COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64054381 RD33 L56 Surgical emergencies ■ppppii H^^H SHl RECAP II trny^ ^^ YWr.&,..C.,.^...Q.iiYilKer. SURGICAL EMERGENCIES 12 LECTURES DELIVERED AT THE UNIVERSITY OF LEIPSIC BY DR. L. VON LESSER Privat Docent of Surgery TRANSLATED AND REVISED BY FREDERICK A. LYONS, A.M., M.D. Surgeon to Bellevue Hospital Out Patient Department, Fellow of the American and New York Academies of Medicine, Etc. NEW YORK BERMINGHAM & CO. 18S3 Copyright, 18%, by BERMINGHAM & CO. u sr(o CONTENTS. LECTURE I. PAGE Reasons for-a special treatise on the subject. — Considerations for the division of the methods of aid in emergencies. — The assistance to be rendered either to a single individual or to a number. — Acci- dents to numbers both in times of war and peace 9 LECTURE II. Loss of vital elements. — Losses of blood. — On the amount of blood present in the organism and on the vascular extent. — Experi- mental increase of the amount of blood. — On the parts where the infused blood collects. — The extensiveness of the capacity of the vascular system. — The bleeding to death of plethoric persons. — On the destiny of the infused blood. — On cases of bleeding to death. — The course of the blood-pressure curves in those cases. — Slow and quick bleeding to death. — Qualitative changes of blood-mixture in phlebotomy 13 LECTURES III. AND IV. Haemostasis. — Blood-saving. — Hsemostasis, especially of blood from injured arteries. — Progress of occurrences during the healing of arterial wounds. — Proliferation of the vascular walls and thrombus organization. — Bruises, cuts and punctures of arteries. — Foreign bodies grazing the arterial tube. — Catgut as material for ligatures, and its action within the different tissues. — Thread-ligature in (aseptic) wounds. — Instruments for vascular ligatures. — Ligature of artery stumps and in the continuity of the vessels. — Substitutes for thread-ligature. — Haemostasis at certain parts of the body. — Places for the compression of arterial trunks 22 LECTURE V. Haemorrhages from veins. — Their frequency, cause, and occur- rence. — Phlebitis. — Periphlebitis. — Phleboplastic haemorrhages of Stromeyer. — Spontaneous haemostasis. — Vein-ligature. — Substi- tutes for vein-ligature. — Tamponing in sequestral cavities, in haemorrhages from the rectum, the vagina, the uterus. — Treatment of haemorrhages from the nose. — Bellocq's tube. — Bandage-wrap- ping. — Capillary haemorrhages. — Search for bleeding point. — 11 CONTENTS. Tamponing with bandage* wrapping. — Styptic tampons. — Heat and cold. — Hot douches as safe haemostatic means. — Glow-heat. — Cautery iron. — Galvano-cauterizer. — Paquelin. — Chemical haemos- tatic means , 41 LECTURE VI. Bleeding. — Its value as a haemostatic remedy. — Other indications formerly and at present. — Places for phlebotomy. — Phlebotomy. — Topography of the elbow. — Technique of phlebotomy. — Phle- botomic aneurisms.— Phlebotomy on the foot and the neck. — Arte- riotomy and its present indications. — Capillary bleeding: Its real value. — Scarification. — Cupping. — Leeches. Transfusion.— Historic periods. — Defibrinated and "intact" blood. — Different methods of transfusion. — Actions of the blood-discs, of the serum and the gaseous contents in the blood of different species of animals. — Significance of fibrin-ferment. — Central arte- rial blood infusion. — Venous transfusion. Ingress of air into veins. — Result of experiments. — Blood-injection under the skin and into the abdominal cavity. — Technique of transfusion. — Symp- toms in transfusions. — Present indications. — Territories of anae- mia. — Auto-transfusion 50 LECTURE VII. Impediments to the supply of air. — Sudden stoppage thereof in strangulation. — Foreign bodies in the trachea and oesophagus. — Perilaryngeal swelling of the tissues. — CEdema glottidis, struma. — Kropftod. — Gradual narrowing of the trachea lumen. — Croup and diphtheria. — Paralysis of the vocal cords. — Tracheotomy, pre- paratory to other operations. — Dilatation of tracheal strictures. — Induction of artificial respiration in chloroform poisoning, opium poisoning, tetanus. — Modus operandi. — Rapid and slow suffoca- tion, their causes and symptoms. — Dangers of suffocation in tun- nels and mines; to divers, aeronauts on high elevations; working in compressed air (caissons in bridge-building). — Narcosis in com- pressed air according to Paul Bert. — Mechanism of artificial respiration. — Opening the cervical bronchus. — Pharyngotomy. — Thyrotomy. — Thyrocricoid laryngotomy. — Cricotomy or crico- tracheotomy. — Supraglandular and infra-glandular tracheotomy. — Procedures in tracheotomies.— Bose's rectangular dissection of the trachea. — Insertion of the tube.— Removal of croup mem- branes and foreign bodies. — Sucking out fluids not to be done in diphtheria. — Dimensions of tubes, and their modes of fastening. — Dressing of the wound in tracheotomy. — Painting it with an eight-per-cent solution of chloride of zinc. — Inhalation through the wound of tracheotomy. — Removal of the tube. — Impediments to respiration after the tracheotomy. — Granuloma. — Strictures. — Posture of the patient in tracheotomy. — Instruments and para- phernalia for tracheotomy . . . 73 LECTURE VIII. Impeded passage of alimentary substances through the intestinal canal. — Impediments in the pharynx and cesophagus: Topo- CONTENTS. ill graphy of the latter. — The most narrow points in the oesophagus, as seats of foreign bodies, tumors and strictures. — Removal of foreign bodies from the faucial, cervical, and thoracic parts of the oesophagus. — Instruments. — CEsophagotomy. — Indications, mode of procedure, after-treatment of the wound. — Tumors of the oesoph- agus. — Strictures, their etiology and treatment. — Catheterizing the (esophagus. Girard's method. — Impediments in the small and large intestines. — Hernias: Reducible, adherent, strangulated. — Hernial orifice, contents, sack, neck; cysts of the sack. — Irreducibility, its etiology; adhesions, faecal invagination. — Strangulation. — Acute and sub-acute strangulation. — Apparent strangulation and its treatment. — Site of strangulation. — Treat- ment of hernia. — Taxis: Mechanisms of Roser, Busch, Lossen. — Supporting postures in taxis. — False reduction. — Herniotomy: No special instruments required. — Modus operandi. — Incisions. — External and internal hernial incision. — Herniotomy. — Debride- ment multiple. — Reposition of hernial contents. — Condition of the loop of intestine. — Suture of intestine in various forms of gangrene. — Enteroraphy: Treatment of artificial anus. — Treatment of pro- lapsed peritoneum. — After-treatment of herniotomy. — Radical operation for hernia 97 LECTURE IX. Gastrotomy. — Indications. — History. — Spontaneous gastric fistulae. — Sites for opening the stomach. — Fixation into the abdominal wall. — Attaching the abdominal wound with the gastric mucous membrane. — Drainage-tube. — Obturators. — Condition of the pa- tient in gastric fistula. — Artificial (external) oesophagus. — Opening the duodenum. — Closing gastric fistulse. — Anomalous anus. — Atresia ani. — Degrees of defectus ani et recti.— Opening atresic anus. — Lumbocolotomy. — Laparocolotomy. — Fistula of small intestines. — Artificial anus. — Foreign bodies in the rectum and in the vagina 119 LECTURE X. Dangerous impediments to respiration and circulation resultant upon accumulation or retention of fluids within the cavities of the body, within certain hollow organs and within pathological cystic spaces. Accumulations of fluids within the thorax. — Historical con- siderations. — Indications for the evacuation of pleuritic exudations in general. — Re-absorption by the pleura. — Pneumothorax, chly- lothorax, haematothorax. — Treatment of punctures into the pleura. — Opening of the thorax and special indications therefor. — Punctio thoracis: Thoracotomy. — Sites for opening the thorax. — Puncture of the thorax. — Haemorrhage from the intercostal vessels. — Trocars. — Apparatus for puncture with exclusion of air. — After-treatment of puncture. — Opening the plura by incision. — Partial sub-periosteal excision of ribs. — After treatment sub- sequent to the production of thoracic fistula. — Accumulations of fluids and air in the pericardium and their treatment. — Wounds in the heart. — Electropuncture and acupuncture of the heart 130 IV CONTENTS. LECTURE XI. II. Free and cystic accumulations of fluids and swellings from retentions in the abdominal cavity. — Indications for puncture in ascites. — Sites of puncture. — Operative procedures. — Differential diagnosis from ovarian tumors. — Accumulations of air in the abdominal cavity and intestines. — Echinococcus cysts. — In the liver. — Modes of treatment. — Hydronephrosis. — Etiology and treatment. — Cysts of the ovaries. — Punctures and their consequences. — Solid abdominal tumors. Cystotomy. — Indications. — Posterior catheterism. — Foreign bodies in the urethra. — Their extraction. — Procedures in cystotomy. — Injuries to the bladder. H^ematometra. — Hydrometra. III. Perilous contraction of the cranial space (see below).. 146 LECTURE XL— Continued. III. Contractions of the intracranial space perilous to life. — Normal pressure within the cranial cavity. — Increase of intra- cranial pressure and transferability of the cerebrospinal liquor. — Its relations to the lymphatic circulation. — Cerebral hyperaemia and its consequences. Cerebral compression: Its causes. — Intracranial Haemor- rhages. — Injuries to the venous sinuses and their treatment. — Haemorrhages from the middle meningeal artery. — Symptoms. — Ligation of the middle meningeal artery. — Haemorrhages from the cerebral division of the carotid artery. — Haemorrhages between the dura mater and pia mater. — Reduction of space by fractures of the skull and foreign bodies. — Complicated injuries to the skull, prognosis, results. — Symptoms of cerebral contusion. — Antiseptics in injuries to the head. — Attainable results. — Treat- ment of infected injuries to the skull. — Action of antiseptic douche, ice, venesection, purgatives, inunctions of ung. ciner. — Operative interference in inflammatory stage of wounds. — Cerebral abscess. — Difficulties of diagnosing locality. — Treatment of open and covered cerebral abscesses. — Cerebral motions. — Causes. — Absence of cerebral motions. — Treatment of prolapsus cerebri. Concussion of the brain, commotio cerebri. — Symptoms. — Pure and complicated descriptions. — Theories. — Light and severe cases. — Course and termination. — Treatment of concussion of the brain and sequelae. Trepanning. — Indications. — Instruments. — Mode of procedure. — Processes which occur in wounds from trepanning 161 LECTURE XII. Aids in accidents to masses of men. — Surgical aid in war. — General considerations. — Objective points of military surgery. — Task of each individual surgeon. — Information requisite. — Lead- ing principles in military practice. — The battle-field. — Division of the wounded into those who are capable and those who are in- capable of marching. — Places for immediate dressings. — Selection of place. — Refreshment for the wounded. — Classification CONTENTS. V of injuries. — Provisional arrest oi dangerous haemorrhages. — How should the primary dressing be made ? — Antiseptic com- presses, bandages, cloths, slings. — Splints, their improvisation. — Stretchers. — Means of transport from the battle-field. — Medical staff. — Carriers of the wounded. — The place of permanent dress- ing. — Only for the wounded who cannot march. — The medical staff and its organization. — Organization of the sanitary detachment. — Consulting surgeons. — Assortment of the wounded. — Tickets. — The diagnosis cards formerly employed. — Dressings for those to be immediately removed. — Injuries belonging to this class. — Form of dressing. — Drainage. — Course and contents of the canal of the shot-wound. — Splints, ready-made and improvised. — Means of transportation from the dressing-station to the field-hospital, to the depot, and to the sanitary train. — Improvisation of these means of transportation. — Injuries in which operative interference is requisite. — No resections to be performed at the dressing station. — Injuries which cannot bear transportation ; 189 EDITOR'S PREFACE. The work herewith presented to the English speaking medical public occupies a unique position, and therefore needs no apology. It treats of subjects that have been left untouched by the few short and imperfect works on surgical emergencies that have appeared, and which, in general treatises on the surgical art, are so encumbered by the mass of other matter that they are inaccessible. Not a small portion of the book is devoted to subjects which can scarcely be classed as surgical emergencies, but which may be included in the term " Life-saving Opera- tions." These matters are extremely important to the practitioner who has not the time to wade through ponder- ous tomes and innumerable journals, and they are dealt with in a precise, sententious and masterly manner. Many of them are so recent in their origin, that they have not as yet even been incorporated in the text-books. Thanks are due to Dr. Ferd. C. Valentine of this city, for his invalua- ble assistance in the preparation of the manuscript. FREDERICK A. LYONS. 244 West Forty-ninth St., New York. PREFACE. I am induced to publish the following course of lectures by the great interest evinced by my hearers in the subject treated of. I am perfectly conscious of the imperfections of this little work. Besides, I have lacked the requisite leisure to put the finishing touches to every detail, as I should have liked. But who has succeeded, in this busy bustling decade, in writing a book at once so interesting and weighty as Diefenbach's " Operative Surgery," or so deeply instructive as Virchow's "Cellular Pathology," or so inspiring as Billroth's "General Surgical Pathology," appeared to us in the years of our academic life ? Above all things, I have striven to be true: not to say more nor less than was necessary to the elucidation of the subject. The clinical preceptor, who has followed without pre- judice the progress of surgical science, and whose ambi- tion is not to be satisfied by the brilliant success of his operations alone, will find but little that is new in this book. On the other hand, I hope the young practitioner will gladly take it up for advice, when he leaves the student's life for independent activity in his profession, and suddenly becomes conscious of the great responsibility which he has taken upon himself. For to this day, as formerly, even to the most industrious of young physicians, and even at our best universities, that practical training and that confi- dence are lacking, which are alone obtainable within hospi- tals. Most of them have seen much, learned much, but experienced little. But even the physician, who has had the privilege of en- larging his knowledge by daily hospital practice, may be PREFACE. stimulated by the present volume to ponder over his own ob- servations. As regards citations, only those works have been noticed which have been a source of instruction to myself or which excel by their impartial presentation of the literature of the subject. I therefore hope not to offend any one, nor call forth touchy questions of priority. I dedicate this small volume to Bernhard von Langenbeck and Carl Ludwig, to whom I am indebted for the best I have learned. To them belongs the credit for all that is good and useful within these pages. L. VON LESSER. Leipsic. SURGICAL EMERGENCIES. LECTURE I. Reasons for a special treatise on the subject. — Considerations for the division of the methods of aid in emergencies. — The assist- ance to be rendered either to a single individual or to a number. — Accidents to numbers both in times of war and peace. Gentlemen : The separate discussion of surgical aid in cases of pressing danger to life is not included in theore- tical lectures on Surgery. Its aim is a direct completion of our clinical instruction. Conditions which are directly life-endangering are but seldom seen at the clinic; for it would depend upon chance that such cases should present themselves for aid just during the hours of instruction. Should this even be the case, the symptoms of the dangerous condition and the means of assistance appear in an altogether too favorable light, simply because at the clinic the most favorable cir- cumstances imaginable obtain as to the place of operation, professional experience, and intelligent assistance. The same cases will appear to you entirely different in your own practice. You will often be called upon to ex- ercise your profession when life is in peril, within narrow, badly lighted rooms, surrounded by despairing relatives, panic-stricken friends, and distrustful old women, In such cases, only the firmest principles and technical surety will give you that measure of self-confidence which forthwith commands respect from both the patient and those surrounding him, but which also preserves from in- excusable passivity as well as from irresponsible officious- ness (delirium operatorum). Secondly, surgical aid in IO SURGICAL EMERGENCIES. sudden emergencies needs a separate discussion, because the course of instruction differs materially from that in a clinic. In the latter only selected cases are laid before the student. Not only their history, but also the special indivi- duality of the patient is circumstantially considered, in ad- dition to an exhaustive investigation of the disease. In emergencies where the patient's life is in imminent danger, or even where he is unconscious, and those around him are unfit for thought or action, unmanned by the sud- denness of the misfortune, then it falls upon you to re- cognize at once the chief symptom and to take promptly the right measures to combat it. Even within the walls of the hospital the urgency of the need scarcely permits a more minute demonstration of the separate phases of the disease. It is exactly for this reason that we feel justified in leaving for the present the sick-bed for the experiment-table at the clinic, for the study of life-endangering conditions. We certainly concur in the protest against simply transferring the results of experiments upon animals to phases of disease in man; we would specially recall to you the results of vaccine-tuberculosis as compared with the progress of human phthisis. For conditions dangerous to life, however, experi?nents upon animals serve excellently well, as prototypes of disturbed life functions. At the experiment-table we are en- abled to study much more precisely the separate phases of a disturbance without regard to the subsequent preserva- tion of the individual's life. It is in my opinion exactly through this peculiarity in the method of instruction that surgical aid in sudden emergencies possesses an advantage over the other applications of surgery. But you will not only meet such emergencies rarely in the clinic, and not only does the course of instruction appear different, but also emergencies occupy a distinct technical position among surgical operations. As remarked above, the latter are performed at the clinic in a specially chosen operating-room, amidst the best possible conditions of light, ventilation' and temperature. Here it is possible to get ready all necessary instruments, to procure new ones, or even to have such constructed as best serve the special case. But when we meet in our every-day practice, unexpect- edly and unequipped, conditions endangering life, then we are often called upon to improvise the necessary instru- ments, to accomplish much with imperfect materials, and in SURGICAL EMERGENCIES. II spite o tne scantiness of our means to approach as near as possible the strict requirements of the art of operating, and particularly that of dressing, of the present day. The surgeon's talent for improvising will be particularly challenged by the accidents of war. It is true this talent is a natural gift, but its development and cultivation must not be left to the moment of necessity — it must be schooled and exercised beforehand. Modern military surgery has learned to appreciate sufficiently the importance of this fact. The surgeon's aid in emergency differs according to its being rendered either to a single individual or to a greater number of people. Of course the consideration of the aid to be rendered to a single individual will form the basis of our remarks on its application to a number of people. The exact apprecia- tion of its essential principles will facilitate the establish- ment of those rules which are to guide us in cases of acci- dents befalling larger numbers of people, and where it is of chief import to select correctly the right kind of aid accor- ding to its urgency, consequently to divide labor most effect- ively and where the surgeon's activity in organizing out- weighs for the moment that of operating. Mortal dangers befalling single individuals may be chiefly classified as follows; A. Cases of loss of vital elements (blood). B. Cases of obstruction to the regular reproduction of the same (air, nourishment). C. Cases in which the accumulation of material endan- gers either mechanically, or chemically, or simultaneously in both ways the constituent parts of individual organs or the entire organism (ascites, empyaema, emphysema diffu- sum, urinary 'retention, quickly growing tumors, abscesses or blood-infiltrations, poisoning by gases, such as carbonic oxide, carbonic acid, hydrosulphurous acid and chloroform, or by fluids, such as opium, morphine, septic substances, etc.). The above classification corresponds also to the contents of the main chapters, and the surgical manipulations to be treated of therein, viz.: I. Haemostasis. II. Air-supply in cases of suffocation and poisoning. III. Laryngotomy and gastrotomy, treat- ment of constriction of the intestines, atresia ant et defectus ani y and the formation of artificial anus. IV. Treatment of the accumulation of fluids in the pleura, peritoneum, blad- der, uterus, etc. V. Treatment of quickly growing cystic 12 SURGICAL EMERGENCIES. and solid tumors (oviarian cysts, echinococci, struma, solid abdominal tumors). For aid in emergencies, in accidents to numbers, we shall use as a type, the aid in military cases, both on the battle- field and in the first halting-places, with due regard to the rules of dressing for transport, and for means of transport to the rear. The difference of accidents in factories, mines, buildings, water-works, on railroads, etc., compared with casualties of war, consists in the fact that in the latter we have to deal mainly with a quite particular form of injury. In contrast with gunshot wounds of the bones and of the viscera, as they almost exclusively characterize modern war- fare, the calamities of peace bring before us in various num- bers injuries by explosion, burns, bruises and contusions. As regards the technique of operations I shall confine my- self to an exact presentation only of the most useful method and to the enumeration of those instruments only which are absolutely necessary to a hasty operation, because, as I em- phasized above, we must learn to perform our task with the least amount of extraneous aid. You will see, gentlemen, that the territory which we are jointly to traverse is very extensive. We must guard against losing sight of the general principles in the examination of the details: we must endeavor to bring into prominence the essential points of our inquiry. Thus I hope you will be- come equipped with a sufficient amount of principles to be applied in cases of need, in which you will have the difficult task of appearing as saviour. The words of Hamlet: "'Tis all in being ready," are applicable to no other branch of medical activity better than to ours. SURGICAL EMERGENCIES. 1 3 LECTURE II. Loss of vital elements. — Losses of blood. — On the amount of blood present in the organism and on the vascular extent. — Experi- mental increase of the amount of blood. — On the parts where the infused blood collects. — The extensiveness of the capacity of the vascular system. — The bleeding to death of plethoric persons. — Oft the destiny of the infused blood. — On cases of bleeding to death. — The course of the blood-pressure curves in those cases. — Slow and quick bleeding to death. — Qualitative changes of blood-mixture in phlebotomy. Gentlemen: Hsemostasis is one of the most important chapters of surgery. The experience of the operator is best evinced by his certainty on this subject. The great num- ber of methods and means of haemostasis, which already exist, and which continually increase, are the best proof of the difficulties which must often be overcome. Before entering upon the theme proper it is our duty to form an exact conception of the vascular system, and of the distribution of blood therein. You see here two dogs. I have provided the carotid of the larger and the jugular vein of the smaller with canulae. By a glass tubing I unite both canulae, and after expulsion of the contained air, I cause — by a proceeding to be explained in Lecture VI. — the blood of the carotid of the larger animal to pass over into the jugular vein of the smaller one. The latter remains perfectly quiet, breathing only less often, and not so deeply. After a short time the larger animal, losing its blood, becomes restless — its restlessness increases, and at last it falls into general convulsions — it has bled to faintness. We finish our transfusion of blood, and leave the recipient of it alone for the present, who, be- ing freed, runs off gaily, and at the most is troubled for a ''short time after the operation merely by tenesmus. But in the animal which has been bled to exhaustion, we see that the blood comes but drop by drop from the pulse- less, almost empty carotid. The animal moans, breathes deep and heavy, grows gradually weaker, and is in an appar- 14 SURGICAL EMERGENCIES. ently unconscious state. Now we place the feet of the anim- al higher than its head, and we squeeze out its extremities several times in a centripetal direction, and bring a vigorous pressure to bear upon its belly and thorax. And we notice that the respiration becomes stronger, likewise the pulse, and the blood commences to flow more copiously from the canula in the carotid, so that we might yet obtain a con- siderable amount of blood. But if we had closed the carotid before, the animal would visibly recover and could be kept alive in spite of the great loss of blood and its life- endangering symptoms. Let us now return to the recipient of the blood. He weighed before the transfusion 4625 kilo, after the trans- fusion 5050 kilo, consequently his own (hypothetical) amount of blood of 32,375 grams (7 per cent of the weight of his body, was increased by 425 grams. He therefore possessed after the transfusion a blood amount of 748.75 grams, or 14.8 per cent of the weight of his body in blood. According to this the loser of the blood had weighed before the transfusion 8.85 kilo., after the transfusion 8.37 kilo. He had therefore suffered a loss of blood of 480 grams (Ex- periment of Nov. 6, 1878). In another experiment (May 8, 1878,) the recipient of the blood weighed before the trans- fusion 3.75 kilo., after the transfusion 3.91 kilo. The in- crease of blood to its own original amount of 262.5 (calcul- ated at 7 percent) amounted to 160 grams. The animal con- sequently possessed after the transfusion 422.5 grams, or 10.8 per cent of the weight of the body in blood. The loser the blood weighed 4.43 kilograms before the transfusion, 4.21 kilo, after death, by the squeezing of the legs, the belly and the thorax, 50 grams more of blood could be obtained from the apparently bloodless animal. Entire loss of blood equals 220 grams or 4.9 per cent of the weight of the body in blood. The interesting fact that the entire amount of blood in- creases to a high degree; that it may even be doubled and trebled without endangering the vitality of the organism, forces the question upon us, in what parts can this so copiously infused blood find room. At first we might imagine that the vascular system has been ruptured somewhere, and that the superfluity of blood has emptied itself as such into the tissues, or that such at least has been the case with the watery elements of the blood. Here the results of dissection of animals overfilled SURGICAL EMERGENCIES. 1 5 with blood are of importance. They show that in the re- gular course of transfusion there are nowhere any blood ex- travasations, nor cedematous places. Nor does the amount of lymph, which during the transfusion appears in an in- creased quantity from the opened thoracic duct accord with a corresponding proportional decrease of blood-pres- sure. In a like manner we notice, by a comparison of the coloring power of the blood before and after the transfusion, only a small discharge of plasma. Worm-Muller * and I f have effectually shown that the copiously transfused blood remains within the vascular system. "And this result is obtained from a comparison of the blood pressure. Thus, Worm-Muller was enabled to set up three territories for the capacity of the vascular system. In the first territory the blood-pressure rises to its normal height, when an anaemic organism, which possesses about 1.5 to 2.5 percent of the body-weight less blood than nor- mally, is re-supplied with the missing fraction of its normal blood quantity. In the second territory there is an abnor- mal increase of blood of 2.4 per cent of the body-weight. Here the blood-pressure is now increased beyond the usual limit, now it sinks below it. That these conditions depend on vaso-motor influences, is proven by the absence of these variations, in cases where the transfusion was performed in animals with a severed spinal cord. The third territory possesses a special interest, because in spite of the twofold or threefold increase of the quan- tity of blood, its pressure remains invariably at the nor- mal height, and can in no manner be increased. This proves that not a simple adaptation of the vascular system but a continuous enlargement of it took place. A com- parison of the blood-pressure curves, when plethoric animals are bled to death, furnishes the best support for this. For if we decrease in a normal individual the quantity of blood to about one half, the pressure will fall to a life-men- acing depth. The same may be obtained without any loss of blood, by discontinuing the influence of the vaso-motor centres on the muscular structure of the vessels by means * Worm-Miiller, Die Abhangigkeit des arteriellen Druckes von der Blutmenge. Berichte der konigl, sachs. Gessellschaft der Wissenschaf- ten. Math-phys. Classe. Sitzung vom 12 Dec, 1875. f L. v. Lesser, Ueber die Anpassungder Gefassean grosse Blutmengen. Daselbst, Sitzung vom 8 August, 1874. l6 SURGICAL EMERGENCIES. of severing the spinal cord. By doing this we do not de- crease the vascular contents, but increase the vascular capacity. What, then, of plethoric individuals ? It is true, in bleed- ing to death they yield more blood than normal individuals. A lively dog, 2.39 kilo, in weight, was subjected (Experi- ment Nov. 6, 1879,) to a transfusion of blood from the car- otid of a larger animal. He thereupon weighed 2.54 kilo., consequently an increase in blood of 150 gr. A week after- wards he weighed 2.414 kilo. At being bled to death he yielded 184 gr. of blood, while in proportion to his ultimate body-weight he should have yielded but 120.7 g r * On the other hand, in smaller losses of blood, the pressure falls much more quickly to a life-menacing depth. Indeed, this may occur when the animals possess not only their original amount of blood, but even an additional part of in- fused blood. They are, in spite if it, in the same danger as normal individuals, whose blood amount may have been decreased below the usual quantity. Plethoric individuals, particularly with hyperemia, are conse- quently by reason of the enlargement of their vascular space more susceptible to loss of blood than normal organisms. But the other question arises, whether in plethora the en- tire vascular system or only single parts of it are subject to enlargement. That the entire accumulation of blood does not take place within the great arterial avenues is best supported by the relative immutability of the blood-pressure. Nor does the infused blood gather within the large veins. This we see, in the first instance, by dissection. Nor are we able to in- crease the bloodpressure or the phlebomtomic quantity, of animals, bled after a copious infusion of blood, by squeezing out of the veins. To no greater extent is the blood-pressure influenced by division of the vagus nerve as the number of beats of the heart is thereby increased, we would also ex- pect that a greater quantity of blood would be forced with- in the same unit of time into the arterial systen if much blood had accumulated within the veins. Moreover the di- rect measurement of the tension of the crural veins during hypersemia shows only temporary, not permanent increase. We have to reduce these changes of increase to an accumu- lation within the veins. But they are also noticeable in other parts, as the visible effect of blood-transfusion, in the face, the conjunctiva, the mucous membranes. Within the SURGICAL EMERGENCIES. VJ confines of the portal circulation we may also have, at a brusque infusion of blood, particularly into the jugular vei»s, a direct plethora by its passage through the liver. The tenesmus (which now and then appear after transfusion) and even haemorrhage from the intestines are attributable to this same cause. Experiments have even shown that in quick injections the liver is lacerated and ruptured.* There remains the last possibility: that the excess of blood accumulates principally in the small vessels. And this is sup- ported by several facts. We know that the blood capacity of the individual organs varies. Here psychic, sensorial and sensible reflexes, are as much to be considered direct mechanical influences, ac- cording to the position of the parte, in existing or absent muscle-contractions, etc. Particularly instructive in this re- spect are the changing redness and pallor of the skin, then the changes of volumes of the extremities under different in fluences, as they are demonstrated by the ingenious contri- vance of Mosso f (plethysmograph) and then particularly the arrangement of the corpora spongiosa. There are consequently within the organism a great num- ber of minor vessels at disposal, within which the moderate- ly infused blood may disseminate itself. Only in case of an immoderate infusion of blood,Worm-Muller's third territory of vascular capacity, a rupture of the vascular walls, would come into question. The division of blood will differ in the individual organs according to their capacity. Thus we have before us within the cutis, within the* muscular vessels, the bone vessels, in all mucous membranes, particularly in the intestine, but also in the liver and spleen, those parts in which blood-in- fusions make a hyperemia first visible, corresponding to the normally considerable blood-capacity. That this is so, you have already learned from the experiment, where we suc- ceeded by the squeezing of the extremities, the pressure of bel- ly and thorax, not only in increasing the blood-pressure, but also the quantity of the blood from the carotid. But you notice at the same time that the blood accumulates to a con- * Casse. De la Transfusion du sang. Memoire presente a l'Academie royale de medecine a Bruxelles, le 29 Novembre, 1873, p. 55. f Mosso, Sopra un nuovo metodo per scrivere i movimenti dei vasi sanguigni nell* uomo. Torino, 1875. (cf. Centralblatt fur Chirurgie, 1876. S. 166). 18 SURGICAL EMERGENCIES. siderable extent also within the vessels which are on one hand not directly subject to the action of the heart, on the other hand inaccessible as well to our manipulations (blood ves- sels of the bones, and of the spinal cord). What now becomes of the infused blood ? Does the or- ganism permanently retain the increased serum and discs of the blood ? Only at first. For soon the increased secre- tion of urine and urea reduces the quantity of blood and the number of blood-corpuscule to their normal limit. If we infuse not heterogeneous but homogenous blood, so that no direct dissolution of the corpuscles takes place, both the blood serum and the urine are without haemoglobine. And the homogeneous but superfluous blood -discs perish within the blood-mass, as happens continually with decrepit discs at other times as well.* Thus Valentin's f opinion that the organism always maintains a constant quantity of blood in proportion to the body-weight is also so far true that within the blood-tissue only a definite number of blood-discs can retain a permanent vitality. Having convinced ourselves, that the division of blood within the individual organs is varying and that this be- comes the more apparent in copious infusion, we must en- quire, whether this peculiarity of blood- dispo sit ion also prevails with losses of blood. Indeed already the course of the blood-pressure curve af- ter phlebotomy offers certain points of support. A sudden opening of a large vascular trunk causes by the rapid de- pletion of the aortic contents an immediate decrease of blood-pressure, which, however, soon gives way to a propor- tionately larger increase, caused by the excitement of the vaso-motor centres. This excitement is less pronounced in a slow loss of blood. Here the pressure may keep at the normal height, till about one half of the normal quantity of blood has been withdrawn from the organism. But after this the blood pressure decreases rapidly to the very lowest point \ when death appears after convulsions. This happens when the individual has lost about 5 per cent, of its body-weight in blood. Only with animals made plethoric, have we noticed death and therefore the corresponding decrease of pres- sure to the lowest point, while the organism disposes of an * Worm-Miiller, Transfusion und Plethora. Christiania, 1875. Uni- versitatsprogramm. S. 63. f Valentin, Lehrbuch der Physiol. 1847. Bd. I. S. 413. SURGICAL EMERGENCIES. 19 amount of blood quite surpassing the normal quantity. More than five per cent of the body-weight in blood can by no means be expected to be drawn. Even in case of tetan- zation of the spinal cord of animals, no greater phlebotomic quantity can be obtained, because in case of bleeding with suddenly decreasing blood-pressure, a blood distribution in the above mentioned sense takes place in the organism in such a manner that a large quantity of blood within these vessels is not subject to vaso-motor influences. A further, practically important point is derived from the observation of the blood-pressure curve, according to the slow or rapid progress of the bleeding. Thus we have seen that a rapid blood-depletion causes an increase of blood- pressure instead of a decrease, and would consequently not be justified, where it is our object to produce by blood-de- pletion a decrease of tension in the aortic system. At any rate, the loss of blood required would be disproportionately great in comparison with the object sought. The course of the blood-pressure curve teaches us that in slow bleeding the normal tensions of the vascular system may be retained for a long time, till suddenly the life-men- acing decrease of the blood-pressure makes its appearance. This insidious course of the blood-pressure conditions in connection with the suddenly approaching catastrophe, is only too often met with at the sick-bed, and is caused either by repeated haemorrhages after surgical operation or by that apparently insignificant continuous puerperal flowing af- ter confinement. Here we must promptly recognize the danger and remove it before it is too late. The battle-field furnishes the most important example of the conditions of rapid rise of blood-pressure after loss of blood in gun-shot wounds of the great vascular trunks. The rapidly appearing vascular spasm and single, but co- pious, haemorrhage, with subsequent sudden decrease of tension in the aortic system have been known for ages as an attempt of nature towards spontaneous haemostasis. The peculiar blood-distribution within the bleeding organ- ism which exhibits so great a similarity with that in blood- injections, constitutes quite frequently the cause of death — and not the loss of blood itself. The individual does not per- ish from want of blood, but from want of motion of the blood* * Vergl. auch L. v. Lesser, Transfusion und Autotransfusion. Samml. klin. Vottrage. Nr. 80. - 26 SURGICAL EMERGENCIES. But to these quantitative conditions of blood-distribution are joined besides qualitative ones of special significance. It is an old-established fact that after phlebotomy the blood becomes more watery and poorer in pigment. But for this thinning of the blood, various attempts at expla- nation have been made. It was claimed chiefly that blood-loss caused tissue juice and lymph to flow into the blood. Later it was believed, that the loss of red blood-discs directly caused the paleness. Closer experimental investigation of these questions has shown, that in rapid bleeding neither the entrance of serum nor lymph, nor the loss of blood-discs directly influences the pigmental contents of the different phlebotomic por- tions. These pigment-contents exhibit relations which, graphically represented, correspond perfectly to the course of the blood-pressure curve venesections* The proportion of blood-corpuscles maintains approximately its normal measure, to decrease suddenly after the loss of about one half of the blood in the body. But while the blood-pressure invariably decreases until death, the proportion of pigment may increase far be- yond the normal height even after death itself. Moreover, a number of other experiments where no blood- depletion had taken place, show that the proportion of pig- ment does not depend directly on the loss of blood, but on blood-pressure conditions. That the peculiar blood-distri- bution which takes place is accompanied by a correspond- ing arrangement of red'blood-discs, in which a large num- ber of blood-corpuscles are temporarily thrown aside from the blood- current. Particularly remarkable is the fact, that in individuals who remain at rest for a considerable space of time, the proportion of pigment in the blood may at times decrease far below the normal measure, even without any loss of blood, and that sudden and violent muscular motions, as well as the squeezing of the extremities, etc., may increase, again, the proportion of pigment even beyond the normal standard. Similarly in venesections with decreasing blood-pressure, there will remain a larger number of red blood-discs within the vessels whose blood-column is no longer under the in- fluence of the impulse of the heart. * L. v. Lesser, Ueber die Vertheilung der rothen Blutscheiben im Blutstrome. Reichert und du Bois' Archiv, 1878. S. 41 — 108 in der physiol. Abth. SURGICAL EMERGENCIES. 21 For the present we shall let it be an open question how far chemical material, which temporarily decreases blood- pressure, may assist in changing the blood-composition. (See below.) Thus the sum total of the experimental facts hitherto dis- cussed, has shown us, first, that the organism needs a certain quantity of arterial tension, to remain alive; secondly, that this tension depends not so much on the absolute quantity of blood, but rather on the distribution of it ; and thirdly that this blood-distribution is closely connected with a peculiar arrangement of the blood-discs. What practical results may now be derived from these facts for our instruction on the subject of haemostasis ? 22 SURGICAL EMERGENCIES. LECTURES III AND IV. Hcemostasis. — Blood-saving. — Hcemostasis, especially of blood jrotn injured arteries. — Progress of occurrences during the healing of arterial wounds. — Proliferation of the vascular walls and thrombus organization. — Bruises, cuts and punctures of arteries. — Foreign bodies grazing the arterial tube. — Cat- gut as material for ligatures and its action within the different tissues. — Thread-ligature in (aseptic) wounds. — Instruments for vascular ligatures. — Ligature of artery stumps a7id in the continuity of the vessels. — Substitutes for thread-ligature. — Hcemostasis at certain parts of the body. — Places for the com- pression of arterial trunks. Generally there are three means of meeting the loss of blood, occasioned by intentional or unintentional wounds, viz.: A. The saving of blood ; B. The stopping of blood ; C. The compensation for loss of blood. We are indebted to Esmarch * for methodically perfect- ing the art of blood-saving during operations, even though in former times the method had been repeatedly applied,, par- ticularly in amputations, of raising the extremities and squeezing them out before beginning the compression of the supplying arterial trunk. Aside from the direct economizing of blood, Esmarch's method can claim the following additional advantages : a. If the progress of the wound is not aseptic, the limited loss of blood diminishes the danger of a septic infection, which in the same manner as extended thrombi, occurs easier in anaemic cases than elsewhere.f b. Fresh wounds, as they do not bleed, need not be sponged so frequently during an operation, which consider- ably lessens irritation ; then * Esmarch, Ueber Blutersparung bei Operationen an den Extremita- ten. Verh. d. deutschen Gesellschaft fur Chirurgie. II. Congress. (Sitzung vom 18 April, 1873). f Esmarch, Ueber kiinstliche Blutleere. Verh. d. deutchen Gesellschaft fur Chirurgie. III. Congress. (Grossere Vortrage Nr. 1.) SURGICAL EMERGENCIES. 23 c. The method allows operation without any assistance whatever. d. Its simplicity is such that any layman may soon learn and perform it independently. e. The circumscribed compression of large vascular trunks is avoided, and this may become a matter of importance, where the vascular walls are liable to rupture. f. The method of blood-depletion is pre-eminently applic- able for the production of local anaesthesia, by combining ischaemia with a congelation of the parts, either by an ether- spray or by the aid of a frigorific mixture, and the like, Thus we are enabled to perform painlessly, even without general narcosis, certain operations, as, for instance, that of an ingrown nail,* the incision of panaritiae, even amputa- tion and resection of phalanges. g. The method of blood-depletion of the parts allows us furthermore to apply more effectively the actual, or galvano- cautery, than formerly, for the intensity and extent of the cauterization is much easier adjusted, if the field of oper- ation is not continually moistened by the rush of blood. h. This method obtains a special importance in oper- ations, where it is necessary to subject the affected parts to a quick and close examination, as in synovitis tuberculosa and tumefactions, in order to remove as thoroughly as pos- sible the affected tissue. i. Likewise are we enabled by this artificial ischaemia to find easily and remove any extraneous body, particularly needles. k. This proceeding proves itself important for the de- tection of injured or severed arteries. It enables us also to proceed more courageously, in the extirpation of aneurisms, than we could formerly. The proposition came from Eng- land that this method should be also applied in the direct treatment of aneurisms, and it has been used there several times with excellent results. /. Finally, this method will be met with in the subject of blood-substitution as a very prompt means of autotrans- fusion. To carry out the method Esmarch proposed a rubber bandage of a certain length and breadth for binding the extremities, and a thick rubber tube for circular constric- * Girard, Zur Erleichterung der Localanasthesie. Centralblatt fur Chirurgie. 1874. Nr. 2. 24 SURGICAL EMERGENCIES. tion of the extremities above the rubber bandage. The rubber bandage must be so applied that we first unroll an extra portion which is to hang out, before the bandaging either of hands or toes commences, and that we draw the bandage only so tight that it evenly envelopes the extremity, and at the same time lightly compresses it, without exerting on any one place a stronger local pressure. It has been recommended to use instead of the rubber tube, which by too tight pulling may easily act injuriously, pieces of strong woven rubber bands with clamps or hooks. It seems sim- plest to wind around the last piece of the band in several turns over one another, for the purpose of constriction, and to fasten these twists securely and permanently by a clamp that may be screwed together and pushed under. It is only for the shoulder and hip joints that this contrivance for constriction is fastened somewhat differently. For the shoulder joint we formerly made a recumbent figure of 8, crossing the two parts of the tube, on top of the shoul- der, while the ends were tied in the armpit of the opposite side. The hindrance to respiration makes it desirable to change this arrangement; we therefore let our assistant hold down with the palm of his hand the two parts of the tube at the point of intersection on top of the shoulder and to prevent its slipping we fasten a strip either across the chest or the back, which pulls in the direction of the other armpit. A hip constriction of the upper thigh can only be obtained by guiding the tube around the root of the leg from the rear, crossing the two parts in front above the femoral artery, i.e., the centre of Poupart's ligament, and twisting the ends around the pelvis, tying them again in front. In order to obtain an energetic compression it is advisable to insert below the crossing point of the two parts, above the Ligamentum Poupartii, a roll or bandage. In operations in the locality of the hip-joint itself, particu- larly for the exarticulation of the upper thigh, this method of blood-depletion does not prove sufficient. Here the direct compression of the aorta claims its right. This is most frequently made in the direction from the abdomen (of course after thorough depletion of the intestines) by aid of the hands, or, better yet, by aid of spinal compressors (Esmarch, III. Chir. Congress. II. Page 7). But sometimes it may be made in the direction from the rectum, perhaps best after its forced dilatation and insertion of the whole hand. SURGICAL EMERGENCIES. 25 The chief objection to the use of rubber bands for wrap- ping after Esmarch's method is the perishableness of the material ; particularly does this objection hold good for war purposes. It has therefore been proposed to substi- tute a well- woven linen bandage for the rubber band (Bar- deleben) and to use instead of the constriction-tube simply as heretofore a gag-tourniquet without pelotte, such as is found in every military surgeon's case.* Among other results of Esmarch's method we have the constriction of an extremity of the sound side of a body, to dam up the blood there, while an operation is performed on the other leg. If the loss of blood should have been too copious that accumulated in the sound leg is furnished to the heart by loosening the constriction and raising the ex- tremity (Bellf). Any elastic band (a pair of suspenders) may serve as a constriction-tube in case of need. Another disadvantage of Esmarch's method is the paraly- sis of the vascular walls within the extremity excluded from blood circulation for a length of time. The bleeding which occurs after loosening the constriction maybe so copious as to outweigh completely the amount of blood saved during the operation. It is, therefore, principally important to close before loosening the constriction all vascular openings and to clasp all yet bleeding points with catch-forceps, of which a great number must be in readiness. Where we need not expect a bleeding from larger vessels, as in sequestrotomy or in scraping out an articular cavity, etc., the antiseptic dressing may be put on, and tight at that, before loosening the constriction. But we must carefully watch it; change it immediately if blood penetrates it, at any rate after twenty- four hours. The advice is also important, to let the com- pression of the supplying arterial trunk continue a consid- erable length of time after detachment of the tube. The second proposition lately made by Konig J is to keep the extremity raised not only during the application of the dress- ing, but also a considerable time after the operation. Among the other means of reducing the loss of blood to the lowest * KShler, Die blutsparende Methode im Felde. Deutsche Militararztl. Zeitschrif, 1877. Heft 8 u. 9. S. 371-381. f Bell, Note on a mode of saving blood in great operations. (Edinb. Med. Journal, 1877. Vol. 2, p. 141.) % Konig, Ueber die Vortheile der Verbindung der verticalen Suspen- sion mit dem Esmarch's chen Verfahren zum Zwecke der Erzielung blut- loser Operation. Centralblatt fiir Chirurgie, 1879. S. 537* 26 SURGICAL EMERGENCIES. quantity, after Esmarch's constriction, we may mention the tampon with antiseptic (hot) sponges and the application of the electric current. I. Stopping bleeding from (A) arteries. As a type of the occurrences taking place in injuries to arteries, the spontaneous stopping of blood may serve us, which sometimes (tearing off of an extremity by a piece of bombshell) may be observed even in very large trunks. We have to consider here, first, the lacerated and ragged condition of the vascular tissues, then the elastic retraction of the severed vascular tube, and finally the blood coagulation, i.e., thrombus formation, within the injured portion of the artery. In the historical development of the search for means of haemostasis from arteries, greater importance has now been given to thrombus formation, and then again to the direct fibrination and agglutination of the vascular walls. In connection with this we find, also, now one kind of thera- peutic propositions, now another, principally recommended and applied. In winding a thread about an artery-tube, the primary stoppage of blood is caused by the tearing of the interior and central vessel coats which roll up inwardly. At the place of ligature, more powerfully toward the centre than the periphery, a blood-coagulation gradually occurs,the place of which is after awhile taken by a cicatrix, which coalesces with the proliferation of the connective tissue proceeding from the severed vascular tube, and prevents the exit of the blood-wave. The so-called organization of the thrombus was ascribed by some to the penetration of cells from the blood into the thrombus.* Others maintained that at the closing of the vascular tube the thrombus lost all importance, and laid the chief stress on the proliferation of the cells of the intima endothelium and the consequent displacement of the vascu- lar lumen, f To-day we know, principally from the experi- ments of Senftleben J that the organization of the thrombus does not proceed from the blood, but that the latter is per- * C. O. Weber, Handb. der Chir. von Pitha und Billroth, 1865. Bd. I. 1. Abth. S. 139 u. f. f Baumgarten, Die sog. Organization des Thrombus. Leipzig, 1877, und Raab, Ueber die Entwicklung der Narbe im Blutgefass naofc der Unterbindung. Arch f. klin. Chir Bd. XXIII. Heft 2. S. 156. \ Senftleben, Ueber den Verschluss der Blutgefasse nach der Unterbinv dung. Virchow's Archiv, 1879. Bd. 77. SURGICAL EMERGENCIES. 27 meated by cells, which penetrate from the vasa vasorum through the vascular walls into the thrombus, become fixed there as cells of the newly formed young connective tissue, while the substance of the thrombus itself becomes subject to resorption. At the same time with this, direct agglu- tination of the intima-fold doubtless occurs, as we have learned by the experiments of Baumgarten and Raab. These healing processes of injured arteries undergo cer- tain modifications according to the nature of the injury. Bruises and contusions of an artery correspond nearest with the nature of a ligature. Thus we saw, for instance, when extremities were crushed or torn off by heavy shots, how very frequently a spontaneous blood-stoppage of even large vessel-trunks, as that of the subclavian or femoral artery, oc- curred. In punctured wounds, which decrease in frequency in war, but increase among certain classes of people, in peace, a parietal thrombus arises primarily at the place of injury, subsequently out of this a cicatrix of connective tissue, which, gradually yielding to the blood-wave, causes the for- mation of an aneurismal dilatation of the vascular tube, or if the puncture affects besides the artery the contiguous vein as well, or vice versa, both the arterial and the venous wound may agglutinate. The arterial blood flows over directly into the vein amidst the varicose enlargement of the peri- pheral venous net. Thus arises the varix anewysifiaticus, as it has often been observed after phlebotomy in the bend of the elbow with accompanying injury of the arteria brach- ialis. We shall speak below more exhaustively on punctures which penetrate the arterial tube, and hence injure it in two spots. Different conditions obtain with sabre-wounds. If these are made obliquely in one part of the arterial tube, the diag- onal slit will be drawn asunder by the elastic fibres, at work in the longitudinal axis of the tube, into a roundish opening, where the obliquely arranged orbicularis muscles are unable to cause either a peripheral or a central constriction of the arterial opening. In such cases we must complete the diago- nal separation and ligate the two ends of the vascular tube. Where, for instance, a ball in its track grazed an artery, without directly injuring the vascular wall, it is best to put a ligature as soon as possible on both sides of the grazed point. For mortification and desquamation of the grazed 28 SURGICAL EMERGENCIES. wall may subsequently take place with fatal secondary haem- orrhage. These considerations also lead us to remove as soon as possible all extraneous bodies, in cases where balls lie in proximity to vascular tubes, or where bone splinters with sharp edges pierce the vascular wall. Similar meas- ures are requisite in complicated fractures, where a large vascular trunk is threatened by bone splinters, and here as well, we must give preference to primary ligature at the in- jured spot, to the less safe ligature in continuity in case of secondary haemorrhage. So we see that in all arterial injuries the safest means against primary and secondary haemorrhages consists in ligature if possible 011 both sides of the injured spot of the vascular wall. And this principle is entitled to the greatest consideration; in- deed we may say that it has obtained an unshakable, universal validity since the introduction of the antiseptic treatment of wounds, and since we have obtained an almost ideal mate- rial for ligature in the carbolized catgut. In comparison with this, the questions whether the blood stoppage is due to thrombus or to the proliferation of the vascular wall, lose their significance, as the catgut does not sever the arterial tube, but furnishes a cicatricial ring at the spot of ligation, which thickens the vascular wall. Lister* himself has first shown how the carbolized cat- gut heals in, as it were. He thought that it changed into a ring of living tissue. Several subsequent investigators have confirmed Lister's statements, but have not been able to establish that the catgut continues to exist at the place of ligation after a shorter or longer period of time. The assumption that the lifeless gut should be changed into a living ring of tissue also causes a certain confusion. Though it was to be expected that in the aseptic progress of the wound the catgut ligature after healing into the tis- sue, could not act otherwise than blood extravasations sub- ject to resorption, dead bone splinters, etc., under similar conditions of wound-healing, yet it was of importance to establish by experiments, how long the catgut remains as such within the tissue and in what way its transformation into stable connective tissue comes about. As we often meet difficulties in completing the antiseptic treatment of wounds with vascular ligatures in animals, I preferred to * Lister, Observations on ligature of arteries on the antiseptic system, {The Lancet, 1869. April 3.) SURGICAL EMERGENCIES. 29 demonstrate the action of catgut within the different tissues and organs in another way, namely, by complete subcutaneous puncture, the skin having been slided to 07ie side* I inserted pieces of catgut under the skin of rabbits on different parts of the body, other pieces I introduced by means of a silver needle obliquely through the thorax, and in different direc- tions through the abdominal cavity, and was thus enabled to let the catgut remain within the different tissues any length of time I pleased. The result was: (1) That the cat- gut is to be recognized as such much longer than was usu- ally supposed. (2) That the gut becomes subject to resorp- tion quickest on those spots where it is exposed to pressure or traction. (3) That an immigration of cells into the catgut takes place, proceeding from the periphery. These cells, which, at first singly, then in radial groups, penetrate the inner parts of the catgut, crumble it, and gradually bring about a substitution of it by young connective tissue, which in time metamorphoses into a cicatricial mass nearly resembling the original catgut; in shape and appearance. With all this, it once happened that the catgut was trace- able as such without much change of texture on the 61st day after its subcutaneous insertion. In other cases we found it thoroughly permeated by cells after 32 and 36 days, or even changed into a cylindrical mass of young connective tissue. But even on the 95th day after insertion the then cicatricial mass was plainly distinguishable from its surroundings. Similar results were obtained with cer- tain modifications by insertion of the catgut into the belly of muscles and into joints, by subperiosteal entwining of bones, by lacing of the trachea with catgut. A similar ap- pearance was presented by pieces of catgut, which by puncture of the abdominal cavity or the thoracic space, had been deposited either in the lungs or the myocardium, the liver, the kidneys, or near the intestine or the bladder. In these cases it was noticeable that on the edge, where the catgut freely penetrated into the intestinal lumen or the vesical cavity, it appeared looser, more lacerable, the chan- nel of the puncture likewise eroded, which perfectly cor- responds to the appearance of the channels of skin punc- ture by the use of catgut for sutures. * L. v. Lesser, Ueber das Verhalten des Catgut im Organismus und Ciber Heteroplastic Druckfertiges Manuscript. 30 SURGICAL EMERGENCIES. The dissolution of the catgut takes place more rapidly when the progress is not purely aseptic; quickest in places where unmistakable decomposition exists, as, for instance, in those experiments where catgut had been inserted into festering channels or fistulse.* Here catgut acts as every other dead organic matter, as mortified sinew scraps, muscle portions or necrotic connective tissue. Therefore no conclusions can be arrived at from these or similar ex- periments for the adaptability of catgut for ligatures. But where we are able to cause the catgut to heal in taking antiseptic cautions»in the above-described manner, it offers for surgical technique results hitherto unattained. Furthermore, where the ligature thread lay in the wound as an extraneous body, saturated with wound-secretions, and had to be expelled after separation of the vascular wall, dangers of various kinds to the progress of the wound had to be considered — primary haemorrhages when the ligature was severed too quickly, secondary haemorrhages when the wound suppurated on the fifth or sixth day after operation, when the fluid, saturating the ligature thread, decomposed and communicating the decomposition to the vascular wall, caused an erosion of the latter and a dis- integration of the thrombus. But the danger of a wound- decomposition was increased in proportion to the quantity of ligature material accumulated in the wound. Hence the endeavor to have as few ligations of a wound as pos- sible ; hence an incomplete blood-stoppage and in conse- quence of this the frequent direct secondary haemorrhages. Another result of the above-mentioned calamities was numerous propositions to create substitutes for ligature, and these propositions furnished an unpleasant picture of bickerings and petty-mindedness, and which propositions were as a rule really more crude, injurious, and more com- plicated than the thread-ligature itself. But even in the further stages of the wound progress a new danger arose on account of the slowness of expulsion of the thread, namely, the so-called ulterior secondary haemorrhages. These were caused either by the fact that the thread had cut through the vascular lumen deeper on one side than on others (arterial fistules), or by the incom- pleteness of the thrombus formation, when the thread had r * P. Brans, Die temporare Ligatur der Arterien u. s. f. Deutsche Zeitschr. f. Chir. 1875. Bd. V. S. 69 (des Sep.-Abdr.) SURGICAL EMERGENCIES. 3 1 been wound around too closely beneath a large lateral branch. Hence the rule to place the ligature always above a large lateral branch. But this very rule proves itself almost illusory in several very important places of ligation on account of the large number of radiating lateral branches (arteria subclavia.) This rule proved unsuitable to a still higher degree in injuries to a vascular trunk in any part of its course, than it was for the theory of ligature in con- tinuity. In those cases it often became necessary to expose the vessel beyond the starting-point of the next higher lateral branch, and this made the procedure cause much injury. As now the catgut does not cut through the vascular trunk, but, so to speak, forms around it at the place of ligature a strengthening ring, it is immaterial, where the arterial wound is and at what place we place the c^'qrut around the artery. But catgut has also certain faults, to judge by the a'xve- mentioned results of our experiments as well as by prac- tical experiences. It cannot fulfill its task where it is ex- posed to too powerful a pressure and traction, or where there is too rapid disintegration of the catgut, as, for instance, within the abdominal cavity. (This happens here, com- pared with other places, probably on account of the ab- normally large quantity of fluid and the frequently imper- fect aseptic progress of the wound.) Catgut seems for the above reasons also unsuitable for relaxation sutures on the skin surface in plastic operations, for muscle-sutures (suture of the abdominal after laparotomy) for uterus- suture after hysterotomy and for pedicle-ligature after ovariotomy. Here we are compelled to use substitutes, such as silver-thread for use on the skin surface, or for sutures and ligatures below the surface, silk of various thicknesses, which has been previously boiled in a five-per-cent solu- tion of carboUc acid and kept there for some time (Czerny*). It only remains now to mention the ligature material formerly in use or still applicable. Thus sea-weed, being a substance which causes very little irritation, has proved serviceable, particularly for sutures. Also horse-hair, thoroughly cleansed and delubricated has been proven to cause but little irritation. Lately braids of prepared horse- * Czerny, Studien zur Radicalbehandlung der Hernien. Wiener med. Wochensshrift, 1877. Nr. 21-24. 32 SURGICAL EMERGENCIES. hair have even been used by Lister as capillary drains instead of rubber tubes for the same purpose. We shall keep this great applicability of horse-hair in view with reference par- ticularly to military surgery. Besides raw Chinese silk, recommended by Astley Cooper and Simon, which we now exclusively prepare after Czerny's method, Spencer Wells has found thick hemp-threads par- ticularly suitable for ligature of the ovarian pedicle. Common thread, saturated with carbolic acid, may also be used in case of need. In rare cases use is made of English silkworm-gut on account of its resistency and its incapacity for imbibition, which is used on English fishing tackle for suspending the hook. For the introduction of silver among metal threads, we are indebted to Marion Sims (1857), who first used it in an original manner for relaxation sutures. Two years later Simpson tried to introduce iron ; while we mention Diffen- bach's lead-threads for staphyloraphy only as of historical interest. To apply a ligature to an injured or completely bisected, or even intact, artery, we need, besides the material, only a very slight apparatus. We shall need a' sharp-pointed hollow scalpel, where the tissues must be cut through as far as the vessel. Where the injured vessel lies deep in the passage of a ball or between splinters of a complicated fracture, we shall need a hernia-knife for dilatation of the skin and muscle wound and for the inclovation of fascial fissures, in order to lay the injured artery bare with accuracy, and to be able to examine it in all directions, and to cut out eventually the injured part of the vessel. (Rose's * blood- less extirpation of arterial punctures). A free-hand cut reaching the subcutaneous connective tissue must be made to sever the uninjured skin, after having determined the exact position of the artery to be exposed. The edges of the cut must be smooth and the skin must be incised in its entire thickness from point to point of the wound. The incision of the lower strata, the fasciae, the perimysia and even of the vascular sheaths must be made in the following manner : By the aid of two hooked forceps, of which the operator holds one with his left hand, while the assistant holds the other, we raise the layer, in which the incision is * Rose, Ueber Stichwunden der Oberschenkelgefasse und ihre sicherste Behandlung. Sammlung klinischer Vortrage. Nr. 92, SURGICAL EMERGENCIES. 33 to be made, in a fold, occupying an oblique direction to the cut, and carefully make the incision. Thus the injury of the vessels is the least, the hemorrhage reduced to its minimum, an injury of the larger vessels impossible, which, in former operations with the director very frequently happened. We regret the use of the director, because it yields exactly the reverse of the advantages derived from incision between two pairs of forceps. Having reached the vascular sheath we open it carefully to a short extent, isolate the vascular tube within its sheath by blunt hooks which are curved either at the edge (Cooper, Grafe) or on the surface (Lang, Rust). Deschamps' needle, bent at right angles, also belongs here. These so-called artery hooks have an eye at the point, guiding the thread which is to be wound around the arterial tube. But such a hook can be easily improvised out of any pliable probe with an eye or out of a strong curved sewing-needle, whose sharp point is held by a ligature forceps; and, indeed, in emergencies, when the necessary instruments are lacking, we might even use our finger for pressing apart the soft parts and isolating the vascular tube. Vessels completely severed are seized with special artery forceps. These differ from each other by the shape of their branches, which take hold, and by their manner of locking. The forceps with movable lock (Schmucker, Fricke, Amussat) cannot be recommended as highly, on account of the difficulty of cleaning them, as those with a spring lock and with bulging blades, which terminate conically. The bulging shape is therefore preferable, because it is impossible to tie up the ends of the forceps with the loop of thread meant for the ligature. But such tying up happens all the easier, the deeper the artery lies which we wish to grasp with our forceps. This was the reason why they formerly con- structed special forceps for deep ligature (Luer, Mathieu). Our object is easiest obtained by seizing the artery-stump with two forceps Hear each other. It is impossible to tie up the points of two forceps. (Hamilton's bull dog forceps are by far the best form to use.) Formerly they also used for seizing and pulling out vessels sharp curved hooks, (Fabricius Hildanus, Bromfield; Sextor's hooks with point- covers) ; The ligature of the ends of completely severed vessels happens most frequently ; (i) With amputation stumps as Ambroise Pare (i509 _I 59°) 34 SURGICAL EMERGENCIES. is said to have applied extensively during his campaign under King Francis I. (2) With wounds, viz.: a. Operation-wounds. b. Wounds within complicated bone-fractures. The already mentioned artery-punctures deserve special mention. There danger lies in their frequent and ap- parently enigmatical secondary haemorrhages. With these we can least of all rely on a simple compress bandage. It is necessary to proceed from the very outset thoroughly and radically to prevent the injuries by the steadily re-occurring losses of blood, which are followed by a life-endangering exhaustion. The patient being chloroformed, we dilate to the required extent the channel of the puncture in the soft parts — and withal as deep as possible, close to the injured blood-vessel, from which a pow- erful blood-wave rushes forth, continually inundating the entire cavity of the wound. Here we must be quick. The operator forthwith inserts his right index into the wound to find by the touch of his finger-tip the opening of the artery and to stop it up. Now the bleeding ceases. After removal of every thrombus we continue to open the soft parts farther around the index, till the vessel above and below the point of injury may be fully isolated. Now the assistant winds, centrally and peripherally,, from the obtura- ting fingertip, a thread around the vascular tube. One would think the haemostasis would be definite and yet such need not be the case. It may be that between the two ligatures at the wall opposite to the puncture a vascular arm branches off, out of which a secondary hemorrhage may issue at the restitution of the collateral circulation. That, indeed, the restoration of the collateral circulation takes place very rapidly, even in large vessels, such as the femoral, is beautifully shown by the experiments of Son- nenberg and Tiegel,* who were able to observe in the ligation of the aorta a considerable rise of pressure but a short time after the ligation, by means of the manometer, which had been attached to the femoral both centrally and peripherally. Similar observations in man were made by Neudorfer & Kocher.f * Sonnenberg und Tiegel, Einige Bemerkungen betreffend die Herstel- lung des Collateralkreislaufes u. s. f. Centralblatt f. Chir. 1876. Nr. 44. S. 689. f Kocher, Beitrag zur Unterbindung der Art. fem. comm. v. Langenb. Archiv, 1869. Bd. XL S. _537*~ SURGICAL EMERGENCIES. 35 Or the puncturing instrument, which has entered ob- liquely to the longitudinal axis of the artery, has touched not only the front wall of the vessel but also the hind wall, but much higher either upward or downward, so that the puncture occupies a position either above the central or beneath the peripheral ligature. Here as well secondary haemorrhage may occur with the same degree of danger as if nothing had been done by the surgeon. Therefore Rose's proposition, to isolate the arterial puncture totally, to bind all affluent vessels separately and extirpate them after securing the arterial tube centrally and peripherally, is worthy of the highest consideration. The ligature of arteries in continuity is applied — 1. in the treatment of aneurisms (after Antyllus, Hunter, Bras- dor and Wardrop), also in the extirpation of aneurisms. 2. As a preparatory act for greater operations to avoid considerable losses of blood, either in case of difficulties having arisen in the timely securing of large vessels, or in case of extirpation of tumors of very large size and con- taining a large amount of blood. Ligation of the lingualis before tongue extirpation — ligation of the subclavian in large mammal tumors with high infiltration of the axillary glands — ligation of the axillary in exarticulation of the shoulder on account of large swelling of the head of the humerus, ligation of the femoral in exarticulation of the thigh. 3. In bleeding from artery wounds, as central ligature; formerly, however, recommended unjustifiably often. The most striking proof of the uncertainty of the procedure is furnished by the history of many cases, in which several ligatures, approaching closer and closer the heart have proved fruitless. Particularly since we have been enabled by Esmarch's method to empty the parts of blood and to have an unimpeded and plain view of the injured vessels within them, we can set up the general and incontrovertible principle that in all artery wounds the sovereign means of hozmo stasis consists in antiseptic thread-ligature at the very poi?it of injury. If in spite of this, we devote a few remarks to substitutes for the ligature, we do so, because the kind and manner of haemostasis is determined in certain cases by the topo- graphical conditions of the bleeding part. Again, a few of the methods about to be mentioned have acquired a lasting citizenship in operative technique, so that we can- not pass them by in silence. 36 SURGICAL EMERGENCIES. We divide the substitutes for ligature into provisory, i.e., such as are to prevent the loss of blood till a ligature per- forms this function; and permanent, i.e., such as have been recommended and introduced to avoid the applica- tion of ligature. Among the (a) provisory substitutes we have chiefly com- pression and first of all its simplest and most important form, viz., i. Digital compression. This is used, a. Either directly in the wound, by closing the chan- nels of shot or puncture-wounds with the finger, as we have seen already (arterial punctures), or we press several fing- ers of one hand upon the bleeding spot in the pharynx, on the tonsils (after tonsillotomy) or on the hard gum upon the place of exit of the arteria palatina desc. (in uranoplas- ty). In default of a resisting base, as for instance, in bleeding tonsils, the palm of one hand must be laid under the corner of the jaw to produce a counter-pressure. In cases of bleeding of the arteria palatina desc. it has been proposed to drive in small wooden plugs. b. Or we may compress the surroundings of the wound, al- ready existing or about to be made, in operations on hare- lips, when the assistant presses together with his thumb and index the upper lip in the region of the corner of the mouth, so that on cutting the lip-gap the child loses as little blood as possible. c. We exert a compression indirectly upon the trunk of the supplying artery. This should be the first thing in all haemorrhages, where we cannot reach its source immedi- ately (continuous digital compression of the supplying artery-trunk has also proved valuable in the treatment of aneurisms), then in amputations, as adjunct to Esmarch's bandage, before and after its completion, or where the presence of suppurating cavities prevents the continuous bandaging as far as the point of constriction. Here we raise the extremity, compress the supplying arterial trunk and wind the bandage only as far as the inflammatory infiltrated region, or that which contains the suppurating cavities and then we add constriction above that region. It is very important, gentlemen, that you use every opportunity of making yourselves familiar with the exact position of the points for pressure of the great arterial trunks. You compress the arteria maxillaris ext. against the SURGICAL EMERGENCIES. 37 margin of the lower jaw near the front edge of the mas- seter muscle. To compress the carotid you must always stand behind the patient, lay your thumb on his neck and exert a pressure with the three middle fingers of your hand in ,the furrow between the larynx and the sterno-cleido mastoid in the direction of the spine and as much as possible in the direction of the central line of the spine; thereby you will avoid the simultaneous and painful com- pression of the vagus nerve. For the compression of the subclavian the patient must lie horizontally or with the upper part of his body raised; you stand at his head and press the artery towards his first rib with your thumb in his fossa supraclavicularis. There is another fact you must remember in case of a sudden haemorrhage from the arteria axillaris, namely, the possibility of completely interrupting the radial pulse, in pressing the arteria sub- clavia between the middle part of the clavicle and the first rib, by pressing the shoulder of the patient heavily down and hindwardly. In order to interrupt the pulsation of the arteria brachialis, you either clasp from the outerside of the' arm the biceps lump from above or the triceps lump from* below, so that your thumb is on the outward side of the upper arm, while the other fingers press the artery in the sulcus bicipit. intern, in the direction of the shaft of the humerus, avoiding the n. median nerve. The point of compression for the arteria radialis is, by reason of its superficial position, easily found by any one, "there where the pulse is felt." Much more difficult, in spite of its superficial position, is the precise compression of the arteria femoralis under Poupart's ligament. The spot is easily found, if we remember that the artey crosses, in its course, the ligament exactly in the middle. We need therefore only to divide the distance between the spina ant. sup. of the ilium, and the symphysis into two equal parts, mark the centre point with some coloring matter, in order to be able to find the artery at any moment without failure, and to press it tightly against the horizontal ramus of the os pubis. Never omit to mark with ink or colored pencil the position of the femoralis, when in impending haemorrhages its rapid compression falls to other hands than yours. Haemorrhages from the art. femoralis, even of very short duration, have frequently resulted in death. We have already spoken of the compression of the aorta from the direction of the rectum. 38 SURGICAL EMERGENCIES. 2. The compression can be made with suitable instruments. Either with such which, as the finger, touch the vessel alone ; these are the compressors : or, the vessel is com- pressed either together with its surroundings or by them. This idea suggested the original construction of tourni- quets. Among the compressors the simplest and directest imitation of the pressing finger is Ehrlich's crutch for the subclavian, which may be improvised out of any strong key, the crest of which is wrapped in cotton. A compressor for the aorta we have already mentioned in in connection with the elastic bandage. A similar one, named after Dupuytren-Colombat, consists of a cushion for the lumbar-vertebral column, of a semi-circular metal arch, which, at correspondent distance, bends over the abdomen, and of an adjustable pelotte, which is to press the epigas- tric aorta perpendicularly towards the vertebral column. On the same pattern is constructed the aortic compressor which Tiemann manufactured for the American army.* Similar to these is Bulley's double-compressor, which, in popliteal aneurisms, is to compress the arteria femoralis in its extent from Poupart's ligament to the middle of the upper thigh, alternately on two spots. Among the tourniquets, the twist-tourniquet is the oldest and the most primitive. Hans von Gerstorff (Schylhaus) describes it in his Text-Book of Surgery in the beginning of the sixteenth century. Others maintain that Morel used the twist-instrument first during the siege of Besancon (1674). At any rate, the twist-tourniquet deserves, on account of its simplicity, and because it may be easiest improvised, the preference over all others, provided the pressure is accu- rately calculated. This is particularly applicable to military surgery, which must not be deprived of the tourniquet. The introduction of Esmarch's rubber bandage for tempo- rary haemostasis on the battle-field is generally impractica- ble, because rubber soon loses its utility, as observed above, under the influence of changing temperature. The propo- sition of Bardeleben is, therefore, more practical, viz., to use for Esmarch's bandage on the battle-field, instead of rubber bands, firmly woven linen bandages; to raise, before putting them on, the respective part of the body, and to moisten * A report on amputations at the hip-joint in military surgery. Circu- lar 7, p. 81, of the War Department. Surgeon-General's Office, U, S. A. 1867. SURGICAL EMERGENCIES. 39 them slowly after the bandaging from the periphery to- wards the center. Instead of the rubber tube and the constriction bandage, a twist-tourniquet without pelotte is fastened on with like result (Kohler, /. c.) Approaching the twist-tourniquet is that proposed by Assalini (1812), the buckle-tourmquzt', more complicated and easier disarranged is the jrn?w-tourniquet of J. L. Petit, which has enjoyed, from the beginning of the eighteenth century, great popularity, and of which many modifications exist. As it is only a matter of historical interest, we shall be as brief as possible in our mention of the permanent substitutes for ligature, since we posess in catgut and carbolized silk, in carrying out the antiseptic method, in- deed the simplest and most perfect means of effectually closing arteries. The oldest, so to speak, the prototype of our modern method of ligation, is the mass-ligature, just as Pare applied it. Roser lately recommended it, justly, as a method of circumsuture for those cases where we are not able to look for or isolate the bleeding vessels. In a wider sense the percutaneous circumsuture belongs here, which was proposed by Middeldorp for haemorrhages from the palmar arch, where compressing threads are con- ducted through the entire thickness of the fleshy parts of the hand, between the bones. The second substitute for simple thread-ligature, the so-called temporary ligature, has an interesting history of development, as it is a sequence to the numerous experi- ments with animals, made by Jones, Travers, Scarpa, B. U. Walther et al, in regard to the mechanism of complete arterial hasmostasis. The different methods of temporary arterial ligature and temporary arterial closure were founded on the observation that an arterial tube, which has been ligated, bruised, or even only compressed for a few days, becomes permanently impervious to the flow of blood; and suggested by the consideration of the former disadvantages and dangers of the simple thread-ligature, which was only dissolved by the complete severance of the artery. In order to be able to remove the thread at the desired time, after a temporary arterial ligature, little pieces of cork were inserted between the thread and the artery (Cline, Forster), or little wooden plates (Desault), or little rolls of sticking-plaster (Rous), or linen (Scarpa's cylinder- 40 SURGICAL EMERGENCIES. ligature), or peculiar ligature knots were made, which were easily loosened by pulling the ends of the thread, (" reef- knot" of Churchill, Mattel's loop a la Ricord, Ogston's simple knot with bow). Finally, threads and loops of metal wire were used, which were drawn through particular little arterial tubes, or ligature-tubes, stretched tightly, and sub- sequently cut through and pulled out of the wound. (Del- pech, Walther, V. Bruns, Peters, Van Gieson, N. P. Smith, Baltimore, Prichard.) The last named used horsehair. For arterial closure we find particular compressors used, of which, to the present day, there exist about two dozen different forms. (Literature, see P. Bruns: " Temporary Ligature of Arteries," /. e.) According to the principles, which came into consideration in applying the above men- tioned compressors, special names have been chosen for the different modifications of arterial closure, (Vanzetti's Unci- pressure, Verneuil's Forcipressure, Pean's " Pincement des Vaisseaux," etc.) The next space in this arrangement is best occupied by the torsion of arterial stumps (Am ussat's torsio arteriarum), which is always useful for small vessels, and has even been found by several surgeons reliable for large arterial trunks (Bryant). And finally the acupressure of Simpson, and the acutorsion of Billroth, which were sent forth with so much eclat, and are widely used. In the former the injured vessel is pressed with the aid of a long needle, which is drawn through behind it, either against the skin surface, or against the fleshy part, or against the bone, according to the position of the vessel in the amputation wound. Acufilopressure is described (Dix, Keith) as a procedure where the vascular tube is pressed with the aid of a wire loop entwined in the shape of an 8, toward a needle, inserted into the fleshy parts. In acutorsion the vascular tube is also twisted, by means of long needles, around its own longitudinal axis, either around one or two right angles, as the case may be, and closed in this manner. SURGICAL EMERGENCIES. 41 LECTURE V. Hemorrhages from veins. — Their frequency, cause, and occur- rence. — Phlebitis. — Periphlebitis. — Phleboplastic hemorrhages of Stromeyer. — Spontaneous hemostasis. — Vein-ligature. — Substitutes for vein-ligature. — Tamponing in sequestral cavi- ties, in hemorrhage* from the rectuni, the vagina, the uterus. — Treatment of hemorrhages from the nose. — Bellocq's tube. — Bandage-wrapping. — Capillary hemorrhages. — Search for bleeding point. — Tamponing with bandage-wrapping . — Styptic tamp07is. — Heat and cold. — Hot douches as safe hemostatic means. — Glow - heat. — Catdery iron. — Galvano - cauterizer. — Paquelin. — Chemical hemostatic means. Haemorrhages from venous vessels are more frequent than those from arteries, partly because the former are more numerous and nearer the surface, partly because the thin venous wall is easily torn and crushed by only mode- rate collision with blunt objects, to which the surface of our body is exposed in ordinary life, while the elastic arterial wall yields to the force exerted upon it. Besides, in fresh wounds, venous haemorrhages occur particularly easily where the development of the venous wall is faulty, as in tumors, or where morbid changes have taken place in the venous wall, principally in varicose de- generations. Haemorrhages from bursting varices, for in- stance, at the upper thigh, in the trigonum urethras, in women in the labia majora, often assume a dangerous character and may cause high degrees of anaemia. The venous haemorrhages, observed in amputation stumps, have likewise particularly attracted the attention of surgeons. The latest pathologico-anatomical researches in regard to the connection of blood-poisoning and suppura- tion fever with the so-called inflammation of the veins and their surroundings, (Cruveilhier) had given rise in the minds of investigators to a fear against direct ligature of injured veins They observed the venous wall, and not without reason, to be particularly susceptible to conveyance of in- fectious processes, and found in the ligature-loop the irn- 42 SURGICAL EMERGENCIES. mediate cause of the development of phlebitis and peri- phlebitis. The spontaneous haemostasis from veins of small calibre is caused by the tumefaction of the surrounding tissues, which occurs soon after the injury, and arises from the clogging up of the tissue juices. In large vein trunks the haemorrhage is prevented by the closing of the valves, if they are sufficient for the purpose. Nevertheless, a con- tinuous bleeding may be maintained, if, underneath the valve-lock, a collateral branch continues to empty its blood into the venous stump. An insufficiency of the venous valves, however, occurs, either in a high increase of pressure, in the vein region, which is centrally situated. Thus in un- compensated heart defects, or in a pressure on the vena cava, either by tumefactions or by fluid accumulations within the abdominal cavity. This is especially the case in amputation of the lower extremities; or the valves are changed by the processes of decomposition which take place within the veins, at times even partly destroyed, and in this manner, the thrombus which obstructs the ve- nous lumen likewise becomes subject to disintegration; haemorrhages occur which have been designated by Stro- meyer as phlebostatic, and have been explained by embolia or thrombosis of venous branches of the higher order. If we wish to understand what Stromeyer may have meant by this mode of explanation, we must recall to our mind that the simple closure of individual veins, even of the larger vein-trunks at any particular point in the venous region, on account of the numerous collateral branches, does as yet not produce any disturbance of circulation in the venous system of an extremity.* But that the obstruction of a larger part of a main trunk by a thrombus, which extends in its retrogression into the collateral branches, very soon causes disturbances of the venous blood circulation, the vis- ible sign of which appears in an engorgement oedema. The latter cannot be caused by a ligation of even several venous trunks in an extremity. The infectious periphlebitis, in vein-injuries or vein-ligations without antiseptic cautions, will, however, easily lead to extensive continuous thrombosis within the venous system of, e.g., a leg (phlegmasia alba dolens). * Sotnitschewsky, Ueber Stauungsadem. Virchow's Archiv f. path, Anat. 1879. Bd. 77. SURGICAL EMERGENCIES. 43 From what we have seen hitherto, it certainly follows that infectious matter exerts its deleterious influence particularly easily within the course of vein-trunks, upon the entire or- ganism, but that it is transported directly through the thrombus and blood-fluid, or through the net of lymph vessels surrounding the veins. Where we are, therefore, able to prevent the processes of disintegration in wounds, intentional or unintentional, there the direct double ligature of veins assumes its claim as the most reliable means of haemostasis. Only that the searching for and ligating of all side-branches is necessary in veins to a much higher degree yet than was required in the treatment of arterial punctures.* Nevertheless, there ar£ cases where we have to forego direct ligation in venous haemorrhages, be it, that the vascu- lar tube is difficult to seize in its surroundings, as, for in- stance, in bones, or that the haemorrhage issues from places which are not directly accessible to the eye and the finger. Here we may endeavor to subdue the haemorrhage by com- pression of the vein with the immediate or remote surround- ings, and only in the rarest cases by ligation of the supply- ing arterial main trunk. (Ligation of the arteria femoralis. B. von Langenbeck.) We have therefore to consider more extensively the tam- pon, with or without bandaging, as a remedy for haemor- rhages from veins. Sequestral cavities in bones wnich nave been chiseled open we best fill with antiseptic dressing material (Volk- man's gauze, or after lining of the bone-cavity with car- bolized gauze or preventive taffeta filling with antisep- tically prepared jute). For many cases, particularly where a simultaneous strong influence of wound- secretion or other fluids (from cysts or body-cavities) is to be expected, compression is better made with antiseptic sponges. The tampon is also used in venous haemorrhages from the recta wi, the vagina, the uterus (in placenta praevia and uter- ine tumors). After removal of the blood, as far as such is possible, we must use for the tampon numerous balls of anti* septic material wrapped tightly with antiseptic threads, of which several ends must hang loose to enable us to remove * Rose, Ueber Stichwunden der Oberschenkelgefusse urvd ihre sicher ste Behandlung. Sammlung klinischer Vortrage. Nr. 02.. 44 SURGICAL EMERGENCIES. the balls by their aid. For bleeding from the rectum, the balls are pressed in, within a glove-shaped piece of gauze linen inserted in the rectum. The balls may be inserted directly into the vagina but always through a speculum to protect the mucous membrane of the vaginal entrance against friction. Perhaps it is preferable to proceed here also, especially if no speculum is at hand, exactly as in tam- poning the rectum. If compression of the urethra should hereby occur, the catheter must be used for the removal of the urine. As a substitute for the method just mentioned, we may also use thin rubber balls, which are inflated with- in the respective channels with air or fluids (kolpeurynter). For haemorrhages from the rectum we must not forget digi- tal compression, particularly when in narcosis we are able to insert several fingers or the whole hand after previous dilatation of the sphincter ani. For this purpose we insert our two indices hook-shaped into the rectum and draw by jerks the sphincter apart in the sagittal and frontal dia- meter. Profuse haemorrhages from the atonic uterus after recent labor have also been successfully stopped by direct compression of the uterus in the direction from the rectum and by counter-pressure from the hypogastrium by the other hand. It scarcely needs mention that all these means only counteract haemorrhages as such, and not their direct cause, and that in case of their repetition their cause itse.Ji must be attacked. The treatment of nose-bleedings remains to be considered. If these issue from the outward part of the nose, within the region of the cartilaginous integument, they are easily stopped by outside compression, by pressing the nostrils against the septum. If the bleeding part lies deeper inward between or upon the conchae or in the vicinity of the choanae the rinsing of the nostrils with a hot solution of chloride of sodium (J per cent.) may be sufficient. In pro- fuse haemorrhages little can be done with this. Here com- pression alone is of avail, but not from the outside, for while thereby the flow of blood from the nostrils may be pre- vented^ it makes its way through the choanae into the pharynx. We first insert a catheter or tube, invented by Bellocq, backward into the nasal cavities, so that the mouth of the catheter or the perforated ball at the top of Bellocq's spring, gliding down in the naso-pharyngeal cavity along the posterior wall of the soft palate, becomes visible in the posterior part of the oral cavity. The loose ends of a SURGICAL EMERGENCIES. 45 thread are fastened to the top of the catheter or to the per* forated metal ball of Bellocq's instrument just described, while the tampon which is to be conveyed upward into the choanse, is to be crossed by the middle of this thread in the same manner as a bale of cotton is tied with ropes. If we now pull the catheter or Bellocq's tube out of the nose, we drag along the tied up ends of the thread, which is pulled out of the nasal cavity, until the tampon, which is tied to the centre of the thread, has passed the soft palate, reached the choanse and is pressed within. But the tampon must have a third thread, a tail, as it were, which hangs out of the mouth and by which we may at any time pull the tam- pon back again out of the naso-pharyngeal cavity. The tampon, however, is fastened in the choanse by tying the ends of'the thread which hang from the nostril over a cotton pledget inserted into the latter or over a piece of thick rubber tube, resting against the nostril. If neither a catheter nor one of Bellocq's instruments is at hand, a pliable, smooth stick of wood may be used for the insertion of the threads. (Thomas.*) For exceptional cases, where no instrument at all is at hand to guide the thread through the nasal into the pharyngeal cavity, by means of which the tampon is to be pulled up into the choanse, we may try in case the nasal cavity is not entirely stopped up or the patient too weak, the following procedure : we fasten the loop of a double thread in a leaden ball of about the size of a cherry-pit, by opening it first and then pressing it together again. The head of the patient is pulled far back and the ball is dropped into one of the nostrils, while the patient is made to snuffle as hard as possible. By its own weight and the aspiratory current of air the ball penetrates into the naso- pharyngeal space and is forced by the patient's suffocative movements into the anterior parts of the mouth. Now we may fasten the tampon to the loop of the double thread just as above. ^ The wrapping with bandages, which is of course required for the tamponing of venous hsemorrhages on the surface of the body, may be applied also more independently. The methodic involution of extremities, named after Theden, where the part is bandaged from the periphery toward the centre, has been recommended, in combination with plac- * Thomas, Traits dcs operations d'urgences, Paris 1875. 46 SURGICAL EMERGENCIES. fng the arm on a splint, after puncture wounds of the brachialis in venesection of the elbow-joint. The bandage is also excellent in haemorrhages from cedematous or in- flammatory infiltrated parts, as well as in haemorrhages from varices. Those haemorrhages where it. is difficult to discover the bleeding-point have always been called capillary, or surface haemorrhages. And yet the discovery will often be possible by great care; and then the application of a ligature will fur- nish a permanent haemostasis. Capillary surface haemorrhages occur, first, after opera- tions, e.g., after dissolution of adhesions within the abdom- inal cavity in ovariotomy. Also after extraction of teeth, particularly of the so-called " bleeders" or " hemophiles." Then after leech-bites and from cut-wounds of the skin, as well as after cut-wounds in plastic operations. Likewise considerable haemorrhages from granulation cells may issue at a pressure upon the large venous trunks of the respira- tory regions, e.g., by tumefactions or by a rise of venous tension in uncompensated defects of the heart; consequently under very similar conditions to those under which haemor- rhages from veins occur. Finally, so-called capillary haem- orrhages occur from ulcerated tumors, e.g., haemorrhoids and disintegrating cancer of breast or uterus. We have already remarked that we must strive to discover the bleeding-points, even in haemorrhages of the smallest vessels, and to seize them after isolation. Where the most reliable means fail we have to adopt substitutes, among which the mechanic, the thermically, and chemically acting ones are to be distinguished. Here, also, as in venous haemorrhages, the direct tampon, supported by centripetal ligation, claims its place. But the direct compression of the bleeding parts with the finger or a ball of antiseptic dressing material appears the simplest, most suitable precursory haemostatic during an operation. In similar manner we stop bleeding in plastic operations, and from obstinately bleeding leech-bites, by suture, acting in the mode of compression. Particularly in plastic oper- ations we would twist only the somewhat larger bleeding trunks. Further, the tampon may be effected with materials which, aside from compression, are also to act on account of their being saturated with substances which act encrustingly both on the blood and on the vessels. As our object is here SURGICAL EMERGENCIES. 47 haemostasis and not disintegration of the vessels, we must always observe the rule, that the styptic balls must be made very small and pressed directly upon the bleeding-point, after it has been thoroughly cleansed of all coagula; other- wise we cause encrustations of the surroundings of the bleeding part, the consequences of which cannot be calcu- lated, and the haemorrhage may continue after all, as many examples have shown. As styptic means, we use most commonly fuming nitric acid, then crystallized carbolic acid and chloride of iron. The cauterization with carbolic acid acts at the same time anaesthetically, so that, for painful cauterization, a previous application of carbolic acid has been recommended. Liq. ferri sesqui-chlor. has been found specially effective in hem- orrhages from the dental alveoli after tooth-extraction, because the crust which it produces remains. It is to be regretted that it is almost not at all antiseptic, so that fre- quent rinsing becomes necessary to avoid its very offensive decomposition. To this day we are not clear as to the application of thermic means, particularly as to the action of cold. Physi- ological experience teaches that cold retards the coagulation of the blood. Haemostatically it can therefore not act by way of coagulation, but only by stimulating vascular con- traction there, where we have a sufficient circular muscular structure of vessels. The action of fluids, heated far above the temperature of the body, is similar (water, solutions of common salt, chloride of zinc, carbolic acid), only that to the stimulation of vascular contraction is added the other action of heat, long known to physiologists, which consists in enhancing coagulation. The application of the hot douche will therefore stand by us also where vascular con- traction is not obtained. It is strange enough that it was the accoucheurs who first called attention to the reliable ap- plication of hot solutions (hot douche in uterine haemor- rhages, particularly after miscarriages). Most text-books on surgery insist with traditional unction on recommending the dripping of icy-cold solutions for stopping capillary haemorrhages. I consider it therefore my duty, gentlemen, to call your attention particularly to it, that in surface haemorrhages, especially in the pharyngeal and nasal cavities, but also from other bony parts of the body, as well as from bone cavities and osteotomic surfaces, after sequestrotomy, after ampu- 48 SURGICAL EMERGENCIES. tations and resections, you will reach your object of stay- ing the flow of blood much more surely by using for drip- ping and douching, hot indifferent solutions containing -£ per cent of chloride of sodium, or like antiseptic solu- tions. Haemostasis is also obtained by using the higher and the highest degree of heat for cauterizing. The cautery-iron, in its different shapes (cone, ball, coin-shapes), the porcelain cauterizer of the galvano-caustic apparatus, and the differ- ently-shaped platina-cupolae of Paquelin's thermo-cauterizer, cauterize, as do styptica, both blood and vessels, and must therefore, like the styptica, only be applied to the bleeding- point. As only certain degrees of heat enhance coagula- tion, degrees which do not exceed the temperature of the body too much, at any rate, lie below the point at which albumen coagulates, so escharotization is only produced by red-glow heat. White-glow heat chars both vessels and blood. White-hot iron does no longer produce haemostasis. The cautery-iron is particularly effective in haemorrhages from disintegrated vessels, because it simultaneously sub- dues, often in a striking manner, by stopping the hitherto florid processes of disintegration, and stimulates the forma- tion of healthy young tissue. So in haemorrhages from granulations, affected by hospital gangrene, in haemorrhages from suppurating cancers of the mammary gland, the uterus and the rectum. There are but few purely chemical means which are reliable in their action for haemostasis. We mention first acidum tannicum, which is strewn in powder upon the bleeding sur- face, or which inform of tannin-glycerine pencils, has been recommended particularly for introduction into the uterus cavity. Argentum nitricum as a haemostatic remedy, pos- sesses but weak power: (compare, however, its strong power of vascular contraction in the experiments made by Rosen- stein*). But much more frequent is the use of liquor ferri sequichlor. in solutions for haemostatic injections into the rec- tum and uterus. Let us, finally, mention the oil of turpen- tine, whose haemostatic action has been frequently proved. For subcutaneous injections ergotine has been used. In this case the extractum secalis cornuti aquos. has been diluted - Rosenstein Untersuchungen iiber die ortliche Einwirkungder sogen- anten Adstringentia auf die Gefasse. Verhandlungen d. physik. med. Gesellschaft in Wurzburg. 1875. Neue Folge IX. Bd. 1 — 2. Keft. SURGICAL EMERGENCIES. 49 with equal parts of aqua distillata; of this solution a quan- tity filling Pravaz's syringe to one quarter or one half, has been hypodermically injected, and simultaneously 10 to 20 drops have been given inwardly every half hour. Besides ergotine, digitalis and plumbum aceticum deserve special mention, as internal remedies for haemorrhages, the lungs, for instance. 50 SURGICAL EMERGENCIES. LECTURE VI. Bleeding. — Its value as a hemostatic remedy. — Other indica- tions formerly and at present. — Places for phlebotomy. — Phlebotomy. — Topography of the elbow. — Technique of phle- botomy. — Phlebotomic aneurisms. — Phebotomy on the foot and the neck. — Arteriotomy and its present indications. — Capillary bleeding: Its real value. — Scarification. — Cupping. — Leeches. Transfusion. — Historic periods. — Defibrinated atid "intact'' blood. — Different methods of transfusion. — Actions of the blood-discs, of the serum and the gaseous contents in the blood of different species of animals. — Significance of fibrin-fer- ment. — Central arterial blood infusion. — Venous transfusion. — Ingress of air into veins. — Result of experiments. — Blood- injection under the skin and into the abdominal cavity. — Tech- nique of transfusion. — Symptoms in transfusions. — Present Indications. — Territories of ancemia. — A uto-transfusion. However paradoxical it may appear to introduce bleed- ing as a means of haemostasis, the position it holds as such is nevertheless perfectly clear. The decrease of blood pressure and the diminution of arterial tension are its haemostatic factors. They may, it is true, be obtained only, as we have seen, by incomparably great losses of blood, which frequently are much larger than the quantity to be economized by haemostasis. In former times venesection was resorted to much more frequently, as bleeding was held in high repute, not only as a haemostatic, but also as an anaesthetic and antiphlo- gistic remedy. As an anaesthetic means we find venesection resorted to as early as Galen, at the time of Marcus Aurelius, 130 after Christ, and until chloroform was introduced to produce unconsciousness and facilitate the performance of difficult surgical operations (reduction of dislocation of the femur, reduction of strangulated ruptures, etc.). As antiphlogistic means venesection came into use through the doctrine of erases. And here we find it chiefly used by the French school of Broussais, and then with alarming frequency SURGICAL EMERGENCIES. 5 I consistently carried on in all typhous diseases, even to anaemia (Jugulade). The Vienna school first succeeded (Van Swieten, Skoda) in resisting this senseless waste of blood. To-day bleeding is pointed out as a remedy in some few cases, aside from those, of course, where the removal of blood which is poisoned or incapable of performing its functions is at issue, or that use of it where the extracted blood is to be injected into a second person. Thus, bleeding has been recommended: a. In sanguineous apoplexy of the brain. Here its action of decreasing the pressure of the blood is considered as the haemostatic cause. (See above.) b. Likewise in hyperaemia of the lungs, bleeding has been recommended by Stromeyer, in consonance with the advice of veteran military surgeons, and, then not as an antiphlogistic means, but likewise as a haemostatic one (because it is better to empty the blood by cupping than to let it flow into the thorax. Stromeyer. Maxims of Military Surgery, p. 444.) But here as well the result of bleeding will only then come about when, as observed above, very large quantities of blood have been withdrawn. Therefore it is preferable, in hyperaemia of the lungs, to mitigate the pain and distress of breathing by hypodermic injections of morphine, and to attempt an immobilization of the respec- tive parts of the thorax by position and by bandages. I at least have gained by the latter and by sleep, as the result of morphine, more than by unconsciousness, resulting from copious bleeding, and I have seen others do the same. But after having learned from the results of antiseptic wound treatment that the dangers in opening large body- cavities lie elsewhere' than in the mere exposure to air, it will be the task of the future to conceive and try a direct haemostasis in pulmonary hemorrhages, if possible, under protection of antiseptics, after the affected part of the thorax has been laid open. Finally, bleeding is recommended c. In pneumonia attended by cyanosis. This is the sur- vival of the old method, when no case of pneumonia escaped bleeding. Bleeding in pneumonia is recommend- able with very robust, powerful persons, before the acme of the disease, whereby and by the momentary insuffi- ciency of the right ventricle, blood accumulations arise in the venous system ; but it should never be employed in $2 SURGICAL EMERGENCIES. pneumonia in the case of drinkers. In this case we must resist the collapse by stimulants, and principally by copious alcoholic doses. Formerly they used to divide bleedings into three classes : large, at 2 pounds of blood (about 1 litre); medium at 300-350 cam., and small at 200-250 c.c.m. of blood. And bleeding was performed on different venous trunks of the body, as, for instance, at the jugular vein in the middle of the neck, particularly in strangulation and apoplexy of the brain. Danger was, apprehended with this method on account of the possibility of the penetration of air into the heart, of which we shall speak more exhaus- tively in the subject-matter of Transfusion. Also on the dorsum pedis and the vena saphena magna of the upper thigh. Now, bleeding is performed almost exclusively at the elbow, mostly on the vena mediana basilica. The trunk of the vena basilica on the ulnar side of the arm, and the vena cephalica running on the radial side of the arm, absorb a few superficial and the deep venous branches of the forearm in such a manner that the latter unite to one trunk, and this one in its turn empties its blood through a diagonal tube or through a forked tube partly into the vena cephalica and partly into the vena basilica, almost twice its own size. Consequently the ulnar branch of the venous fork, the vena mediana basilica, is the stronger developed and the. more suitable for bleeding, which also appears as the second thicker cord, when the veins of the upper arm are compressed circularly at the figure M of the confluence of veins, which shines through in a bluish color. The vein lies upon the aponeurotic continuation of the biceps tendon, which radiates towards the ulnar side of the arm and is separated by it from the arteria brachialis, which lies underneath, crossing its direction. Above the vein run the branches of the nervus cutaneus brachii medius. The median vein, with its forked branches, is rarely wanting ; only at times the vena med. cephalica and the med. basilica run as two separate branches. In case we should not find a suitable vein in the elbow, Lis- franc advises to look for a vena salvatella on the back of the hand or for the vena cephalica, where it runs on the upper arm between the deltoid muscle and the pec- toral. In performing our phlebotomy we must observe the strictest rules of cleanliness. Formerly periphlebitic, and SURGICAL EMERGENCIES. 53 sven pyaemic processes were quite often observed after this apparently innocent operation. After carefully cleansing the field of operation we lay on a constricting bandage around the centre of the upper arm (phlebotomic bandage, formerly of red color), and close it with a loose and easily-opened knot (fascia ante venae- sectionem comprimens). The operator places himself so that he holds the hand of the arm on which the bleeding is to be performed firmly between his hip and his right elbow. The thumb of his left hand presses upon the now copiously filled venous trunk below that part of the elbow on which the vein is to be opened. This is best done with a special knife-blade, protected by a movable covering. This is the phlebotomic lancet which has become so re- markable in the history of many a physician, and which in by-gone times was often the sole symbol of medical knowl- edge and surgical ability. According to the form of the flat two-edged point they used to distinguish a more thick- bellied and a more slender shape (the phlebotomes of barley-grain and oat-grain shape). With the safety-covers opened upward we seize the lancet close to the point with the thumb and index of our right hand. While now the fourth finger of our operating hand supports itself on the fore arm of the patient, and the third and second fingers are bent in, the point of the phlebotome penetrates into the vein in an oblique direction to the axis of the vascular tube. The oblique direction is chosen to obtain a wider fissure of the vein. On diminishing the pressure of our left thumb the accumulated venous blood rushes in a stream into the measuring vessel held underneath. (Phlebotomic vessel.) If the bleeding is to be interrupted we need only to renew the pressure of our left thumb. The same is to be done at the end of the operation, when the phlebotomic bandage is quickly unwound and a further loss of blood is perman- ently prevented by an antiseptic compression bandage, which is to take the place of the finger pressure. In time of war we shall often be compelled to content ourselves with an antiseptic ball pressed upon the phlebotomic wound. At any rate, it is advisable to wrap subsequently the entire arm in a bandage, and to secure its quiet position in a sling. An injury to the arteria brachialis is prevented by using a very sharp lancet, and by inserting its point very slowly into the vein. This injury, and the subsequent formation 54 SURGICAL EMERGENCIES. of a so-called phlebotomic aneurism, was much more fre- quent after the substitution of the usual lancet by the spring-lancet, an instrument so unworthy of the hand of a surgeon. (Invention of Paasch, a Dutchman.) An injury to the artery is indicated by the brightened color of the blood-stream, which at times shows pulsations. But a much less deceptive sign is the discontinuance of the bleed- ing on central compression of the trunk of the arteria bra- chialis in the centre of the upper arm. Sometimes, when both signs are absent, a swelling is to be noticed in the depth of the phlebotomic wound, when the blood from the artery does not flow outward, but spreads through the vas- cular layers surrounding the artery. If there is evidently an injury of the artery, do not waste time in attempting compression, but lay both the artery and vein open and ligate both doubly, according to the rules given for the treatment of arterial punctures. It is only in dubious cases that you can content yourselves with a compressing ligature of the entire arm with subjoined longitudinal pelotte (thick rubber tube), corresponding to the course of the brachialis. The ligatures mentioned by former surgeons : fascia pro venaesectione in cubito and fascia pro aneurysmate are only applicable, together with a total bandaging of the arm. In phlebotomy, on the dorsum pedis, the bandage was applied above the calf; in that of the vena jugularis the bandage had to be supplied by compression of the bulb of the vein in thetrigonum of the sternocleido-mastoid muscle. The opening of an artery (arteriotomy) to withdraw blood, without intending a subsequent transfusion, is prob- ably at present not made use of. It was recommended formerly on the arteria temporalis in affections of the eye (Wardrop), and it has been risked to puncture the artery like a vein, through the skin, which ought never to be done, just as little as the supplementary application of a simple compression-bandage, even if we were to choose for it a ligature knot (fascia nodosa). If an artery is to be opened, be it for the purpose of making a blood-infusion into its peripheral course, as Hueter once proposed, or with the in- tention of injecting blood into the artery toward the heart, or, finally, with the object of transfusing the arterial stream directly into a vein of another individual, the arterial vessel must always be carefully isolated and doubly ligated after the transfusion is completed. SURGICAL EMERGENCIES. 55 Bleeding of smaller vessels, for obtaining blood for transfusion, has been proposed but in isolated instances (Gesellius), while the so-called capillary bleeding was for- merly resorted to all the more frequently to remove a sup- posititious local hypersemia. The facility of performing the pertinent procedures, together with the importance which the vulgar attributed to local bleeding, explains how these, even more than venous bleeding, became part of the practice of " nurses and barbers," who even to-day in the eyes of the public represent the first resource for surgical aid. Since our ideas on hyperemia and blood-distribution in the organism, as you saw in our first lecture, became wholly different from our former ones, the indications for local bleeding had to dwindle down to a minimum. We shall consider its application justifiable only there, or, to speak more correctly, we shall find an indication for local influenc- ing of the conditions of circulation there, where, either by mechanical or inflammatory processes, the local arterial pressure has been diminished, or where a direct obstruc- tion to venous bleeding exists. In both cases we shall have an accumulation of blood in the affected parts, and, as its consequence, either nutrition disturbances or abnor- mal accumulations of fluids within the tissues. For these cases it will mostly be sufficient to bring about the flow of the blood by opening collateral passages; be it that we produce a collateral reflex vascular paralysis by means of mechanical, thermic, or chemical irritation (hsemospasis, humid heat, so-called derivatives, as cantharides, sinapisms, tincture of iodine). It will be but rarely required to draw the blood directly to the outside, which is, so to speak, temporarily excluded from the circulation, and menaces by its non-circulability the healthy stability of the tissues. And even then we shall reach our end more precisely and in a cleaner manner by correct incision with the knife than by "capillary" bleedings, which were formerly so much in favor, of which we shall speak more exhaustively, and of which we mention scarification, the cupping-glass, and the leech. Scarification, formerly praised for conjunctivitis-pannosa, hypertrophy of the tonsils, metritis chronica, and acute glossitis, consisted in puncturing the vessels with fine knives. Lately this puncturing has again been resorted to in the treatment of lupus; but there it is claimed that it 56 SURGICAL EMERGENCIES. causes the shrinking of the vessels, not by blood depletion, which must be as small as possible, but by the accompany- ing bisection of numerous vessels, which spread to the dif- ferent tumor-nodes, and by this, resulting obliteration. In acute glossitis, long and deep knife-incisions, parallel with the sagittal lingual axis, which, by the way, are but little painful, often have surprisingly rapid results, particularly for decreasing the swelling of the organ. In hypertrophy of the tonsils, the best, remedy, both in the inflammatory stage and after its abatement, consists in excision or resec- tion. For cupping, an apparatus is required which cuts the main vessels and draws the blood into an attenuated air- space. The so-called English spring-lancet, invented by Lamzweerde at the end of the seventeenth century, answers the first purpose ; so do glass or metal, about hemi- spherical, concave capsules or cups (cupping-glasses, cucurbitse ventouses). These are heated over an alcohol lamp and pressed, after wetting the edges, to the skin. The cooling of the cup causes an attenuation of the air within, allowing the blood to enter the vacuum of the tightly- adhering cup. Opposed to these so-called wet cups are the dry cups (ventouses seches), where a previous incision of the skin by the lancet has not been made. Their pur- pose consists only in producing local hyperaemia of the skin. With this purpose we see them yet often applied to the skin of the thorax in inflammations of the lungs and the pleura. Such hyperaemia on a large scale, and with in- tended reaction on the entire body, was formerly applied to the leg, including the foot, with the aid of the giant-cup (ventouse monstre) of the so-called Junod's boot. For haemospasia, but also for local bleeding in the vicin- ity of the eye, we use the so-called artificial leech, invented by Heurteloup, in which the skin-wound is produced by a quickly revolving cylindrical concave knife, the blood- suction by a glass syringe, in which the air-attenuation is obtained by raising up the piston, after pressing the syringe close to the skin. While the cups can only be applied to large flat surfaces, capillary bleeding of small and very uneven places (abdo- men, forehead, temples, regio mastoidea and regio sub- occipitals, gums, mouth of the womb, etc.), was effected by the aid of a suction-bowl, constructed on the principle of the dwarf-cup, and that species of leech which has six SURGICAL EMERGENCIES. 57 brown stripes at the neck (hirudo officinalis). The spot where the leech is to bite must be well cleansed and touched with milk or a sugar solution, or a little puncture of the skin is made with the lancet. To cause the leech to drop off we strew some common salt on the end of his tail. We must use test-tubes to set the leeches to the gum or the mouth of the womb. It is also best to draw a thread through the tail of the leeches, and to watch them closely, so that they do not drop off from the appointed spot and bite at another — the larynx, for instan'ce, as has been ob- served. The sucking of leeches easily becomes painful, par- ticularly in those territories of the skin which abound in nerves. It is estimated that a leech draws about 8 grams of blood, which, with an after-bleeding of two hours, amount- ing in all to about 15 grams, is decidedly too low an estimate. The after-bleeding was formerly assisted by the application of warm cataplasms to the wound. In order to increase the activity of the leech they used to cut off his tail, after the example of Miinchhausen's horse, cut in two by the closing of the city gate. It is much less cruel, and does not at all interfere with the vitality of the animal, to open the gastric-bags on its two sides, as Beer recommended. (Bdellotomy.) The leech-bites often continue to bleed undesirably long; it is true, the bleeding may mostly be stopped by continu- ous compression. But on spots, where such is either im- possible or inconvenient, we shall be compelled to resort to a circumsuture-ligature of the leech-bite, or to puncture of the main eminence produced by the suction of the leech, in the centre of which the bite is bleeding. We do this with the aid of a needle, which is drawn through the base of the eminence, around which we then wind a thread, in 8-shaped twists, as was done in the sutura circumvoluta. The theory of transfusion is difficult of representation. There is scarcely another subject on which we meet with so much fanciful speculation, so much that is unscientific, so much uncritical credulity, and so much carelessness. To search in this haystack for the scientific needle, and to evolve the practically useful principles, shall now be our task. Even the history of transfusion shows us so indistinct a Michel Rosa, Lettre fisiologiches Napoli, 1783. Paul Scheel, Die Transfusion und Einspritzung der Arzeneien in die Adern. 2 vols, Copenhagen, 1802 and 1803. 58 SURGICAL EMERGENCIES. picture of obscure tendencies and ambiguous indications, that the actual history of the development of the doctrine of transfusion begins in fact only with the latest acquisi- tions to our knowledge of the physiology of the blood. We best distinguish four larger historical periods. The oldest, which finds its sources in the description of Greek and Roman poets (Ovid's Metamorphosis, lib. vii.) and starts from the legend of the transfusion of blood with which Medea is said .to have rejuvenated the father of Jason. This is the mythological period. The second, the mystic period, reaches to the 17th century after Christ, and included all the rude attempts to produce by infusion of nutritive and medicinal substances, and also of blood, into the vascular system, certain changes either in the character, or the disposition of the mind of the respective individual. These Changes savored only too often of the miraculous. The third period reaches into the beginning of our present century : it is the empirical, excelling by controlling animal experiments, which were undertaken by men in whose science confidence may be placed, and who were universally held in high esteem. In France Denis and Emmereygave the first impulse to scientific discussion of the question of transfusion; indeed, it was partly due to them that this sub- ject occupied for a long time the scientific minds and learned societies in England as well as in Italy. In England the experiments made by Clarke, Lower, King and Boyle with scientific judgment, deserve special mention, while in Italy Michel Rose made interesting observations on the exchange of blood between different species of animals. He also dis- covered that large quantities of blood can be injected into the vessels, and that, even if no previous phlebotomy has been made, }^et plethora is in no manner observed in the subject of the experiment. Transfusion soon fell again into disrepute, and indeed from very plain reasons, when they began to use it for all possible chronic and even psychic diseases (as in lyssa hu- mana, cancer, febris putrida). And first through Bischoff,* Prevost and Dumas, f Panum,J Brown-Sequard § et al., by * Bischoff, M uller's Archiv, 1835. Vol. II., page 354. f Dumas et Genieve T. 17 and Ann. de Chemie. T. 18 p. 294. \ Panum, Experimentelle Untersuchungen tiber Transfusion, etc. Vir- chow's Archiv. 1S63. Bd. 27. § Brown Sequard, Comptes rendus de la soc. de biologie, 1849, 1850, 1851, of the Acad, de Sciences, 1851, 1855 and 1857; ^so, jour, de phy- siol. T. I. SURGICAL EMERGENCIES. 59 their partly historic and partly chemical studies on blood, the doctrine of transfusion entered its fourth and scientific period, which we shall briefly call the modern. Here we meet for the first time the important knowledge, that it is the red blood-discs which constitute the important factor of transfusion, and that only arterial or arterialized blood possesses vivifying power. The utility of defibrinated blood and the greater facility for its injection contributed materially to the popularization of transfusion, and forced the use of the formerly favored animal blood quite into the back-ground. Human defibrin- ated blood has since received exclusive preference. Thus Blundell * transfused in puerperal haemorrhage and puer- peral fever. Waller f in chronic anaemia, Neudorffer, after prolonged suppuration, in chronic pyaemia, Polli in neuropa- thies, DieffenbachJ; in cholera, Blasius§ in leucaemia, Traube|| and Martin^ in carbonic oxide gas poisoning. But as Mar- tin % had successfully employed non - defibrinated human blood, the question was again discussed whether preference should be given to beaten (defibrinated) blood or to not- beaten (complete) blood. Violent disputers urged the loss of vitality of defibrinated blood, and the fear of introducing coagulain its use. Though no scientific proof was offered in support of the above allegations, they were important factors in the resumption of the employment of intact (non- defibrinated) blood. And thus also the recently recom- mended transfusion of animal's (lamb's) blood was exten- sively employed. Yet it was soon discarded, because the sanguine expectations which were attached to it, especially in chronic affections (particularly phthisis) were by no means fulfilled. Previous to formulating our attitude, and designating the * Blundell's Vorlesungen liber Geburtshilfe, by Thomas Castle, transl. by L. Caiman, Leipzig, 1838, complete ; also, Cline's Articles in Medico-chirug Transactions. Vol. IX. Part I. 1818. f Waller, Diss, inaug. med. de sanguinis in periculosa hsemorrhagia uterina transfusione. Erlangen, 1832. X Dieffenbach, Die Transfusion des Plutes, etc. Berlin, 1828, and Die operative Cherurgie, 1845. Bd. I. § Blasius, Monatsblatt fur med. Statistik Beilage zur deutchen Klinik. 18C3. || Friedberg, Die Vergiftung urcdh Kohlendunst. Berlin, 1863. Martin und Barth, Verhandl d. Berlin med. Gesellschaft 1867. ^ Martin, Ueber die Transfusion bei Blutungen Neuentbundener. Berlin, 1859. 60 SURGICAL EMERGENCIES. really practical methods, we will briefly recapitulate the procedures which have been proposed and executed. According to the form in which blood is used, we dis- tinguish: 1. Transfusion of intact (not defibrinated) blood. i. Conduction into the vein of the recipient directly from the vein of the donor by means of special apparatus (Rous- sel,* veno-venous transfusion). • 2. Conduction of blood obtained by venesection, which is introduced into the recipient's vein by pumping apparatus (Moncocq,f Collin, Mathieu) or syringes (Martin, /. c). 3. Transfusion of capillary blood (obtained by cupping) by means of pumping it into the vein (Gessellius J). 4. Transference from artery to artery by pumping (Schliep,§ arterio-arterial tranfusion). 5. Direct transfusion from artery to vein. As yet this procedure has been employed only by using the carotid artery of the lamb directly into the human median basilic vein. II. Transfusion of defibrinated blood (almost exclusively that of man): 1. Into veins,by syringes (Landois,|| Uterhart,^[ Braune**) or with the use of simple receptacles for measurement) Na- gel, Casse).ff 2. Into arteries (Hueter'sJJ periphero-arterial injection of blood.) We distinguish, according to the donor : A. Transfusion of the blood of the same species (man to man). To this di- vision belong: (a) Most of the transfusions with defibrin- ated blood; (b) Veno-venous transfusion of non-defibrinat- ed blood (directly from the vein, or the product of venesec- tion, or capillary blood); (c) Arterio-arterial transfusion (Schliep). B. Transfusion of the blood of different species. * Roussel, Arch, de l'anat, et de la physiol. 1868, p. 552. f Moncog, Transfusion instantanee du sang. Paris, 1874. \ Gesellius, Die Transf. des Blutes, Eine Studie. St. Petersburg and Leipzig, 1873. § Schleep, Berl. klin. Wochenschr, 1874. No. 3. I Eulenburg und Sandois, Die Transfusion, des Blutes. Berlin, 1866. *[T ( Uterhart, Berl. klin. Wochenschr, 1868. No. 10. ** Braune, Arch, ftir klin. Chirurgie. Bd. VI. ff Casse, De la transf. du sang. Mem. presente a l'acad. royale de med. de Belgique le 29, Novembre, 1873. XX Pueter, Die arterielle Transfusion. Arch, fur klin. Chirurgie, 1870, Bd. 12. S. I. SURGICAL EMERGENCIES. 6l — Transfusion of animal blood to man. This comprises: (a) All of those direct transfusions made with intact arte- rial blood (see Hasse's Monograph *). (b) A great part of the arterio-venous transfusions of intact blood, by means of pumping apparatus; (c) Injections of defibrinated ani- mal blood and of the serum of animal blood. How shall we select the most rational procedures, and upon what principles shall we judge of their utility?. The object of transfusion is the introduction of viable red blood-discs, which are destined to serve respiration and the metamorphoses in general. To these ends, it is neces- sary that the blood-discs be in a liquid favorable to their existence and that the recipient's blood be not of such a character as to endanger their vitality. It is well known that the power of resistance of the blood-discs differs in dif- ferent animal species, and that the serum of different kinds of blood does not injure the blood-discs of a number of an- imals, while other blood-discs invariably die in it. These facts are of the greatest possible importance in transfusion of animal blood, because perhaps the blood-discs of the or- ganism which requires blood will not be affected by the injected blood (e.g., lamb's blood). Again, the injected blood-corpuscles can retain their vitality but a short time in human blood. Landois f asserts that the reverse condi- tion prevails when dog's blood is employed. Among other points which must be considered, are the gaseous constituents of the blood (Brown-Sequard, /. c, and Panum, /. c). The dyspnoea which has often been observed in most alarming form after transfusions with lamb's blood, has been attributed to the large amount of carbonic acid which it contains. This called forth Traube's proposition to render the animals apnceic previous to performing the transfusion.^ Alexander Schmidt's§ investigations of the fibrin-fer- ment and its tendencies to the furtherance of coagulation, resulted in new views as to the utility of defibrinated blood. * Hasse, Die Lamenblut Transfusion beim Menschen. St. Peters- burg u. Leipzig, 1874. j L. Landois, Die Transf. des Blutes. Leipzig, 1875. \ Kiister, Ueber die directe arterielle Thierbluttransfusion. Verh. der deutschen Gesellschaft, f. Chir. III. Congr. 1874. § Alexander Schmidt, Die Lehre von den fermentativesi Geriunungs- erscheinungen u. s. f. Dorpat, 1876. (Also cites some original investi- gations upon which it' is based.) 62 SURGICAL EMERGENCIES. Coagula within the circulating apparatus, which have been observed after the transfusion of beaten blood, are attrib- uted to faulty procedure, especially defective filtering off and allowing the transfused fluid to regain coagula. Thence the transferred coagula of fibrin should give rise to further coagulation, as the plugs of fibrin, even if they appear as simple emboli in a larger quantity, would not be followed by threatening phenomena. A. Schmidt has shown that the defibrination of blood may generate fibrin-ferment, and that, as soon as it is introduced into the circulation, may produce multiple coagula. It is probable that a febrile state of, or septic processes in the donor, increase the coag- ulating power of the fibrin-ferment. Possibly similar con- ditions in the donor may increase the quantity of the fibrin- ferment in the defibrinated blood (Kohler,*.) According to Kohler the activity of the blood containing fibrin-ferment is also increased, if, upon injection, it is allowed to traverse a peripheral capillary region of the body, as, for instance, injection into the peripheral end of an artery, as Hueter pro- poses for his arterial transfusion. But periphero-arterial transfusion should preclude the introduction of coagula into the vessels, as the capillary net would intercept them. Aside from the fact that the difficulties of forcing defibri- nated blood into a capillary region ofttimes become great and even unsurmountable, which may be attributable to a spasm of the muscles of the vessels as well as to coagula- tion, within these regions, Schmidt's experiences must cause us to decide against Hueter's method. The danger in a transfusion of defibrinated blood is not in introducing the retained coagula, but the fibrin ferment formed by defibrination. Its activity is materially increas- ed in peripheral arterial transfusion. Landois's (/. c.) pro- position, to inject into a large vein or the central end of an artery, whenever the surgeon is compelled to employ defi- brinated blood, appears far more rational. This proposi- tion, curiously enough, has met with no further indorse- ment, though it is easily proven that blood loaded with fibrin-ferment entirely loses its coagulating properties as soon as it is injected directly into an artery, towards the heart. A syringe must be used for central arterial transfusion, * Kohler, Ueber Thrombose und Transfusion, Eiter und Sepitische Infection. Inaug. Diss. Dorpat, 1877. SURGICAL EMERGENCIES. 63 and ttie danger of forcing in air-bubbles is not so great as when the injection is made into a vein which might conduct the air into the right heart. Venous blood-infusion admits of but two serviceable pro- cedures, viz., the direct admission of the arterial stream im- pelled by the vis-a-tergo of the donor's heart, and secondly, allowing the defibrinated blood to press its way into the vein by its own weight as it rests in the measuring-recep tacle. As has been stated, the first method has as yet been employed only in transfusion from animal to man. Still, in an emergency, there would be nothing to preclude the same procedure in transfusion from man to man. A canule might be introduced, with all antiseptic precautions, into the central end of the radial artery of a healthy donor and be united with another which has been fastened into the median basilic vein of the patient, after the hand of the donor has been firmly bound to the arm of the recipient. This, like all other direct transfusions, may be performed without complicated apparatus; easily made glass canules, united by rubber tubes, suffice. Preparatory filling of the canules with an indifferent liquid is unnecessary. A sound inserted between the peripheral canule (7. e. the one in the vein) and the rubber tube, amply suffices to prevent the in- troduction of air, the operation being performed as follows: while the vein is still tied the artery is opened, and the blood, shooting into the canule, crowds out the air before it. As soon as drops of blood instead of air issue at the side of the sound, it is to be withdrawn, as then the connections are filled with blood. All that is requisite then is to loosen the ligature which confines the veins, and the arterial blood will flow unimpeded into the venous territory towards the heart.* Direct conduction from artery to artery will be found possible only in those cases in which the arterial tension of the donor is greater than that of the receiver. Thus, in a profound anaemia it might be essayed, transfusing blood directly, that is, through simple canules from the central end of an artery of the donor into the peripheral end of the artery of the receiver. When the tension of both arterial systems is equal, the effort will prove futile. In the human being these transfers have as yet been made only by means * V. Transfusion unci Autotransfusion. Sammlung klin. Vortrlige, No. 86. 64 SURGICAL EMERGENCIES. of pumping apparatus (Schliep /. c). If it be decided to employ such a forcing apparatus at all, we would recom- mend central transfusion, /. e., from the central end of the donor's artery to the central end of the receiver's, as being a method of easier execution. Formerly syringes were used for the introduction of de- fibrinated blood into the veins. But far simpler and less dangerous than thus to force in the blood, is to allow it to flow in, impelled only by its weight and the pressure it exercises upon the vessel which contains it. There is no danger if the blood carry with it a few isolated air-bubbles, especially when the transfusion is made into a vein distant from the heart, as are the veins of the extremities. But when a syringe is used, the force to be employed for the injection of each quantity of blood cannot be so exactly calculated as to assure against overfilling the right heart, with consequent phenomena of engorgement in the large venous trunks or even a direct forcing of blood into the latter, as for instance the portal system. Experiments made in this procedure have yielded observations of haemorrhage into the intestines and liver, even to the extent of tearing the latter organ (Casse, /. c). The danger, resulting from the introduction of air into veins have had their fatal issues explained in many ways. First, it is claimed that the air-bubbles which arrive into the heart are forced thence into the lungs and there pro- duce a stoppage in the capillaries, with marked hindrance to the pulmonary circulation. But Lowenthal,* has shown that animals subjected to the injection of large syr- ingefuls of air into the peripheral veins bear the operation quite well. Furthermore, it is known that even an inunda- tion of the pulmonary circulation, as, for instance, with emul- sions of fat or wax, is not followed by any direct danger to life. Panum and others have assumed not only these impedi- ments to the pulmonary circulation, but also a similar cir- culatory disturbance within the brain, and those nervous centres which are prolonged into the spinal marrow. This can be demonstrated experimentally and graphically (Coutyf), especially when air is gradually forced into the veins. * Loewenthal, Ueber die Transfusion. Inaug. Diss. Heidelberg, 1871. f Couty, Etude experim. sur l'entree de l'air dans les veines. Paris, 1875. SURGICAL EMERGENCIES. ^65 Yet those cases in which sudden death follows the admission of air, show that the primary cause is found in a pure arrest of the heart's action and must be taken into consideration in connection with such fatal mishaps as may occur in trans- fusions. The valves of the heart, of which the tricuspid is most important in this connection, are destined to arrest fluids or let them pass. If air instead of blood enters the heart, the valves, especially the tricuspid, become insufficient in proportion to the abnormal distension, the degree of which depends upon the quality of air and blood which have en- tered the heart. The contractions of the distended heart are not capable of propelling the blood to the pulmonary vessels and beat the blood in its right side to a froth. Owing to the valvular insufficiency the abnormal contents of the right heart are thrown to and fro between the pulmonary artery andvenoz cavoz. But few bubbles of air or froth reach the pulmonary circu- lation and the coronary vessels. The air-bubbles do not prevent the blood from entering the lungs and nutrient vessels of the heart, but the valvular insufficiency allows no blood to flow into the heart from the venae cavae. Thus the entrance of air into the heart kills by primary pa- ralysis of the organ, provided that large quantities have entered at once. When small quantities of air enter the heart slowly, the blood which enters with it prevents the rapid death of the heart-muscles and does not give rise to a definite interruption of the pulmonary circulation. If, after longitudinally dividing the sternum of an animal, the heart be exposed without opening the pleura, and air be allowed to enter the heart through a wound in the jugular vein, the ineffectual efforts of the heart to contract upon its contents become evident. Gradually the coronary vessels fill with air or bloody froth and soon contractions cease entirely. If then an indifferent fluid, say a one half per cent chloride of sodium solution, be injected by a fine instrument through the heart-muscle directly into the right ventricle to such an extent as to overbalance the air in quantity, the following phenomena will be observed : the contents of the heart are gradually pushed forward by weak contractions, as the valves again become sufficient ; soon blood follows, the cardiac impulse becomes stronger and the pulmonary cir- culation is re-established. Further investigations will be required to demonstrate to what extent and in what manner the above observations may be practically applied, and 66 SURGICAL EMERGENCIES. whether at all life-saving results will be attainable in sud- den deaths from the entrance of air. We will now mention two methods which have been essayed as substitutes for the injection of blood into the ves- sels, viz.: Subcutaneous injection of blood and injection thereof into the abdominal cavity. Both methods, whether intact or defibr-inated blood is used, yield absorption of the red blood-discs by the circuitous route of the lymphatics. Thus the red discs enter the circu- lation indirectly and but slowly, therefore these methods are not available for those cases in which a rapid restitution of blood is urgently necessary. Casse* and several others have injected blood subcutaneously in experiments and in patients, but the results were very doubtful. The sites of in- jection were repeatedly affected with abscesses. It is claimed that Ponfickf injected blood successfully into the abdom- inal cavities of three patients. Browicz and ObalinskiJ have proved the latter experimentally. In proceeding to the discussion of the performance of transfusion, it must be noted that the vessel into which the in- jection is to be made, must be well dissected out as in ligations; and this applies to veins as well as arteries. The use of canules to penetrate a vein through the skin is unsafe and may even become dangerous when large arteries are near, as in the bend of the elbow. After the artery or vein has been dis- sected from its surroundings, three ligatures are placed about the vessel thus isolated, one peripherical ligature clos- ing the vessel permanently, one central temporary ligature, and between them a thread with which to fasten the infusion canule into the vessel. The canule is inserted into the ves- sel after the wall thereof has been incised with a fine scis- sors. The direction of this incision is made diagonal to the long axis of the vessel. After the transfusion is made the temporary (central) ligature is tied firmly, then the canule is extracted, and finally the vessel is cut between the two ligatures. All arteries into which transfusions have been * Casse, De la valeur des injections du sang dans le tissu cellulaire sonscutane, Bull, de l'acad. royale de med. de Belgique, 1879. T. xiii. 3 ser. No. 7 f Ponfick, Buslaner, artyl. Zeitschrift, 1879. No. 16. \ Obalinski, Experimentelles Beitrag zur peritonealen Bluttransfusion. Przegled lekarski, 1880. No. 9, art. 10 (Polish). Compare also : Nikol- ski, Ueber den Einfluss der Blutinfusion in die Bauchhohleets. Wratsch, 1880. No. 4 (Russian). SURGICAL EMERGENCIES. 6y made must be so treated, while when a vein is used, the canule may in many cases be merely pushed into the lumen of the vessel without securing it further. After the canule is removed a simple compress upon the site of operation will suffice. The choice between defibrinated and intact blood merits separate consideration. We have seen that the use of beaten blood does not appear less recommendable because the fibrin is removed, but because fibrin-ferment is developed by the beating and may lead to the formation of coagula. This coagulation within the vessels is blamable principally for the fatal issues of cases in which defibrinated blood was trans- fused, and not, as was formerly assumed, a consequence of the introduction of flakes of fibrin into the circulation, the presence of which was attributed to defective filtration. Still special care must be devoted to ensuring thorough filtra- tion. For this purpose filters of satin, from which the siz- ing has been removed, are most recommendable. The filter is set into a glass funnel whence the blood flows into a most carefully cleaned glass vessel. The blood is best beaten with two thick, thoroughly cleaned glass rods, in a porcelain dish into which the blood of the donor was received. Too little time must not, by any means, be spent in defibrination, lest secondary coagulation take place in the defibrinated blood. The glass vessel into which the blood has been conducted after defibrination and careful filtering, need not be specially warmed, as was formerly strenuously urged. No evil results have followed the injection of blood which corresponded to the temperature of the room, as Polli* formerly, and Casse (/. c.) recently proved. Ore,f Duranty,^ Schliep (/. c.) and others, have proven the fact that when using intact blood cold retards coagulation. Therefore they recom- mend that the transfusion apparatus, after being filled with blood be laid on ice, previous to its employment. When a syringe is employed for transfusion, blood must be introduced slowly and at intervals, to avoid, as before indicated, the dangers of overfilling the portal circulation, or even rupture of the liver. Yet frequently tenesmus, col- ics and vomiting supervene. These can be avoided by emptying the bowels previous to the operation. * Polli, Glorie e sventure delle transfusione. Armali universali de medicina, 1854, and iu the Archives gen. de med. 1854, Oct. et Nov. f Ore, Gaz. des hopit., 1865. Decembre 30. % N. Duranty, These de Paris, i860. 68 SURGICAL EMERGENCIES. Among the other symptoms which may arise at a trans- fusion, we will mention: dyspricea, which, at least in the trans- fusion of lamb's blood, is attributed by Traube (/. c.) to its containing greater quantities of carbonic acid. The lumbar pains, which have been explained on the score of renal hyperemia, as hsematuria, often follow transfusions. Fre- quently a rigor follows some time after a transfusion, and later, especially after transfusions of lamb's blood, the entire skin of the receiver has been covered with violently itching wheals of urticaria. What, then, are the indications for the introduction of via- ble blood into the circulatory apparatus ? The preceding considerations will indubitably have shown you that a marked degree of anamia gives the principal indication. We would also transfuse in extensive deep burns, as in severe cases the fatal termination is brought about by the death of a large number of red blood-discs (Ponfick,* L. von Les- ser f). Thirdly, transfusion is suggested in poisonings, which, as in extensive scalds, alter the capacity of many red blood- discs to perform their functions and produce acute func- tional oligocythemia (v. Lesser, /. r.) In this connection poisoning with carbonic-oxide-gas merits serious considera- tion, which Claude Bernard \ compared with extensive vene- section. Furthermore, there may be discussed in this con- nection poisoning with chlorate of potash (Marchand §), pyrogallic acid (Neisser ||) and nitro-benzole (Yiidell, Filehne^f) in all of which analogous destruction of the blood- discs has been established. Again, transfusion is demanded in poisonings with mat- ters which, owing to their presence in the blood, thence influ- ence the nervous centres. Such are chloroform, opium and its alkaloids, strychnia, etc. In these cases it is necessary quickly to abstract large quantities of blood and thus remove with it corresponding quantities of the noxious substances it * Ponfick, Amtlicher Bericht der 50 Naturforscherversammlung in Miinchen im Jahre 1877, p. 259. f L. v Lesser, Ueber die Todesursachen nach Verbrennungen. Vir- chow's Archiv. Bd. 76. % Claude Bernard, Lecons sur les ahsesthesiques et sur l'asphyxis. Paris, 1875. § Marchand, Virchow's Archiv. Bd. 77. 3. Heft. || Neisser, Zeitschrift fur klin. Medicin. Bd. I. 1 Heft. \ Filehne, Ueber die Giftwirkungen des Nitrobenzols. Brchif. exper. Path, und Pharmakol. Bd. xL SURGICAL EMERGENCIES. 69 contains The loss of blood must be covered by a correspond- ing introduction of healthy blood from without. In those intoxications with such matters as have been mentioned, (carbonic oxide gas, chlorate of potash, pyrogallic acid, nitrite of amyl— and in burns as well) which threaten hie almost only through the death of the blood-discs, venesec- tion previous to transfusion is indicated only to lighten the labor of the kidneys, which almost alone must devote themselves to the elimination of the products of the disinte- gration of the red blood-discs. _ In accord with our explanations of the capacity ot the vascular system, depletion previous to transfusion, even of great quantities, would, as is self-evident, be quite out of place in the anaemia following haemorrhages. Previous to again directing our attention to anaemic con- ditions we must now mention one indication for transfusion, which we intentionally omitted when citing the others. The history of transfusion presents frequent reappearances of the suggestion of injection of blood in chronic diseases. As yet we know but little of the distinctive modifications which the functions of the red blood-discs suffer in various affec- tions Equally limited is our information upon the influ- ences of these disturbances upon the changes which modify metamorphosis and the several tissues in chronic affections. Therefore the injection of blood in chronic diseases cannot be considered other than an empirical measure. We must likewise decidedly regret the opinion which occa- sionally is still uttered, that an introduction of blood in star- vation can elevate nutrition. This view has been thoroughly refuted by Casse's (/. c.) experiments, as well as by Panum's classical investigations. The animals which he had starved could in no manner be kept alive by transfusion. The injected blood at first increases the destruction of albu- men through its greater oxidation, and owing to the lack of those albuminous matters which should be introduced with normal nutrition. Then, again, we have demonstrated that the excessive red blood-discs are subject to destruction with concurrent increase of nitrogenous elimination through the urine (Worm-Muller f). Now, if we return to direct anaemia, we distinguish, in accord with Worm-Muller s the- * Panum, Virchow's Arch. 1864. Bd. 29. \ Worm-Muller, Transfusion und Plethora. Chnstiania, 1875. ?0 SURGICAL EMERGENCIES. ory on the capacity of the vascular system (/. c), three territo- ries of anaemia. I. Passive anaemia affecting loss of blood of from one and a half to two per cent of the weight of the body. Most frequently a spontaneous re-establishment of the blood- constituents takes place, as, for instance, after syncope, etc. ; therefore we may designate this territory as the physio- logical stage of anaemia, II. Anaemia threatening life in which the loss of blood is as much as three per cent of the weight of the blood con- tained in the body. As we have seen that this is the limit in which the pressure of the blood and the number of the red discs in it suffer sudden diminution, dependent on a peculiar distribution within the vessels, we will in view of that distribution perhaps be able to avoid danger by auto- transfusion without being compelled to introduce blood from without. Auto-transfusion will' shortly be discussed in detail. III. Fatal Anozmia. — This is the true domain of trans- fusion, in which it only and alone can save life, because auto-transfusion will neither bring about an elevation of the blood-pressure nor be able to reproduce a proper admixture of its constituents, which approximates the normal condition. (Compare von Lesser, Transfusion und auto-transfusion, Sammlung Klinischer Vortrage, No. 86 ; and see the following chapter on auto-transfusion). We have just seen that loss of blood within a certain limit can be replaced from without by conducting to the heart the blood which has been accumulated in certain vascular districts, as the consequence of sudden sinking of the blood-tension resultant upon the haemorrhages which have reached a certain degree. And when centripetal ex- pression of the extremities by kneading and likewise pressing the abdomen was practised, elevation of the blood-pressure and greater filling of the aorta was attained, as has been shown you in the second lecture. Importance does not attach to blood which normally-is found in the said parts, but only to a local stasis, while the aorta system is but slightly filled. When fatal haemorrhage occurs under such disturbances of the blood-distribution an anaemic individual will die if the necessary assistance be not given him, and yet may possess a sufficiency of blood to main- tain life had the blood been properly distributed. The patient dies not from lack of blood, butfrotn lack of blood-circalation. SURGICAL EMERGENCIES. 7 1 Auto-transfusion as a means of restoring engorged quan- tities of blood to usefulness to the organism was first sub- jected to scientific explanation through the works of Worm- Miiller (/. c). It was long known and practised as a popular remedy, especially in haemorrhages, during and after parturition (Hausmann*). The proper field for auto-transfusion is that anaemia which endangers life (second territory). In this a key to the quantity of blood of which the body can still dispose is given us. As is self-evident, auto-transfusion is most efficacious in the lightest forms of transitory anaemia (first territory). In those cases in which the effect of auto-trans- fusion is so limited that for the purpose of saving life which is being extinguished, we must bring blood from without as quickly as possible, auto-transfusion serves as a positive means of diagnosis to indicate to us the quantity of blood which we should introduce. For this purpose it is better and more reliable than the symptcnvs of haemorrhage which the pulse and other means furnish, as they depend to a great extent upon nervous reflex. In these cases also auto- transfusion will be of great use as a preparation of the patient for transfusion. It also subserves the purpose of forcing into the circulation all of the blood which remains in the body, and thus to sustain life until the injection of blood can be made. Furthermore, the execution of transfusion is recommend- able in all cases of profound anaemia which are to be sub- jected to operations in which haemorrhage is inevitable (extraction of the child in placenta-praevia and after, haemorrhage, etc.). Finally, it should be used in profound anaemias previous to the administration of chloroform, which, as is well known, diminishes the blood-tension and may lead to a deadly collapse in those who have been ex- hausted by loss of blood (see Koch, Ueber das Chloroform und seine Anwendung in der Chirurgie. Sammlung Klinischer Vortrage, No. 89). Auto-transfusion is very simply executed. The patient is placed with his head lower than his pelvis. The extremi- ties are elevated singly or together to the vertical posture, and either bandaged or stroked from the periphery to the centre. Hereto are added kneadings of the abdomen and * Hausmann, Zeitschrift fur Geburtshilfe und Grynakologie. Bd. I. Heft. 2. J2 SURGICAL EMERGENCIES. a progressive pressure on the intestines from the symphysis pubis to the margin of the ribs and special compression of the region of the liver. The thorax should also be com- pressed from time to time by pressure upon the ribs in the axillary line, as in Marshall Hall's Artificial Respiration, the action of which most probably favors respiration, but indirectly, while it principally facilitates the flow of blood to the right heart. Undoubtedly the action of direct mechanical pressure upon the heart assists in this pro- cedure (Bohm*). From time to time the head should be elevated for brief moments so as to allow the blood of the jugular veins to arrive at the heart more quickly. Nelaton's suspension by the heels in the asphyxia of chloroform belongs to the domain of auto-transfusion. Note. — In the preceding footnotes no claim is made to completeness. Fuller bibliographical reports will be found in the monographs of Scheel, Dieffenbach, Martin, Landois, Geselius, Casse, and others. * Bohm, Centralblatt fiir med. Wissenschaften, 1874. No. 21. SURGICAL EMERGENCIES. 73 LECTURE VII. Impediments to the supply of air. — Sudden stoppage thereof in strangulation. — Foreign bodies in the trachea and oesophagus. — Perilaryngeal swelling of the tissues. — oedema glottidis, struma. Kropftod. — Gradual narrowing of the trachea lumen. — Croup and diphtheria. — Paralysis of the vocal cords. — Tracheotomy, preparatory to other operations. — Dilatation of tracheal stric- tures. — Induction of artificial respiration in chloroform poi- soning, opium poisoning, tetanus. — Modus operandi. — Rapid and slow suffocation, their causes and symptoms. — Dangers of suffocation in tunnels and mines; to divers, aeronauts on high elevations; working in compressed air {caissons in bridge-building). — Narcosis in compressed air according to Paul Bert. — Mechanism of artificial respiration. — Opening the cervical bronchus. — Pharyngotomy. — Thyrotomy. — Thyro- c? icoid laryngotomy. — Cricotomy or crico-tracheotomy. — Siiper- glandular and infra-glandular tracheotomy. — Procedures in tracheotomies. — Pose's rectangular dissection of the trachea. — Insertion of the tube. — Removal of croup membra?ies and foreign bodies. — Sucking out fluids not to be done in diph- theria. — Dimensions of tubes, and their modes of fastening. — Dressing of the wound in tracheotomy. — Painting it with an eight-per-cent solution of chloride of zinc. — Inhalation through the wound of tracheotomy. — Removal of the tube. — Impedi- ments to respiration after the tracheotomy. — Granuloma. — Stric- tures. — Posture of the patient in tracheotomy. — Instruments and paraphernalia for tracheotomy. Gentlemen: A study of the supply of air and early recognition of its limitations is as important a matter for the physician, as is the arrest of haemorrhages. The correct interpretation of the symptoms in respiratory disturbances, as well as the rapid removal of the cause of disturbance, is ofttimes of the highest importance in the saving of life. This is above all applicable to the sudden deprivation of the sup- ply of air, to which we will now give a detailed attention. Sudden shutting off of the air-supply from the lungs is pro- duced either by a direct narrowing of the lumen of the 74 SURGICAL EMERGENCIES. trachea or by its compression from without. The latter maybe caused by constringent power about the neck, as in hanging or strangulation. In these, if they be adults with ossification of the laryngeal cartilage, we will find peri- laryngeal haemorrhages, contusions and bloody suffusion of the bronchial mucous membrane, as well as frequently injury to the laryngeal cartilage. In all injuries to the laryngeal structures, whether by gun-shot wounds or blunt missiles projected against the anterior cervical region, we must always perform tracheotomy to guard against the possible apncea of oedema glottidis. The tracheal lumen is frequently reduced by the presence of foreign bodies. If these are firm bodies they fall down into the lower part of the trachea, as might coins, beads, pins and needles, bits of bones, etc., or they may occlude the laryngeal entrance, as would large and hastily swallowed pieces of meat. These may be firmly wedged in by the peristaltic action of the oesophagus (from above downwards) or by violent inspiration forced into the rima glottidis and held there by a spasm of the vocal cords. There are many cases recorded in which bits of meat thus caught by the above mechanism have been followed by rapid fatal suffo- cation. These pieces are usually so firmly wedged in, that though the)? - can be easily reached, the fingers and even for- ceps will often have great difficulty in removing them, and it may appear impossible. At those moments the pressure of the motions of deglutition added to the spasmodic con- traction of the soft palate, which both act upon the foreign body from above downwards, contribute to its perfect im- mobility. Hereto the circumstance is added that the larynx is pressed tightly against the posterior pharyngeal wall by the muscles attached to the hyoid bone, and thus contribute to the complete closing of the faucial entrance. The foreign body is most easily made movable when the larynx can be drawn away from the vertebra. This is accomplished most quickly by inserting a sharp strong hook in the center of the hyoid bone and forcibly drawing it towards the chin, while a bent forceps grasps the foreign body ar*d endeavors to accomplish its removal. When foreign bodies have fallen into the bronchus no effort must ever be made to remove them by the mouth. Aside from the difficulty of grasping the foreign body, the manipulations incidental thereto may serve only to force it further down into the bronchial tubes. When a foreign SURGICAL EMERGENCIES. 75 body is in the trachea, as in injuries to that organ, tracheotomy must be performed as a prophylactic measure without awaiting the oedema glottidis which may supervene. The site of the opera- tion should be if possible below the place under which the foreign body is presumed to rest. Then it should be en- deavored to force it back into the fauces by instruments passed through the tracheotomy-wound. Only when foreign bodies have fallen as far as the bronchial bifurcation will it be permissible to insert forceps or a spoon (Roserf) through the wound, which, in these cases should be one of the infra- glandular tracheotomy. However, instruments should not be inserted unless it has been found impossible to dislodge the foreign body and have it fall out through the wound after violent succussion, the patient being suspended by the heels. All voluminous, hard foreign bodies which are wedged in the oesophagus behind the larynx, and compress it, call for tracheotomy previous to making any efforts for their removal. But if those bodies be voluminous yet soft (potatoes, dough), they may be broken up by compression of the throat by the points of the fingers on both sides of the larynx. Among liquid foreign bodies which reach the bronchial tubes through the larynx and inundate them should be men- tioned : water, in drowning; blood, in operations on the facial part of the cranium and in the naso-pharyngeal spaces; pus, upon the bursting of a large retro-pharyngeal abscess, etc. After performing tracheotomy these fluids must be sucked out as much as possible. Sudden closure of the larynx through swelling of the tissues occurs in oedema glottidis, which we have already men- tioned as a phenomenon of injuries to the larynx, especially •by gun-shot. It also occurs after typhus, most frequently concomitant with ulceration of the arytenoid cartilage or necrosis of the laryngeal cartilages. Acute narrowing of the bronchial tube occurs in sudden increase of peri -laryngeal swellings or inflammatory swellings, as also in rapid pus-formation in Perichondritis laryngea, in Angina Ludwigii (phlegmone colli diffusa), in the rapid * Falk and H. Kronecker, Ueber den Mechanisms der Schluckbeweg- ung. Verhandl. der Physiolog. Gesellsch. zii Berlin, vom 21 Mai, 1880. No. 13. f Roser, Vortrag auf dem IX. Congress der deutschen gesellsch. f. Chir. Compare Verhandl. and reference in the Centralblatt. f. Chir. 1880. Supplement to No. 20. j6 SURGICAL EMERGENCIES. increase of carotid aneurism or rapid enlargement of cervical cysts (dermoid cysts, cysts of the bronchial canal, cystoid lymphangiomata); also in rapidly-growing sarcomata of the cervical lymph glands, and, beyond all, in the rapid growth of strumata, whether they involve inflammatory swelling, or softening within parenchymatous goitre, or a haemorrhage into the cystic goitre. An enigmatical form of sudden suffocation in struma called Kropftod, has been explained by Rose* as follows: small, hard, fibrinous, scrofulous tumors may wear away places or spots in the tracheal rings, thus causing the trachea to lose its fine spiral, spring-like frame. Then a sudden motion may twist it upon its long axis, or may break it through its transverse axis (Kippstenose of Rose). The last-named causes which produce a compression of the bronchial canal can manifest their results also slowly, thus producing a gradual narrowing of the tracheal lumen. The latter, the action of which does not suddenly cut off the supply of air, but manifests itself by a deficient renovation of the air in the lungs, takes place when swellings grow and impinge upon the tracheal entrance as in fibroids of the epiglottis, in fibromata which extend from the posterior na- sal spine or in the often very vascular tumors at the base of the skull, the superior maxilla and of the cavernous retro- maxillary connective tissue which may gradually fill the en- tire naso-pharyngeal space. Lingual tumors as well, prin- cipally epithelioma, which extend from the base of the tongue to the epiglottis, and finally even swellings and ex- tensive hypertrophies of the tonsils may, because of the gradual impediments which they offer the supply of air, de- mand a tracheotomy. In hypertrophies of the tonsils it must be particularly considered, especially in very young children where the smallness of the site of operation and the dan- gers of narcosis under such circumstances preclude the sim- ple removal of the enlarged tonsils. The reduction of the tracheal lumen caused by patholog- ical processes within the air-tube merit most serious con- sideration. Beyond all things croup and diphtheria must here be men- tioned as diseases which, at least in childhood, give the most frequent indication for tracheotomy. It is not our purpose * Rose. Ueber den Kropftod und die Radicalcur der KrSpfe. Verhandl. des VI. Cong, der deutsch gesellsch. f. Chir. Grosser© Vortr. p. 75. SURGICAL EMERGENCIES. 77 to discuss these diseases in detail. We will but mention that croup occurs almost exclusively in the trachea and shows finely reticulated membranes and coagulated fibrine, which rest upon spots of the basal mucous membrane which have been deprived of their epithelium. Membrane forma- tion also occurs in Weigert's* pseudo-diphtheritis, which is an extension of tonsillo-faucial diphtheria to the larynx. But the membranes cannot be removed during life without damage to the mucous connective tissue upon which they lie. In this instance the membranes consist of heaps of dead round cells which exactly resemble those of the connective tissue. Besides the pseudo-diphtheritic deposits, or often combined with them, is found real diphtheria, that is, rigi- dity of the superficial layers or the mucous stroma itself in a mass resembling coagulated fibrine and in which but few or no visible nuclei are found. The unnucleated mass shows more or less nuclear migratory cells. The diminution of the tracheal lumen depends in these cases upon an increased thickening of the mucous mem- brane owing to accumulated croup membranes or through the inflammatory swelling of parts of the mucous membrane, which are found beneath the superficial mucous layers which have been killed by diphtheria, otherwise the croup membranes, which, separate, may occlude in a flap-like man- ner and thus cause sudden suffocation. On the contrary, in diphtheria the process may extend from the primary bron- chi to their ramifications within the lung and thus reduce their lumen and consequently diminish the breathing sur- face. Tumors which grow within the larynx can bring about gradual narrowing, as, for instance, carcinoma of the vocal cords, in which, when it is impossible to operate on them tracheotomy would be in place, while when they are still in local limits extirpation of the trachea should be performed. Again benign proliferations of the tracheal mucous mem- brane, as developed at the margins of a tracheal fistula in the form of glandular polyps, may reduce the volume of the trachea partly because their narrow stem upon a broad base may throw them upwards with expiration and thus plug the trachea, intercepting the further supply of air. Special distinction is required in paralysis of the vocal cords. This may be the result of paresis, of inaction from contin- * Weigert, Virchow's Archiv. Bd. 70 and Bd. 78. Heft 2 (1878.) 78 SURGICAL EMERGENCIES. ued wearing of a tracheal tube and where the tracheal mus- cles have been subjected to prolonged inactivity. From these should be distinguished pareses partly of central origin, partly in consequence of compression of the recurrent nerves, as, for instance, through the growth of oesophageal carcinoma, or, through aneurism of the bul- bus aortse, which compresses the left recurrent nerve. In the latter case the increasing dyspnoea will finally demand tracheotomy, while paralysis inactivity should be treated by electricity. Strictures of the trachea, be they syphilitic, traumatic or of chronic inflammatory origin (Storck) causing increased dyspnoea, demand an opening of the trachea below the con- striction which will also subserve the purpose of gradual dilatation of the stricture in allowing the use of tin dilators through the opening made. Tracheotomy is also required for certain special purposes. Thus, in resection of the superior maxilla, extirpation of laryngeal tumors and of the larynx itself, etc., it serves to chloroform the patient through the tracheotomy tube and at the same time allows tamponing of the trachea, thus im- peding a flow of blood into the lungs in the above-named operations. The trachea was occasionally tamponed by means of a double-walled rubber hollow cylinder which was drawn over the tube and inflated when within the trachea. This has now been more correctly substituted, in resection of the superior maxilla, and other operations, by inducing nar- cosis with morphine and chloroform and maintaining the head of the patient below the level of the body (Rose). On the other hand, we perform tracheotomy when in the induction of artificial respiration an increasing inactivity of the respiratory muscles is found. It is also applicable in chloroform and opium-poisoning, and in tetanus. We have been taught by the investigations of Scheinesson and others (see Koch, Sammlung. Klin. Vortr. No. 80) that chloroform poisoning has as its most important manifestation a primary paralysis of vasomotor nerve-centres, evidenced in considerable depression of the blood-tension, and have recommended auto-transfusion in case these manifestations assume a threatening character. The anaemia of the brain- centres, causing diminution of the blood-pressure might ex- plain the transitory paralysis of the sensory and motor sphere; while the centres, which lie in the medulla oblon- gata and govern respiration and the movements of the heart SURCICAL EMERGENCIES. 79 are not affected. When, however, an impedient to respi- ration occurs, as in defective posture of the head or body of a narcotized patient, or, as we will see, whenever car- bonic acid accumulates in the blood, then the centres of respiration and circulation are subject to the paralyzing influences of both carbonic acid and chloroform. Auto- transfusion alone would not suffice, then; artificial res- piration and kneading of the heart (Bohm, /. c.) must be made and thus oxidation of the blood maintained until a sufficiency of chloroform has been eliminated. But auto- transfusion and artificial respiration must be persisted in for a sufficient length of time, and life will return, though it had almost ceased for half or even three quarters of an hour; provided, however, that not too long an interval elapsed between the cessation of the heart's action and res- piration, and efforts at resuscitation have been begun. Similar conditions prevail in opium-poisoning and re- quire similar presistance in the execution of artificial respi- ration. Opium and its alkaloids depress the sensibility of the various nerve-centers, pre-eminently the centre of res- piration (Filehne*). In this connection we must consider the profound reductions of sensibility which permit the ac- cumulation of such great quantities of carbonic acid, even in the arterial blood, that the carbonic acid associated with the action of opium can exercise its paralyzing influence upon the tissues and again upon the functions of the centre of respiration and its neighboring nerve-centers. The neces- sity and efficacy of artificial respiration in opium-poisoning are thus rendered self-evident. It should be continued un- til the organism has eliminated a sufficiency of the poison. In desperate cases, transfusion should be tried. Poisonings by opium occur not only from swallowing, etc., of large quantities, but also from painting the laryngeal entrance with tincture of opium to reduce its sensibility. The lat- ter region seems particularly prone to produce rapid ab- sorption of the poison. You see here a rabbit, with which we will demonstrate the points just discussed. It is lightly bound, and its carotid is attached to a mercurial manometer. We will administer chloroform with a proper inhaler. At the inception of nar- cosis and the incidental excitement, the normal blood- * Filehne, Ueber d. Einvverkung des Morph. aiif d. Athmung. Arch, f. experius. Pathologic u. Pharmakol. 1879. Bd. X and XI. 80 SURGICAL EMERGENCIES. pressure and respiration are transitorily increased, but soon again become normal. The blood-pressure alone soon shows a gradual sinking, while respiration, though it be- comes somewhat superficial, remains equable and quiet. After the animal has become motionless, and corneal reflex action can no more be elicited, the pressure sinks lower and lower in the direction of the lowest point. The pulse- waves become smaller and about one half less frequent; respiration becomes deeper and very frequent. Finally the pulse is hardly perceptible, and the respiration, despite its frequency, appears flatter and flatter. When the blood- pressure amounts to but about 10 mm. mercury, the curve shows neither pulse nor respiration. If this condition were continued, the individual would be irretrievably lost. But we elevate the animal's legs and depress its head, and while an assistant exerts pressure upon the legs and body (periphero-centrally), we open the trachea as rapidly as possible and induce artificial respiration. Gradually eleva- tion of the blood-pressure occurs; pulsation becomes visi- ble again, and occasionally single, spontaneous inspiration occurs. We continue auto-transfusion and artificial respira- tion energetically; the number of pulsations and respira- tions becomes greater, each respiratory and heart-move- ment stronger; blood-pressure rises still more, sensibility returns to the cornea — the animal is saved. I have not succeeded in demonstrating an alteration of the blood-mixture during depression in the blood-tension in a narcotized animal, though I have made experiments to elicit an increase or decrease in the number of the red blood-discs, during narcosis. (Compare Von Lesser, Die Vertheilung der rothen Blutscheiben, etc.) In like manner it could be shown you that the heart's action and respiration, which were arrested by opium- poisoning, can be re-established by persistent execution of artificial respiration, and the individual called back to life thereby. I beg you to impress this advice prominently in your minds, and that you will not lose time when treating poisonings with the alkaloids of opium, by the administra- tion of atropine or electrical irritation of the phrenic nerve, but that you will tracheotomize and induce artificial respi- ration as soon as possible. At the same time the above- named adjuvants may be applied as well. When large quantities of the poison have been taken, and even long- continued artificial respiration appears useless, you must, SURGICAL EMERGENCIES. 8l as has been mentioned, remove goodly quantities of the poisoned blood, and substitute it with approximately equal large quantities of the normal blood of another individual. In tetanus as well, artificial respiration, especially in acute cases, appears the only means which can be expected to maintain life. The sub-acute forms recover, as we know, either spontaneously or as the result of the application of various, mostly narcotic, remedies. This gives us a large number of remedies, and the numerous descriptions of re- coveries under them — chloroform, chloral, opium, calabar, curare, etc. In acute tetanus all of these remedies are useless. Even nerve-stretching in acute cases has thus far yielded but doubtful results. To thoroughly establish the indications for tracheotomy we must elicit in detail what the consequences of impeded respiration would be. To this end we will recall the inci- dent of rapid suffocation, as well as those in which there is gradually increased difficult respiration. Our atmosphere is composed of a mixture of twenty-one parts of oxygen and seventy-nine parts of nitrogen, with more or less contaminating gaseous admixture. It fur- nishes to our organisms — e.g., principally the blood — its oxygen, and returns to the atmosphere the final result of the metamorphoses — carbonic acid. The exchange of atmo- spheric air and that of the lungs is brought about by the respiratory movements. The renewed air in the bronchi, which, when within the pulmonary alveoli, is brought into close contact with the blood flowing through the pulmonary arteries, .exchanges gaseous constituents by diffusion. The quantity of oxygen in serum and in plasma is but slight, perhaps reaching two or three per cent in volume. Serum which has simply absorbed oxygen can take up only as much as water can. Almost the entire oxygen of the blood appears combined with the haemoglobin of the red blood-discs as oxyhemoglobin. Its percentage is fifteen to eighteen in arterial blood, and ten to five in venous blood. This combination is independent of the pressure of the oxygen in the atmosphere, and it is so constant that whether respiration takes place in oxygen or in atmospheric air the arterial blood can take up no more oxygen. The quantity consumed in twenty-four hours is invariable. The organism is thus capacitated to entirely consume the oxygen within the space in which breathing is performed. If, however, the amount of oxygen in the air respired is decreased, the 82 SURGICAL EMERGENCIES. blood does not take up in each unity sufficient oxygen to satisfy the coincident need of the organism for oxygen. When eleven per cent in volume of the atmospheric air consists of oxygen, breathing becomes difficult. When the percentage in volume sinks below six, the limit of possi- bility of life therein may be reached, especially if respira- tion be performed in a closed space where the partial pressure of oxygen rapidly falls to 45 mm. mercury. If the supply of air be suddenly interrupted, the oxygen of the air in the lungs will be almost entirely consumed. Likewise, the amount of oxygen in the venous blood can sink to nothing. The proportions of carbonic acid in the blood are de- pendent upon the proportions of the carbonic acid in the atmosphere, subject also to influences of the temperature. Thus we ordinarily find in the lymph and serum perhaps as much carbonic acid as water would take up (100 per cent at a low temperature, and seven per cent at high bodily temperature). The blood can take up altogether 150 to 180 per cent in volume of carbonic acid at a medium temperature and barometric pressure, because of the salts — phosphates, car- bonates — which it contains, loosely combined with a part of the carbonic acid and bi-carbonate of soda. Finally, a third part of the fixed carbonic acid can leave the living blood through the action of oxyhaemoglobin. The essentials to an accumulation of carbonic acid in the blood lie in its saline constituents and defective arterializa- tion, when such occurs. In an atmosphere where there is a paucity of carbonic acid the blood contains only such acid as it has absorbed in diffusion. The tension of C0 2 in the blood amounts to between 30-90 mm. Hg ; that in the atmosphere varies be- tween 25 and 60 mm. Hg ; thus the slighter and varying difference must be compensated by the other forces which derive carbonic acid from the serum if a sufficiently con- tinued decarbonization of the blood is to take place. The amount of C0 2 in arterial blood is between 26 and 30 per cent, in volume, while the venous blood contains about 4 per cent. more. Upon suddenly closing off the respiratory passages the amount of C0 2 in the blood rises to about 53 per cent in volume, but not higher. The indi- vidual dies for lack of oxygen before the carbonic acid can exert its toxic influences upon the organism. SURGICAL EMERGENCIES. 83 The conditions are different when only the elimination of carbonic acid from the blood is impeded. We will call this impediment " slow suffocation," which consists either in an accumulation of carbonic acid in the surrounding atmo- sphere, as, for instance, upon enclosing an individual in an hermetically sealed space; or the carbonic acid may escape from the lungs in but insufficient quantities. Hereto con- tribute gradual contractions of the larger air-passages, as, for instance, in croup and diphtheria, or it is owing to inac- tivity of the respiratory muscles, as we find it in poisoning by opium or chloroform. In slow suffocation the paralytic action of carbonic acid is evident, because, despite the insufficient removal of car- bonic acid, there yet reaches the blood sufficient quantities of oxygen. Death from slow suffocation is a paralysis in conse- qiience of the continually increasing carbonic- acid poisoning of the nerve-centres. When the accumulation of carbonic acid is gradual, and the atmospheric air contains sufficient oxygen, the stage of excitement and convulsions may not occur and death may take place, accompanied by paralytic manifestations during apparent subjective health of the patient. We should im- press our minds with a very distinct picture of this condi- tion, so as to be prepared for the frequent and apparently unexpected deaths in diphtheria. Then we can save many a young life by a properly timed tracheotomy, and will not need to accuse ourselves of having taken operative meas- ures " too late" because of our defective knowledge of the symptoms of gradual carbonic-acid poisoning. At the beginning of narrowing of the larger air-passages those nerve-centres which are still intact rebel against the limitation of the supply of oxygen through symptoms of moderate dyspnoea with a general restlessness. The little patients suffer insomnia, throw themselves about and alter- nate the horizontal position with the erect. The deepened respiration is accompanied by motions of the alae nasi and perhaps also with contraction of the scrobiculus cordis and of the jugulum (fossa suprasternalis). But as the air-tube contracts still more, the picture changes. The nerve- centers, influenced as they have been, by the action of CO a have accommodated themselves to the diminished supply of oxygen. The child becomes quiet, it does not change its posture so frequently, notwithstanding the increased dyspnoea and despite the augmented contractions of the 84 SURGICAL EMERGENCIES. thorax. Somnolence and apathy to surroundings occur, the temperature which at the beginning of the process was markedly increased, now shows a considerable reduction below the normal. And thus death occurs imperceptibly, while breathing becomes flatter and reduced in frequeucy and the pulse finally is but filiform. If tracheotomy be performed in this stage the operator must be prepared to experience a failure, because of the advanced paralysis of the nerve-centers by carbonic acid. Thus the operation should not be deferred beyond the stage of excitement unless in exceptional cases. It is unnecessary to detail the symptoms of sudden suffocation. We have mentioned that sudden lack of oxy- gen is the cause of death. The nerve-centers in these instances are robbed more rapidly of their vitality after they have suffered severe excitement. Thus death occurs with violent muscular twitchings, as is well known in cases of hanging. As a lack of oxygen kills nervous apparatus more quickly than the gradual action of carbonic acid, we must immedi- ately seek an artificial supply of air in cases of sudden suffocation. It is hardly necessary to discuss the urgency of doing this in hanged people. Cutting the rope will not suffice when an injury has occurred to the tracheal cartil- age ; the trachea .must be opened quickly. The same applies to foreign bodies in the trachea. The manner of treating them has been discussed in detail. The symptoms of acute and slow suffocation are easily demon- strated by experiments. The signs of a sudden lack of oxygen, the violent disquiet and labored respiratory move- ments, then the voluntary twitchings of the extremities which finally become a general convulsion of the voluntary muscles, are observed in suddenly closing the trachea or in plugging the tube which has been inserted into the trachea. The general muscular convulsion is followed by an equally rapid general relaxation; the cornea is deprived of all sensation; and after death we note but isolated fibrillary twitchings of the muscles and increased peristaltic motion of the intestines, as evidences that there still survives in Compare C. Friedlander and E. Herter, Ueber die Wirkung de Rohlensaure auf d. thier organismus. Zeitschr. f. physiol. Chemie. Bd. II. pp. 99 to 148. And Ibid. Ueber d. Wirkung d. Sauerstoffmangels, etc. Zeithschr. f. physiol. Chemie. Bd. III. pp. 19 to 51. SURGICAL EMERGENCIES. 85 the organs an accumulation of venous blood which is over- charged with carbonic acid. If we wish to observe the consequences of slow suffoca- tion, we have a simple means thereto at hand, viz., attach- ing an open rubber tube to the one which has been inserted into the trachea. In proportion to the length which we give the tube; that is, in proportion of its contents to the volume of the expiratory air, the different degrees of suffocation can be produced. If the space in the tube is as large or larger than the volume of the expiratory air the latter will be breathed over and over again. The entire volume of air remains within the tube and at each respira- tory act, simply moves to and fro. As is evident, the individual must soon be suffocated. If we choose a smaller tube, we can allow a part of the respiratory air to escape and to be replaced by atmospheric air. Thus, according to the length of the tube, various mixtures of expiratory and outer air occur and these serve for respiratory purposes. However, these mixtures become poorer and poorer in oxygen and richer in carbonic acid than our common respiratory air. As long as the blood can secure sufficient quantities of oxygen from these mixtures, neither convul- sions nor disquiet appear. But the excess of carbonic acid in these mixtures causes an accumulation of carbonic acid in the organism which finally may become so great that the individual dies under the paralytic influences of car- bonic acid, during which respiration and pulsation are gradually extinguished. This simple experiment, which can be variously modified, indicates to us why permanency in mines and in tunnels appears incompatible with respiration, provided no pumps are employed to supply air to ventilate the surroundings of the living beings, and which would render impossible what we may call endogenous carbonic acid poisoning. Similar considerations apply to divers whose breathing-mask is connected by means of a tube with the surface of the water. But so as to supply these divers with sufficient oxygen, special pumping apparatus must be employed, to furnish air under a pressure which will counterbalance the pressure which the water exercises upon the body-surface of the diver (Paul Bert*). Furthermore, aeronauts and persons who ascend high * Paul Bert, La pression barometrique. Paris 1878. p. 410. 86 SURGICAL EMERGENCIES. mountains suffer more or less grave symptoms, such as vomiting, vertigo, severe pressing headache, bleeding and syncope, (Bergkrankheit), which depend upon a lack of oxygen in the red blood-discs owing to a reduced partial pressure of the oxygen in the atmosphere of the higher strata. Jourdanet* calls this condition anoxyhemie and considers it an analogue to anaemia, resultant upon direct loss of blood-discs. Other accidents, such as we will mention, require a different explanation. We refer to the workers in caissons (within streams, etc.), which are used in the construction of bridges. To allow such laborers to work in the bed of the stream, the atmosphere within the caisson must be sufficiently compressed to counterbalance the weight of the column of water from the surface to the ground. The absorption of carbonic acid into the blood is hardly in- creased thereby, and the amount of carbonic acid in the blood is not at all influenced. A change occurs in the quantity of nitrogen which is taken up and which is not reabsorbable.f Its quantity is increased by the high compression of the air some four or five times. If the laborers leave the caissons suddenly, without subjecting themselves to a gradual decompression of the air in the caisson down to that of the free atmosphere a large quantity of bubbles of not re-absorbable nitrogen are freed in the blood and drag with them a part of carbonic acid in gas- eous form. The same applies when the diver removes his breathing-mask rapidly. The multiple gas emboli pro- duce permanent functional disturbances of various organs, principally paralyses, by rapid death of those nerve-centers which are particularly susceptible to the consequences of a rapid deprivation of blood. In acute cases, death occurs by an accumulation of gas in the right heart and within the cerebral vessels, just as would happen if air were suddenly injected into the veins. In both these organs we find large quantities of bloody froth (compare Panum J), besides which the heart presents large quantities of a mix- ture of nitrogen with some carbonic acid (P. Bert, /. c). * Jourdanet, L'influence de la pression. de l'air sur la vie de l'homme, etc. Paris, 2nd. ed. 1876. f Bert, /. c, p. 964. X Panum, Experimentelle Beitr. z. Lehre v. d. Embolie, Virchow's Archiv. Bd. 25. SURGICAL EMERGENCIES. 8? Hoppe-Seyler * mentions the phenomena consequent upon liberation of nitrogen in the blood in rapid decom- pression, as Bert proved them. Paul Bert (/. c, p. 980 and p. 1 148) assumes that the elimination of the bubbles of nitrogen from the pulmonary circulation is impeded be- cause the air in the lungs contains a very free admixture of nitrogen and therefore he recommends in cases of too rapid decompression in divers and workers in caissons the inhalation of pure and preferably compressed oxygen. He at- tained good results in removing the bubbles of nitrogen from the pulmonary circulation and partly from the heart of the animals on which he experimented. For the pur- pose of returning those bubbles of nitrogen from the capillaries and the quantities of nitrogen from the connec- tive tissue into the blood, renewed compression of the air {recompression) followed by a slow decompression, will be found the only useful means. The same procedure is recom- mended by Bert, in entrance of air into the veins (compare Couty, /. c, in Sixth Lecture). An interesting and important application of compressed air has been made by Paul Bert f in the narcosis of nitrous oxide (laughing-gas). P. Bert found that the simple administration of laughing-gas produces a very ex- citing and even dangerous narcosis, owing to the reduced amount of oxygen which is taken up; therefore he pro- posed the production of nitrous oxide narcosis with co- incident application of compressed air, so as to supply the the blood with sufficient quantities of oxygen while the anaesthetic gas was being applied. These narcoses, which, it is to be regretted, can be produced only in large estab- lishments which possess expensive apparatus for the com- pression of air, are said to be eminently satisfactory in the course of anaesthesia, as well as in the rapidity of restoring consciousness and the absence of all after-effects (vomiting, headache). Even more extensive surgical operations have been essayed under Paul Bert's ingenious procedure (Pean,J Labbe, Deroubaix §). * Hoppe-Seyler, Ueber d. Einfluss, Weichen d.Wechsel d. Laftdrukes a. d. Blut ansiibt. Miiller's Archiv. 1857, p. 63 to 73. f Paul Bert, Sur la possibility d'obtenir, a 1'aide du protoxyde d'azote, une insensibilite de longue duree, etc. Comptes rendus, T. 87, No. 20. % Lutand, l'Anaesthesie par le protoxyde d'azote sans tension. Gaz. Hebdom, 1879, No. 14. § Deroubaix, l'art medical de Bruzelles, 1880. Mai. Compare also Raphael Blancbard, De l'anaesthesie par le protox. d'azote, etc. Paris. 1880 (aux bureaux du progres medical). 88 SURGICAL EMERGENCIES. Previous to considering the operations for opening the trachea let us say a few words about the artificial insufflation of air after tracheotomy and the changes which are brought about by it in the circulation. A reversal of the propor- tions of pressure in the thorax occurs and consequently a similar effect is produced on the circulation. In contra- distinction to natural inspiration, artificial insufflation of air produces a positive pressure in the thorax with venous engorgement. After expiration following artificial insuffla- tion a negative pressure with aspiration of the blood occurs in the chest because the absence of activity of the respira- tory muscles, allow the elasticity of the lung-tissues to ex- ceed that of the thoracic walls. At all events the condition of the heart and the lungs will have to be observed in re- ference to the frequency of insufflation of air, the quantity of air to be insufflated each time and the power to be em- ployed. But few operations of those which are performed to enter the air-tube from without, are suitable for immediate or permanent supply of air. Opening the pharynx by an incision at the lower margin of, and parallel to the hyoid bone and between it and the thyroid cartilage (Malgaigne's Laryngotomia Subhyoidea or von Langenbeck's Pharyngotomy) is not proper for air supply. Only Vidal recommended it formerly, as a means of catheterizing the larynx through the opened laryngeal entrance (tubage du larynx?) It is remarkable that this method was recommended by Hippocrates, to be performed per os in danger of suffocation. It cannot be indorsed owing to the lack of safety in its execution and because it takes no consideration of the locality of the impediment. Least of all is it permissible to probe foreign bodies through the laryngeal opening, when they are within the larynx or trachea. Desault's thyroid laryngotomy is equally improper for our purposes and is useful only for the removal of tumors from the laryngeal space. It is performed by splitting the larynx through its commissure between the thyroid plates. If the tube were to be inserted between the thyroid plates, necrosis of these plates might easily follow as might ulcera- tion of the vocal cords. The same applies to thyro-cricoid laryngotomy (Vicq d'Azy), or diagonal incision of the conoid ligament, as it would be of no avail for permanently wearing a tube, as SURGICAL EMERGENCIES. 89 the resultant opening is too small. The operation could be recommended only in sudden asphyxia owing to the superficial position of the conoid ligament and the facility of locating it. Inasmuch as the anastomosis of the thyro- cricoid artery lies upon the ligament, it may be required to ligate the artery doubly and cut it through its middle, before incising the ligament itself. The dimensions of the opening made in the conoid ligament can be increased only by splitting the cricoid cartilage, but the wound will, at best, serve only to suck water out of the lungs through a catheter (as in drownings) or to force foreign bodies which have fallen into the larynx back into the pha- rynx. The methods which are employed for slitting the trachea above or below the thyroid gland are of particular interest. They are supra and infra-thyroid tracheotomies, or, better, supra and infra-glandular tracheotomies. Supra-glandular tracheotomy yields too small an open- ing in children to permit the introduction of a tube. There- fore the orifice in the trachea is enlarged by splitting the cricoid cartilage. Then the tube can be easily inserted. The execution of this operation is as follows : The nail of the left thumb marks the upper margin of the thyroid cartilage, whence the skin is incised in the median line of the neck some three cm. downwards, laying it open as far as the sub-cutaneous connective tissue and exposing the uniting line of the straight cervical muscles. This line must be carefully sought and separated by two pairs of forfceps, or if venous vessels transcourse the median line (V. colli media) it should be drawn apart with dull hooks. If the indication given by this linea alba be not followed an incision might easily be made in the straight cervical muscles of either side which would produce a much stronger haemorrhage. If we have penetrated the middle line the trachea will be exposed, but more or less covered by the thyroid gland, especially when the isthmus still exists, and then it may cover the trachea entirely (Lissard *). Formerly it was considered necessary to dissect the thyroid gland off, to reach the trachea. This was frequently accompanied by considerable loss of blood and contributed to prolong the operation and increase its difficulties. It has even been proposed to cut through the isthmus after doubly ligating * Lissard, Anleitung zur Tracheotomie bei Croup. Greesen, 1861, 90 SURGICAL EMERGENCIES. it to thus expose the trachea (Roser). Bose* merits decided approbation for his retro-glandular method of exposing the trachea, in which the thyroid gland is not dissected from the trachea after splitting its capsule, but it is levered or rtther torn in tact from the anterior tracheal wall. For ais, purpose, after the straight cervical muscles have been pulled apart and the trachea (covered by the thyroid gland) is exposed, a diagonal incision is made through the anterior aspect of the cricoid cartilage at that place where the two layers of the deep cervical fascia are re-united and attached after having separated to form the capsule of the thyroid gland. While the lower margin of the slit thus made is drawn upwards with a pair of forceps, a dull lever (eleva- tor or handle of scalpel) is inserted between the larynx and the posterior wall of the thyroid capsule to tear off the latter sufficiently. Then a strong hook is inserted into the cricoid cartilage and drawn strongly against the chin, out of the wound. The thyroid gland which has thus been torn off with its capsule, is drawn down toward the sternum with a broad dull hook or if necessary a spatula in the hands of a second assistant. While the first assistant's right hand draws the hook which is inserted into the cricoid cartilage upwards, we place a large, sharp strabismus hook in his right hand and grasp a similar one in our left hand. Now the sharp knife in our right hand which is held closely above the protecting plate upon the thyroid cartilage, is inserted into the trachea which it opens by short, sawing motions as far as the cricoid cartilage. Then the surgeon and as- sistant insert the two sharp hooks into the tracheal wound and the surgeon, in case the trachea is not sufficiently opened to introduce the tube, cuts the cricoid cartilage from below upwards in such a manner as to liberate the thick hook which has been inserted into it. The incision of the cricoid cartilage converts the supra-glandular tra- cheotomy into Boyer's so-called laryngo-tracheotomy, which is also designated crico-tracheotomy (Hueter). The incision of the conoid ligament, as was made by Boyer is unnecessary. In children crico-tracheotomy should be performed in recognition of the principle that the tubes should be as wide as possible. The opening thus made is so large that it is * Bose, Zur Technik d. Tracheotomie. v. Langenbeck's Archiv. f. Klin. Chir. Bd. XIV. pp. 137 to 147. SURGICAL EMERGENCIES. QI not only adequate for convenient supply of air but also is useful for the extraction of foreign bodies which have fallen deeply into the trachea, provided there is no swelling of the thyroid gland. Diagonal incisions at the upper and lower margin of the tracheal cut, allowing two fateral trac- heal quadrangular flaps to be opened outwards, as recom- mended by Dieffenbach would be in place only exception- ally when an abnormally large opening into the trachea is required. In infra-glandular tracheotomy the trachea is opened from about its seventh cartilage downwards to the upper margin of the sternum. Some recommend it especially in croup (Wilms*). We prefer crico-tracheotomy in children and people with short necks. Infra-glandular opening of the trachea will be urgently required, where there is a contraction of the trachea in the region of the thyroid gland, in enlargement of the gland or where foreign bodies which have fallen down to the bronchial bifurcation, are to be extracted. Above the sternum the trachea is covered only by in- tegument and several layers of the cervical fascia. The straight cervical muscles here, are well separated, especially in enlargement of the cervical glands. But between the skin and fascia as also between the various layers of the fascia and the trachea is found connective tissue often full of fat and still oftener traversed by an extensive venous net. The veins may be tensely filled with blood when there is strong dyspnoea. Therefore after the incision through the skin from the sternal notch is conducted four or five cm. upwards in the middle line of the neck the connective tissue is carefully split, layer by layer, as it is elevated from the wound with two forceps. When an extensive venous net is found dull hooks should be used to crowd the veins apart, and the knife should be employed as little as possible. Furthermore, embedded between the layers of fascia above the sternum a lymph-gland is found, and in it a side-branch of the thoracic duct terminates. The gland is often en- larged. At the lower margin of the thyroid gland the thymus gland is found more or less developed in chil- dren. In adults with goitre, enlarged flaps thereof may hang down behind the sternum (substernalis). Occasi- onally an arterial branch (arteria thyroidea imaj arising * See several Jahres veriche d. krankenhauses Bethanier zur Berlin in v. Langenbeck's Archiv. f. Klin. Chir. 92 SURGICAL EMERGENCIES. from the innominate, courses upwards, along the trachea, to the thyroid gland. This arterial branch must not be in- jured. The tearing of the layers of the connective tissue which cover the trachea produces emphysema of the me- diastinal connective tissue, and when the operation can- not be performed with antiseptic precautions, it may lead to formation of pus in the mediastinum, especially in cases of croup or diphtheria of the trachea. After exposing the trachea it is to be opened in the median line from the sternum upwards, while the lower mar- gin of the thyroid gland is covered by a dull broad hook and drawn up to the chin. During this incision injury to the arteria thyroidea ima must be avoided. As to further procedures upon opening the treachea at any place, the tracheal wound must be held open with sharp hooks until respiration has again become entirely free. This applies to drowning and croup, or until foreign bodies have been removed through the tracheal opening by long curved forceps or by efforts at coughing. Frequently foreign bodies fall out of the trachea when the patient is suspended by the heels. When sufficient assistants are not obtainable the tracheal wound must be separated by spring instruments resembling palpebral specula (Bose) or with forceps which act similarly (Trousseau). In accumulations of fluids in the lungs (blood after haemorrhages, pus after evacuated retro-pharyngeal abscesses, water in drowning, liquor amnii in premature respiration of the new-born) efforts must be made to remove them by means of deeply inserted catheters as before mentioned. In croup the mem- branes must rather be removed by forceps than by suction, because of the irritation and coughing which it would pro- duce by touching the swollen posterior tracheal wall and bronchial bifurcation. In diphtheria suction is useless and reprehensible in the interests of the operator. It is to be regretted that it still figures in many texts and is accom- panied by phraseological praises, as a life-saving means. This hare-brained foolhardiness has cost many an operator his life, without saving that of the patient. When there is no more dyspnoea the tube is inserted. This consists of a double tube bent in a segment of a circle having a movable plate at one end to rest on the skin of the neck. The inner end of the apparatus which is to lie within the trachea has both of its tubes cut off diagonally at a level, or the inner one may project about i c.m. from the outer SURGICAL EMERGENCIES. 93 one, and be rounded off like the point of a catheter with a very large eye. The surgeon should be provided with two or three tubes of diameters, varying from 4 to 6 m.m., so as to be prepared for adults as well as children. The tubes are attached to the neck by broace,or, in case of necessity, to limit ourselves to the space bounded by the fourth and sixth ribs. This corresponds to the cer- tainly rational advice given by Bardeleben f to fix the boun- dary line between the abdomen and thorax and then to ope- rate 5 cm. above that line on the left side and 7 cm. on the right. The establishment of the boundaries between the abdo- men and thorax in the different positions of the body, the physical examination of the lungs and the circulatory appa- ratus, and above all the course of the febrile curve, are the principal points which you will need for the appreciation of each case, in forming a correct opinion of the quantity, consistency, and growth of pleural exudations. You must never omit methodical attention to each one of these ele- ments, so that your operative procedures may not be unsafe or perilous to the patient. Thus, for instance, the simple recognition of the boundaries between the abdomen and thorax gives you no key whatever as to the quantity of the exudation, because though the fluid exerts an equal pressure in all directions, the different thoracic walls are differently elastic and consequently are expanded in different degrees with corresponding displacement of the neighboring or- gans. As we pass to a special consideration of the modes of ope- ration we must mention that puncture (paracentesis thora- cis) was always made under efforts to exclude the air; thus * Billroth in Pitha— Billroth's Handbuch d. Chiv. Bd. III. 2. Abth. 152 et sequitur. _t Bardeleben, Lehrbuch, etc. Bd. III. p. 633. SURGICAL EMERGENCIES. 1 39 Henricus Bassius (see Sprengel's Geschichte der Chirur- gie) recommended drawing the skin so that after the ope- ration it might act as a valve, permitting the outflow but impeding the entrance of air. Trousseau (/. c), who wished to operate according to Boyer's counsel, between the sev- enth and eighth right ribs, made his diagonal incision at the lower margin of the eighth rib, and drew the wound to the upper margin of the same rib, where he inserted the trocar. The trocar must always be inserted at the upper margin of the ribs because intercostal vessels course at their lower margins or at the upper boundary of each intercostal space. In injuries to an intercostal artery compresses have been recommended which were intended to press the wounded arterial tube against the rib. A much simpler and really effi- cacious means is to envelop the rib and vessel with a cor- respondingly thick antiseptic thread on both sides of the ar- terial wound by means of which the artery is pressed to the rib. This procedure is also the most reliable means in hem- orrhage from injured intercostal veins, which may become very copious by the pumping action of the motions of the ribs (Venous pumping, Ludwig Dybkowsky, /. c). Puncture is made by the trocar, which consists of a canula provided with a sharp-pointed polygonal stylet. For the purpose of impeding the possibility of the entrance of air into the pleural cavity during respiratory movements, many means and manipulations were devised, which were quite important previous to the antiseptic period (use of the spray). First a cock was provided for the canula. A simpler pro- cedure was suggested, namely, that of placing the finger upon the opening of the canula at each forced inspiration. Schuh had a small trough made, into one of the corners of which, at its base, the canula was inserted, thus keeping it ever beneath the upper level of the evacuated fluid. The same principle guided Biermer's proposition to insert the opening of the canula into a bottle over the margin of which the pleural fluid was to flow. Thompson's and Frantzel's (/. c.) T-shaped trocar was constructed on a similar princi- ple. While the stylet can be inserted and withdrawn her- metically in the long arm of the trocar the fluid, only after the stylet is pushed back, can flow from the forward part of the long arm, through the short arm, into a vessel, standing on the floor, to which it is conducted by a long rubber tube, which is fastened to the short arm. The above-mentioned 140 SURGICAL EMERGENCIES. vessel is filled by a certain (antiseptic) fluid and the free end of the gum tube is continually maintained beneath the upper level of this fluid. We have yet to mention Reybard's well-known proposition, which is not to cover the canula with the point of the finger but to stop it by means of a fish blad- der or a condom which had been previously drawn over it, so that a part of the bladder lies curtain-like over the open- ing of the canula, acting like a flap when it is attracted by reduction of pressure within the thorax. As has been said, the danger of entrance of air into the pleural cavities through punctures has lost its terrors since the operation is made with carefully disinfected instruments and under the protection of the carbolic spray. The result- ant simplicity of the procedure causes us to give it decided preference over aspiration even with such perfected appa- ratus as were constructed especially by Dieulafoy (/. c.) After executing the puncture we must disinfect the skin for a considerable extent around the opening, and cover it with an antiseptic compress which contains antiseptic sponges, for the purpose of receiving the secretions, which ofttimes ooze from the wound in considerable quantities. After successfully puncturing sero-fibrinous exudations without re-accumulation of the fluid, particular attention must be directed to re-establish normal extension of the lungs, which is brought about by good feeding and vigorous exercise of the respiratory movements (gymnastics and mounting hills). We evacuate purulent exudations according to the laws which govern the opening of abscesses, and afterwards treat them in the same manner. Antisepsis is important, as also is complete and permanent evacuation of the pus and of the liquids used for washing, all of which is accomplished by adequate drainage. The latter requirements are rather difficult of execution for two reasons : first, as we have seen, because the most pendant point of the pus cavity can be established only with difficulty. On the other hand, because the thoracic fistula contracts with great facility by approximation of the ribs, which depends upon contraction of the walls of the inter-thoracic pus cavity. Hippocrates recognized this unfavorable occurrence in the free evacuation of pus. Therefore he recommended the insertion of flax pledgets into the wound of thorac- otomy. Reybard preferred Pare's direct trepanation of a rib, to thus obtain a tense, non-contractile, thoracic fistula. SURGICAL EMERGENCIES. I4I We will consider three procedures, which merit discus- sion for their efficacy in evacuation of inter-thoracic accu- mulations of pus: first, the insertion of a sufficiently long and amply wide drainage-tube into the pleura; secondly, the production of appropriate counter-openings for the purpose of washing the cavity; and thirdly, partial sub- periosteal resection of pieces of one or more ribs, whereby free evacuation is attained in a most admirable manner, and thus also a rapid contraction of the inter-thoracic ab- scess-cavity. The execution of partial resection of ribs is very simple. After splitting the soft parts and the periosteum on the rib, the latter is lifted off around the rib with an elevator, then the elevator is pushed between the rib and the pleural wall, for the protection of the latter, and the rib is cut through with a bone forceps or sawed with a straight saw. Then the piece of rib which has been sawn through is lifted vigor- ously out of its periosteal covering, and as much of its length cut off with the bone forceps as may be desired. Subperiosteal excision permits avoidance of injury to the intercostal vessels. These are then ligated en masse, with the emptied periosteum of the excised piece of bone and cut through between the two ligatures with the inter- costal muscles. Thus as large a wound as may be desired is secured in the thoracic wall without any haemorrhage whatever. During execution of resection of the ribs we may wash out the pleural cavity with antiseptics. Pirogoff recom- mended a one to two-per-cent aqueous solution of tincture of iodine for this purpose. Diluted carbolic acid (10 to 20 per 1000) has been successfully employed; but in chil- dren, or where carbolic poisoning supervenes, it may be substituted by salicylic acid (1 to 500) or solutions of thymol (1 to 1000) or solutions of hypermanganate of potash (1 to 500) or even by one-half-per-cent solutions of common salt (Frantzel, /. c, p. 149). Great importance must be attached not only to expulsion of the pleural contents, but also to most rapid and complete evacuation of the liquid used for washing immediately thereafter; this applies especially to carbolic solutions. The after-treatment subsequent to the establishment of a thoracic fistula must be directed especially to good nutrition. The evacuation of the masses of pus which have accumulated under high pressure in the pleural cavity, as well as care 142 SURGICAL EMERGENCIES. directed to the prevention of a re-accumulation or reten- tion of pus, will contribute most rapidly to an elevation of the patient's strength, as then the absorption of septic py- rogenous matters will be reduced to a minimum. The fever will fall, and with its fall there will be a relief of disturbed nutrition and assimilation which were maintained coinci- dent with increased destruction of albumen. To completely cure the inter-thoracic cavity, rest and residence in a mild climate will be required, besides the appliances for the evacuation of pus, which have been discussed. The more favorable the auspices under which all of these conditions are united, the sooner the thoracic fistula can be cured, which, it is true, often taxes the patience of the sufferer, as well as that of the physician. It occurs, in case purulent pleuritis was not developed in a tuberculous constitution, or in case secon- dary tubercles were not developed. In some cases we will be justified in stimulating the cicatrization of the cavity by scarification, when the contraction of the inter-thoracic space arrives at a standstill. When the thoracic fistula is cured, and the contraction of the granulations draw the lung,which had been collapsed, again to the thoracic wall, and the lung-tissue has again become elastic (Billroth, /. c, p. 156), respiratory exercises may be employed to re-extend the lung. Accumulations of fluids and air in the pericardium will re- quire operative procedures much more rarely, although when they exercise great tension they may materially dis- turb the action of the heart. This applies especially to haemorrhages into the pericardium, as in spontaneous rup- tures of the heart or more frequently in traumatisms of the heart, as in injuries by stabs or gun-shot. Dropsical effu- sions into the heart-sac occur in affections of the kidneys, but mostly with accumulations of fluid in the pleurae. If the effusion is rapid, or if re-absorption of a chronic in- flammatory exudation is made impossible, by changes in the serous membrane, the increased pressure on the con- tents of the pericardium may produce disturbances of the circulation and, secondarily, of respiration as well. Anxiety and oppression, dull pressure and a sensation of weight in the cardiac region, are the symptoms which are aggravated by motion, as well as the dorsal decubitis. The heart's action is irregular, arythmic, sometimes small and faint, at other times tumultuous and violent. Extensive filling of the heart-sac is said to produce a bulging from the third SURGICAL EMERGENCIES. 143 to the fifth rib; occasionally, also, a kind of fluctuation is felt. Evacuation of pericardial effusions is permissible only when physical diagnosis establishes the effusion and its ex- tent. Dieffenbach (Oper. Chirurgie, Bd. II. p. 397) advo- cates Karawjew's procedure for large effusions, viz., the insertion of a trocar between the fifth and sixth ribs at a point distant three fingers'-breadth left of the left margin of the sternum through the intercostal space into the peri- cardium. Roger* bespeaks favor for the application of small capillary trocars, and unites Dieulafoy's aspiration with puncture. Roger prefers the fifth intercostal space as the site of election, and makes the puncture in the para- sternal line or beyond it, according to the point of the im- pulse of the apex. The trocar, then, should not be sunk perpendicularly upon the heart's surface, but, as much as possible parallel to it; thus backwards and towards the mesian line. Skjelderup'sf method is much more rational, because it facilitates a view of the parts. He recommended trepanning the sternum between the fifth and sixth ribs, at the union of the cartilage of the fifth rib with the sternum, and thus to expose the heart-sack, which then may be opened by the knife or trocar with complete safety. This procedure is only apparently more injurious than direct puncture of the pericardium. Yet this circumstance merits less consideration, since we do not perform any such ope- rations without antiseptic precautions. Isolated cases of the puncture of pericardiac exudations which saved life, temporarily at least, and in which large qnantities of fluids were evacuated, may, perhaps, admit the explanation that the relief was as much owing to the coincident opening of the left pleura and evacuation of fluid therefrom. If the accumulation of fluid in the heart is based upon tuberculosis, or if acute pericarditis is only an accompani- ment to infectious endo-carditis or myocarditas (as in ty- phus, acute articular rheumatism, etc.) or dependent on a traumatic inflammation of the heart-muscle, then puncture will accomplish but little. Purulent exudations in the heart-sac but seldom assume great proportions, and are found as concomitants to and * Roger, Bull, de l'acad. de Wed 1875, Nos. 42 and 43. f Skjelderup, Acta nova societatas med. Hafriensis. T. I. Hafu. 1818, p. 280. 144 SURGICAL EMERGENCIES. dependents upon the general condition when post-mortem examinations are made of those dead of sepsis, puerperal fever, or infectious osteomyelitis. Accumulations of blood are found in contusions of the heart, most especially after direct injuries. In the latter cases pneumopericardium may also result. But accumulations of air in the heart-sac have been found after adhesions of it with the diaphragm and the perforation of a gastric ulcer through the diaphragm into the heart-sac (Rosen- stirn's case*). Not all injuries to the heart are fatal. Perforations of the heart have often healed, and cases are recorded where bullets were found encapsulated in the heart-muscle. Bul- lets may also lie for a long time within a cavity of the heart without producing any disturbances, as can be proven by the introduction of foreign bodies (glass balls, little glass tubes, etc.) into the right heart, through the jugular vein, as is done experimentally. In stabs into the heart, fatal haem- orrhage is prevented, when the penetration has been deep, by closing the wound through muscular action, or through the establishment of a valve-like mechanism. Wounds into the heart have healed by cicatrization where the scar could become adherent to the heart-sac. Small accumu- lations of blood or air in the pericardium are re-absorbed, as we have detailed in considering these occurrences in the pleura. Recent injuries to the heart, especially stabs, may be best closed by suture, while gun-shot wounds to the heart may be closed by antiseptic compresses, besides which, as is self-evident, absolute rest and venesection are required. Digital exploration of the wound is indicated only when the perforating instrument is broken off in the wound, and could not have been extracted by the witnesses to the inju^r or by the wounded person himself. It must be done only when the foreign body can be easily reached. Projectiles must not be sought for in injuries to the heart. Pare's dictum, " Je le pansais; Dieu l'a gueri" holds good to- day, owing to the uncertainty of their diagnosis. Acu- puncture and electro-puncture of the heart, as have been recommended in paralysis of the heart, to stimulate it to action, as all intentional punctures to the heart, are repre- hensible. * Timmers, Pneumopericardium, Academisch. Proefschrift. Leiden 1879. SURGICAL EMERGENCIES. 14$ Electro-puncture is reprehensible because weak currents cannot stimulate the heart-muscle, while strong currents may definitely paralyze it. Acu-puncture, to develop me- chanical heart-beats, is reprehensible because its result is uncertain, and because fatal injuries to the coronary arteries of the heart may result (verbal communication of a post- mortem examination in Breslau by Prof. Weigert). Instead of acu-puncture, mechanical kneadings of the heart through the thoracic walls are recommendable, as we mentioned in auto-transfusion (Bohni*). Frequently the success of the so-called artificial respiration of Marshall Hall are to be attributed to it alone, especially in chloroform asphyxia, in which the increased flow of blood to the heart is furthered by the forced thoracic movements. *Bohm, Centralbl, f. med. Wiss, Hippocrates, Galen, Celsus, and later, Ambroise Pare, have acyiered to this conception to designate disturbances of the brain functions which result from violent forces being exerted upon the skull, as in blows, falls from great heights upon the head, etc., and manifest themselves in material interruption of consciousness or at least an ob- tunding of the sensorium, in general muscular debility and a reduction of sensibility. To these symptoms there are associated, as in compressiontof the brain, vomiting, slow- ing of the pulse, and reduction of respiration ; in severe cases sopor, coma and death result. Or death follows im- mediately after the reception of said traumatisms. Primarily, all of those conditions which are established * Roser, Was bedentet das Fehlen der Hirnbewegung bei blosslieg- ender, Dura Centralbl. f. Chir. 1875. No. 11, p. 161. SURGICAL EMERGENCIES. 1 79 in complicated injuries of the head must be segregated from the picture of the entity designated as concussion of the brain. Nor must severe crushings of the brain, with ex- travasations of blood into the cranial cavity, or into the brain-substance itself, even when damage to the bony cranial shell is not provable, be considered in this connection. We must finally eliminate all of the conditions which pre- vail when great violence has been applied to the skull, and injuries of a life-threatening character have been received in other organs, such as occur in falls from great heights. Carefully made autopsies have frequently revealed such injuries in cases which clinically had been assumed to be concussion of the brain, with rapid fatal issue. This has oc- curred in severe injuries and extravasations of blood in and about the spinal marrow (Deville), in ruptures of the heart (Prescott Hewett), in a tearing into the kidneys (Bergmann, /. c), or in diffuse fatty embolism of the lungs, kidneys, etc. Recently several such cases have been described oc- curring after multiple severe bone-lesions, elucidating enigmatical conditions found after bone-lesions which had a rapid, fatal termination.* Similar results are attainable experimentally by moderate injection of fluid fat, not only directly into the veins and the heart, but also by injecting the fat into peripheral lymph-vessels of an extremity. Only such cases may be added to a pure picture of cere- bral concussion, which upon careful autopsy of the entire cadaver, present no severe lesions in the brain or other organs. Slight brain-crushings are often found in concus- sion of the brain. Though similar and even more extensive brain-lesions are found without the occurrence of symp- toms of concussion during life, the slight lesions cannot be considered the prime cause of the cerebral commotio. Cases of pure cerebral concussion occur without palpable or provable changes in the cerebral substance, though this has been frequently placed in question. The experiments made in this regard have yielded undeniable evidence in support of the assertion. The views which prevailed as to concussion since Littre'sf * For bibliography compare: Flournoy, Contribution a l'etude de l'em- bolie graisseuse. Inaug.-Diss, Strassburg, 1878; Wiener, Wesen und Schicksal der Fettembolie, Habilit-Schrift, Breslau, 1879; an d Scribla, Untersuchungen iiber Fettembolie, Deutsche Zeitschrift f. Chir. Bd. XII., Heft. 1 and 2. f Littre, Histoire de l'Acad. Royale des Sciences, 1705, p. 54. 180 SURGICAL EMERGENCIES. time, as to a quaking or succussion through the brain-mattef, in consequence of the communication of the undulations caused by the traumatism applied to the skull, and trans- ferred to the brain, through it, have been entirely refuted by Gama's experiments, which were considerably modified by the investigations of Nelaton, Alquie* and Fischer.f Beck (/. c.) calls attention to the fact that the most marked disturbances in concussions of the brain point to certain regions of the brain and their affections, thus, especially, the medulla oblongata. He found extravasations of blood in the fourth ventricle in concussion of the brain artificially produced, while WestphalJ wHo made experimental blows on the skull, reports numerous small haemorrhages scattered in the spinal marrow.§ Capillary extravasations of blood scattered over the en- tire brain have been observed clinically. Sometimes they are entirely absent. When the entity of concussion is separated into an affec- tion of individual brain-centres it becomes evident that probably the force applied primarily affects certain centres, for instance, those of the vascular nerves, those of the heart and respiration, and that, above all, the primary disturbance of circulation produces a disturbance of nutrition of the other centres, whether by arterial anaemia, venous hyperae- mia, or of both in succession. Various reasons can be cited for this. Above all, rapid recovery in certain cases of concussion seems to prove that there can hardly be a material change within the brain-mass, but that it can have been affected by only a transitory disturbance of nutrition. Beck (/. c.) found, upon removing the cranial cover in animals in whom clear symptoms of concussion of the brain were manifest, that the brain was. very pale and all of the vessels were strongly contracted. A similar condition was proved by * Alquie. Etude Clinique et Experimental de la Commotion Trauma- tique, etc. Gaz. Med. de Paris, 1865. f Fischer, Ueber die Commotio cerebri, Samml. Klin. Vortrage von R. Volkmann, 1871, No. 27. X Westphal. Bed. Klin. Wochenschr., 1871, p. 461. § See also Duret. Notes sur la Physiologie Pathologiquedes Trauma- tismes Cerebraux. Gaz. Med. de Paris. 1877. Nos. 40, 59 and 61. In forced increase of intracranial pressure Duret found haemorrhages into the walls of the several ventricles, especially the fourth ; into the aqueduct of Syl- vius, etc., which he combines with the disturbances of the various brain functions observed in concussion. SURGICAL EMERGENCIES. l8l iBergmann (/. c, p. 213) in the background of the eye of rabbits with profound cerebral commotion. Furthermore, all of the records of post mortems made in those dead of cerebral concussion show great repletion of the veins of the brain and those of its envelopments. Fischer (/. c.) compared the action of traumatism in a concussion of the brain to the effect of the experiments of Goltz, made by striking a frog. A rapid spasm of the vascular system after primary irritation of the vascular nerve-centers is said to follow their paralysis, with a gene- ral vascular paralysis. The difference between the experi- ments in which a blow was employed and the gradual influ- ence of a great power upon the skull, may be solved by the fact that in traumatism of the head the sudden crowding of the cerebro-spinal fluid and of the whole brain, suffices as a direct mechanical irritation to produce a rapid excite- ment followed by a continned paralysis of the brain-centres while in experimenting with blows on the belly, oft-repeated (reflected ?) irritation would be requisite. The primary arterial cerebral anaemia is followed by hy- peremia in connection with the vascular paralysis, which, however, as has been explained, under compression of the brain, again secondarily retards the arterial flow by the interpolation of large impediments to the capillary circula- tion. Furthermore, paralysis of the vascular nerve-centres produces a dilatation of the vessels in all of the regions of the body with engorgement of blood in them, which im- plies a deep sinking of the blood-pressure. To the brain in which the arterial flow is retarded, this means, further- more, that the arterial blood flows through its various regions, not only more slowly, but also in lesser quantities. Koch and Filehne* in a similar manner endeavored to derive the symptoms of concussion of the brain from a direct mechanical affection of all the brain-centres. Cer- tainly the affection of the vasomotor centres plays a princi- pal part in this connection. We also see in cerebral con- cussion disturbances of those centres which are most suscep- tible to anomalies of nutrition, that is, disturbances in the various centers lying within the cerebral cortex, where they are most strongly marked. The fact that such disturbances of nutrition of the brain- * Koch and Filehne, Ueber Commotio cerebri, Verhandl. d. deutschen Gesellsch. f. Chir., 1874, HI. Congr. Grossere Vortrage, p. 10. 1 82 SURGICAL EMERGENCIES. centres really occur in concussion of the brain is again shown very clearly in the cases which terminate in recovery. In these, each of the functions of the brain was restored as slowly, as after profound chloroform narcosis, in which a dangerous asphyxia existed. I would call your attention particularly to the manifestation which Bohm* described in his reports of animals which he had chloroformed almost to death and which he details as manifestations after re- covery from apparent death (" Erscheinungen nach geho- benem Scheintod "). This analogy is particularly note- worthy because you know how deeply the blood-pressure can sink for a long time in dangerous chloroform narcosis. We distinguish, in cases of cerebral concussion which do not terminate fatally, between light cases and severe ones. In both, the principal symptom is unconsciousness lasting for a lesser or greater length of time. In the lighter cases the patient breaks down with a sen- sation of giddiness, glittering before the eyes, and whirring in the ears. His face becomes pale, the eyes become fixed and non-responsive. The respiration appears flat, the pulse filiform and barely perceptible. Soon the patient recovers and complains only of headache, debility, languour and tingling in the ears. Sometimes various subsequent dis- turbances of the motor sphere appear, thus as in the move- ments of the eye ; there also may be stammering or at least difficult articulation. Permanent disturbances of the various co-ordinate movements, as grasping, etc., are par- ticularly worthy of attention. Diabetes mellitus and in- sipidus, and albuminuria have been observed after concus- sions of the brain. The symptoms of severe cases of concussion of the brain are more complicated. Unconsciousness is absolute; the injured person does not respond to strong irritations. The pupil contracts but slowly upon the approach of light, but frequently swallowing takes place upon fluids being poured in. The features are deadly pale and collapsed. The body soon becomes quite cool. The pulse is intermittent, small, and often slow. Urine and faeces are retained or are passed unconsciously. Vomiting often follows later on. After the lapse of hours or days an improvement occurs. Re- spiration becomes deeper, the heart and pulse beat more * Bohm. Ueber Wiederbelebung nach Vergiftung und Asphyxie, Archiv. f. experim. Pathol, und Pharmakol., Bd. VIII., pp. 68 to 101. SURGICAL EMERGENCIES. 1 83 fully and strongly, the bodily temperature rises, voluntary motions again are made, and finally consciousness returns. Most frequently the general depression is followed by a stage of excitement. The temperature of the skin rises, the pulse becomes hard and frequent, the face is flushed, the pupils are contracted and the eyes glisten. Furthermore, when true meningitic manifestations are developed, then a pure concussion has not occurred, but a complication with evident injury to the skull and brain has taken place. We must assume the same when the comatose condition continues very long, or when the sopor becomes more profound, also when convulsions or paralyses of cer- tain regions occur. This issue has been noted particularly in concussion with co-incident fracture of the base of the skull. Though the patient recovers rapidly after concussion of the brain he may by no means be removed from medical supervision. Sometimes serious manifestations occur later. Sudden symptoms of compression of the brain may appear when the extravasations of blood within the skull become enlarged, or when a not diagnosable crushing of the brain gives rise to the appearance of general inflammatory pro- cesses in the brain and its coverings. The treatinent of cerebral concussion must be purely symptomatic. The depression of the blood-pressure re- quires the application of means which would elevate it, among which irritations to the skin play an important part. Perhaps autotransfusion, by depressing the head lower than the body, may prove efficacious. Repeated subcutaneous injections of ether (a Pravaz syringe-full, about a gram, at a time) have been recommended. Large doses of musk should be given internally when the patient can swallow. Particular provisions should be made against the reduction of the bodily temperature by enveloping it in warm cloths, and the application of hot bottles to the body of the pa- tient as well as long-continued warm baths. Beyond all, the hair should be cut or the head shaved, and carefully examined for whatever injuries there maybe. If later on inflammatory manifestations occur they must be treated as has been detailed above. In the discussion of therapeutic measures in contractions of the space within the skull, such as are dangerous to life, and in injuries to the skull, we have noted that trephining the cranium has given us some indication - which incite us to devote some remarks to this operation. 1 1 84 . SURGICAL EMERGENCIES. For centuries the applicability or non-applicability of this operation, which was well known and practised by the oldest nations, was widely discussed. The most extreme views prevail as to the applicability of trepanning in all complicated injuries to the head (prophylactic trepanning — Pott), while others have advocated its complete elimina- tion from surgical practice (Textor, Dieffenbach, Malgaigne, Stromeyer). In general we find that the more complete the surgical school the rarer the trepan was employed. Even those who saw their patients die with injuries to the head, notwith- standing trepanning more frequently, yet in consequence of it they rescinded more and more from the employment of the operation. At all events we may consider prophylactic trepanning in recent injuries to the head as definitely set aside. We sub- stitute it by carefully-executed antiseptic cleansing of the wounds and subsequent antiseptic occlusion, just as we have ceased to make primary resections of the joints in re- cent injuries to them, as was done especially to favor con- ditions to guard against the inroads which suppuration, established within the synovial cavities, would make. This process usually established itself when antiseptic precau- tions are not employed. Exploratory trepanning for the purpose of extracting foreign bodies, or to find abscesses which had been formed within the brain and evacuated, has recently suffered much limitation. In foreign bodies we will trephine only when they are wedged into the cranial parietes and can not be removed without the bony substance that surrounds them (such as knife-blades, ramrods, etc., which are wedged into the bone). Exploration for foreign bodies that are not visible, especially bullets, is reprehensible as long as there are no cerebral manifestations indicating the presence of the foreign body, or inflammations or suppurations pro- duced by it. The absence of a wound of exit in gun-shots to the head does not justify the assumption that the bullet lies within the cranial space. Despite the firm assertions of the patient or of other witnesses, the force of the ball may have become spent after the concussion and produc- tion of the depression in the bone, and may have simply fallen to the ground. As to the value of exploratory tre- phining in abscess of the brain we have repeatedly expressed ourselves. A more concise knowledge of the localization SURGICAL EMERGENCIES. 1 85 of the individual brain functions will give us definite points of departure in the future. Therefore we will proceed to trephining, that is, to the removal of a firm piece of bone from the continuity of the cranial roof; first, for the purpose of enlarging the space in the bone through which to extract splinters of bone or foreign bodies that are difficult to move or grasp; secondly, for the purpose of ligating the injured middle meningeal artery in case it cannot be tied in the wound; thirdly, to remove blood from the skull or masses of pus from the brain substance. When there is no fracture of the skull we trephine only to remove such a piece of bone into which a foreign body has been firmly wedged; furthermore, for the purpose of ligat- ing the middle meningeal artery when, notwithstanding slight damage to the bone there are clear symptoms of haemorrhage from this artery, and, finally, for the purpose of evacuating abscesses which have been diagnosticated in certain regions of the brain. We will begin, in describing the typical procedures, by those of bori?ig out the bony disc from the intact cranial arch. We alluded to it in discussing the procedures for ligating the middle meningeal artery. After splitting the skin, the soft parts, and the periosteum, we arrive immediately upon the bone, which we free by levering off the periosteum to a sufficient extent. The disc of bone is bored out by means of the crown of the trepan; a metal cylinder,the under margin of which is provided with saw-teeth. Its upper closed end is continued in a hollow axle into which a rotary curved, or a diagonal handle is fastened by means of which the crown can be given a rotary motion upon its axis. The first combination is called the arched trepan (Bogen trepan), when a diagonal handle is used the combination represents the trephine or hand-trepan. The cylindrical saw might slip when placed upon the arched surface of the cranial roof, therefore these instruments carry within their cylinder a spear, called the pyramid, which may be moved upwards or downwards. This pyra- mid is allowed to project over the free, toothed-edge of the crown of the trepan, and is inserted into a small hole which has previously been made by the perforating trepan (a hand trepan with a heart-shaped point) or with a gimlet. If the spear penetrates sufficiently deep into the hole prepared for it, the teeth of the crown of the trepan gradually en- 1 86 SURGICAL EMERGENCIES. croach upon the bone, forming a disk, which is to be removed within the furrow which the saw-teeth produce. Then the pyramidal spear, within the cylinder of the trepan, is drawn upward so as to facilitate further sawing. Before the bony disc has become entirely movable a screw must be fastened into the central hole to form a sort of handle with a corresponding quadrangular opening at the upper end of the screw. The hook or lever with the screw bear the collective name of Tirfonds. In emergencies this may be substituted by a pointed elevator, or a chisel, to be used as levers, or Bruris sequestrwn pliers. When every pre- paratory production of a hole within the bone disc is impos- sible, as when the middle of the disk is a movable fragment of bone which lies within the depression, slipping of the crown of the trepan must be prevented by pressing metal rings with lateral handles (crown holders) upon the skull, and rotating the crown of the trepan within their open space. Perforated discs of pasteboard, leather, and wood have been used for the same purpose. During the sawing a sound should be inserted from time to time in the furrow, to elicit whether it is equally deep in all its parts. When this is not the case, further motions of the crown of the trepan must be depressed more towards the side at which it has not as yet penetrated as deeply as it did on the other. This is one of the reasons for ihepref- erence of the hand trephine over the arched trepan, because the former allows perforation with greater delicacy. If, after the disc of bone has been removed, the trephined orifice shows a rough margin or projecting bony points, especially to- wards the cranial cavity, they must be smoothed off with an appropriate instrument (linsenmesser : lentil-knife), a chisel, the sides of which are sharpened, but the point of which is blunted by a flat, lentil-shaped button, which oc- cupies a diagonal position to it. The button is placed be- tween the bone and the dura mater, while the knife is ro- tated upon its axis and its sharp edges pressed against the uneven bony margin, so as to cut it or scrape it smooth. Luer's rongeurs are very handy for the removal of project- ing points of bone, or for rounding off toothed projections within the margin of a space in the bone. It were well to have several of these instruments, of various sizes, on hand. For the removal of splinters of the inner plate which have slipped under the margin of the trepanned opening, be- tween the dura mater and the bone, Bruns' long pincettes, SURGICAL EMERGENCIES. 1 87 with doubly crossed legs and scoop-shaped ends, are very- useful. These forceps are either straight or bent to an angle on their flat surfaces. Wherever the purpose is not to produce an opening in the intact cranial roof, but to enlarge or round off trauma- tic defects in the bone, as in splintered fractures, etc., the us« of the hammer and chisel deserve preference over tre- phining instruments, as being more conveniently man- aged (Roser*). It is equally recommendable to re- move foreign bodies which are wedged into the cranial bone (projectiles, knife-blades, etc.), with a chisel, a safer procedure, which entails less injury than does the removal of a disc of bone. The fear of the production of fissures by the use of the chisel is as little justifiable as is the fear that the use of the chisel would produce necrosis of the margins of the solution of continuity. The chisel which is employed should be preferably sharpened on one side, such as sculptors use, instead of the wedge-shaped, thin blade which is usually employed. Experiments made on other bones of the skeleton, of which large numbers are now recorded, because of the increasing frequency with which osteotomies and similar operations are now made, have also contributed their share to relieve the prejudice against the use of the chisel, and have established its un- qualified preference over the saw. The long bones have also been trephined through the diaphyses in infectious osteo- myelitis, so as to wash out the ichorous medullary substance through the trephined opening, to disinfect it, and to drain the osseous canal. Trephined openings heal but slowly, as do all fractures and fissures of the cranial roof. According to Kosmowski's f experiments, the principal proliferation proceeds from the opened medullary spaces of the diploe. The new formed (osteoid) connective tissue yields, directly, bony substance, which radiates from the periphery of the hole into the fibrous connective tissue, which closes the open- ing. This, however, occurs in but a defective way. In the beginning, the brain crowds the dura mater into the opening, and manifests clearly perceptible pulsations. But gradually the connective tissue cicatrix in the trepan- * Roser, Archiv. f. Heilkunde, 1867, p. 553. f Kosmowski, Heilung von Trepanationswunden, St. Petersburg, 1871 (in Russia). 188 SURGICAL EMERGENCIES. ned hole becomes so firm and callously tough that the brain-pulsations are not transmissible through it, although the formation of bone in it is but incomplete, occurring only in the form of bony islets. In larger solutions of continuity of the skull, especially in necrosis of the bone (for instance in syphilis), the scar is more resilient, allowing perceptible brain-pulsations to persist for years. Owing to the danger to which such patients are exposed in cases of repeated traumatisms to the head, they are ordered to wear protectors, which have inserted into them correspondingly curved and padded metal or leather plates, to cover the defect in the bone or the hole produced by the trephine. It is said that efforts to heal in the discs which had been removed have succeeded in isolated cases. According to the experiments of J. Wolff,* success in this regard is materially facilitated when a bony flap is lifted up, cover- like, and its base allowed to remain in connection with the cranial roof by periosteum, and subsequently re-inserted into the opening. This procedure has, as yet, not been practically applied. * J. Wolff, v. Langenbeck's Archiv. Bd. IV., p. 250, u. ft. SURGIGAL EMERGENCIES. 189 LECTURE XII. Aids in accidents to masses of men. — Surgical aid in war. — General consideratio?is . — Objective points of military surgery. — ■ Task of each individual surgeon. — Information requisite. — Leading principles in military practice. — The battle-field. — Division of the wounded into those tvho are capable and those who are incapable of marching. — Places for immediate dressings. — Selection of place. — Refreshment for the wounded. — Classification of injuries. — Provisional arrest of dangerous hozmorrhages. — How should the primary dressing be made ? — Antiseptic compresses, bandages, cloths, slings. — Splints, their im- provisation. — Stretchers. — Means of transport from the battle- field. — Medical staff. — Carriers of the wounded. — The place of permanent dressing. — Only for the wounded who cannot march. The medical staff and its organization. — Organization of the sanitary detachment. — Consulting surgeons. — Assortment of the wounded. — Tickets. — The diagnosis cards formerly employed. — Dressings for those to be immediately removed. — Injuries belonging to this class. — Form of dressing. — Drainage. — Course and contents of the canal of the shot-wound. — Splints, ready-made and improvised. — Means of transportation from the dressing-station to the field-hospital, to the depot, and to the sanitary train — Improvisation of these means of transportation. — Injuries in which operative interference is requisite. — No re- sections to be performed at the dressing station. — Injuries ivhich cannot bear transportation. Gentlemen: You will comprehend that, if we should be required to compress within the limits of a single lecture every fact of value for your work as military surgeons, no exhaustive presentation of the subject, but only the leading principles in their general outline, could be set forth. It is, however, not our task to add one more to the numerous works on military surgery to which the last two belligerent decenniums have given rise. You will merely obtain in the labor of the surgeon in war time an example of how I90 SURGICAL EMERGENCIES. and when you are to apply, or to modify, the rules for assis- tance which you have learned to employ in saving the life of a single individual, whenever it should be your lot to have to do with serious conditions occurring among larger bodies of men. A glance at the history of military surgery shows that, among various nations, greater attention began to be directed to the care of the wounded, at the time when these nations had arrived at a certain rather high degree of civi- lization. In regard to the requisites which are here involved, the closest approximation to their fulfilment yet made was in the last Franco-Prussian war (1870-71). And as the final result of all labors directed to this end two problems have originated, whose solution must be sought for in our future way in history by every possible means, if we wish to attain any real progress in the domain of military surgery. The first problem implies the task of combining the most earnest endeavors for the care and treatment of the wounded in war time, with the maintenance, hitherto neg- lected, of the hygiene of soldiers in time of peace. In the way thus marked out, Saxony alone has out- stripped other nations by the establishment of the Albert- opolis in Dresden, thus setting an illustrious example. The application and further extension of the results thus ob- tained must be left by civil and military authorities alike to the army surgeons. For you, gentlemen, who, as practising physicians in every-day life are called upon to act among greater and smaller communities of people, the second problem is of far greater importance. For the second problem depends upon the task of advantageously organizing the volun- teer corps of nurses for the wounded, and of making them serviceable to the widest possible extent. Here is the field in which you, as scientific experts and advisers of the self-sacrificing multitude, must regulate the correct division and application of the forces at your com- mand. In order to be wholly quit of these claims upon you, cer- tain prerequisites are necessary, namely : 1. Acquaintance with the sanitary establishment of the army in time of war. As is evident, we cannot here enter upon this subject. SURGICAL EMERGENCIES. I9I 2. Acquaintance with the duty of the physician in time of war, either (a) Upon the battle-field. (b) At the place for immediate dressing. !c) At the field hospital. d) At the depots and in the hospital at home. 3d. Acquaintance with the means of transportation from the battle-field to the place selected for temporary dressing and the field-hospital, from there to the depot, and from the latter home (land, water and railroad transportation). Only a few of the above categories can form the subject of a more intimate inquiry. In the first place, it appears of importance to establish the general standpoint, which can serve us as a guide to our duty as physicians in war. Briefly summarized, this is as follows: 1. Correct division of labor among the assistant force. 2. Immediate assortment of the wounded, according to the severity of their injuries. 3. Rational attention to the immediate shelter and care of the wounded. (Removal to buildings, sheds and tents; feeding.) 4. Immediate dressing, with special reference to the sub- sequent antiseptic treatment and to transportation. 4th. Suitable adaptation of matters at hand (soldiers' clothes, weapons, furniture in dwellings, vehicles in cities and in the country, etc.), to form improvised materials for dressing, lodging and transportation. After the above remarks it will be clear to you that it is the work expended on the battle-field and at the place of temporary dressing which appears the most important and the most laborious. Moreover, it requires a very particu- lar consideration, because it is in many respects so different from surgical practice in times of peace. THE BATTLE-FIELD. Here the task for the sanitary service consists in the transportation of all of the surviving wounded to the place of immediate dressing or to the field-hospital. The wounded, accordingly, are simply to be separated into two chief divisions. * Knorr, Ueber Entwickelung und Gestaltung des Heeres-Sanitats wesens d. europaischen Staaten. Hanover, 1878 u. 1879. 6 Hefte. IQ2 SURGICAL EMERGENCIES. (a) Those capable of marching, to be transported to the field-hospital. (b) Those incapable of marching, to be transported to the place for temporary dressing. In order to be able to conduct this classification upon a large scale, certain places of rendezvous (places for dress- ings of urgent necessity) should be located upon the battle- field itself, out of the range of musket-fire, if possible, and marked by the sign of the Geneva Convention — a red cross on a white field. If possible, a plot of ground should be chosen, with a shady group of trees, perhaps, too, with a brook or a shed; at all events, a place should be selected where a tent can be pitched for the severely wounded. The first duty at the place for urgent dressings must con- sist in the administration of cordials and stimulants to the wounded. Next, we shall have to direct our chief care to the assortment of injuries for the application of dressings. Of operative procedures, the only one which can come into question is the provisional arrest of haemorrhages of suffi- cient magnitude to threaten life. In what way should the first dressing be constructed, upon the field of battle? In modern warfare, gun-shot wounds preponderate over all other forms of injury. Thus, in the campaign of 1866, the wounds in the Prussian army* of 13,202 cases, 79 per per cent were by gun-shot, 16 per cent by shells, while the injuries from sabres and lances formed only about 5 per cent, and by bayonet about 0.4 per cent. Still more apparent are the relations in the statistics of the war of 1870-71.! Here the entire loss of the Prussian army amounted to 65,610 men, 86 per cent of whom were from gun-shot wounds, and 7.8 per cent from injuries produced by large shot and splinters of shells. If, in addition, we subtract .4 per cent for injuries in which an accurate desig- nation of the weapon inflicting them is lacking, the remain- der accounts for wounds which were due to the sabre-cuts, blows from the butts of guns, bayonet or lance thrusts, in- * Militar-Wochenblatt, 1867, p. 244. f G. Fischer, Statistik der in dem Kriege 1870-71 im preussischen Heere vorgekommenen Verwundungen und Todtungen. Berlin, 1876; p. 6. % Esmarch, Die antiseptische Wundbehandlung in der Kriegschirurgie. Verhandl. des V. Congresses d. deutsch. Gesellsch. f. Chir. I., p. 13 to 17 (Discussion), and II., p. 104. SURGICAL EMERGENCIES. 193 juries from fragments of stone and earth, and from explo- sions of mines, as well as burned wounds. Since we have, therefore, to deal chiefly with shot- wounds, produced by the action of projectiles from small arms, our attention in the application of immediate dress- ings must be chiefly, and with especial regard to the attain- ment of aseptic conduct of the wound, directed to the prevention of the entrance of all impure substances which could excite decomposition within the wound. As the first protective measure, in a negative sense, is to be regarded the limitation, as far as possible, of digital examination of the wound, in case the finger cannot be amply disinfected, which is only rarely possible on the bat- tle-field even under most favorable circumstances. In op- position to the indication which, even at the beginning of the Franco-German war, was still enjoined upon surgeons to acquaint themselves as early as possible with the nature of the injury by the introduction of the finger into the recent wound, we must now emphasize the necessity of entirely omitting the primary examination of wounds, provided no dangerous haemorrhage is present, and of renouncing an accurate diagnosis in favor of an antiseptic treatment of the wound. In this method of treatment we are confirmed by the observations, continually increasing in number, of shot-wounds healing by first intention, either under a slough or under the employment of antiseptic precautions. (Stromeyer, Pirogoff, v. Langenbeck, Volkmann, Fischer, Socin, * Klebs.f) To this end, we must cover the orifices of entry and exit with substances which, on the one hand, render any direct contamination of the wound impossible, and, on the other hand, contain so much antiseptic matter that, in case the soiling of the materials used for dressing is unavoidable, decomposition could not possibly take place among the impurities which had penetrated into the dressing. The significance of the antiseptic material in the dressing, as affecting the secretion of the wound, is a consideration of secondary importance; since, at most, it is only in wounds which go to the field-hospital for further treatment that the primary dressing remains on any length of time. In the * Socin, Kriegschirurgische Erfahrungen. Leipzig, 1873; p. 6. f Klebs, Beitrage zur pathologischen Anatomie der Schusswunden. Leipzig, 1872; p. 50, et seq. 104 SURGICAL EMERGENCIES. other wounds which come to the place of immediate dress- ing, it has only the significance of a temporary protective. It will be readily understood by you that we can employ only a relatively small amount of material for dressing, and hence it follows that the antiseptic substance with which the dressing is impregnated should be distributed uniformly and in undiminished quantity through the latter. Just here lies a difficulty which, up to the present day, must still be re- garded as unsolved. It has been proposed to use for these immediate dressings compresses of jute (balls of jute at- tached to strips of gauze), which have been impregnated with carbolized resin, salicylic acid, or chloride of zinc, then the compresses are to be applied to the wOund and secured by bandages or cloths. The compresses, with a bandage or triangularly-shaped piece of cloth, wrapped in water-tight paper (Esmarch, /. c), should be distributed to each soldier, and either carried in the knapsack or attached to a certain part of the uniform, so that every soldier, if need be, can apply an immediate dressing to himself or his comrade. It will be more important and more advantageous to provide a certain number only of soldiers, and particularly the hospital aids, who have been detailed beforehand for sanitary service, with a greater number of specially packed compresses of the sort above mentioned. And this on the score that the compresses which each soldier carries around with him in his knapsack or on his clothes, and which share in all the exposures to which the latter, especially the uniform, are subject, can only with difficulty retain the properties of cleanliness and antisepsis which are required of them. Carbolic acid above all, as a volatile antiseptic, will very quickly evaporate, as we know from investigations in re- gard to the amount contained in the carbolized bandages prepared after Lister's directions by Miinnich and P. Bruns.* Again, the compresses recommended by Esmarch, of salicylized jute, in which the relative non-volatility of salicylic acid was brought into account, have not, accord- ing to the experiments made by the Prussian Ministry of * Kaufmann, Centralbl. f. Chir., 1879, No. 50; also Miinnich, Deutsche militararztliche Zeitschrift, 1880; Heft 2, p. 47-81. SURGICAL EMERGENCIES. I95 War, proved satisfactory.* Since it is not possible to unite salicylic acid intimately with the jute, the former is de- posited in the form of crystals, and these are found among the surrounding articles, along with the jute compresses, which have been deprived of their salicylic acid and are not antiseptic, and this if the soldier's coat has been shaken but £ few times. Chloride of zinc, too, falls out in the form of powder. While, then, we insist upon the principle of the antiseptic compresses, we must wait to see whether it is possible to saturate them with an antiseptic which will preserve for a long time its antiputrefactive properties. In the wounded who are capable of marching, who for the most part will have slight wound? of the head and upper extremities, the retention of . the compresses is secured by bandages or cloths. For the support of the arm with slings, we use large, triangular pieces of cloth. In case of necessity the slings can be improvised from the sleeves and skirts of coats, f If possible, canteens filled with strengthening drink are distributed to the bandaged warriors. In regard to the wounded who are not capable of march- ing, in whom, for the most part, injuries of bones in their continuity are present, we will, during their transportation to the place of permanent dressing, apply of course the same antiseptic compresses; but, to enable them to under- go the necessary transportation, splints must also be applied, which will secure in place the ends of the fractured bones. Such splints can be improvised out of weapons — bayonets, scabbards, and even out of branches, straw, straw-mats, saddles, cloaks, etc. In the transportation, which for the most part will be accomplished by hand-bearers, on stretch- ers or litters, the knapsack will be used as a cushion. (De- tails will be found in the admirable work already cited, the " Hand-book of the Practice of Military Surgery," by Esmarch, which must be most earnestly recommended to every young surgeon for study.) The stretchers themselves are covered with drilling or sail-cloth. More rarely will it be possible to carry on * Verhandl. des VIII. Congresses d. deutschen Gesellschaft. f. Chir. 2. Sitzung vom 17 April, 1879; P- 47 et seq. f Esmarch, Handb. des Kriegschirurg. Technik., 1877; p. 58. I96 SURGICAL EMERGENCIES. transportation to any great extent in ambulances, and still more rarely in contrivances slung from the saddles of horses or mules.* Stretchers can also be improvised from stakes, or branches of trees (Smithf) with cross-pieces and covered with straw-matting. Short ladders, also guns with coats spread over them, etc., are applicable. As already mentioned, the only one among surgical operations to be employed upon the battle-field is the pro- visional arrest of haemorrhage with the tourniquet, or bet- ter still, the elastic bandage (after the plan of Esmarch and Bardeleben). In regard to the personnel necessary for the removal of the wounded from the battle-field, it is to be remarked that we need only a few physicians at the place of immediate dressing, whose chief duty will consist in the assortment of the wounded. For the application of the primary dressing, a pretty large number of hospital aids is sufficient. A greater number of men to carry the injured is re- quired. To them shall be assigned, under military direc- tion, the removal of those of the wounded who are incap- able of marching. When, besides, there is a great number of the wounded who can be readily transported, the aid of volunteers to assist in carrying the injured may come into consideration, but onlv under the proviso that these latter shall be subordinated ?o expert military direction. THE PLACE OF PERMANENT DRESSING. This forms the first halting-place beyond the battle-field for the reception of those already incapable of marching, or those who would become so in the process of transporta- tion from the battle-field to the field-hospital. The position of the place for permanent dressing must be as secure a one as possible, and yet easily discoverable and accessible from the battle-field. For reception in the place for permanent dressings, then, only those of the wounded should come who are incapable of marching, and they should be classified directly, accord- * H. Fischer, Allgmein Kriegschirurgie, p. 301. Handb. v. Pitha u. Billroth. f Smith (Norway), Nogle nye Transport midler for Saarede. Kris- tiania, 1876; compare also Miihlwenzel, Internat. Ausstell. f. Gesund- heitspflege, etc. Briissel, 1876. Feldarzt, 1876, Nos. 22, 23, and 24. SURGICAL EMERGENCIES. I97 ing to the severity of their injuries, into the following categories: 1st. Those who are to be transported immediately to the rear, after application of a dressing suitable for the journey. 2d. Those who are capable of removal to the rear after several hours' rest, or after the performance of the requisite operations. 3d. Those unsuited to transportation. The classification of the wounded at the place of per- manent dressing is the most difficult, and, to the wounded, the most important part of the physician's duty. In great measure it decides the future fate of the injured warrior. This duty must, therefore, be assigned to experienced hands, well schooled in military surgery. The surgical force should not, as has been so often done hitherto, be massed upon the battle-field, without being able to develop a profitable activity. It is expedient, there- fore, to have ready, at the place of permanent dressing, a large medical corps, which, divided into sections, will be able to carry out their varied and extensive labors. This is not the place to describe more exactly how the medical staff necessary for an action should be organized for the sanitary detachments to whom the work at the place of permanent dressing is allotted. The experiences of the Franco-German war have afforded ideas something like the following: 1 st. Doubling the sanitary detachments for each army-corps, so that in every case one sanitary detachment shall be assigned to each brigade. 2d. Diminution of the permanent medical staff of the sanitary detach- ment from 7 or 8 physicians to at most 3 physicians. 3d. Separation of the companies of men detailed for carrying the wounded, from the san- itary detail, so that each half-company shall, under the command of a lieutenant and the medical supervision of an assistant physician, be di- rectly subordinated to the brigade. 4th. The command and supervision of the sanitary detachment should be assigned to the physician-in-chief. 5th. Omnibus-wagons should be provided for the transportation of the subordinates in the sanitary detachment (hospital-aids, nurses), and these again can be used for the transportation of the wounded to the place of permanent dressing, when the sanitary detachment is in course of estab- lishment. In this way the mobility of the sanitary detachment as a whole, and the efficiency of its subordinates, when it is in working order, are increased. 6th. The ambulances are to be assigned to the companies, or rather half-companies, of the carrier-corps. 7th. Besides two pack- wagons (one for the physicians, the other for the subordinates), the san- itary detachment should carry along with it (a), an operating-wagon, con- taining an operating tent, operating table, instruments, antiseptic ap- paratus, and apothecaries' stores (consisting of a large stock of carbolic acid, smaller quantities of chloroform, chloride of zinc, two per cent, car- I98 SURGICAL EMERGENCIES. bolized vaseline, morphine for subcutaneous injection, castor oil; also still smaller quantities of the preparations of opium for internal use, and sodium sulphate, and small quantities of the liquor ferri sesquichloridi, argenti nitras, tinctura sem. strychnin, tannin, croton oil, bicarbonate of sodium, tinctura quininae comp., etc,), {b). A dressing-wagon, with all the materials for an antiseptic dressing, carbolized jute, salicylized cot- ton, mull and gauze bandages, and flannel and linen bandages impreg- nated with chloride of zinc, splints and splint-materials (see below), water-proof textures (pressed rubber, oiled paper), adhesive plaster, rub- ber rings for extension, ice-bags. Finally (c), a commissary-wagon, containing pea-sausages, preserved meat, rice, liquor, wine, coffee and sugar. 8th. In case of action, the physicians attending the troops and the physicians of field-hospitals which are not on duty, may be detailed in accordance with the demands of necessity or the requirements of the surgeon of division or the corps-surgeon, to a sanitary detachment for the time, in which the latter is in operation. 9th. While the sanitary de- tachment is in active service, the consulting surgeon assigned to the brigade or the division takes command of it, being represented by the physician-in-chief of the sanitary detachment. (Compare also V. Scheven, Deutsch Militararzt Zeitschr. 1877, Heft 6, p. 265.) At the station for dressing, moreover, is the spot where the most experienced surgeons, even if for a time only, must put themselves at the head of the rest of the medical staff. Here they will be able to make all their knowledge and ability available to the very fullest extent. Here, where the fate of hundreds and hundreds is decided, their counsel and judgment can be of especial service, perhaps more than in the field-hospitals and military depots, where the con- sulting surgeons, for the most part, have only to enter upon the after-treatment, and that often to the discouragement of those who, for weeks and months previous, have carried on in the most careful manner the medical treatment of the patients entrusted to their charge. The first duty of the head-surgeon, at the place of dress- ing, consists in the division of the medical staff into four sections, according to the individual capacity of each phy- sician. As we shall see, a special duty is assigned to each one of these sections. The surgeon himself takes his place at the head of the first section, and in connection with it undertakes the as- sortment of the wounded as they are from time to time brought in to the place of permanent dressing. Differently colored tickets are now attached to the breasts of each of the wounded, to distinguish them most readily, accord- ing to the categories which have been already given. These tickets should have printed on both sides a single word to SURGICAL EMERGENCIES. I99 signify the different divisions. Thus, on the yellow card the word " Immediate" can be printed; on the blue card, the words "To wait;" on the red card, the words "To remain." Previous to the present time, in place of the tickets here recommended, the so-called " Diagnosis cards" were introduced and distributed in great numbers among the physicians. On these cards the physicians were to desig- nate, as accurately as possible, the result of their primary examinations. These cards take their origin from the time when primary digital examination of wounds was strenuously enjoined. It must be laid to the charge of these cards and of the de- sire to make as accurate and correct diagnoses as possible, that fingers have been thrust into so many wounds which, without this exploration, might have healed without delay. Blood, rain, or dust often render the hastily written and scarcely legible characters indistinguishable.. The diagno- sis-card was written to no purpose, and to no purpose was the life of the wounded man sacrificed. The different colored cards which are recommended, have the object of facilitating, at the dressing-station, only the supervision of the assortment and grouping of the injured. The second separate medical section has to do with that division of the wounded who, after the application of a dressing suitable for the journey, are to be conveyed directly to the rear. In this division belong all injuries (of soldiers incapable of marching) which require no immediate oper- ative interference; more particularly all shot- wounds of the soft parts, all shot-wounds of the joints, and all wounds pro- duced by shots glancing off without solution of continuity of bone. So, too, shot-wounds of the lungs, without haemop- tysis, and wounds of the abdomen, without intestinal prolapse. In all these cases, the region of the injury is to be care- fully cleansed, and a Lister dressing (if possible under the carbolic spray) applied; and for this purpose we will em- ploy carbolized jute (Munnich*), or dry jute saturated with chloride of zincf, either in the form of flat layers or of * Miinnich, Ueber die Verwendbarkeit, etc. Deutsche milifararztl. Zeitschrift, 1877. VI. Jahrgang Heft 10. f Kohler, Ber. liber die Klinik von Bardeleben pro 1878. CharitG Annalen, 5 Jahrg. 1880, p. 563, 200 SURGICAL EMERGENCIES. cushions packed in sacks of antiseptic gauze.* Here, too, the carbolized gauze prepared by P. Brunsf in the cold way might be employed. The securing of the antiseptic dress- ing is accomplished on the extremities by the aid of simple, starched gauze bandages, moistened with a 3 to 5 per cent solution of carbolic acid; on the chest, abdomen, shoulder and hip, with the addition of a few strengthened bandages of gauze, or flannel, or linen bandages, which have been previously impregnated with a 10 per cent solution of chloride of zinc. Drainage of wounds is to be employed only exceptionally, in order not to hinder a possible healing by first intention. To determine the course of the wound, it appears to be of importance to discover the attitude in which the injury was received, in order the more easily to discover the course of the projectile, by subsequent imitation of this attitude. In the second place, special attention must be directed to the nature of the pieces of garments (or armor) in the neighborhood of the wound of entry, in order to be able to judge beforehand whether any particles of the clothing, etc., and if so, how many and what ones, have been carried into the canal of the wound. Again, in injuries of this class, even if no fractures are present, we will generally proceed to the application of splints, because this contributes, on the one hand, to secure and firm compression of the parts, on the other hand, to the- immobilization of the joints. In part we can employ ready-made splint apparatus; for example, tin-splints (Volkmann), wire-hose (Mayor, Bon- net, Roser), etc. In great measure we shall be able to readily improvise splints from materials corresponding to those above given; for instance, from wire-sieves, from wood-ware (Gooch, Schnyder, Esmarch), or from zinc-plate (Guillery, SchoenJ), etc. In regard to splints improvised * Corresponding somewhat in form and size to the marks of identifica- tion as they were used in the American war, and as they are pictured in Gurlt, Abbildungen zur Kraukenpfiege in Felde nach besten Hodellen der pariser Austellung rom J., 1867, Taf. XVI., Fig. 10. f Paul Bruns, Zur Antiseptik. in Kriege. Arch. f. Klin. Chirurgie, 1879. Bd. XXIV., Heft 2, also Deutsche militararztl. Ztschr., 1879; Heft 12, pp. 609-617, and ditto, 1880, Heft I., p. 42. £ Neuber, Ein antiseptischer Danerverband Archiv. f. klin. Chir., 1879. Bd. XXIV., Heft 2, und the same. Ueber den antiseptischen Polster- verband Verhandl. des IX. Congr. d. deutschen Gesellsch. f. Chir. SURGICAL EMERGENCIES. 201 from branches, bundles of straw, bayonets, scabbards, and guns, compare Esmarch.* As regards means of transportation from the place of dressing to the field-hospital, or, in case stations for the removal of the sick by rail (by " sanitary trains"), are to be found at not too great a distance, in their transportation home we must employ the same apparatus which we have already learned to use for transportation from the battle- field to the place of dressing. Only now removal by wagons or contrivances of similar nature predominates over re- moval upon stretchers by hand-bearers. At the international exhibition of hygiene and life-saving apparatus in Brussels in the year 1876, the ambulance wagons of E. Mayer, in Hanover, met with most general favor. But in general, wagons which have been prepared before- hand for the removal of the wounded, whether belonging to the military equipment or to the volunteer sanitary corps, very soon, in the course of great battles, are found to be inadequate. Accordingly, it will be our duty, even in time of peace, to concern ourselves with the adaptation of the ordinary traveling conveyances proper to each coun- try, to the special object of the transportation of the wounded. Every new idea in this department, no matter from what side it may come, will be received the more thankfully, in that it exposes neither the State nor the vol- unteer sanitary corps to especial expense in time of peace, as has been hitherto very often the case when people al- lowed themselves to be employed in making very expensive ambulances, which should be as convenient as possible, and specially constructed for containing the greatest possible number of patients. The experiences of the Franco-Ger- man war, and of the last Russian campaign, have satisfac- torily proved that such ambulances are available only on favorable ground. In the absence of a good road, in swampy * Weisbach, Deutsche militararztl. Zeitschrift., 1877; Heft II. f Esmarch, Handb. d. Kriegschir. Technik., p. 34. % Catalogue de l'expos. internat., etc. a Bruxelles, 1876; p. 104; and "Specialschrift nebst Abbildungen des Vereins zur Pflege der verwun- deten und Krauken Krieger." Hanover. Furthermore : Peltzer, Das MilitarsanitUtswesen, etc. Berlin, 1877. % Riaut, Le materiel de secours de la societ6 francaise a l'exposition de 1878. 202 SURGICAL EMERGENCIES. regions or in mountainous districts, they have proved useless. We will endeavor, then, to arrange the local means of conveyance (two-wheeled carts, kibitki, wagons arranged with racks, etc.), for the comfortable disposition of the wounded, and this we shall accomplish best by the dis- position of the latter upon stretchers. The best example of how this is accomplished is supplied us by the model of the Norwegian peasant-wagon (Smith, /. c), at the Brussels Exhibition of 1876. Another is the contrivance for trans- portation on two-wheeled carts, from the Paris Exhibition of 1878, which we will find on p. 41 of Riaut's " Report." And still another is the noteworthy summary in regard to the transportation of the wounded by the aid of beasts of burden, contained in circular No. 9 of the American War Department,* issued March 1, 1877. To the third section of the medical staff is to be assigned another class of injuries, under which are arranged all such as require immediate operative interference, and which we have provided with a blue ticket (" To wait ") . Since here we have to do with the performance of major surgical op- erations, the best operative ability must be brought to- gether in this section. In the division just described belong: 1. All bleeding wounds. Here the different means for the immediate arrest of haemorrhage are to be applied, and above all the detection of the bleeding vessel; and for this purpose a free incision of the path of the shot will often be necessary. 2. All injuries of vessels, even when no bleeding occurs, on the spot. In all such cases, central and peripheral liga- tion is to be performed, with or without excision of the portion of the vessel ruptured or penetrated by the shot. 3 and 4. Shot-wounds of bones and joints, with comminu- tion. These injuries will be treated according to the rules for the antiseptic treatment of complicated fractures, whether we consider, with Volkmann,f the correct proceed- ing to be extensive incision of the path of the shot, laying bare the seat of fracture, removal of all loose splinters, * Otis, A report to the Surgeon-general on the transport of sick and wounded by pack animals. Circular No. 9. f R. Volkmann, Die Behandlung der complicirten Fracturen. Samuel Klin. Vortr. 1877, Nos. 117-118. SURGICAL EMERGENCIES. 203 thorough disinfection of the wound, etc., or whether in correspondence with the experience of Reyher* and Berg- mannf in the Turco-Russian war, we venture the endeavor to obtain a cure, under a rigidly antiseptic protective dress- ing, without making any attack upon the comminuted fracture itself until the subsequent course of the case shows the impossibility of a cure by antiseptic means. 5. All injuries of the bones of the skull; especially such as penetrate to the brain. Here we shall have to proceed entirely according to the rules given under 3 and 4. Ex- cept that here the active mode of procedure (laying bare the site of fracture, extraction of loose splinters, applica- tion of chloride of zinc, drainage, Lister dressing) is still more expedient on account of the irritation which the brain suffers through fragments of bone which press upon it. Moreover, Soring by the procedure here described, has ob- tained very remarkable results in the analogous injuries sustained during a time of peace (see Lecture XI). 6. Shot wounds of the larynx. For these we have al- ready pronounced the performance of tracheotomy as an act of prophylaxis necessary for every case. 7. Shot-wounds of the lungs, with haemoptysis. Here it must be left to the judgment in each case by itself, whether in addition to the subcutaneous injection of mor- phine, venesection should be performed or not (see Lecture VI.) 8. Shot-wounds of the abdomen, with prolapse of the intestines. After cleansing and subsequent suture of the intestine, the latter is to be replaced and a suture applied to the abdominal wall. 9. Shot-wounds of the bladder. If in these it be pos- sible to introduce a catheter, it ought to be left permanently in the bladder to effect a continuous removal of the urine. If the urethra is injured and impassable at the time, an open- ing into the bladder must be made immediately, and, in addition, external urethrotomy performed, with the intro- duction of a permanent catheter (see treatment of shot- * Reyher, Die antiseptische Wundbehandlung in d. Kriegs. Chirurgie. Samuel Klin. Vortrage, Nos. 142 to 143. f Bergmann, Die Behandlung der Schusswunden des Kniegelenks im Kriege. Stuttgart, 1878. \ Socin, Zur Behandlung der Kopfoerletzungen. Corresponderzblatt f. schweizer terzte, 1876, No. 24. 204 SURGICAL EMERGENCIES. wounds of the bladder, p. 157 ; and also posterior catheteri- zation, p. 153). 10. Shot-wounds of the testicles. These are among the most painful of gun-shot injuries. They are to be treated together with the administration of morphine, by antiseptic compression and suspension. 11. Shattering of entire extremities. Most frequently occurring from the action of fragments of shells. Here amputation is called for. The performance of resections at the dressing-station is to be confined within the narrowest limits possible, and to be deferred to the field-hospital. When antisepsis is rigidly carried out, resections can generally be performed as secondary operations. We turn, finally, to the last class of the wounded (red cards with " To remain" upon them), who, as not capable of transportation, must remain at the dressing-station. Should the wounded of this class survive their injuries, their removal would be ordered when all the other patients had been removed from the dressing-station. Hereto belong : 1. All who are excessively exsanguinated. 2. All who are unconscious. 3. All head injuries with considerable hernia of the brain or extensive injury to the brain-substance. 4. Injuries of the spinal column and of the pelvis, the latter especially if associated with comminution or extensive solution of continuity. 5. Multiple severe injuries. The patients here considered, who are to be transferred to section four of the medical staff, need especially careful attention and a continuous intelligent supervision, in order to save what yet is capable of being saved. More particularly in head-injuries of this class it might be that antisepsis would afford happier results than such as we had the mournful opportunity of witnessing, together with the indescribable distress associated with them, at the dressing-stations in the Franco-German war. For these patients it is above all things necessary to pro- cure as good and as secure quarters as possible, since, as has already been said, we must delay their removal almost up to the time of the cessation of our activity at the dress- ing-station; and only in cases where our duty concerns not the victorious but the defeated and retreating army, will SURGICAL EMERGENCIES. 205 the removal to the rear be accelerated in accordance with the strength of those who are most severely injured. So you see that the complicated and often excessive labor at the dressing-station can be carried on in the most efficient manner, if in every case of injuries to numbers of men we follow the important principles of division of labor and harmonious cooperation of the working forces. INDEX. Abdomen, indications for evacua- ation of fluid in, 147 operation for puncture of, 148 sites for evacuation of fluid in, 147 exploratory puncture of, 149 Abscess, cerebral, 172 diagnosis of cerebral, 172 of brain, diagnosis, 177 Abnormal anus, 125 Absence of sigmoid flexure, 126 Accidents to numbers, 9 Actual cautery in haemorrhage, 48 Acupressure, 40 Acupuncture of heart, 144 Acute invagination, symptoms of, 106 Accumulations of blood in peri- cardium, 144 of fluid within tho- rax, 130 of blood in small vessels, 17 Air-supply in cases of suffocation and poisoning, 11 Anus, supra-inguinal operation for artificial, 128 " imperforate, 126 " imperforate, operations for, 126 " abnormal J 25 Antiseptic thread ligature at point of injury of arteries, 35 sponges, tampon of, 26 Aneurism, ligation in, 35 Aneurismal varix, formation of, after wounds of vessels, 27 Anatomy of pre-tracheal region, 91 Anaemia, transfusion in, 68 Aorta, compressors for, 38 Apoplexy, cerebral, bleeding in, 51 Apparatus for cupping, 56 Application of Esmarch's bandage, 24 of ligature to injured artery, 32 Arrest of haemorrhage, means for, 22 " of bleeding from arteries, 26 " of bleeding from leach bites, 57 Arterial wounds, central ligation in, 35 Artery, method of ligation, 32 " haemorrhage from middle meningeal, 166 " hooks, 33 " ligation of main, in ven- ous haemorrhage, 43 ligation of middle menin- geal, 168 Arteries, compression of, with in- struments, 38 " antiseptic thread liga- ture of, at point of in- jury, 35 " arrest of bleeding from, 26 Arteriotomy, 54 Artificial leech, 56 Artificial respiration in chloroform poisoning, 79 " respiration after tracheo- tomy, 88 " respiration in opium poi- soning, 79 Atresia ani, 126 " operation for relief of, 126 Auto-Tranfusion, 71 208 INDEX. Bandage, Esmarch's, method of application, 24 Bellocq's catheter, 44 Bladder, causes of injuries to, 157 Bleeding from leech bites, arrest of, 57 ' ' in pulmonary hyperemia, 5i " in pneumonia, 51 " in cerebral apoplexy, 51 as a haemostatic, 50 arrest of, from arteries, 26 ■' of plethoric individuals, 16 Blood, gaseous constituents of, in transfusion, 61 " corpuscles, red, viability of, 60 " changes in, in carbonic acid poisoning, 81, 82 " subcutaneous injection of, 66 " saving of, 22 " compensation for loss of, 22 " loss of, compensation for, 22 " stopping of, 22 " loss of, 13 " experimental increase of, 13 " accumulation in small ves- sels, 17 " pressure curve, relation to rapidity of bleeding, 19 " pressure curve after phle- botomy, 18 " death from want of motion of, 19 Brain, concussion of, 178 " concussion of, symptoms, 182 Buckle tourinquet, 39 Burns, transfusion in, 68 Caissons, death from working in, 86 Capacity of vascular system, 14 Capillary haemorrhages, 46 " " tampon in, 46 Carbolic acid as a styptic, 47 Carbonic acid poisoning, changes in blood in, 81, 82 Carbolized catgut ligature, 28 Carotid, compression of, 37 cerebral haemorrhage from, 168 Catgut ligature, carbolized, 28 " organization of, 29 " objections to, 31 Catheter, Bellocq's, 44 Causes of stricture of oesophagus, 102 " of irreducibility of hernia, 104 Cautery, actual, in haemorrhage, 48 Central ligature in arterial wounds, 35 Cerebral abscess, 172 " " diagnosis of, 172 Cerebral compression, 164 Cerebral concussion, treatment, 183 Cerebral motions, causes of, 177 Changes in blood in carbonic acid poisoning, 81, 82 Chloride of iron as a styptic, 47 Chylothorax, indications for opera- tion in, 135 Chemical haemostatics, 48 Chloroform poisoning, artificial respiration in, 79 " poisoning, tracheo- tomy in, 78 Chronic diseases, transfusion in, 69 Circumsuture, 39 Classification of mortal dangers, n " of wounded, 192 Cold in haemorrhage, 47 Colotomy, 127 Compensation for loss of blood, 22 Compressed air in poisoning from nitrous oxide, 87 Compression of arteries with in- struments, 38 " of carotid, 37 " of external maxil- lary, 36 " of femoral, 37 " of radial, 37 " of subclavian, 37 " cerebral, 164 " digital, 36 Compressors for aorta, 38 Concussion,- cerebral, treatment, 179 Concussion of brain, 178 " " pathology, 179 INDEX. 209 Concussion of brain, symptoms, 182 Considerations, general, 9 Contraction of cavity of skull, 161 " " me- chanism of, 162 Croup, tracheotomy in, 76 Cupping, 56 " apparatus for, 56 dry, 56 Cystotomy, 153 " indications for, 153 " supra-pubic, 156 " supra-pubic, operation of, 156 " through rectum, 155 Danger of defribrinated blood transfusion, 62 " of entrance of air in thora- centesis, 140 Dangers, mortal, classification of, 11 Death, causes of, from slow suffo- cation, 83 " from haemorrhage, 18 " from want of motion of blood, 19 Dental haemorrhage, liq. ferri ses- qui-chlor. in, 47 Decompression of divers, inhala- tion of oxygen in, 87 Digital compression, 36 Digitalis as a haemostatic, 49 Dilatation of strictures of oesopha- gus, 102 Diphtheria, tracheotomy in, 76 Disadvantages of Esmarch's meth- od, 25 Divers, death from accident, 86 Douche, hot, in haemorrhage, 47 Double puncture, 151 Dry cupping, 56 Dyspnoea from transfusion, 68 Echinococci of kidney, 152 Echinococcus, treatment of, 150 Electric current, application of, in haemostasis, 26 Electro-puncture of heart, 145 Elements, vital, loss of, 13 Empyema, evacuation of fluid in, 133 Enteroraphy, 115 Epistaxis, treatment of, 44 Ergotine, as a haemostatic, 48 Esmarch's bandage, 23 " bandage, method of ap- plication, 24 " method, advantages of, 22 " method, disadvantages of, 25 " rubber tube, 23 Experimental increase of amount of blood, 13 Experiments with catgut ligature, 29 Exploratory puncture of abdomen, 149 External maxillary, compression of, 36 External pressure in obstruction of oesophagus, 99 Extravasation of blood in brain, 164 False reduction of hernia, no Femoral, compression of, 37 Fibrin ferment in transfusion, 61 Fistula, gastric, closure of, 125 " spontaneous gastric, 121 Fluid in abdomen, 146 " " differential diag- nosis, 149 " " indications for evacuation of, 147 " " sites for evacua- tion of, 147 Fluid in air-passages, treatment, 92 " in thorax, 130 " in thorax, historical consider- ation, 131 " in thorax, indications for evacuation, 131 Fluid within the uterus, 159 " " causes of, 159 Forceps for removal of foreign bodies from oesophagus, 98 Foreign bodies in bronchus, re- moval of, 74 " " in larynx, remov- al of, 74 " " in oesophagus, 98 " " in the rectum, treatment, 128 " " in trachea, 74 " " in urethra, indi- cations for re- moval of, 154 2IO INDEX. Foreign bodies in vagina, remov- al of, 129 Fracture of skull, 169 " '* antiseptic treat- ment, 171 " " symptoms, 169 Frequency of venous haemorrhage, Fuming nitric acid as a styptic, 47 Galvano-cautery in haemorrhage 48 Gaseous constituents of blood in transfusion, 61 Gastric fistula, closure of, 125 " " spontaneous, 121 Gastrotomy, 119 " after treatment, 124 " feeding after, 124 history of, 121 " indications for, 119 " sites for incision, 121 " operation of, 121 General considerations, 9 Girard's method of introduction of oesophageal sound, 103 Guide for introduction of oesopha- geal sound, 103 Hanging, 74 Hsematometra, 159 treatment, 159 Haemostasis, 11 application of electric current for, 26 " spontaneous, 19-26 " spontaneous from small veins, 42 Hsemostatic, bleeding as a, 50 " chemical, 48 digitalis as, 49 " ergotine as a, 48 lead acetate as a, 49 liq. ferri sesqui-chlor as a, 48 silver nitrate as a, 48 tannic acid as, 48 Haemorrhage, actual cautery in, 48 " between dura and pia mater, 169 11 capillary, 46 " capillary, tampon in, 46 " cold in, 47 Haemorrhage, death from, 18 dental, liq. ferri ses- qui-chlor in, 47 galvano-cautery in, 48 from cerebral car- otid, 168 hot douche in, 47 from intercostal ar- tery, method of ar- resting, 139 from meningeal ar- tery, 166 from middle menin- geal artery, 166 means for arresting, 22 within thorax, indi- cations for opera- tion, 135 pigment in relation to, 20 phlebostatic, 42 qualitative change of blood in, 20 relation to blood- pressure curve, 19 secondary, in punc- tured wounds, 34 secondary, from bruises of balls, 28 venous, frequency of, 41 venous, tampon in, 43 venous, ligation of artery in, 43 Heart, acupuncture of, 144 " electro-puncture of, 145 Hernia, 103 " dangers of invagination of, 105 " differential diagnosis, 107 " false reduction of, no " incarcerated, 104 " invagination of, 105 " irreducible, 104 " radical cure of, 117 " symptoms of strangulation, 106 " taxis in, 106 " treatment of, 107 " treatment of strangulated, 108 INDEX. 211 Hernial contents, 104 " neck, 104 " sac, 104 " orifice of, 104 " peritonitis within, 107 " strangulation, site of, 107 Herniotomy, 111 history of, in operation of, 11 1 internal, 112 treatment of gangren- ous intestine, 114 after treatment, 117 History of Transfusion, 57-58 Hooks, artery, 33 Hot douche in haemorrhage, 47 Hydronephrosis, treatment of, 152 Hydropericardium, indications for operation, 142 Hyperemia, pulmonary, bleeding in, 51 Hypogastric puncture, 155 Immediate dressing of wounds, 192 Imperforate anus, 126 " operation for, 126 Incarcerated hernia, 104 Increase, experimental, of amount of blood, 13 Incisions for cesophagotomy, 100 Indications for local bleeding, 55 for cesophagotomy, 100 Inflammatory invagination, 107 Infra-glandular tracheotomy, 89 Inhalation of oxygen in decom- pression of divers, 87 Injuries of heart, prognosis of, 144 " of bladder, causes, 157 " to bladder, intra-perito- neal, prognosis of, 158 " to walls of cerebral sinuses, 165 Injury of skull, treatment, 172 " of vessels, ligature in, 28 " to brachial artery in phlebot- omy, 54 Injection, subcutaneous, of blo.od, 66 Instruments for removing foreign bodfes from urethra, 155 Intestinal canal, impediments in, 97 Intussusception, 107 Internal herniotomy, 112 Intestine, resection of, 115 Invagination, acute, symptoms of, 106 " subacute, 106 inflammatory, 107 spasmodic, 107 of hernia, dangers of, 105 Irreducible hernia, 104 Irreducibility of hernia, causes of, 104 Kidneys, echinococci of, 152 Kolpeurynter, 44 Kropftod, 76 Laparo-colotomy, 127 Laryngeal injuries, tracheotomy for, 74 Laryngo-tracheotomy, 90 Lead acetate as a haemostatic, 49 Leech, application of, 57 " artificial, 56 " bites, arrest of bleeding from, 57 Ligature of injured vessels, 28 antiseptic silk, 31 antiseptic thread, at point of injury of arteries, 35 carbolized catgut, 28 catgut, organization of, 29 catgut, objections to, 31 " Chinese silk, 32 common thread, carbol- ized, 32 horse-hair, 31 hemp, 32 permanent substitutes for, 36 provisory substitutes for, 36 sea-weed, 31 English silkworm gut, 32 " silver, 32 Ligation in aneurism, 35 preparatory to great oper- ations, 35 in p .nctured wounds, 34 of main artery in venous haemorrhage, 43 of injured artery, 32 of middle meningeal ar- tery, 168 212 INDEX. Liq-ferri sesquichlor as a haemos- tatic, 48 as styptic in dental haem- orrhage, 47 Local bleeding, indications for, 55 Loss of blood, 13 " compensation for, 22 Loss of vital elements, 13 Lumbo-colotomy, 127 operation of, 127 Mass-ligature, 39 Maxillary, external, compression of. 36 Means for arresting haemorrhage, 22 Meningeal artery, haemorrhage from, 166 Method of removing foreign bodies from larynx, 74 " of ligating an artery, 32 '■' Esmarch's, advantages of, 22 Military cases, a type, 12 Mortal dangers, classification of, n Motion of blood, death from want of, 19 Neck, hernial, 104 Nitrous oxide, compressed air in poisoning from, 87 Nitric acid, fuming, as a styptic, 47 Nurses, 190 Objections to catgut ligature, 31 (Edema glottidis, 75 ' (Esophageal sound, 99 " introduction of, 102 guide for in- troduction, 103 " " Girard's meth- od of intro- duction, 103 (Esophagus, sites of obstruction in, 98 foreign bodies in, 98 " resection of, 101 removal of tumors from, 1 01 L (Esophagus, site of strictures of, 101 traumatic strictures of, 101 causes of stricture of, 102 " spasmodic stricture of, 102