flap if necessary. The palmar flap and dorsal scar is ideal, but rarely attainable (Fig. 482). There are, however, surgeons of large experience who insist that a palmar flap be secured even at the cost of more finger, and that less than half a phalanx should not be saved, but cut back to the joint to avoid flexure. (See Ir»ji ries to the Hand.) If ? iutal phalanx is to be removed, begin by pronating the hand, forcibly flex the phalanx and divide the skin one-half inch distal to the Fig. 483. — Atypical amputation of a finger, the bone projecting beyond the skin. Dorsal incision. (Veau.) knuckle; this incision deepened will open the joint. Divide the lateral ligaments. The edge of the knife is carried under the phalanx and swept downward, grazing the bone and cutting with a steady sawing movement. The result is indicated in Fig. 482. Do not cut the flap too short, a common mistake with the inexperienced. AN ATYPICAL AMPUTATION. Suppose a finger to have been sawed off. The bone projects be- yond the retracted skin. It is not possible to fashion a flap without removing some bone. \ I \ PICAL I |\,,| |. : WH'I I \ ||i >N. 653 Local anesthesia (Figs. 8 and 9). Circular constriction al the base will control bleeding ami prevenl rapid absorption of tin- solution. Begin by making a dorsal linear incision an inch long down to the bone (Fig. 483). I ,iberate the whole circumferem e of the bone one-third inch up, either with a rugine or a bistoury (Fig. 484), and at thai level divide the hone with hone forceps (Fig. 485). Employ two or three sutures with drainage if there is much chance oi infection (Fig. 486). PlG. 484. — Liberating the bone. (Vcau.) Fig. 485. — Section of the bone. (Veau.) If the dorsal linear incision opens into a joint, the section may be made there — disarticulate. Divide first the dorsal ligament, then the lateral ligament to the left, and as the phalanx is twisted toward the left, divide the lateral liga- ment to the right. Suture as before. It may be necessary to slice on' the head of the remaining portion of the digit if it is too prominent. TYPICAL AMPUTATION OF THE WHOLE FINGER. General anesthesia is usually necessary. The method of procedure is different for the middle and ring fingers, the index and little fingers, and the thumb. 654 SOME PRACTICAL AMPUTATIONS. (I) The Middle and Ring Fingers.— Locate the articular line by making traction on the finger with one hand and palpating each side of the joint with the index finger and thumb of the other hand. Fig. 486. — Atypical amputation: Suture and drainage. (Veau.) Fig. 487. — Typical amputation of middle finger: Primary incision directed to the right. (Veau.) Begin the incision at the upper level of the joint; carry it obliquely downward and forward between the fingers so that it reaches the palmar surface at the right, a little below the crease (Fig. 487). win I \ I [ON OF nil'. MIDDLE PING1 R. 655 Lift up the band so that you face the palm and cut transversely to the left (Fig. 488). Now lower the hand and complete the incision, bringing it obliquely upward and backward to the knuckle, the starting- point (Fig. 489). Having outlined the incision in this manner, repeat the movement, cutting to the bone. Retract the Bap, exposing the articulation Fig. 488. — Amputation of the middle finger: Lifting the hand while making the transverse, palmar incision, (veau.) Disarticulate. Pull on the linger to separate the joint surfaces, which helps to locate the joint line. Hold the bistoury vertically, and with its point divide the lateral ligament to the left, then the dorsal ligament (Fig. 490), then the ligaments to the right, at the same time 1 lending the finger to the right. Tic the digital arteries, usually one on each side, and suture (Fig. 491). (II) Index and Little Fingers. — In these two instances, the aim 6 5 6 SOME PRACTICAL AMPUTATIONS. is to carry the scar toward the dorsum and the axis of the hand. In the case of the index, it falls toward the ulnar side; in the case of the FtG. 489. — Amputation of the middle finger: Completing the skin incision. {Veau.) Fig. 490. — Amputation of the middle finger: Traction en the finger while the bistoury- cuts first the left and then the dorsal ligaments. (Veau.) little finger, toward the radial side. The scar is, then, in each case, furthest removed from pressure. The flap itself, of rounded outline, folds over on an axis passing AMPUTATION OP THE I I I I I I FINGER. 657 obliquely through the joint cavity and approximates the adjoining lager. In the case of the little finger, begin the incision just below the joint line on the ulnar side of the extensor tendon, and carry it obliquely downward and forward and then across the palmar surface, inscribing Fig. J91. — Amputation of the middle finger completed. (Vcati.) a regular semicircle which ends at the free border of the web between the little and ring fingers. Complete the incision by cutting from this point to the starling-point, inscribing a semicircle with its concavity toward the web. Follow this same track again, cutting to the bone. Denude the bone completely (Fig. 492). You will observe that the ex- tensor tendon is difficult to divide and requires especial attention. Disarticulate. Pull on the digit to expose the joint line and divide 42 6 5 8 SOME PRACTICAL AMPUTATIONS. Fig. 492. — Amputation of the little finger- Flaps completed. (Veau.) Fig. 493. — Amputation of the little finger: Disarticulation, cutting from left to right. (Veau.) Fig. 494.— Amputation of the little {vfJu) P aft6r disarticul ation. Fig. 495. — Amputation of the little finger: flap sutured. The line of union lies toward the axis of the hand on the dorsum. (Veau.) AMI'I IVi'lON <>l mi imikx FINGER. 659 the lateral ligaments to the left and then the dorsal, facilitated by slight flexion. Next, rotate the finger to the left and divide the lateral ligaments to the right. The joint is completely opened and the rest is easy (Fig. 493). The appearance of the flap is indicated in Fig. 494. Employ three or four interrupted sutures (Fig. 495). Fig. 496. — Amputation of index; showing form of flap. (Veau.) Fig. 497. — Amputation of index and little fingers completed. (Veau.) The removal of the index finger is conducted along the same lines. The first semicircular incision is carried around the radial side and completed by a second, following the web of the finger. The appear- ance of the flap is indicated in Fig. 496, and the final result in Fig. 497. If the patient is a laborer, it is necessary to render the hand as useful 66o SOME PRACTICAL AMPUTATIONS. as possible, nor must the cosmetic effect be neglected. It is neces- ij sary to reduce the size of the heads of the metacarpal bones. The head of the metacarpal bone of the index is best reduced by an ' oblique section of the radial side; of the little finger, the ulnar side ; ; ; of the ring finger, by transverse section (Fig. 498). With regard to the j middle finger, the head of its metacarpus should not be removed:; unless shapeliness rather than strength is desired (see page 99). Fig. 498. — Lines of section of the metacarpal heads. (Veau.) ATYPICAL AMPUTATION OF THE ENTIRE FINGER. In the case of the ring or middle finger mashed off near the meta- carpo-phalangeal joint, it is useless to try to save the stump, as its presence will be an actual hindrance to the other fingers. Disarticulate. Make a dorsal incision (Fig. 499), extending a centimeter above the metacarpal head. Raising the finger and cutting from left to right, carry the incision around the base near the limit of the sound tissue (Fig. 500). Denude the bone, exposing well the metacarpal head and hold the AMPUTATIONS OF THE Till ML. 66l flaps well back out of the way. Divide the tendons in the manner al- ready indicated for the amputation of the finger (Fig. 501). Steady the head of the bone and pinch off with a bone forceps (Fig. 502). (Ill) The Thumb.— The thumb must be treated with the utmost conservatism. The smallest part must never be removed unneces- sarily, as it is almost as useful as the rest of the fingers together, Fig. 499. — Crush of ring finger requiring atypical amputation. Dorsal incision to expose articulation. (Lejars.) and nearly always after a traumatism, it is best to do an atypical amputation. In the typical amputation, employ a palmar flap. Begin on the dorsal surface just below the articular line and incise to the right, reaching the edge of the palmar surface just above the interphalangeal crease. Now go back to the starting-point and make an incision to the left 662 SOME PRACTICAL AMPUTATIONS. similar to the first, and complete it by a transverse incision joining the first. The "U "-shape is indicated (Fig. 503). Repeat the incision, cutting to the bone, and dissect up the flap. Strip back all the soft parts down to the joint, while an assistant holds the thumb. Disarticulate. Take hold of the thumb again and direct the as- Fig. 500. — Atypical amputation of the entire finger: Anterior circular incision. (Lejars.) sistant to retract the flaps. Make strong traction and cut the liga- ments to the left, above, and then to the right, twisting the thumb to make them tense. Suture. AMPUTATION OF A FINGER AND ITS METACARPAL. Typical amputation (infrequent) : (1) Middle and Ring Fingers. — Begin the incision over the carpo- metacarpal line (on the line drawn between the bases of the meta- carpals of the thumb, and little finger) and descend along the bone; SO. UK TU \i I [CAL AMI'! I \ [IONS. 663 Fig. 501.— Atypical amputation of the entire finper: Disarticulation. (Lejars.) Fig. 502. — Atypical amputation of the entire finger: Resection of the head of the metacarpus. (Lejars.) 664 SOME PRACTICAL AMPUTATIONS. follow the web, cross the palmar surface, and ascend to the starting- point (Fig. 504). Denude. This is sometimes difficult. Dividing all the tissues around the head of the metacarpal, work up and toward the wrist, remembering particularly that the deep palmar arch crosses the middle of the bone and is in touch with it. It must not be injured. Disarticulate by dividing the bone at its base with a bone forceps. (2) The Index and Little Fingers. — The procedure is the same as before except that the incision on the side opposite the axis of the hand Fig. 503- — Line of incision for amputa- tion of thumb. {Farabeuf.) Fig. 504. — Lines of incision for remov- ing index and ring fingers and their cor- responding metacarpals. (Veau.) extends below the level of the web, in order that on that side the flap may be longer so that the scar will fall away from the margin of the hand. (3) The metacarpal of the thumb may be regarded as a finger; make the same sort of racket incision. Save all of the metacarpal possible (Figs. 505, 506, 507). Atypical Amputation of the Hand. — (Traumatism of the meta- carpals) (Fig. 508). It is often inadvisable to amputate at once, for parts that seem de- vitalized may survive. AM IM I \ I |c>\ OP Mil II \M'- 66 5 Secure hemostasis and cany out a most rigorous disinfection, suture with ample drainage and await the course of events; the limits of viable tissue tan soon be determined. Amputate before gangrene sets in. Rather, as Lejars says, you do aol amputate, but trim up. It is the rule to remove the projecting bone without any regard to a typical amputation. PlG. 505. — Crushing injury destroy- ing thumb. Part of its metacarpal to be saved. (Lejars.) Fig. 506. — Denuding metacarpus preparatory to its section. (Lejars?) Denude the bone as far back as the skin flaps demand (Fig. 509). Use bone forceps (Fig. 510). Suture loosely with ample drainage (Fig. 511). Apply a moist dressing, which is to be changed daily; and if the temperature rises, remove the sutures and give the hand a pro- longed immersion in hot normal salt solution and renew the dressings. Similar amputation, thumb saved (Fig. 512). 666 SOME PRACTICAL AMPUTATIONS. AMPUTATION OF THE FOREARM. Disarticulation at the wrist is very rarely done in general practice. If a tuberculosis of the wrist calls for intervention, amputate the fore- arm (Fig. 513). Following traumatism, do an atypical amputation, conserving as much as possible of the member. Fig. 507. — Atypical amputation of the thumb complete; part of metacarpus preserved. Drainage. (Lejars.) Typical amputations of the forearm are most easily performed at any level, by a modified circular incision; the dissection of the cuff is facili- tated by two lateral vertical incisions if at the level of the section the mem- ber is conical. Determine first where you propose to divide the bone. The section of the skin must fall some distance below that of the bone. The section of the bone should be made about the distance equal to the diameter of the limb above the skin section. SOME PRACTICAL AMPUTATIONS. 667 Fig. 508. — Injury to hand. Useless to try to save any but the index finger. (Veau.) Fig. 509. — The metacarpals are denuded upward for an inch ; all the soft parts saved. (Veau.) 668 SOME PRACTICAL AMPUTATIONS. Circular Incision.— Begin by dividing the skin in front (Fig. 514), and complete the circle posteriorly (Fig. 515). Divide nothing but the skin and fascia. Lateral incisions are to be made extending upward two or three fingers' breadth (Fig. 516). Transfix. Direct the assistant to hold the hand supinated and flexed to relax the flexor muscles, while the point of the knife is intro- FlG. s 10. —Section of metacarpals with bone-cutting forceps. (Veau.) duced laterally at the upper end of the nearest vertical incision (Fig. 517). Elevate the point of the knife as it approaches the bone so that it grazes over the bone. Drop the point into the interosseous space and elevate again as it comes in contact with the second bone. When it emerges at the opposite side at the same level, the knife is swept downward, its cutting edge held close to the bones, and the tissues are cleanly divided longitudinally until the level of the circular skin in- SOMi: PRACTICAL AMPir.MIoNS. 669 cision is reached, when the blade is made abruptly t<> cut toward the surface (Fig. 518). As the section toward the surface is made, the assistant should extend the hand slightly, the tense tendons being more easily divided. Pass the blade posteriorly in the same manner, and as the knife cuts Fig. si i. — Amputation completed. {Vcau.) toward the surface the hand should be flexed. The muscles which fill in the interosseous space as well as those which are closely attached to the bones are yet to be divided. Fig. 519 indicates the manner in which this is accomplished. The interosseous membrane requires special attention. Denude the bones of periosteum from below upward (Fig. 520). 670 SOME PRACTICAL AMPUTATIONS. Fig. 512. — Ampu- tation of the hand. Thumb saved. (Senn.) The adjacent surfaces of the bones are especially difficult to denude, but take the time for it. Pass a sterile compress between the two bones and one on either side to act as retractors while the bones are sawed. Saw the bones at the level of the periosteal flaps. Notch the ulna first, then completely divide the radius and finally the ulna. The median nerve will be found in the midst of the muscles of the anterior flap and the ulnar internally, the posterior interosseous is more diffi- cult to find posteriorly. Resect them high enough to escape the scar. Draw the periosteal flaps over the end of the bones and if desired, they may be sutured with catgut. Suture the skin and muscle flaps, and, if necessary, drain (Fig. 521). AMPUTATION AT THE ELBOW-JOINT. Make a circular incision three inches below the joint, involving the skin and fascia. Turn back the cuff to the joint. Divide the muscles over the joint line. Divide the lateral liga- ments. Open the outer side of the joint first and, directing the assistant to make traction on the arm, separate the ulna and divide the triceps. Tie the arteries, resect the nerves, and suture. AMPUTATION OF THE ARM. Apply an Esmarch tube high up near the axilla, or an assistant may compress the artery in the upper part of the arm or behind the clavicle. Stand to the outer side of the arm. Retract the skin with the left hand if operating on the fig. 513. -Amputation right arm, or direct the assistant to retract the il&thT^rist. T (S SOMK PRACTICAL AM l'l TATIONS. 67I Fig. 514 — Amputation of the forearm: Beginning the circular incision. {Veau.) Fig. sis. — Amputation of the forearm: Completing the circular incision. (Veau.) 672 SOME PRACTICAL AMPUTATIONS. skin if operating on the left arm. The skin section must lie about one diameter below the proposed bone section (Fig. 522). Divide the tegument and fascia anteriorly first and then posteriorly. When dividing internally, remember that the artery is quite superficial. If a long blade is used, the complete incision of the skin may be accomplished by a single circular sweep; the hand carrying the knife is passed under the limb until the heel of the knife rests on the top of the limb, and then with slight sawing movements, the knife is made to Fig. 516. — Lateral incisions. (Veau.) encircle the arm, dividing the skin successively above, internally, below, externally, and above again, reaching the starting-point. It may be necessary to make the pass a second time to divide the fascia. Retract the skin freely; it may be necessary to free the fascial at- tachments with the point of the knife. Do not "button-hole " the flap. The adhesions are most marked internally over the artery. The divided skin retracts about one and one-half inches (Fig. 523). In the meantime there is considerable venous hemorrhage. Divide the muscles by a circular sweep at the level of the retracted S0M1 PB \« l n M, win I \ riONS. 673 Fig. 517. — Transfixion. (Vcau.) I'ig. 518. Completing the anterior Hap, cutting outward following transfixion. (Vraw.) 43 674 SOME PRACTICAL AMPUTATIONS. skin, cutting to the bone (Fig. 525). If a scalpel is used, cut internally last, so that the artery is last divided. Work fast, for the bleeding will be free. Divide the muscles a second time, for the first section finds them retracting unequally. Divide them at the level of the retracted skin (Fig. 526). Be sure that all the soft parts are divided. Catch up the bleeding points and then denude the bone for an inch (Fig. 527). Retract the flaps with sterile compresses and saw the bone as high as the flaps will permit. Fig. si 9. — Lines of incision to complete section of the soft parts. (Farabeuf.) Begin the section with the heel of the saw on the bone steadied by the thumb; take care, at the end, not to sliver the bone. Tie the brachial artery and then the veins with strong catgut; finally tie all of the smaller vessels. Suture the muscles first over the end of the bone, and then suture the skin. AMPUTATION AT THE SHOULDER-JOINT. Amputation at the shoulder may be performed by a variety of methods, each of which has its advantages and disadvantages. The special points to be thought of in making the operation are the control of hemorrhage, good drainage, easy disarticulation and a good stump. No one operation, perhaps, secures all of these principles in equal degree. Spence's method is recommended as generally serviceable. Recall the principal landmarks of the shoulder-joint, the acromion process, the coracoid, the tuberosities; recall the attachments of the various muscles; and the relations of the blood vessels. W1IM l.\l |(>.\ AX mi; SIK >l 1 I >l K. 675 The patient is placed with his shoulder close to the edge of the table, with shoulder elevated, and face turned to the opposite Side. The operator stands to the outer side. The operator aims at the exposure of the joint and disarticulation, and finally the formation of an axillary flap. Incision. — (1) Begin just in front of the coracoid process and cut vertically downward to the lower level of the tendon of the pectoralis Fig. 520. — Stripping back the perios- teum with the rugine. (Veau.) Fig. 521. — Amputation complete. Trans- verse drainage. (Vcau.) major, keeping in front of the groove between the pectoralis major and deltoid. This incision should reach the bone; the pectoralis major tendon is divided. The bleeding comes from the humeral branches of the acromio-thoracic and from the anterior cicrumtlex. These vessels may be clamped. (2) Next carry the incision outward across the arm, making a slight 676 SOME PRACTICAL AMPUTATIONS. curve, convex downward, and ending at the axillary border. All the structures are divided to the bone. The deltoid is divided just above its insertion and the hemorrhage comes from the muscular branches. The next step consists in outlining the internal flap by making an Fig. 522. — Circular section of the skin. (Veau.) oval skin incision, which extends from the termination of the first across the inner surface of the abducted arm to the end of the vertical part of the first incision (Fig. 527). The third step consists in elevating the external flap which contains the deltoid. It is easily dissected and by this means the joint is ex- WIIM I \l I < » N A l I III SHOT LDER. 67' posed. The posterior circumflex artery must not lie injured and is preserved in the deltoid flap. The fourth stage: Disarticulate. Begin by dividing tin- l>ii" tin- shoulder-joint or as an emergency in the case of crushing injury to tin- shoulder <>r of gun- shol wounds. The procedure as defined by Berger contemplates the resection oi tlu- middle third of the clavicle and Ligation of the subclavian; the Fig. 525. — Second circular incision of soft parts at level of retracted skin. (Veau.) Fig. 526. — Denuding periosteum with rugine. (Veau.) formation of the anteroinferior and a postero-superior flap; and finally the division of the muscles connecting the scapula with the trunk. The operation is thus described: Place the patient on his hack close to the edge of the table, with the shoulder slightly elevated. Begin the incision over the clavicle at the outer border of the sterno-mastoid, and follow the clavicle outward to the acrominal end, cutting to the bone. Denude the middle third i)i its periosteum with the rugine, and divide the bone at the junction of the inner and middle thirds. Elevate the bone and divide again at the junction of the middle and outer third. Separate by blunt dis- 68o SOME PRACTICAL AMPUTATIONS. section the fascias overlying the subclavian vessels and first ligate the artery at the outer border of the first rib and then the vein. Now change the patient's position: the shoulder is brought over the edge of the table, the arm abducted, and the head turned to the oppo- site side. Form the antero-inferior flap. Begin an incision at the middle of the first and carry it obliquely downward and outward; just to the outer side of the coracoid process, along the anterior border of the deltoid, to the axillary border and thence across the inner surface of the arm just below the axillary fold and thence down the axillary border of the scapula. Divide the pectorals and the latis- simus dorsi close to their insertions. Resect the nerves of brachial plexus. From the poster o-superior flap. Begin the incision over and just internal to the acromio- clavicular joint and carry it downward over the spine of the scapula to the lower angle of the scapula, where it joins the preceding incision. Dissect the flap and expose the muscles. Divide first the trapezius and then with heavy scissors divide close to the bone, the muscles attached to the posterior border, the serratus magnus, the rhomboideus major and minor, and the levator anguli scapulae. Complete the hemostasis and drain through button-holes in the flaps in the axilla and scapular region. Bandage firmly so as to obliterate the cavities. Pig 527. — Spence's amputa- tion. (Moullin.) The arm falls away. AMPUTATION OF THE TOES. These amputations are more frequently consequent upon trauma- tism; occasionally for deformity or other painful conditions. In the amputation of fingers, as much as possible is saved; in the amputation of toes, the whole toe is nearly always removed. In consequence, these amputations are usually typical, for one does not so much need to concern himself with the conservation of tissue. win i \ i io\ ui i ill GR1 \ i i"i 68] In the case of total ablation of the finger, a pan of the metacarpal lead must usually be removed i" enhance function; the bead of the metatarsals must always be saved, where possible, t<> preserve the func- tions of the loot. The position of the cicatrix demands more attention in the case <»t tin- toes. A special effort must be made to leave the scar farthest from pressure; that is, dorsal and to the inner side with reference t<» the axis of the foot. Local anesthesia is often sufficient, forming an anesthetic ring around tin' entire toe, involving the skin. The injection may need to be renewed for the deeper tissues; and before disarticulation, inject the joint. AMPUTATION OF THE GREAT TOE. In amputation of the great toe, the flap resembles that of the index finger and the scar adjoins the base of the second toe. Begin by locating the joint line. The incision commences just 1 PlG. 528. — Lines of incision for am- putation of big toe. (Farabcu}.) Fig. 529. — Amputation of big toe completed. (Farabeuf .) Fig. 530. below this, and over the tibial border of the extensor tendon, and extends with a slight outward convexity, downward and forward to the interphalangeal crease on the plantar surface and across the palmar surface obliquely, ending at the web. Begin on the dorsum again at the original starting-point and with a slightly curved incision, join the ends of the first (Fig. 528). 68 2 SOME PRACTICAL AMPUTATIONS. Dissect the flap, keeping close to the bone, so that all the soft parts shall be preserved in the flap. Divide the flexor tendon — sometimes rather difficult. Disarticulate. Divide, first, the lateral ligaments to your left, then the dorsal, and finally those at your right. Divide the plantar liga- ments, twisting the toe, as in the case of the finger. Employ drainage; pull the flap into position and suture. The shape of the flap and the position it assumes are represented in Figs. 529 and 530. AMPUTATION OF THE LITTLE TOE. Incision. — Begin at the inner end of the joint line and cut obliquely downward and outward, meeting the plantar surface at the joint line below, and then backward and inward toward the web (Fig. 531). Fig. 531. _ Fig. 532. Fig. 533. Amputation of the little toe. (Farabeuf.) In this manner a convex flap is formed (Fig. 532). Dissect the flap, preserving in it all the soft parts. Expose the joint line. Disarticulate. Making vigorous traction on the toe, divide in reg- ular order the lateral, the dorsal, the lateral (to your right), and plantar ligaments. Drain from the upper part of the incision and suture. The position of the cicatrix is represented in Fig. 533. AMPUTATION OF ONE OF THE MEDIAN TOES. Incision. — The line of the joint having been determined, begin just above it on the dorsum, incising forward and downward to just below WIIM I'AIION Ml K.I \\ Mil [TS Ml I \T\KSrS. 683 the web, crossing tin- palmar surface and bach to the starting point, Completing the racke! (Fig. 534). Remember thai the metatarso phalangeal joint is considerably above the line of the web. Denude mil divide the flexor tendon. Disarticulate in the manner already described for the other toes. Drain from the upper end of the in< ision and suture (Fig. 535). Fig. 534. — Line of incision for amputation of toe. (Veau.) Fig. 535. — Suture and drainage after amputation. (Veau.) AMPUTATION OF A TOE WITH PART OF ITS METATARSUS. This amputation presents some difficulties in dissecting the flaps, )ecause of the palmar projection of the head of the metatarsal. The incision is racket-shaped, as in amputation of the toe, but it >egins higher up, above the level of the diseased bone, and runs down o the web, across the palmar surface and back to the starting-point, .s represented in Fig. 536. To dissect the Haps for the middle toes, lenude the dorsum of the metatarsus and divide it with the bone for- eps, and lifting upon the divided end, dissect forward along the pal- nar surface. The metatarsus of the little and great toes may be sawed. In 684 SOME PRACTICAL AMPUTATIONS. forming the flap for the great toe and its metatarsus (Fig. 537) doil forget to remove the sesamoid. Drain as in amputation of the tot, and suture. Fig. 536. — Lines of incision for removal of toes with head of corresponding metatarsals. (Veau.) Fl G. 53 7. — Amputation of big toe with head of metatarsal. (Farabeuf.) AMPUTATION OF A PART OF THE FOOT. As in the case of the hand, the rule is to conserve as much as possibl' of the foot with this proviso, that a painful mass of scar tissue dod not form in the stump and the action of the flexors of the foot i retained. In the case of traumatism or gangrene, where the soft parts ar \i \ I'll \i win i \ i m\ oi i in FOOT. 685 oore involved than the bone, the line of section follows the healthy J kin and the hone section will be made to accommodate itself to the kin flaps. Atypical Amputation.— 1i the case is one of tuberculosis, the bone is acre involved than the skin, and one may determine the Upper limit ig. 538. — Following the line of demarcation. Atypical amputation. (Veau.) Fig. 539. — Dividing the bones. (Veau.) f the diseased hone and divide it there. In such a case, one may ishion a palmar flap, and make a dorsal scar — the typical amputa- on. But, as Veau says, do not concern yourself with the formal perations, such as a Lisfranc or a Chopart — excellent exercises on ic cadaver — but saw the hones where you must, to remove all the risease. 686 SOME PRACTICAL AMPUTATIONS. In the case of gangrene or traumatism, then, divide the tissues t the bone, along the line of demarcation. The borders of the palmar and dorsal flaps must correspond t the borders of the foot (Fig. 538). Once the soft parts are dividec Fig. 540. — Suturing extensor tendons to skin flap. (Veau.) Fig. 541. — Suture and drainage. (Veau.) they should be retracted by dividing their attachments close to the bone, and the bones are divided high enough for the flaps to come'; together (Fig. 53 9 ). In the case of tuberculosis make a transverse incision dorsally anc [NCISION I i iK' 1 1 1 1 \ i. wii'i fATION OJ I H I P001 687 gbape the long palmar flap by transfixion and cutting outward, <>i- by Cutting from without inward (Fig. .S40). Suture the tendons to the periosteum or fibrous tissues, f« >r it the tendo- ;uhillis is left unopposed the result will be a useless stump. Ri the nerves and suture, using drainage (Fig. 541). TOTAL AMPUTATION OF THE FOOT. In total amputation of the foot, the exact procedure will depend chiefly upon the condition of the os calcis. If it is sound, Pirogoff's Osteoplastic amputation is indicated. If the os calcis is diseased, Symcs' amputation is indicated a disarticulation at the ankle-joint, with erasion of the malleoli. But one cannot always determine before- Fig. 542. — Line of incision /or complete amputation of foot, (Vcau.) .land the state of the os calcis, and therefore an incision should be Blade which will permit either procedure after the os calcis has been xa mined. First Incision. The first incision extends across the sole with one aid at the tip of the external malleolus and the other a finger's breadth •clow the tip of the internal malleolus. (The internal malleolus does lot extend c^nite so low as the external) (Fig. 542). An assistant elevates the limb; you seize the foot with the left hand md make this plantar incision from left to right; that is to say, in the ase of the right foot begin the incision at the end of the outer malleolus iind terminate it a finger's breadth below the internal. In the case if the left foot, begin at the internal and end at the external malleolus. Repeat the movement several times, for there is always considerable SOME PRACTICAL AMPUTATIONS. difficulty in accomplishing complete section of the tendons, some of which are oblique to the line of incision and others deep and im- bedded in grooves. Second Incision. — Connect the extremities of the first incision by a dorsal incision, which should be slightly convex forward toward the toes. This line crosses over the head of the astragalus. The foot Fig. 543. — Section of the lateral liga- ments. {Veau.) Fig. 544. — Clearing the upper and internal surfaces of the os calcis. {Veau.) should be lowered and the cut made from left to right. Extension of the foot will facilitate the division of the anterior tendons and liga- ments. Now distinguish the head of the astragalus, and between it and the articular surface of the malleolus pass the point of the knife and cut downward (Fig. 543). By this means, the lateral ligaments are divided. The posterior ligaments are divided by cutting along the upper surface of the os calcis (Fig. 544). The joint is now freely exposed ui-' ii :i 'i i 's win i \ i tON. 689 and the os calcis may be brought ini<> view and examined. In examin bag the outer side, dissei 1 back the soft parts fur an in< h, but not quite so far on the inner side. To be sure of the condition of the bone, its substance must be inspected. (A) Suppose the Os Calcis is Sound. Grasp die foot firmly with the left hand, depress it and pull upon it at the same time, while the assistant retracts the flaps, which have been loosed from the sides of the hone. The flaps are held back by retractors on each side, which are slipped down with the progress of the saw, the assistant bracing his thumbs against the heel. The saw is started in the upper face of the os calcis, a finger's Fig. 545. — Section of the os calcis. The saw directed downward and forward. The retractors slipped downward as the saw progresses. (Fiirabcuj.) breadth behind the astragalus in a manner to take off a slice from above downward and forward (Fig. 545). With the completion of this section, the foot is removed, and the posterior part of the divided os calcis is left in the heel flap. The next step is to saw off the malleoli. Begin by completely de- nuding these processes of their covering, skin, fascia and tendons. Carry the denudation upward, a distance of two fingers' breadth be- hind; just above the level of the articular surface of the tibia, in front. The posterior tendons especially are sometimes difficult to dislodge from their groove. The line of section being thus cleared, the heel flap is held well up toward the calf, out of the way, by the assistant, who also supports the leg in the horizontal position. 1 1 690 SOME PRACTICAL AMPUTATIONS. It is well for the operator to steady the limb by seizing one of the malleoli with a bone-holding forceps. The saw enters just above the articular line in front, and emerges a full finger's breadth above that level (Fig. 546). If the section is not carefully made, the coaptation of the sawed surface of the os calcis to that of the tibia may be imperfect. Complete the hemostasis, bring the two bone surfaces together, and suture the anterior tendons to the fibrous covering of the under surface Fig. 546. — Parts removed in Pirogoff's amputation represented in dark. (Veau.) of the os calcis, the better to fix this stump in position. If it is fearec the bone will slip, one or two bone sutures may be employed. Sutui the skin, usually employing drainage. (B) Suppose the Os Calcis is Diseased. — In case the os calcis is dis eased, it must be entirely removed, instead of sawed. The left hand strongly flexes the foot, until the posterior end of the os calcis points upward (Fig. 547), and as the point of the knife dissects the tissues off the left side, the foot is rotated to the right, and when working on the right side, rotated to the left; in this manner theos calcis is finally enucleated, being careful to follow the bone closely and not toj "button-hole" the flap. s\ \n S IMPUTATION. 691 Fig. 547. — Denudation of the posterior surface of the os calcis. (Farabeuf.) Fig. 548. — Syme's amputation of the foot. (Farabeuf.) 692 SOME PRACTICAL AMPUTATIONS. Remember the principal vessels are to the inner side and are to be lifted up with the flap. Especial care is required when the attachment of the tendo-achillis is divided ; the bone must be shaved, for it is here practically subcutane- ous, and it is easy to puncture the flap. You may expect this stage to be tedious. Finally the foot will be removed (Fig. 548). Now denude the lower end of the bones of the leg, observing that Fig. 549. — Suture and drainage. (Veau.) the tendons in front are held down by their fibrous sheaths. In order to facilitate this dissection, sweep the point of the knife around the bone, keeping it in close contact with the bone. This dissection must be carried upward for an inch and the malleoli will be completely exposed. Steady the leg with a bone-holding forceps, and saw the bones at the level of the cartilage. Begin by notching the tibia, then com- plete the section of the external malleolus and terminate with the section of the tibia. If some cartilage remains, it may be scraped off. Resect the nerves, suture and drain (Fig. 549). wiim i.\ rn in 01 mi LEG. AMPUTATION OF THE II G The leg may be amputated at any level. Formerly, when suppura- tion was the rule, and the Cicatrix was large, adherent, and painful, prohibiting the use of artificial limbs, the " point <>f election " was high Fie. 550. — Knee Hexed for "peg-leg." (Veau.) 1 ' *'V'„-V f Fig. 551. — Artificial limb applied. (Veau.) Fig. 552. — Amputation of leg. Lines of section of soft parts and bone. (Wwm.) up. The knee was flexed and the patient made use of a "peg-leg," the weight falling on the patella (Fig. 550). With present methods the scar is a matter of less concern and the aim should be to amputate as low down as possible, to the end that the muscles may be preserved to render efficient an artificial limb (Fig. 551), This principle is true only within certain limits. Amputations 694 SOME PRACTICAL AMPUTATIONS. just above the ankle never furnish a good stump for an artificial limb. It is better to amputate at the junction of the middle and lower thirds. In the case of traumatism and gangrene, then, do an atypical ampu- tation, preserving carefully the sound tissue and dividing the bone to accommodate the skin flap. If the bone is involved to a greater extent than the skin, as in tuber- Fig. SS3- — Loosening the attachments of the flap to the tibia. (Veau.) Fig. 554. — Dissecting up the muscles with the artery. (Veau.) culosis, a typical amputation may be done. If the stump below the knee is four inches long it can manage an artificial limb. There are numerous methods of amputating the leg, some appro- priate to one level and some to another, but for the sake of simplicity but one need be described — one which may be used with fair success in any part of the leg. In any case avoid redundancy of flap if an artificial leg is to be worn. Incision. — Begin with a circular incision of the skin about two and win i \Tii" the proposed bone section (Fig. 552). This incision will divide the skin and aponeurosis. If front, < art- fully separate the skin from the tibial cresl (Fig. 553). \'< \i : ;irtiii( ial limb. Resect the nerves, ligate the vessels, drain and suture." (Jacobson's Operative Surgery.) .WIN TATK >.\ < IF THE THIGH. Determine the level of the bone section: About the distance of one liameter oi the limb below this level, describe a circular incision, lividing the skin and fascia, which may descend a little further behind than in front, il desired. Fig. 557. — Loosening the flap after a circular skin section. The patient's legs are drawn out well over the edge of the table, the well limb flexed and the injured one held by an assistant. The oper- ator stands to the outside. Another assistant encircles the thigh above the level of the incision, with his hands. If the conventional am- putating knife is used, begin (on the right thigh) by passing the knife under the limb and with its heel resting upon the upper surface, bring it in a circular sweep back around the thigh, dividing successively the integument of the internal, inferior and external surfaces. The position of the hand may be slightly changed and the incision continued ptpover the anterior surface; or that may be divided by a second movement (Fig. 556). 698 SOME PRACTICAL AMPUTATIONS. In the meantime, the left hand has steadied the skin; the assistant now retracts it while its fibrous attachments are loosened (Fig. 557) until there is a separation of at least three fingers' breadth. At the level of the retracted skin, divide the muscles as the skin was divided, aiming to reach the bone. But the divided muscles do not equally re- tract, and a second circular incision of the muscles at the level of the retracted skin is necessary to insure a uniform stump (Fig. 558). oK '. ¥UtjJ>c. Fig. S58. — Circular section of the muscles after retraction of skin. Denude the femur beyond the level of the proposed bone section. Direct the assistant to retract the flap with two lateral compresses or retractors. Saw the femur, ligate all vessels likely to bleed, suture the muscles over the end of the femur, drain, and suture the skin. AMPUTATION OF THE HIP-JOINT. "Primary amputation of the hip comes under consideration in any extensive crush of the thigh or gunshot injury, but offers hardly any change while the primary shock exists. >i w's .wiimi \i [ON AT Tin. mi'. 699 "The better plan is to try and check the hemorrhage, clean the wound as much as possible, pack with gauze and wait. The patient laving rallied from the shock, and gangrene, sloughing and uecrosis leing imminent, amputation is indicated with a fair prospei t of saving life. * * * The first stc- j > is t<> control hemorrhage. * * * But there is one method safe and applicable to all cases and especially when the surgeon is unaccustomed to the operation, and that is to divide the common femoral vein and artery, each between two ligatures. There- is then no further bleeding, except from the region of the crucial anastomosis behind, the vessels forming which are easily picked up and divided." For malum of the Flaps. — "From the lower end of the longitudinal mcision for tying the vessels, a circular incision is continued around the thigh, the skin flaps retracted and the soft parts divided as ampu- tation of the thigh." (Walsham's Surgery.) Semi's Bloodless Amputation at the Hip-joint. — First incision: with the pelvis resting on the lower edge of the table, make a straight in- cision (beginning about three inches above the great trochanter) about eight inches in length, directly over the center of the great trochanter, and parallel to the long axis of the limb. When the knife reaches the great trochanter, its point should be kept in contact with the bone the whole length of the remaining part of the incision. The margins of the wound are now retracted and any spurting ves- sels secured. The trochanteric muscular attachments are now severed close to the bone with a stout scalpel. The cleaning of the digital fossa and the division of the obturator externus tendon, require special care. The thigh is now flexed, strongly abducted, rotated inward, when the capsular ligament is divided transversely at its upper and posterior aspect. The remaining portion of the capsular ligament is severed, while the thigh is brought back to a position of slight flexion, after which it is rotated outward and, if possible, the ligamentum teres is cut. If this cannot be done, the head of the bone is forcibly dislocated upon the dorsum of the ilium by flexion, adduction and rotation of the thigh. The trochanter minor and upper part of the shaft of the femur are cleared by using a scalpel and periosteal elevator alternately. At 700 SOME PRACTICAL AMPUTATIONS. the completion of this part of the operation, the femur is in a position of extreme adduction and the upper portion projects some distance from the wound. If the surgeon has kept in close contact with the bone and has used the knife sparingly and the periosteal elevator freely, the hemorrhage has been slight. Elastic constriction is now applied. Bring the limb down in a straight line with the body. A long straight hemostatic forceps is inserted into the wound behind the femur and on a level with the tro- Fig. 559. — Elastic constriction completed by constricting the posterior segment of the thigh Flaps formed, including all the tissues down to the muscles. (Senn.) chanter minor when in a normal position. The instrument is then pushed inward and downward two inches below the ramus of the is- chium and just behind the adductor muscles. As soon as the point can be felt under the skin in this location, two-inch incision is made through the skin, through which the instrument is made to emerge. After enlarging the tunnel made in the soft tissues by dilating the branches of the forceps, a piece of aseptic rubber tubing, three or four feet in length, is grasped in the middle with the forceps and drawn along the tunnel as the forceps are withdrawn, whereupon the rubber tube is cut in two where it was held by the forceps. senn's \mi p i i \ I I" - - I I I in mi*. 701 With one half of the tube, the anterior 3egmen1 of the thigh is ■onstricted sufficiently firmly to intercept l«>th the arterial and venous an illation 1 ompletely. Before the constrii tor is tied, the limli should be held in the vertical ,6o. — Senn's method of performing bloodless amputation at the hip-joint: Dislo- cation of head of femur and upper portion of shaft through straight external incision. Elastic constrict< rs in place; the anterior one tied. position long enough to render it practically bloodless. The elastic constrictor is either tied or, still better, held with a forceps at the point of crossing. The posterior segment of the thigh is constricted by the remaining half of the tube, which is drawn sufficiently tight behind; the ends of 702 SOME PRACTICAL AMPUTATIONS. the tube are made to cross each other and are brought forward and made to include the anterior segment, when they are again firmly drawn and tied, or otherwise fastened above the first constrictor, furnishing an additional security against hemorrhage from the larger vessels in the anterior flap, when cut during the amputation (Fig. 559). After the principal blood vessels have been tied, the posterior con-. strictor is removed and additional bleeding points are secured before the anterior constrictor is removed (Fig. 560). Surface compression with a compress wrung out of hot, normal salt solution, is a valuable aid in minimizing the hemorrhage, after the removal of the constrictors. "As this method of controlling hemorrhage does not require the presence of a skilled assistant, it will prove of especial value in emer- gency cases. The operation can be performed with the instruments contained in every pocket case. Should an elastic tube not be at hand, the constriction can be made in a satisfactory manner by sub- stituting a cord made of sterile gauze, tightened with a lever of some kind, as is done in applying the ordinary Spanish windlass." (Senn, Practical Surgery.) The amputation is completed by cutting antero-posterior flaps as shown in Fig. 559. CHAPTER XXIII. DILATATION OF THE SPHINCTER ANI ; OPERATION FOR PILES; OPERATION FOR FISTULA. DILATATION. Temporary paralysis of the ana! sphincter is the preliminary step to mosl of the interventions on the rectum, and may be of itself suf- ficient for the cure of fissures. The patient should be purged the day preceding the operation; and Fig. 561. — Dilatation of the rectum. (Vcau.) the rectum should be washed out with soap and water, preliminary to the actual operation. General anesthesia is almost indispensable and it needs to be pro- bund, for the anal reflex is one of the last to yield. Spinal anesthesia .S often useful in anal operations. In the absence of a special dilator, begin by inserting the two thumbs 703 7°4 DILATATION OF THE SPHINCTER ANI. back to back, and bracing the fingers against the outer surface of the hips, stretching the sphincter by rhythmic movements of the thumbs, gradually increasing the force. There is no danger of overdilatation, so continue until the thumbs are in contact with the ischial tuberosities (Fig. 561). Drainage is indicated in simple dilatation for fissure. Employ either one large or two or three small tubes well wrapped Fig. 562. — Drainage after dilatation. (Veau.) with iodoform gauze soaked in cocainized vaseline (vaseline thirty parts, cocaine one part), in order that the subsequent pain may not be so severe (Fig. 562). The tubes may be removed on the second; day and the bowels moved on the third. OPERATION FOR HEMORRHOIDS. Most cases of piles are curable by local and constitutional treatment; however, those that are very large, bleeding and inflamed, require anil operation for their removal and radical cure. There are several methods of procedure, many of which are success- ful; none dangerous and quite within the scope of every practitioner. <>l'l l'\ riON l OB I'll I s. f°5 The following may be recommended in those cases in which the marginal tumors are well defined but do! pedunculated: Begin l>y a careful cleansing of the bowel by purgation and lavage. Tlmr days before tin- operation, give a free purge and prescribe ;l ■quid diet. Prescribe an enema each morning and evening for the next two days. I m the day preceding the operation, it is a good idea to check peristalsis with a small dose of opium. Employ genera] anesthesia. Carefully cleanse the peri-anal region and send, the rectum with soap and water. Dilate the anus, as pre- FlG. 563. — Making the first incision. (IVjii.) Fig. 564. — Passing the first suture. (Wcjm.) viously described; and when the dilatation is complete the anal orifice will be everted more or less, presenting a ring of pile tumors. Fasten the pile tumor with a forceps, and at its lower end, make a short curved incision (Fig. 563). The incision involves only the skin, which is to be Bosened from the underlying structures by a little blunt dissection. Suture this part of the skin before proceeding further, using a small curved needle armed with a No. 2 catgut. Tie the suture moderately bight and leave the threads long for a landmark, which will be ap- preciated later on. Pass two or three sutures in this manner, depend- ing upon the length of the incision (Fig. 564). 45 706 DILATATION OF THE SPHINCTER ANI. Again prolong the incision on either side a little way and detach, by blunt dissection, the lips of the wound from the veins beneath, by which means a sort of pedicle is formed (Fig. 565). This pedicle con- sists of a part of the veins which are to be ligated and excised. Fig. 565. — Freeing the veins by blunt dis- j» section. (Veau.) Fig. 566. — Ligation of the first vascular pedicle. {Veau.) Fig. 567.— Burying the pedicle by suture. (Veau.) Fig. 568. — Ligation of the last vascular pedicle. (Veau.) Pass a ligature around a part of the veins (Fig. 566) and tie. Divide the ligated veins to the outer side and cut the ligatures short. Now pass a suture so as to enclose and cover in the stump (Fig. 567). OPERATION I OB PILES. 707 Again prolong the original incision on each side of the base ol the tumor and expose more of 1 1 1 « - pedi< le; ligate, ex< ise and suture as be- fore, until finally the upper pole of the tumor is rea< bed, and the last of the pedicle tied off (Fig. 568). The terminal sutures enclose the las! stump of the pedii le and i om plete the repair of the incision at the same time (Fig. 569). It is better to proceed thus from In-low upward in order that the Mood, always considerable, will flow downward and mask only the field already sutured. Fig. 569. — Applying the last suture, (veau.) PlG. 570. — Treatment of ulcerated piles by cautery. {Veau.) The line of incision must follow closely the base of the tumor, for if the edges of the wound are too widely separated, the strain may cause the sutures to tear out. If the whole of the anal circumference is involved, it is necessary to treat in the manner described the two sides only. Do not disturb the anterior and posterior poles of the anal border, although, if necessary, those points may be touched up with the thermo- cautery. Place drainage-tubes wrapped with iodoform gauze saturated in vaseline, as described under the head of Dilatation of the Sphincter. The subsequent pain is always severe and will require a hypodermic injection of morphia. Retention of urine is often present. The ex- 708 DILATATION OF THE SPHINCTER ANI. ternal dressings should be changed daily and liquid diet maintained for five or six days and the bowels kept under restraint. Do not be con- cerned with the swelling. On the sixth day, remove the drainage-tube; on the seventh, open the bowels with castor oil, and instruct the patient to cleanse carefully the anal region after each movement. The sutures will be absorbed and if none give way too soon, the Fig. 5 7 1- — Laying open the track of fistula on the grooved-director. (Veau.) healing will be complete in about two weeks; otherwise there may be a raw surface which will need to be dressed a little longer. In certain cases there is no well-defined tumor, but the surface is ulcerated, infected and exceedingly painful, and is unaffected by patient local treatment. In such a case, the thermo-cautery will probably give the best results. For .one or two days the patient is kept in bed and a moist dressing applied which will diminish the swelling. Employ general anesthesia, cleanse and dilate the anus. The ther- mo-cautery is heated to a dull red. Pressed into the tumor, it loses its CAUTERIZATION 01 ULCERATED PILES. 709 glow (Fig. 570). Reheat it and reapply a short distan< e from the poinl of appli< ation, and in this manner pro< eed until the pile has been well punctured. It is nol necessary to puncture deeply. Apply drainage and a moist dressing. The subsequent pain is always severe and must be < ontrolled by a hypodermic of morphia. There may be retention oi urine requiring relief by catheterization. The dressing must l>e re- PlG. =,72. — Cauterization of the diverticula of the fistula. (Vcau.) Dewed twice daily. The eschar will drop off between the fourth and eighth day, and the bowels should be moved about the eighth day. The cure will be complete in about a month. OPERATION FOR ANAL FISTULA. A grooved director is passed through the fistulous tract and emerg- ing in the rectum, its point is caught by the finger in the rectum and brought outside the anus. The whole length of the tract is laid open (Fig- 570- The diseased tissues arc then curetted or touched with the cautery (Fig. 572). Pack with gauze until repair by granulation is complete. CHAPTER XXIV. PHIMOSIS; PARAPHIMOSIS; CIRCUMCISION; HYDROCELE; CASTRATION. PHIMOSIS. Phimosis may be congenital or acquired, though it is much more frequently the former. There is usually present one or both of two conditions: a redundant prepuce with contracted orifice; or a frenum so short as not to permit retraction without marked bowing of the organ. The disturbances produced by congenital phimosis are due either to mechanical interference or reflex irritability, although, of course, many cases of phimosis seem to give rise to the symptoms. The mechanical interference may lead to infection, balanitis, or even urethritis, or to straining which may be the origin of an inguinal or umbilical hernia; the straining may also produce prolapsus ani or hydrocele by pres- sure on the spermatic vessels. The reflex symptoms, often due perhaps to the adhesions of the prepuce to the glans, are numerous and varied, the most common be- ing disturbances of micturition, erethrism, and functional nervous derangements. Every case of phimosis, therefore, should receive attention in in- fancy, and in general the only treatment worth while is circumcision. The acquired phimosis of adult life, most often due to acute infect- ive inflammations, is usually to be relieved by antiseptic washes and treatment addressed to the septic cause. PARAPHIMOSIS. Paraphimosis has its origin in certain malformations, traumatism, or inflammations, and appears in many degrees of severity. In some cases it is easily reduced; in others, irreducible without an operation. There is always the danger, in severe and neglected cases, of ulceration, 710 PARAPHIMOSIS. 7' ' sloughing, or gangrene. The appearances are more or less constant: the exposed glans is swollen and reddened ; behind it is a i ollar of « on- Bested mucous membrane; behind iliis a deep furrow in which lies the constricting band; and behind this, another band of swollen integument. An effort must be made al once to reduce the foreskin. The redui tion is always painful. Begin by thoroughly cleansing and cocainizing the parts. Apply a compress saturated with a twenty per cent, solution of i o. aine and then wait ten minutes. Smear a little vaseline on the balano preputial furrow, but not over the glans generally, else the manipulating angers will slip. Fig. 573. — Reducing a paraphimosis. (Stewart.) The purpose is to apply a slow, firm, and progressive pressure to the engorged tissues, at the same time making traction forward on the fore- skin and pressure backward on the glans. There are several ways of doing this, of which the following is an excellent method: grasp the penis behind the glans, between the first and second fingers of each hand, and while these make compression and traction, the two thumbs are braced against the apex of the glans ( Fi g- 573)- After reduction is accomplished, measures must be employed to sub- due the inflammation and the patient advised of the necessity for a ( in umi ision later to insure against a recurrence. 712 PARAPHIMOSIS. If reduction cannot be accomplished by these measures, an operation must be done without delay. The purpose is to divide the restricting band, which lies in the groove between the two ridges. Inject a little cocaine along the line of incision which is usually in the middle line of the dorsum and just behind the corona (Fig. 574). Use the point of the knife, making short, firm, shallow cuts, until the constricting band is felt to yield. A too bold incision may result in seriously wounding the corpora cavernosa. Fig. 574. — Dividing the constricting band in paraphimosis. (Veau.) The bleeding in any event will usually be free but ceases spontane- ously. The wound which at first was vertical, becomes transverse when reduction is completed, and is sutured in that direction. Apply a moist dressing and if there is no ulceration or gangrene, the swelling will soon subside. But in this case also the patient must be advised of the danger of recurrence unless a circumcision is done for the relief of the narrowed prepuce or the short frenum after the in- flammation has subsided. OP] R \ ii"-- FOB I II- 1 i m< [SION. 713 CIRCUMCISH »\ This is an excellent operation probably nol often enough done in infamy, when it is simple and without danger, and may prevent the nsturbances of adolescence, consequent upon phimosis. In adult life it is often the primary step toward the relief of acute disorders and sexual irregularities. The Operation. General anesthesia is nearly always indicated in children; local, in adults. To secure local anesthesia, begin by Lightly fcmponing the preputial orifice with a pledget of cotton saturated with Fig. 575. — Resection of the prepuce. (Veau.) ten per cent, solution of cocaine, and left in position for at least five ninutes. Next inject the foreskin in the line of the proposed incision, sing a four per cent, solution of cocaine or Schleich's solution. The do rapid absorption of cocaine may be prevented by constriction of ne base of the penis. When the anesthesia is established, break up the preputial ad- esions with a grooved director or probe, usually not difficult in an lfant but sometimes difficult in the adult, following balanitis. There are various methods of making the incision, any of which, roperly employed, will give good results. Suppose the prepuce is >ng and slender: begin by holding the penis vertically and without 714 CIRCUMCISION. making traction on the foreskin, apply a forceps so that its blades lie parallel with the oblique line of the corona (Fig. 575). Use care, of| course, not to pinch the glans. Divide the foreskin with the bistoury, allowing the blade to hug the upper side of the forceps, that no bruised tissues may be left behind. The skin retracts, leaving the mucosa covering the glans. Divide this mucous covering along the middle line to within one-fifth inch of the coronal border (Fig. 576). The glans will now be completely exposed. Trim off the two mucous flaps so that a narrow cuff is left. It is better to begin near the frenum and trim toward the terminal point of Fig. 576. — Splitting the mucous membrane. (Veau.) the dorsal incision (Fig. 577). If the frenum is too short, divide it transversely with the scissors (Fig. 578), catching up the little artery which will be divided. This completes the necessary incisions. Hemostasis must be assured. It may be necessary to tie two or three small -vessels and nearly always the artery of the frenum re- quires ligation, using catgut No. 1. A brief application of adrenalin solution on a compress will check the oozing if it should persist. Suture. The mucous and cutaneous borders are brought into exact contact and united by several small, interrupted sutures of catgut (Fig. I J 1 - « i \i< [SION. /'5 Bo. 577. — Resection of the mucous membrane. FiG.578. — Section of the frenum. (.Veau.) ,. -Maintaining coaptation by means Pig. 580. — Aftersection of the frenura the of a small clip. (Veau.) raw edges are coapted. (\ 716 CIRCUMCISION. 579). The transverse incision of the frenum is made a vertical one by extending the glans, and is sutured in that direction (Fig. 580). In the case of children, it may be sufficient, instead of suturing, to use small clips, by which means, it is claimed, swelling is avoided. Dressing. — Wrap the penis in a sterile compress, leaving the glans exposed. Enclose the whole in a second compress perforated over the meatus, and secure with adhesive strips. Adults require bromides to prevent painful erections. The dress- ings are not to be changed unless soiled. Remove the sutures and re-dress the fifth day. It will probably require ten to twelve days for repair to be complete. Children usually need a daily change of dressing. If clips are used instead of sutures, they are to be removed at the end of twenty-four hours, and if the adjustment was perfect, the reunion by that time will often be practically complete. HYDROCELE. The chief test of a hydrocele is its "translucency." The first treat- ment usually tried is tapping and the injection of an alterative. If the hydrocele recurs, then a radical operation should be done. Often this should be resorted to from the first without preliminary tapping, especially in the long-standing cases, where the tunica vaginalis is thickened and it is almost obvious that the trouble will recur. Occasionally the patient will prefer repeated simple puncture and evacuation without subsequent injection, rather than the more radical procedures which will lay him up for some days. Tapping. — Anesthesia is not necessary. Prepare the field as for a surgical operation. Seize the tumor behind with the left hand so as to make it tense in front. The trocar, held in the right hand with index finger an inch from the point to limit its penetration, is entered with a sharp thrust into the middle and lower part of the anterior sur- face of the tumor (previously assure yourself that the testicle is notf inverted). Withdraw the plunger, being careful that the tube is notj displaced. When the fluid is evacuated, attach a syringe to the trocar and inject a drachm of a one-half per cent, solution of cocaine; gently I IP1 R \ I [ON FOR IIVl'K'uii i.i 717 piassage the scrotum so as if which the bone may be Fig. 592. — The matrix removed. (Veau.) A.M Fig. 593. — Wound sutured. (Vcau.) (Fig. 592). This cavity should be packed with sterile gauze and allowed to heal by granulation, which will require two or three wicks. It is advisable to diminish the size of the cavity by a suture, including on one side the skin, and on the other, the subungual tissues (Fig. 593). It will probably give way finally, yet it facilitates repair. CHAPTER XXVI. REMOVAL OF SMALL TUMORS. The technic for the removal of small tumors on or under the skin should be kept in mind. As in more difficult operations, a definite procedure should be followed. A lack of system may make a minor matter one of difficulty. Local anesthesia will usually suffice. It should be complete. To secure a complete local anesthesia, begin by determining the lines of incision, and along these lines inject a two per cent, solution of cocaine; Fig. 594- — Anesthesia of the skin. (Veau.) Fig. 595. — Anesthesia of the deeper layers. (Veau.) intradermic, not subcutaneous. If the tumor is large or if the skin is loose, redundancy may be avoided by making two semicircular in- cisions, thus removing an ellipse of the skin (Fig. 594). Next loosen the edges of the skin and partially expose the tumor and make a new injection along its sides. Later inject the base of the tumor as the dissection proceeds (Fig. 595). In the case of sebaceous cysts, the main point is to remove the sac in its entirety; anything else insures a return of the trouble. If possible, 724 Rl \iu\ \| 01 ->i BAI i "i g CYSTS. 725 Kissed the sac out without emptying its contents. The dissection will he done with rase only in 1 ase all the layers arc Ln< ised down to the true capsule. If the cyst walls an- particularly thick, the contents may he emptied out from the first. ( >m c the 1 J Si is exposed retract y the practitioner. Very often it would save time and trouble in the treatment of those conditions in which epidermitization is long de- layed, for this it hastens and also it tends to prevent the formation of scar tissue. Thus chronic ulcers, burns, and lacerated wounds fol- lowed by extensive sloughs may require grafting. The operation is simple in theory yet attended by many failures through lack of attention to detail. Three factors require the minutest supervision: (i) the field must be properly prepared; (2) the grafts must be cut correctly; (3) the after-treatment must be appropriate. (1) The area to be grafted must be sterile and must be free of any oozing. If an ulcer is to be treated, the granulations must previously be made as healthy as possible: if sluggish, by currettement; if exuber- ant, by touching up with nitrate of silver. A few days afterward it will be ready to receive the graft. A dry sterile dressing should be applied a day previous to the operation; before the graft is applied, the surface should be thoroughly douched with normal salt solution. (2) The skin which is to furnish the graft should be shaved and thoroughly scrubbed with soap and water. Antiseptics had better be avoided for they may compromise the vitality of the cellular ele- ments. A sufficient anesthesia may be obtained by injection of Si hleich's solution No. 3. Two methods of cutting the grafts are currently employed, Rever- din's and Thiersch's. (I) Reverdin's Method. — A small fold of the skin is picked up with tine tissue or mouse-toothed forceps and cut off at its base with small pointed scissors (Fig. 598). This section includes practically all the layers of the skin (Fig. 599). The graft is appb'ed and gently pressed 727 728 SKIN GRAFTING. out. Fifteen or twenty points are thus placed about 15 mm. or say 1/2 inch apart. If the surface is large enough to require more, the center should be left bare and treated by a second operation (Fig. 600). A Fig. 598. — Manner of cutting the Reverdin graft. (Veau.) Fig. 599. — The graft removed. {Veau.) (II) Thiersch'' s Method. — This method is the better when it succeeds, but the conditions of success are more exacting. Granulation tissue usually needs to be removed by curettement, exposing the fibrous layer. Fig. 600. — Placing Reverdin grafts. Ulcer of leg. (Veau.) The edges of the ulcer must be scraped (Fig. 601). The oozing which follows must be completely checked. A firm compress applied for ten or fifteen minutes will usually suffice. If oozing persists, the operation will fail. I llll RS< II S Ml I I lop. 729 The grafts in this 1 ase 1 onsisl of thin sli< es of the epidermis, as long as necessary ami a- wide as . ns, i 1 2 gunsh< 't wounds, [34, [45, incised wounds, 1 1 (1 injuries, 1 1 a laparoti >my, i 1 3 non-penetrating wounds, 1 penetrating wounds, 1 1 5 punctured wounds, 1 1 5 Stab wounds, i 1 5 AImI, iminal drainage, 1 1 7 hemorrhage, 465 section, 463 Abducens nerve, 297 Abscess, acute, 312 alveolar, 321 antrum, mastoid, 455 appendiceal, 503 axillary, 332 Bartholin's gland, 346 breast, 330 cervical glands, 329 chronic, 31 5 definitions, 312 dental, 321 drainage, 314 eyelids, 318 external auditory meatus, lace, 317 floor 1 >t tlie mouth, 323 iliac, 355 ischio-rectal, 337 kidney, 484 labium, 346 lachryn al, 319 liver, 351 lung, 436 mammary, 330 mastoid, 455 nasal septum, 318 palmar, 335 parotid, 320 pelvic, 348 peri-anal, 340 AbsceSS, perineal, 34 1 1 5.) plantar, 337 popliteal, 335 pr< 'Static, 34 1 psoas, 3 55 14 rectal, 340 retropharyngeal, 326 scalp subaponeurotic, 316 subperiosteal, 317 superficial, 3 1 6 seminal ducts, 345 submaxillary, 322 submammary, 332 subphrenic, 3 51 symptoms of, 312 tongue, 325 tonsillar, 325 treatment, acute, 313 chronic, 315 urinary, 633 vulvar, 346 vulvo-vaginal, 346 Accidents, anesthesia, 14 Acupressure, 58 Acute intestinal obstruction, 508 retention of urine, 619 319 Actual cautery, phlegmon, 368 Adrenalin chloride anesthesia, 14 epistaxis, 65 gauze tape, 61 shock, 52 Air passages, foreign bodies, 396 burns, 409 Alcohol, antisepsis, 3 Allison, strangulated hernia, 539 Alveolar abscess, 321 Ammonia after anesthesia, 16 Amputations, arm, 670 atypical, 650 Chopart, 685 elb< iw, <>7o finger, 057 foot, 684 733 734 INDEX. Amputations, forearm, 666 great toe, 68 1 hand, 664 hip-joint, 698 index finger, 659 knee-joint, 695 leg, 693 little finger, 657 toe, 682 metacarpal, 662 metatarsal, 683 middle finger, 654 toes, 682 Pirogoff's, 689 principles, 649 Syme's, 687 thumb, atypical, 664 typical, 661 thigh, 697 toes, 680 scapulo-humeral, 679 shoulder, 674 Anal abscess, 340 dilatation, 703 fistula, 709 Anastomosis, intestinal, 573 Anderson, Cesarean section, 607 Andrews, Colles' fracture, 215 Anesthesia, 1 1 accidents, 14 ammonia, 16 chloroform, 1 1 cocaine, 17 ether, 13 ethyl chloride, 17 local, 17 spinal, 20 stovaine, 20 vomiting, 16 Aneurism, gunshot, 123 Aneurismal varix, 125 Angina, Ludwig's, 323 Angiomas, 726 Angus, torsion, 593 Ankle amputation, 687 arthrotomy, 383 dislocation, 277 fracture, 242 sprain, 282 Anterior crural nerve, exposure, 304 injury, 303 Anterior tibial artery, ligation, 646 nerve, injury, 309 Antipyrine, epistaxis, 65 Antisepsis, emergency, 6 Antiseptics, 3 Antitetanic serum, 167 Antistreptococcic serum, phlegmon 3 2 4 Antrum, mastoid, 455 Anus, abscess, 340 artificial, permanent, 523 temporary, 519 dilatation, 703 fistula, 709 imperforate, 584 piles, 704 Appendectomy, 498 Appendicial abscess, 503 Appendicitis, 488 after treatment, 50 5 catarrhal, 491 diagnosis, 488 gangrenous, 491 operation, 498 perforating, 491 treatment, 498 ulceration, 491 varieties, 491 Appendix in hernia, 544 Arm, amputation, 670 bandages, 42 fractures, 195 phlegmons, 366 Aristol in burns, 408 Arrest of hemorrhage, 57 Arteries, ligations, rules, 638 suture, 638 torsion, 59 wounds, gunshot, 122 Arterial hemorrhage, 54 Artery forceps, 4 ligation, anterior tibial, 646 axillary, 643 brachial, 643 common carotid, 640 compression, 63 dorsalis pedis, 647 external carotid, 641 femoral, 646 lingual, 641 obturator, 306 posterior tibial, 647 radial, 644 subclavian, 641 ulnar, 645 Artificial anus, permanent, 523 temporary, 519 I\l'l \. 735 An ificial limbs, 693 respiral i( »n, 1 5 Art luit is, septic, 376 An hrotomy, 377 ankle, 383 elbi >w, $8 i hip, 385 knee, 37 7 shoulder, 385 wrist , 384 Asphyxia, anesthesia, 1 5 foreign 1" idies, 393 retropharyngeal abscess, 327 Aspirat i< in, bladder, 6 1 6 pericardium, 433 pleura, 438 \ agalus, disli ication, 277 Auditory nerve, injuries, 297 Automatic centers, paralysis, 12 Axillary artery, ligation, 643 abscess, acute, 334 chr< »nic, 334 Axtell, wound of chest, 107 trephining, 453 Bandage, Barb m's, 44 arm, 4 2 breast, 4 1 eye, 44 anger, 41 foot, 35 groin, 38 hand, 42 head, 44 knee, 37 leg, 36 neck, 42 sin lulder, 42 St. Andrew's cross, 40 stump, 45 thumli, 41 Bandages, 34 method of applying, 3 5 plaster, 46 Bartholin's gland, abscess, 346 Hart. in's bandage, 44 Base of thorax, wounds, 108 Bassini, operation for hernia, 5 58 Bavarian splints, 48 Bi -lt'u Id, drainage of seminal dints, 345 Bellocq's cannula, 66 Bennett, Sir \\\, torsions, 592 Bennett' fracture, 123 Biceps tindoii disl< >ca1 i< >n, 38 1 ude, 1 at heter, iuo Bier t reatmenl , 36] " Black eye," 69 Bladder, aspiration in retention, 628 Bladder, i v 1 . .I. .1 1 1 \ . 639 ii ireign 1" idies, 403 hernia operatii in, 5 1 j gunshol wounds, 135 puncture, 628 rupture, 485 suture, 48(1 wounds, 485 Blank cartridges, 1 66 Bleeding (see Hemorrhage) Bloodgood, intestinal obstruction, 508 fractures, 191 Blood vessels, injuries, 88-90 Boldt, scopolamine narcosis, 14 Bolo wounds, 146 Bone wiring, 216 Bonney, emergency operations, 6 Bowel, acute obstruction, 508 Bowls, sterilization, 10 Brachial artery, compression, 63 ligation, 643 Brain, abscess, 144 compression, 176 concussion, 1 74 contusii >n, 1 76 gunshot wounds, 129, 143 hemorrhage, 444 injuries, 169 topography, 445 Branchial cysts, 726 Breast abscesses, 330 bandage, 41 Brickner, tubal pregnancy, 598 Bronchi, foreign bodies, 396 Bronchoscopy, Killian, 398 Brown, Cesarean section, 606 Bruises (see Contused wounds) Brushes, hand, 2 Bryant, esophagotomv, 422 Bullet wounds, civil, 1 55 military, 122 Bullets, types, 1 23 Burns and scalds, 405 Burns, air passages, 401) Burns, electrical, 4 1 o Burns, mouth, 400 736 INDEX. Cahill, torsions, 592 Calmette's antitetanic powder, 167 Cannaday, subcuticular suture, 28 Capitellum, 43 Carbuncle, 318 Carpus, dislocation, 280 fracture, 219 Carotid artery compression, 63 ligation, 640 Carron oil, 409 Carstens, empyema, 438 Castration, 718 emergency, 120 Catheterization equipn ent, 620 retrograde, 617 Catgut, 24 chromicized, 24 Catheters, box for, 4 sterilization, 620 acute retention, 620 Cecum in hernia, 542 Cerebro-spinal fluid, characters, 170 Cervical glands, suppuration, 329 Cesarean section, 604 Championniere, fractures, 192 Chest contusions, 103 wounds, 104 Cheyne, phlegmon of neck, 368 Chloral, wounds of tongue, 82 Chloroform anesthesia, 1 1 face in, 12 pulse in, 12 pupil in, 1 2 container, 12 Chipman, reduction of shoulder, 261 Chopart's amputation, 685 Cigarette drain, 30 Circular enterorrhaphy, 575 Circumflex nerve, exposure, 302 injury, 302 Circumcision, 713 Clark, appendicitis, 490 intussusception, 515 Clavicle, fracture, 183 Cocaine anesthesia, 1 7 Coley, femoral hernia, 569 Collapse, 50 Colles' fracture, 212 Colon bacillus, 488 Colostomy, 523 Colpotomy, 348 Combs, foreign body in rectum, 401 Comminuted fractures, 168 Compound dislocations, 278 elbow, 280 hip, 280 knee, 280 shoulder, 280 fractures, 246 ankle and foot, 2 50 Compression of arteries, brachial, 63 carotids, 63 coronary, 63 facial, 63 occipital, 63 subclavian, 63 temporal, 63 of brain, 176 - Concussion of brain, 174 Condyles of humerus, fracture, 207^ Congenital hernia, 557 Coin catchers, 394 Conjunctiva, foreign bodies, 388 wounds, 85 Continuous suture, 24 Contusions, 69 abdomen, 112 brain, 175 chest wall, 103 eye, 85 eyelid, 82 knee-joint, 281 lung, 103 nerves, 294 scalp, 78 urethra, 611 Cook, appendicitis, 495 Corner, torsions, 596 Coracoid process, examination, 200 Coronary artery, compression, 63 Cotton, injuries to testicle, 120 Cranial nerves, injuries, 296 Craniectomy, emergency, 444 Crepitus, 189 Crile, direct transfusion, 56 shock, 51 Crushing injuries to the extremi- ties, 90 Cullen, 596 Cushing, shock, 53 Cut throat, 83 wrist, 88 Cystotomy, operation, 617, 629 [\l'l \. 737 Deep epigastric artery, <> 5 Dental abscess, 3 -• 1 Depressed fracture, skull, 1 7 -• Diaphragm, wounds, 1 10 I' Lai arteries, compression, 64 Pilatati< >n < >f the amis, 70 $ urel oral s1 rid ure, 6a 2 I pressure in hemorrhage, 57 Disli ical i< 'us, j 52 ankle, 277 c< impound, a 78 elbow, -<>(> finger, 270 hip, 270 jaw, a66 knee, 276 patella, 277 sh< iulder, a 5a after-treatment, 365 subclavicular, 2 56 subglenoid, 262 subspinous, 265 semilunar cartilages, 2 70 thumb, 268 wrist, j So Dixon, tubal pregnancy, 598 Dorsalis pedis artery ligation, 647 Dorsum ilii, dislocation, 270 Double spica, 40 Downey, fracture of femur, 231 I >< lyen's trephine, 448 Drainage, 29 abdominal, 1 1 7 abscess, 3 1 4 accidental wounds, 31 amputations, 650 appendicitis, 503 arthrotomy, 378 aseptic wounds, 29 cigarette, 30 Compound fractures, 31 empyema, 442 gauze wick, 30 heart wounds, 430 operative w< lunds, 3 1 tld>es, 30 urinary infiltration, 637 I >n jsings, 32 tirst aid, 1 41) frequency, 33 Dupuytren's splint, 243 Dura mater, wounds, 151 47 1 >ui. h cane plinl . 15, 138 ; 1 nea, heart wound , 1 1 1 Ear drum, paracentesi . 156 forceps, 300 f. ireign 1 m Bastman, J. R., hernia, 565 intestinal 1 »DSl ruction, 509 Bastman, T. B ., appendiciti 1 ■ ipic gestation, 597 Edema 01 glottis, 419 Elbow, amputation, ^70 arthrotomy, dish nation, 266 fracture, 206 gunshot wi Hinds, 142 wound, 90 Electrical burns, 410 shock, 410 Elliott, wounds of kidney, 484 Emergency antisepsis, (1 operations, preparation, 6 surgery, equipment, 2 military, 153 Emphysema, chest injuries, 101 Empyema of thorax, 436 adult, 440 after-treatment, 443 child, 43Q diagnosis, 436 puncture for, 438 Enemas, technic, 511 Enterostomy, 519 Enterectomy, 573 Enterorrhaphy, 575 Epistaxis, 65 Equipment, emergencies, a Esmarch bandage, 62 Esophagotomy, 420 Esophagus, foreign bodies, 392 wounds, 85 Estes, intussusception, 513 Ether anesthesia, 13 adrenalin chloride in, 14 External auditory meatus abscess, 319 carotid artery ligation, -04 1 urethrotomy, <>i 2 Extra-capsular fracture. 224 Extravasation of urine, 633 Extremities, fractures, iss wounds, 87 Eye bandage, 44 foreign bodies, 388 738 INDEX. Eye injuries, 85 Eyelid, abscess, 318 contusion, 82 wounds, 82 Face, abscesses, 317 fractures, 180 furuncle, 317 gunshot wounds, 144 wounds, 81 Facial artery, compression, 63 ligation, 641 nerve injuries, 296 mastoid operation, 461 Femoral artery, compression, 64 ligation, 646 stab wound, 88 hernia, anatomy, 546 radical cure, 567 strangulated, 546 taxis, 533 Femur, amputations, 697 fractures, 224 osteomyelitis, 374 Fibula, fractures, 236 Field of operation, sterilization, 10 Figure-of-eight bandage, 35 Fingers, amputations, 651 bandages, 41 dislocations, 270 fractures, 220 infections, 359 First aid, dressing, 148 fractures, 194, 223 hemorrhage, 62 splints, 151 Fiske, wounds of spleen, 483 Fistula, anal, 709 urinary, 633 Floor of mouth, abscess, 323 Foot, amputations, 684 bandages, 35 fractures, 250 Forceps, artery, 4 aural, 390 nasal, 392 urethral, 402 Forcipressure, 59 Ford, ether anesthesia, 14 fracture of patella, 232 skull, 452 Forearm, amputation, 666 phlegmon, 365J Foreign bodies, air passages, 396 bladder, 403 ear, 389 esophagus, 392 eye, 388 larynx, 396 nose, 391 pharynx, 392 rectum, 399 trachea, 396 urethra, 402 Fountain syringe, 3 Fowling piece, gunshot wound, 165 Foxworthy, bolo wounds, 146 Fractures, 168 ankle, 250 arm, 195 carpus, 219 Colles', 212 clavicle, 183 compound, 246 condylar, 207 crepitus, 189 definitions, 168 diagnosis, 189 elbow, 206 extremities, 188 face, 180 gunshot, 144 femur, 224 gunshot, 140 fibula, 236 fingers, 220 first aid, 194 foot, 250 forearm, 210 gunshot, 136 hand, 219 head, 169 humerus, 195 immobilization, 192 intercondylar, 209 jaw, lower, 181 upper, 180 leg, 236 malar, 180 maxillae, 180 metacarpus, 220 nasal bone, 179 olecranon process, 216 pain, 190 patella, 231 pelvis, 245 Pott's, 242 I\l>l \. 739 Prad urc , radiu . -mo reduction, [91 ribs, 183 scapula, 1 1 skull, [69 compound, 17; supracondylar, 205 spine, 178 splints, 193 tarsus, 250 thumb, 22\ tibia, 236 toeS, 250 treatment, 191 ulna, 210 vertebra, 17 s wrist, 219 Freezing, 1 1 1 Fr< »st bite, 405 Furuncle of face, 3 1 7 Fysche, gunshol wound, 160 Gage, rupture quadriceps extensor, 285 Gangrene, amputation, 649 Gastric lavage, 14, 510 Gastro-enterostomy, 478 Gauze, 4 dressings, 32 drainage, 30 General practitioner as emergency surgeon, 1 Genito-crural nerve injury, 307 Gerster, treatment of peritonitis, 507 Gibbon, suture of heart, 430 Gloves, rubber, 9 Gluteal hernia, 556 Gi ><>ch's splint, 45 Granger, burns, 409 Great toe, 681 ( in .in, bandage, 38 Guibal, subphrenic abscess, 351 Gunshot fractures, 136 wound of abdomen, 134, 145, 159 bladder, 135 bone, 124 brain, 129, 14,; cranium, 127, 143 face, in. 157 band, 164 head, 155 heart, 133 1 Jun 1 1 • 't \\i >und of inte tine, jl .lilt , I .'!., I }l. 163 kidney, 135 knrr, 1 1 J, 163 liver, 135 lungs, 13a neck, 144, 157 nerves, [33 pancreas, 135 rectum, 135 skull, 130, 143 spine, 130, 145, 157 spleen, 135 stomach, 135 thorax, 132, 145, 158 trachea, 144 wounds, civil, 155 effects on tissues, 122 hemorrhage, 122 military, 122 prognosis, 135 shock, 122 suicidal, 156 treatment, 135 Gun-splint, 154 Guyon, catheterization, 626 Hand, abscess, 335 amputations, 664 bandages, 42 brushes, 2 fractures, 219 gunshot wound, 164 infections, 361 injuries, 96 sterilization, 9 Harrington's solution, 10 Harsha, torsions, 592 Hartmann, splenectomy, 595 Havard, gunshot wounds, 134, 146 Hayes, peritonitis, 506 Haynes, wounds of liver, 47^ Head, wounds, 78 bandages, 44 Heart, gunshot wounds, 133 wounds, no massage, 15 repair, 425 suture, 430 Heile, treatment of ileus, 518 Ihmarthrosis, 142, [64 Hematoma, 70 I [ematuria, 486 Hemopericardium, 102 74Q INDEX. Hemopneumothorax, 101 Hemoptysis, ioo Hemorrhage, 54 acupressure, 58 adrenalin chloride, 55 arrest, 57 arterial, 54 capillary, 54 chemicals in, 57 constitutional effects, 54 definitions, 54 diagnosis, 55 ectopic gestation, rupture, 597 fatal, 55 first aid, 62 forcipressure, 59 heat, 57 hypodermoclysis, 56 infusion, intravenous, 56 internal, 54 intermediary, 54 kidney, 473 laparotomy, 465 liver, 473 meningeal, 170 mesentery, 473 normal salt solution, 56 operative, 50 parenchymatous, 54 primary, 54 secondary, 54 spleen, 473 spontaneous arrest, 57 symptoms, 54 torsion, 59 tourniquets, 58 treatment, 55 tubal pregnancy, 597 venous, 54 Hemorrhoids, operations, 704 Hemostasis, 57 Hemothorax, 100, 133 Hennequin's dressing, 197 Hernia, appendix, 544 bladder, 543 cecum, 542 encysted, 542 femoral, 567 gangrenous, 539 gluteal, 556 inguinal, 533 interstitial, 543 lumbar, 556 lung, 102 Hernia, obturator, 554 ovaries, 556 perineal, 556 preperitoneal, 543 sciatic, 556 stomach, 545 septic absorption, 528 sigmoid, 542 strangulated, 528 umbilical, 533 radical cure, femoral, 567 inguinal, 557 umbilical, 550 vaginal, 556 Hernial sac, anomalies, 542 Hernio-laparotomy, 542 Hertzfeld, epistaxis, 66 Hilton, abscess, 335 Hip-joint, arthrotomy, 385 amputations, 698 dislocations, 270 gun-shot wounds, 142 Hodgen's splint, 141 Holliday, splenectomy, 482 Humerus, fractures, 195 gunshot, 139 lower end, 202 shaft, 195 surgical neck, 200 upper end, 198 osteomyelitis, 374 Hunt, tubal pregnancy, 603 Hydrocele, 716 radical operation, 717 tapping, 716 Hypodermoclysis, 56 Hysterectomy, 603 Ice, appendicitis, 493 Ileus, postoperative, 517 Iliac abscess, 356 Ilio-inguinal nerve injury, 307 Imperforate anus, 584 Incised wounds, 70 of elbow, 90 of neck, 83 of wrist, 88 Infected wounds, 76 Infections, acute, 358 Inferior maxilla fracture, 180 Infiltration of urine, 633 Ingrowing toe-nail, 721 Inguinal hernia, anatomy, 534 radical cure, 557 r.l'l \. 7 1' Inguinal hernia, trangulated, 533 Injuries, abdi imen, 1 1 1 joints, 25a nerves, -"o^ I ntestinal anastomosis, 573 obstructi* m, acute, 508 gastric lavage, 510 (apart >t< >my, 5 1 2 rectal enema, 510 symptoms, 509 treatment, 510 reseetii >n, 57 1 Intestines, suture, 47; wounds. 473 Intracapsular fracture, :ji Intracranial hemorrhage, 444 Intravenous infusion, hemorrhage, 56 shock, 52 technic, 56 Intussusception, 513 Iodine, sterilization of the skin, 10 Irrigator, 3 Ischiotic dislocation, 274 Ischio-rectal abscess, 337 Jaw. dislocation, 266 fracture 180 gunshot, 157 Joints, contusions, 281 dislocations, 252 compound, 278 gunshot wounds, 141, 163 hemorrhage into, 142, [64 injuries, 252 incised wounds, 282 punctured w. mnds, 281 sprains, jNj stal> wounds, 281 suppurations, 376 Keen. Cesarean section, 607 Kelley, t' irsions, 589 Kidney, absces hemorrhage, 1.73 Kidney, injuii) rem< >val rupture, 183 wound Killian, br< mch< 1 >■. ipy, fracl ure 1 , [88 Km >i t . ut ure 1 if liver, 171; Kollman, filiform guide, 624 K( timer, Cesarean ie< 1 i' 'ii. 6 7 ECdnig, preparation of the skin, 10 Knee, amputatii »n, 695 arthrotomy, 377 bandage, s? c< mtusions, 281 disl< icati< nis, 276 gunshot \\i mmls 1 (j, 163 puncture, 382 sprains, 282 stab wounds, 281 wounds, 281 Kiitner, wounds of lung, 159 Kyle, foreign body in nose, 392 Labium, abscess, ; \6 Lacerated wounds, 73 Laceration of brain, 169 Lachrymal abscess, 319 Lanphear, Cesarean section, 605 Laparotomy for Cesarean section 604 general technic, 463 gunshot wounds, civil, 159 military, 145 intestinal obstruction, 510 for traumatism, 469 Laplace, peritonitis, 507 Laryngotomy, 420 Larynx, foreign bodies, 396 wounds, 85 Lateral anastomosis, intestine, 580 sinus thrombosis, 455 Lavage, gastric, 14, 510 Leg, amputations, 693 bandage, 36 fractures, 236 osteomyelitis, 372 Lejars, appendicitis, 193 reduction of shoulder. 253 thumb, 269 rupture 1 >f the lung, 103 splint for leg, 239 preparations for operation, 7 Lembert suture, 17(1 Lichtenstern, torsi, m, 595 742 INDEX. Ligation en masse, 60 Ligations, anterior tibial, 646 arterial, 638 axillary, 643 brachial, 643 common carotid, 640 dorsalis pedis, 647 external carotid, 641 facial, 641 femoral, 646 lingual, 641 occipital, 641 posterior tibial, 647 radial, 644 subclavian, 641 superior thyroid, 641 ulnar, 645 Lingual artery, ligation, 641 Link, tracheotomy, 419 Lipomas, removal, 726 Lips, wounds, 81 Little toe, 682 Liver, hemorrhage, 473 injuries, 478 suture, 479 Local anesthesia, 17 Lower extremity, fractures, 223 Lower jaw, dislocation, 266 Lowery, compound fracture, 248 Luckett, Fourth-of-July injuries, 166 Ludlow, wounds, diaphragm, 109 Ludwig's angina, 323 Lung, abscess, 436 gunshot wounds, 132 hernia, 107 rupture, 104 stab wounds, 105 suture, 425 Malar bone fracture, 180 Malaleuca sempervirens, 622 Mammary gland abscess, 330 Marsee, fracture of fingers, 221 injuries to hand, 96 suture of tendons, 291 Martin, Cesarean section, 606 Mastoid operation, 455 Mastoiditis, 455 Materials for sutures, 23 Mayo, umbilical hernia, 554 Mayor's sling, 186 Maxilla, fractures, 180 Meatus, foreign bodies, 389 Median nerve exposure, 298 injury, 297 Meningeal hemorrhage, 177 Metacarpals, fracture, 220 Metal splints, 46 Mesentery, hemorrhage, 472 repair, 473 McEwen, strangulated hernia, 545 McFarland, antitetanic powder, 167 McGrath, appendicitis, 494 Middle meningeal artery, hemor- rhage, 177 Miller, pelvic abscess, 351 Miller, kidney, injury, 484 Mitchell, peritonitis, 506 Morley, bandage for head, 44 Morris, appendicitis, 489 Morrison, wounds of eye, 85 Mosetig-Moorhof bone wax, 370 Mothe, dislocation of shoulder, 257 Motor-oculi nerve injury, 297 Mouth burns, 409 Moynihan, intestinal anastomosis, 573 purulent peritonitis, 505 Murphy button, 579 purulent peritonitis, 505 suture of arteries, 638 olecranon, 218 Musculo-cutaneous nerve, 308 Musculo-spiral nerve exposure, 302 injury, 301 Nares, plugging, 66 Nasal bone, fracture, 179 - septum abscess, 318 Nassau, esophagotomy, 422 Nausea, anesthesia, 16 Neck, bandage, 42 wounds, 83 gunshot, 144, 157 Neff , rupture of urethra, 608 Nelaton's line, 225 Nephrectomy, 483 Nerve, compression, 295 contusion, 295 grafting, 296 suturing, 294 wounds, 295 gunshot, 123 Nerves, individual, 296 abducens, 297 anterior crural, 303 auditory, 297 [NDEX. 743 Nerves circumflex, 302 facial, 296 fifth, 297 genito crural, 307 llio-inguinal, .,07 laryngeal, 297 median, 299 motor-oculi, 297 musculocutaneous, 308 musculo 1 spiral, 301 1 .1 it nr.it. >r, 306 optic, 296 peroneal, 308 phrenic, 297 pneumogastric, 297 pi ipliteal, 308 radial, 301 recurrent laryngeal, jijj sciatic, 307 til>ial anterior, 309 ]m isterii >r, ,^0(j trifacial, 2qj ulnar, 299 Noble, Cesarean section, 606 Noetzel, wounds of spleen, 4S2 Nose, foreign bodies, 391 hemorrhage, 65 Obturator artery Ligation, 306 dislocation, 276 hernia, strangulated, 554 nerve, 306 Occipital artery ligation, 641 CEdema of the glottis, 419 1 E it I'hagotomy, 420 CE ophagus, foreign bodies, 392 injuries, 83 Ointment of Reclus, 408 Olecranon, fracture, 216 Oliver, strangulated hernia, 545 jaw fracture, 181 Omentum, hemorrhage, 471 resection, 568 torsion, 596 Open wounds of thorax, 104 Operative wounds, 71 Operation in private houses, 6 Opium, appendicitis, 493 Optic nerve injury, 296 Os calcis, Pirogoff's amputation, 689 Oschner, appendicitis, m( femoral hernia, 569 torsion, 592 1 1 tei »myeln ii , acute, 369 lemur, 37 1 humerus, .,7 1 tibia, 37a ( tvarian cysts, t< »r >ii m 1 A pedicle, 590 •1 itecher, linen, 1 \ Palmar abscess, 33s arches, 63 Panaris, 359 Pancreas, gunsh »1 wounds, 135 injuries, 481 suture, pi Paraphimosis, 710 Paracentesis, eardrum, 1.56 pericardium, 1.33 1 ileura, 438 Parotid gland abscess, 320 Patella, dislocation, 277 fracture, 231 wiring, 2^ Peck, wounds ol heart, 432 Pedicles, ligation, 590 Pelvic abscess, 348 Pelvis, fractures, 245 Penis, injuries, 118 Perborate of soda, epistaxis, 67 Peri-anal abscess, 340 Pericardiotomy, 435 Pericardium, paracentesis, 433 puncture, 433 suture, 430 wounds, no Perineal abscess, 341 bruises, 635 section, 636 Peritonitis, purulent, 506 treatment, 507 typhoid, 506 septic, 506 Peroneal nerve, 308 Pfaff, appendicitis, 492 tubal pregnancy, 602 Phalanges, fractures, 220 Pharynx, foreign bodies, 392 Phimosis, 710 Phlegmon, 362 arm, 366 fingers, 362 f( irearm, 365 neck, 367 perineum, 635 tendon sheaths, 362 Phrenic nerve, 297 744 INDEX. Picric acid, burns, 408 Piles operation, 704 ■ Pinna, wounds, 80 Pirogoff 's amputation, 689 Plantar abscess, 337 Plaster-of-Paris bandages, 46 preservation, 4 splints, 47 Bavarian, 48 Pleura, empyema, 439 incision, 439 puncture, 438 wounds, 105 Pneumogastric nerve, 297 Pneumothorax, 101 Poisoned wounds, 68 Popliteal abscess, 335 artery compression, 64 Porter, treatment of wounds, 75 Posterior nares, plugging, 66 tibial artery, 647 nerve, 309 Post-operative ileus, 517 Potain's aspirator, 438 Pott's fracture, 242 Precordial wounds, no Pregnancy, extra-uterine, 597 Preparation, emergency opera- tions, 8 hands, 9 skin, 8 Primary hemorrhage, 54 Probang, foreign bodies, 395 Preperitoneal hernia, 543 Prostatic abscess, 341 Psoas abscess, 355 Pulse, abdominal injury, 113 appendicitis, 490 chloroform anesthesia, 12 ether anesthesia, 14 • hemorrhage, 55 shock, 50 Puncture, bladder, 628 knee joint, 382 pericardium, 433 pleura, 438 scrotum, 716 Punctured wounds, 73 Purulent pleurisy, 436 Quadriceps extensor tendon, rup- ture, 285 Quinsy, 325 Quenu, preparation of room, 8 Radial artery, compression, 63 ligation, 644 synovial sheath drainage, 363 Radius, fractures, 210 gunshot, 139 Ranzi, torsions, 590 Reclus, lacerated wounds, 95 ointment, 408 Rectal injections, 511 Rectum, abscess, 340 dilatation, 703 foreign bodies, 399 hemorrhoids, 704 wounds, 121 Recurrent laryngeal nerve, 297 Reduction "en masse," 532 dislocations, 253 fractures, 191 hernia, 531 Removal of small tumors, 724 Respiratory paralysis, 14 Responsibility of general practi- tioner, 2 Retention of urine, 619 Retropharyngeal abscess, 326. Reverdin, skin grafting, 727 Ribs, fracture, 183 resection, 438 Robinson, shock, 53 Romer, fracture, clavicle, 185 Rongeur forceps, 445 Rossi, fractures, 193 Rosving, appendicitis, 489 Roux, femoral hernia, 572 Royster, fracture of humerus, 201 Rubber gloves, 9 Rugine, 440 Rupture, tubal pregnancy, 598 urethra, 612 Russ, fracture of thumb, 223 Saber splint, 154 Sacro-iliac synchondrosis, 246 Saline solution in hemorrhage, 56 sepsis, 505 Sayres' dressing, 185 Scalds, 405 Scalp, abscesses, 316 arteries, 63 hematoma, 172 wounds, 78 Scapula amputations, 679 fracture, 243 Schaute, Cesarean section, 607 I\l>l \. 7 15 Schell, < '<• sarean >e» t ii m, (>o(i Schleich's formulae, [9 Sciatic nerve injury, 307 Sclerotic w< >und Sic ip( .1. iininc narci isis, 1 1 Scr( itum, injuries, 1 iS Scudder, fracture 1 if leg, 239 Sebaceous cysts, removal, 7-1 Seec mdary hemorrhage, 5 1 Semilunar cartilages, dislocation, Seminal ducts abscess, 3 |^ Senn, first aid on battlefield, 1 |8 I'raet ure i if lemur, :.•(■ hip-joint amputal i' in, 699 intussusception, 514 Septic arthritis, <;<> Septum nasi abscess, 318 Shaving skin, s Shell wounds, 1 i'> She >ek, 40 diagnosis, 50 treatment, 5 1 Shoulder amputation, 674 arthrotomy, 385 bandage, 42 dislocations, 252 fractures, 198 Shrapnel! wounds, 146 Silk sutures, 23 Silkworm sutures, 24 Simons, crushing wounds, 94 Skin grafting, 727 preparal ii in, 10 Skull, bullet wounds, 127, 155 fracture, base, C69 compound, 173 vault, 171 trephining, 444 Spence, shoulder amputation, 680 Spermatic cord, ligation, 720 torsion, 593 vasectomy, 345 Spica f< >r breast . 1 1 foot, 36 gr< 'in, 38 shoulder, 12 Spinal anesthesia, 20 cord injuries, 179 Spine, fractures, 1 78 gunshot wounds, 130, [57 wounds, 1 1 7 Spleen, hem< irrhage, |J8] injuries, (Si , rem< >va ruptun \> irsii >n, 595 Splenectomy, . Splint, Bavarian, 18 I lupuytren'i , fir t aid, 1 S 1 I [odgen's, 1 1 1 Splint }, 1 ^ I >utch cane, 45 metal, \(< plaster 1 if Pari 1, [6 silicate I if 1" itash, l , w< Milieu, 45 wire gauze, [6 Sprains, 283 St . Andrew's cri iSS, 40 Stab wounds, 72 abdomen, 1 1 5 heart, 1.25 knee, 28l thigh, 88 thorax, 104 Sterilization, dressing, 7 hands, 9 instruments, 8 skin, 10 Stimson, pain in fracture, 190 Stomach, hemorrhage, 135 hernia, 545 suture, 478 wounds, 478 Stewart, suture of heart, 431 Stovaine, spinal anesthesia, 20 Strangulated hernia, 528 complications, 541 diagnosis, 529 femoral, 533 inguinal, 533 obturator, 554 1 iperation, 533 taxis, 530 umbilical, 549 Stricture of urethra, 619 Stump bandage, 15 Subclavian artery, compression, 63 ligation, 641 Subclavicular dislocation, 256 Subcutaneous wounds, 69 Subcuticular suture, 28 Subglenoid dislocation, 2(>2 Submammary abscess. Submaxillary abscess. 746 INDEX. Subphrenic abscess, 351 Subpubic dislocation, 275 Subspinous dislocation, 265 Suicide, attempts, 155 Superior maxilla fracture, 180 thyroid artery ligation, 641 Suprapubic cystotomy, 617 puncture, 628 Surgical dressings, 32 Suture of arteries, 638 bladder, 486 heart, 430 intestine, 475 liver, 479 lung, 425 nerves, 294 pancreas, 481 tendons, 289 ureter, 486 wounds, 23 Sutures, catgut, 24 continuous, 24 horsehair, 23 interrupted, 25 Lembert, 476 linen, 24 methods and materials, 23 quilted, 24 sero-serous, 476 silk, 23 silkworm-gut, 24 subcuticular, 28 Syme's amputation, 687 Syncope, 55 Synovial sheath suppurations, 361 cysts, 726 Tampon for intercostal hemor- rhage, 65 Tapping, hydrocele, 716 Tarso-metatarsah amputation, 683 Tarsus, dislocations, 277 fracture, 250 Taxis, indications, 530 technic femoral hernia, 533 inguinal hernia, 531 umbilical, 533 Taylor, empyema, 436 fracture of humerus, 202 Temporal artery compression, 63 Temporo-maxillary joint disloca- tion, 266 Tendon, dislocations, 284 divided, 288 Tendon, rupture, 284 suture, 289 wounds, 284 Testis, removal, 718 suture, 119 wounds, 119 Tetanus, bolo wounds, 147 Fourth-of-July injuries, 166 prophylaxis, 166 punctured wounds, 73 Thiersch, skin grafting, 728 Thigha, mputations, 697 Thoracotomy, indications, 423 technic, 423 Thorax, injuries, 99 Throat, cut, 83 Thrombosis, lateral sinus, 455 Thumb, amputations, 661 bandage, 41 dislocations, 268 fracture, 223 Tibia, fractures, 236 osteomyelitis, 372 trephining, 373 Tibial arteries, ligation, 646 compression, 64 Tillaux's dressing, 228 Toe-nail, ingrowing, 721 Toes, amputation, 680 Tongue, abscess, 325 suture, 82 wounds, 82 Tongue-traction, asphyxia, 15 Tonsil, abscess, 325 Torsion, arteries, 59 diagnosis, 589 omentum, 596 pedicle ovarian cysts, 589 spleen, 595 spermatic cord, 593 uterus, 591 Townsend, catheterization, 622 Trachea, foreign bodies, 396 gunshot wounds, 144 incised wounds, 85 Tracheotomy, after-treatment, 418 foreign bodies, 417 indications, 413 operations, 413 tubes, 413 Travers, suture of the heart, 431 Trephining, femur, 374 fracture of skull, 444 humerus, 374 [NDEX. 717 Trephining, tibia, .^7-: Trephine, I )■ iycn, 1 \8 Gait, us IV. es, strangulated hernia, 538 Trunk injuries, >)<> Tubal pregnancy, diagnosis, 598 operal i< in, 599 rupture, 597 rubercular abscess, ,; 1 5 Tumors, superficial, 72 1 Turpentine burns, 408 Tunica vaginalis, resection, 717 Tuttle, imperforate anus, 588 Tvpli' 'id perfi >rati< in, 507 (Tina, fraci ures, 210 LMnar artery, ligatii m, << [$ nerve exposure, 299 injury, 299 synovial sheath, 363 Umbilical hernia, strangulated, 549 radical cure, 550 Ureter, repair, 487 wounds, 4S7 lira, anatomy, 610 catheterization, 620 contusions, 611 foreign bodies, 402 rupture bulbous portion, 612 diagnosis, 608 membranous portion, 618 pendulous portion, 618 symptoms, 609 treatment, 612 Jrethral forceps, 402 Urethrotomy, 612 Hrgent craniectomy, 444 thoracotomy, 423 Jrinary abscess, 633 Jrine, extravasation, 633 retention, 619 Jterus, torsions, 591 Van der Walker, emergency surgery, 6 ifegina, abscess, 346 injuries, 118 Vagus nerve, 297 Van Hook's anastomosis, 4N7 Valentine, emergency catheteriza- tion, 622 Vasectomy, 3 \^ Vaughn, wounds of heart, 11 _• Vault ' >! skull fraci ure, 1 7 1 compound, 17s Veins <»f Liver, ligal \> in, 1 7 • ^ Velpeau 1 bandage, [84 Vem 'us hem' irrhage, ^ 1 Vincenl , t rephining, 1.5a Vim l ierg, t ubal pregnancy, s<; s Vertel irae, fra< 1 ures, 1 78 V i ■ era, abd< iminal, rupture, 1 \ ; Volvulus, 510 Von Bergman, gunshol wounds, 1 27 Vulvar abscess, 3 \.6 Vulvo-vaginal abscess, 346 injuries, 1 c8 Waite. shock, 49 Walker, fractures of femur, 227 Warbasse, treatment of fracture, 192 Wathen, wounds of liver, 47c) Westmoreland, tracheotomy, 117 Whitman, fracture of femur, 227 Wick drains, 30 Wire gauze splints, 46 Wiring fractured fingers, 222 olecranon, 216 patella, 233 Wooden splints, 45 Wounds, abdomen, 114 aseptic, 70 base of thorax, 108 bend of elbow, 90 bladder, 485 blank cartridge, 166 bolo, 146 chest, 104 cleansing, 75 contused, 69 definitions, 68 diaphragm, no drainage, 89 dressings, 75 elbow, 90 eye, 85 eyelids, 82 extremities, 87 face, 81 femoral artery, 88 fingers, 95 general principles, 68 gunshi it, civil, 1 55 military, u: hand, <)(> 74 8 INDEX. Wounds, head, 78 heart, no hemorrhage, 70 incised, 70 infected, 76 intestine, 475 kidney, 483 lacerated, 73 larynx, 85 lips, 81 liver, 478 lung, 105 neck, 83 operative, 71 pancreas, 481 penis, 118 pericardium, no pinna, 80 pleura, 105 precordial, no punctured, 73 rectum, 121 scalp, 78 scrotum, 118 shell, 146 special regions, 78 spine, 117 Wounds, spleen, 481 stab, 72 stomach, 478 subcutaneous, 69 suture, 24 symptoms, 69 testicle, 119 thigh, 88 thorax, 99 trachea, 85 treatment, 70 tongue, 82 toy pistols, 166 ureter, 487 vagina, 118 vulva, 118 wrist, 88 Wrist, arthrotomy, 384 dislocation, 280 fractures, 219 wounds, 88 X-ray, foreign bodies, 394 fractures, 191 Zone of anesthesia, 18 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. 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