The relations between the thymus and the thyroid are unmistakable, yet

obscure. In perhaps one-half of the cases where the thymus is enlarged

the thyroid is also increased in size. When one is removed the other

seems to undergo more or less compensatory enlargement. This would seem

to indicate a species of interchangeable function. Much less has been

ascertained between the relations of either of these bodies and the

pituitary, while nothing has as yet appeared concerning any sympathetic

involvement of the coccygeal body or Luschka’s gland.

=Diagnosis.=--Recognition of the status lymphaticus during life is

somewhat difficult, nevertheless there are certain suggestive features

which should arouse suspicion. Of these the close relation between the

status lymphaticus and rickets, already alluded to, furnishes a hint,

and, when recognized, a positive warning. Widespread enlargement of the

lymph nodes may furnish another. Adenoid growths in the nasopharynx

accompanied by enlargement of the spleen should be regarded as a

suspicious combination; and when an area of dulness is discovered over

the thymus, or when it can be detected by palpation, the diagnosis

may be regarded as established. Moreover, children who are subject to

this condition usually have a pasty complexion and an anxious facies.

Besides showing evidences of rickets they are anemic, with liability

to spasm of the glottis. The thyroid is often enlarged. In young

adults the condition may simulate cretinism, in that they are retarded

in growth and infantile in appearance, while sexual development is

incomplete.

=Treatment.=--In well-marked instances of status lymphaticus there

should be ordinarily no operative intervention; yet when the nose

and pharynx are obstructed it is advisable to give free channels for

breathing purposes.

Assuming that the result of experimental injection of thymic juice

shows it to have a depressing and pressure-lowering effect, an effort

should be made to ward off danger by the use of adrenalin, which should

be given previous to the commencement of the anesthesia. These are

cases where it is best to treat the surfaces to be operated with a

spray of mild cocaine solution, in order to deaden liability to those

impressions which may produce secondary and reflex cardiac disturbances

if conveyed to the brain. When operation is necessary for glottic

spasm or laryngismus stridulus it may be commenced with a tracheotomy,

with the use of a long trachea tube. When operation is required for

the relief of thymic enlargement, a preliminary tracheotomy should be

made, with the use of a long tube. The improvement which results after

the completion of the surgical treatment, for instance after removing

adenoids from the nasopharynx, is gratifying.

The most reliable measures have proved to be adrenalin and artificial

respiration, used as described in the chapters on Blood Pressure and

Shock and Anesthetics.

CHAPTER XV.

SURGICAL ASPECTS AND SEQUELS OF OTHER INFECTIONS AND DISEASES.

As a result of the conditions which two centuries ago and more so

distinctly separated the barber surgeon from the practitioner of

medicine, there has been evolved an artificial separation of surgery

from so-called internal medicine. The consequence has been a more

or less deep-rooted feeling that medical cases were to be treated

exclusively by non-operative measures, and that surgical cases could

scarcely be expected to present any perplexities that were not to

be solved by an operating surgeon. It has been no small part of

the benefit resulting from modern teachings that these imaginary

boundaries and limitations have been swept away; and one of the

lessons which this text-book is intended to inculcate is that broad

principles underlie disease conditions, and that their bearings must be

appreciated thoroughly in order to practise either medicine or surgery

successfully. In order better to inculcate this teaching a chapter with

the above general heading has been inserted, in order to impress the

statement that any of the so-called internal diseases may present at

almost any time indications for distinctly surgical intervention.

Some of the surgical sequels of the exanthematous and continued

fevers are well known and commonly recognized: for example, _orchitis

following mumps_, _suppurative inflammation of the middle ear after

scarlatina_, _and bed-sores after typhus and typhoid_. These are easily

recognized. Moreover, scarlatiniform eruptions occasionally follow

various operations and give rise to great perplexity.[4]

[4] Medical News, February 20, 1897, p. 234.

DYSENTERY.

Joint complications in this disease have been recognized from the

earliest times. One hundred and fifty years ago Strack expressed

himself thus: “If the dysenteric poison affect only the chest, it

causes asthma; if the limbs, it produces arthritis; if both, abscess.”

Joint pains and swellings, with other suppurations, have been noted in

several of the epidemics of this disease which have ravaged various

parts of the world at different times. Postdysenteric arthritis

may assume noticeable and even pyemic aspects, and is occasionally

fatal. The bones and joints may become involved in painful and even

suppurative swellings, not alone during the active stage of the

disease, but during the period of convalescence; while mildness of

the primary attack does not necessarily provide immunity from later

complications. Here thrombosis of large veins or thrombophlebitis are

also observed. When the joints are involved it is usually in irregular

order and not simultaneously. Joint lesion does not necessarily proceed

to suppuration, but perhaps only to the point of edema and fluid

exudation or hydrops. In the Cuban and South African campaigns, during

which dysentery prevailed, joint complications were noted.

CHOLERA.

Cholera is usually too rapid and too violent in its course to be

followed by secondary infections. Nevertheless, Poulet reports from

Val-de-Grace several instances of articular and osseous lesions, some

of these characterized by effusion of fluid which was sometimes very

thick and resembled balsam, while at other times pus was present.

PNEUMONIA.

Pneumonia having now taken its place as a distinct germ disease, and

the micrococcus of Fränkel and the capsule coccus of Friedländer

being well established as the active agents in the two principal

forms of this disease, pus may be found in other parts of the body.

The most common surgical sequels of pneumonia occur as postpneumonic

pyarthrosis, which has been wrongly considered a rheumatic affection.

These lesions are of embolic or of metastatic origin.

INFLUENZA, OR LA GRIPPE.

This disease has assumed prominence in medical literature, and not

a few instances have been reported of surgical sequels--abscesses,

purulent ear disease, pyarthrosis, bone lesions, etc. Even necrosis has

been repeatedly observed.

MEASLES AND SCARLATINA.

The infectious agent in these affections is not yet recognized and

their surgical sequels should be regarded as due to secondary pyogenic

infections.

Surgical tuberculosis appears often as a sequel of the exanthemas.

In the lymphatics, periosteum, bones, and joint cavities, and in and

about the eye and ear, manifestations of suppurative disease are often

found. It is believed that these sequels are likely to appear when the

eruption has been incomplete. Hyperplastic thickening of periosteum and

neuralgic pains of the affected parts occur without suppuration, hence

the rheumatic character which Bonnet and others have wrongly ascribed

to these manifestations.

While the absence of pus takes these out of the category of pyogenic

infections, it nevertheless leaves them still as surgical complications

which have often to be dealt with by mechanical measures, such as

orthopedic apparatus, etc.; while more or less formidable operations,

as for relief of ankylosis, have to be performed. Postscarlatinal

arthralgia may be explained as a local ischemia; so may acute swelling

or chronic thickening. But pus is an expression of infection, and

cannot be otherwise regarded. Retropharyngeal abscesses and a peculiar

necrosis of the alveolar process of the jaws, described by Salter,

are among the various serious surgical complications of scarlatina.

Epiphyseal separations and purulent destruction of ribs have also been

noted.

TYPHOID FEVER.

Although in elaborate treatises, as by Liebermeister and Murchison,

there is no mention of bone and joint complications as sequels of

typhoid, they have, nevertheless, been recognized by surgeons.

Post-typhoid hip dislocations have been reported by several German

surgeons. Boyer observed spontaneous dislocation of both thighs after

what he called “essential fever,” and the general topic of spontaneous

luxations subsequent to typhoid has been frequently discussed.

Those affections of joints formerly considered rheumatic occur

much less often after typhoid than after dysentery. Nevertheless,

post-typhoidal arthralgia and myodynia have been recognized by several

French writers. Some with affected joints, supposed to be rheumatic,

have later been discovered to be suffering from genuine typhoid

fever, and it has been afterward recognized that the joint lesion was

a bizarre expression of the typhoid poisoning. The works on general

practice call attention to the frequent complications of the pleural

and pericardial serous membranes in this disease. They say little,

however, about the implications of the articular serous membranes,

though one is as easy to explain as the other. Post-typhoidal

polyarticular serous arthritis has been described by more than one

writer. Multiple joint abscesses have been rarely seen. Pus has been

known to collect not only in the joints, but also in the tendon sheaths

and bursæ. The lymph nodes are also frequently affected, and cervical,

axillary, and inguinal abscesses are not rare. Post-typhoidal

pyarthrosis, as leading to spontaneous luxation, has had a medicolegal

interest, for luxation has been known to occur while raising or lifting

a patient, the question of violence being subsequently brought into

court. When the joint disease assumes the mono-articular form it is

likely to terminate in suppuration; when polyarticular, pyarthrosis is

less common. In the pus from many of these abscesses typhoid bacilli

may be recognized, but by no means in all. The writer has found them in

a case of abscess in the abdominal wall occurring during convalescence

from typhoid in a young woman. A non-suppurative but painful form of

periostitis is occasionally observed. I have never seen more exquisite

tenderness nor expressions of suffering than I met in a case of this

kind in a boy in whom the bones of both lower extremities, of the

pelvis, and the lower spine were involved. The slightest jar upon the

floor would make him exclaim with pain, and to minister to his ordinary

wants was a distressing task. He eventually recovered without any pus

formation. Deep suppuration in bones occasionally occurs, and even

necrosis with separation of sequestra.

Thrombosis and thrombophlebitis are also well-known sequels of typhoid,

which may lead to unpleasant complications. Typhoid fever appears

to bear a peculiar relation to the growth of bones, as it has been

noticed that during its course, or during convalescence, they show an

extraordinarily rapid growth in length, even to the extent of 1 Mm. a

day. This is probably caused by the irritation of the typhoid toxin

upon the osteogenic tissue, since hyperemic areas have been found in

the bone-marrow of those dying of the disease, and bone pains are a

frequent accompaniment of the disease. Typhoid bacilli have the power

of remaining latent in the tissues for a long time after cessation of

active symptoms, and have been found alive and capable of active growth

seven months after cessation of the fever. Remembering the multiple

ulcers of the lymphoid tissue which characterize the intestinal lesions

of typhoid, it is difficult to explain pyogenic or other septic

infection by absorption through these open ports of entry; and the

typhoid bacilli themselves, entering the circulation through these

paths, may be carried to all parts of the body, and have been found in

the pia.

A large amount of interest has attached to the so-called “_surgery of

typhoid fever_,” which, however, has been permitted to include only

abdominal section for perforation of intestinal ulcers. The mortality

due to this accident is nearly 70 per cent.--_i. e._, is formidable.

It occurs generally during the third week. It is usually preceded by

leukocytosis, and is followed by profound shock. Operation offers

almost the only hope. It has been successful in about one out of five

cases. (See Surgery of the Intestines.)

Post-typhoidal infections of the _biliary and pancreatic ducts_, with

their resulting complications, play a conspicuous part in the etiology

of biliary obstruction. They are regarded as among the most common

causes of acute and chronic or latent disease in these passages.

DIPHTHERIA.

This also belongs to the diseases frequently complicated by lesions,

aside from those of laryngeal obstruction calling for surgical relief.

Abscess occurs so frequently as to scarcely call for comment. Here,

as in the cases of scarlatina, the location of the throat lesions

and the absorbing powers of the lymphadenoid tissue so completely

involved will readily account for all septic or pyogenic manifestations

at a distance. Multiple abscesses have been found in the liver, the

spleen, and lungs, in and around bones, betokening thereby a pyemic

manifestation. Infectious nephritis is also common.

Mann, of Denver, has communicated to me personally cases of embolus of

the femoral artery with resulting gangrene as sequels of diphtheria,

as well as instances of true diphtheria of the penis, established by

bacteriological diagnosis.

MUMPS.

The infectious character of this disease is not questioned, although

not definitely established. Orchitis, ovaritis, stomatitis, enlargement

of the tonsils and spleen, and albuminuria are frequent accompaniments

of the disease, while articular and peri-articular complications have

been noted. Bursal abscesses and pyarthroses have also been reported.

These surgical complications have been regarded as rheumatoid or

rheumatic, their essential significance not being recognized until

recently.

VARIOLA.

The writers of the earlier part of this century allude frequently to

the rheumatoid complications of smallpox, among which pyarthrosis

seemed the most common and most serious. The various arthropathies are

the most interesting of the surgical complications of this disease. The

joints become swollen, red, and painful, one joint after another being

involved.

INFECTIOUS ENDOCARDITIS.

The individuality of this condition has been recognized only within

the last thirty years. That it deserves the characterization of

“malignant” often given to it is well known. It is an infectious

disease with a special localization in the heart, the term _cardiac

typhus_ being very expressive. Although so apparently spontaneous,

it is usually a secondary lesion, sometimes a primary infection. The

arthritic manifestations often assume a pyemic character, and even at

the beginning of the affection, as Trousseau pointed out, there are

frequently severe joint pains.

DENTAL CARIES.

Nearly one hundred species of microörganisms from the mouth have been

studied and identified by W. D. Miller, who has clearly established

that dental caries is due to the specific action of some of these

parasites, which, gaining entrance into the dental tubules, determine

fermentation and acid production, with erosion of the dental structure

of the teeth and an increase in softening and destruction. In this

way the teeth, as already indicated in Chapter IV, become paths of

infection for germs which may travel but a short distance, causing only

local disturbance, or which may be carried to other points about the

head, producing disturbance in the antrum, in the neighboring bones,

in the middle ear, and not infrequently in the brain. Abscess in the

brain has been distinctly traced to caries of the teeth. Tuberculous

infection is also common through this channel, and its most common

expression is probably the invasion of the cervical lymphatics,

superficial and deep, constituting those lymphatic tumors of the neck,

formerly known as scrofulous, with their disastrous train of adhesions,

suppuration, erosion, etc.

SYPHILIS AND GONORRHEA.

These are surgical affections whose secondary complications in the way

of abscesses, infarcts, tumors, etc., have been dealt with in other

parts of this work. It will be well to group all of these infections

with anthrax, glanders, etc., into a class of infections which may be

followed by tardy or late surgical sequels that may call for more or

less radical operation. In the case of gonorrhea this is best seen,

perhaps, in the so-called pus tubes of the female pelvis, which often

require removal years after the date of the primary invasion.

Endocarditis and pyemia are occasionally of solely gonorrheal origin,

as well as peritonitis by extension from infected pelvic viscera.

THE PUERPERAL STATE.

This is seldom followed by surgical sequels, save in the instance

of mechanical lacerations demanding plastic repair, or of septic

infections, which, when life is saved, sometimes lead to disastrous

consequences. Puerperal septicemia is in no respect different,

pathologically speaking, from septicemia due to any other presumably

streptococcus invasion; and the predilection which streptococci

manifest for serous membranes, and especially joints, is well known.

Consequently after puerperal fever one may meet with articular or

peri-articular abscesses, affections of tendon sheaths, lymphatics,

etc., or the complication may assume a different type, the veins and

their contents being mainly involved, with thrombosis, infarct, etc.,

for its immediate results.

There is probably no disease of known or suspected germ origin which

may not be followed by disastrous or unexpected surgical complications,

while even degenerative changes, for which as yet no theory of

parasitism has been invoked, are followed by conditions which may

call for serious surgical measures. _In other words, the surgical

complications of any so-called non-surgical disease may loom up at any

moment in any case._

CHAPTER XVI.

POISONING BY ANIMALS AND PLANTS.

Certain poisons or deleterious substances are introduced in various

ways into the human system from without, some of which produce

only symptoms of moderate intensity, while others are fatal. It is

authentically stated that in India many thousands of individuals lose

their lives every year as the result of the bites of poisonous snakes.

In 1903 there were officially reported 23,164 deaths from this cause.

Nothing approaching such injuries in frequency or intensity can be

found in any other part of the world. Animal poisons may be introduced

by animals of many species. The poison of hydrophobia has been

described. The bites of the mammalia may be serious and may be followed

by septic symptoms, but are not ordinarily regarded as due to any

special toxin secreted by the animal. A number of reptiles, however,

possess special _poison glands_ which are connected, in most of them,

with a tooth on either side of the upper jaw which is canaliculated,

and serves as a duct through which the poison is injected when the

animal inflicts its bite.

SNAKE BITES.

The principal poisonous serpents in North America are the

_rattlesnakes_--of which there are several species, usually placed at

eighteen--the _copperheads_, the _moccasins_, and the _vipers_. Some

of these have movable poison fangs, some fixed. In other parts of the

world others equally or even more poisonous are known.

The poison gland is analogous to the parotid in location and structure.

The duct which runs through it is so dilated as to contain a small

amount of the peculiar poison. The amount of poison contained in these

reservoirs varies from eight to twelve minims, and is secreted somewhat

slowly. It seems to be, in some cases at least, a _glucoside_; in

others, a _toxalbumin_. It is capable of being preserved either dry

or in alcohol or in glycerin. The active poisonous principle seems to

pertain to a _globulin_ or to a _peptone_. Almost all of these venoms

are innocuous if swallowed, and like septic infections seem inoculable

only through the tissues and the circulating fluids. According to

Mitchell, the venom of the rattlesnake renders the blood incoagulable,

paralyzes the walls of the capillaries, and facilitates escape of

leukocytes into the tissues, thus making actual hemorrhagic swelling

occur; while the red corpuscles rapidly lose shape and fuse into

irregular masses and their hemoglobin is dissolved or disappears. This

poison seems to paralyze both the respiratory centre and the heart.

Cobra poison, not containing globulin, at least to a great extent, does

not produce the rapid changes of rattlesnake poison.

=Symptoms.=--A snake bite is like a hypodermic injection of a deadly

poison, and symptoms set in promptly. These are both local and general.

There is more or less local pain, with swelling and discoloration,

which are due to effusion of blood. They increase in intensity, and are

followed by vesication and necrosis of tissues--that is, gangrene--if

the patient survive for some time. Constitutional symptoms are not long

delayed, and are characterized by severe prostration, including cold,

clammy sweat; feeble and rapid pulse, irregular respiration, etc. When

patients succumb they usually die in collapse. The pathological changes

are not well-marked or characteristic.

=Treatment.=--Treatment of snake bite must be prompt if it is to be

successful. It should consist of incision and drainage of blood from

the part, in order to prevent diffusion into the rest of the body by

means of the returning blood and lymph. Bleeding should be facilitated

by cups or by sucking the wound. An elastic tourniquet should be

applied around the limb near the trunk, the site of the wound freely

incised, and the blood worked both ways toward the wound by “stripping”

the member. If there be any known antidote to snake poison it consists

of potassium permanganate or calcium hypochlorite (chloride of lime),

applied locally in solution, the former sufficiently strong to have a

marked color and capable of producing local irritation (1 per cent.).

With these local measures, constitutional stimulation should be

indulged by means of volatile and other stimulants. There is a popular

fallacy in favor of inducing alcoholic intoxication. To do this is

a mistake. Nevertheless, alcohol may be given freely, dosage being

limited not by amount but by effect. Strychnine, digitalis, atropine,

etc., will often prove serviceable. The tourniquet should be gradually

released after being in use for two or three hours, and an assistant

ready to antidote the poison which may then enter the system with

the necessary doses of stimulants above mentioned. One-half grain of

strychnine may be administered in divided doses, it apparently being

an antidote to the snake venom. There is much reason from recent

experimentation to expect benefit from serum therapy--_i. e._, by

injection of serum from immunized animals who have been fortified by

increasing doses of the snake poison. Calmette advises the use of 20

Cc. of serum from a horse which has been immunized by cobra poison. He

believes the active poison of all venomous serpents to be essentially

identical. Good results have been reported even after an interval of an

hour. In this country, however, such treatment will be called for so

seldom that there is not the hopeful outlook for the serum therapy of

snake bite that there is in India.

POISONING BY LIZARDS.

A large lizard found in the southwestern part of this country and in

Northern Mexico, known as the _Gila Monster_ (_Heloderma suspectum_),

is credited with being a poisonous animal. The probability is that the

bite is fatal to some of the lower animals and may produce more or less

serious disturbances in man. Nevertheless there is little real evidence

that this is to be considered in the same category with the venomous

serpents above mentioned.

POISONING BY SPIDERS AND SCORPIONS.

Certain species of _spiders_ are venomous, the _tarantula_ being

the best known. Certain _scorpions_ also inflict poisonous stings,

and _centipedes_ and other animals occasion at least serious local

disturbance by bites or stings. These insects and animals seldom

attack unless irritated or disturbed. Tarantula bites are occasionally

inflicted in the Northern States by spiders which have concealed

themselves in shipments of fruit, bunches of bananas being especially

likely to be their hiding places. The injuries inflicted by these

animal organisms cause local pain, considerable swelling, with remote

effects on the nervous system, prostration, restlessness, etc. They are

seldom fatal, but may cause annoyance and serious disturbance. These

cases are to be treated in the same way as bites of poisonous serpents,

adapting the measures and the energy of the treatment to the severity

of the symptoms.

POISONING BY WASPS, HORNETS, AND BEES.

_Wasps_, _hornets_, and _bees_ are capable of inflicting severe stings;

domestic insects, like _mosquitoes_, _bed-bugs_, etc., inflict minute

wounds which sometimes occasion excessive annoyance. Their sting is

followed by pain, burning sensation, sometimes intense itching, and

more or less swelling. Enough poison is deposited to produce local

vasomotor paralysis, as the result of which wheals resembling those

of urticaria, or more extensive swellings, quickly result. If the

sting of an insect has been broken off in the flesh it may remain and

intensify the disturbance. Two or three injuries of this kind create

local disturbance, but there are some instances on record where men

and animals have been stung to death when attacked by swarms of these

insects, death apparently being due to intensification of effect owing

to increased dosage of poison. If a sting occur upon loose tissues,

like the eyelid, or upon the tongue or lips, swelling and suffering may

be extreme. If symptoms of depression present, they should be combated

by stimulants, diffusible or other, and by hypodermic medication _pro

re nata_. Local discomfort may be alleviated by ice, by menthol, by

chloral camphor, etc.[5]

[5] Oil of lavender is a pleasant means of local protection against

mosquitoes, etc. Oil of tar is also in common use. A mixture of equal

parts of camphor and chloral, with menthol dissolved in the mixture

(camphor and chloral when mixed without other ingredients quickly

form a dense fluid like glycerin), gives great local relief from the

itching and pain of insect bites.

_Many of the lower forms of marine animals_ are capable of inflicting

stings by their rays, or minute injuries in other ways, which give

rise to great temporary annoyance. The _stinging nettle_, etc., is an

instance of this kind. The lesions produced in this way partake of the

nature of a more or less acute dermatitis.

ARROW POISON.

The _arrow poison_ of various Indian and savage tribes is a composition

of variable and usually unknown nature. It is compounded, for the

most part, from vegetable substances, and, if one may judge from the

specimens of _curare_ sold by importing houses, their strength is

unreliable.

While some of these preparations are made by the natives from a species

of Strychnos growing in the northern part of South America, this tree

is not in universal use for this purpose: in the East Indies they are

made from a species of Upas (the deadly Upas of song and story). Some

of the poisoned arrows are dipped in putrefying blood. A wound made

by these is not necessarily promptly fatal, but would tend to kill by

setting up septic disturbance. The vegetable poisons have the property

of paralyzing the motor nerves and the circulation to such an extent

that death may occur within a few moments after injury. All of these

poisons are innocuous when swallowed, and game killed by their agency

may be eaten without fear of ill results. Arrow poison of the vegetable

variety which is not fatal within a few hours may be recovered from if

stimulation be vigorous. Artificial respiration is a factor in keeping

such patients alive.

IVY POISONING.

_In the vegetable kingdom_ there is one kind of plant, the so-called

_poison ivy_ (_Rhus toxicodendron_), which is capable of producing

intense dermatitis. All persons are not susceptible to this

poison--least so those of thick skin and dark hair. It is generally

those of blonde type and thin skin who seem most liable to its

irritation.

The active agent is _toxicodendric acid_, and it is capable of setting

up an intense irritation of the eczematous type, with a large amount

of hyperemia and edema, especially of soft tissues. When the face is

involved the eyelids become puffed so as to make it almost impossible

to separate them for purposes of vision. _Ivy poisoning_ is usually

contracted by contact with the plant. Symptoms supervene generally

within twenty-four hours, and in well-marked cases do not subside for

three or four days. The itching is intolerable, and is best combated by

strong alkaline solutions or brine. A dilute bromine solution sometimes

proves beneficial. Salt and soda in strong solution and vigorous

catharsis are also useful. Hypodermic injections may be necessary to

induce sleep.

Certain species of _sumach_, particularly the genus Cypripedium, may

produce similar symptoms, usually less severe.

CHAPTER XVII.

ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS.

DELIRIUM TREMENS.

Delirium tremens as an expression of acute or subacute alcoholic

poisoning is in no essential degree a surgical condition. This form

of toxic delirium may occur while the individual is still drinking

inordinately, or not until several days have elapsed after active

drinking has ceased. It is precipitated in many cases, where otherwise

it would simply remain imminent, by surgical injuries and operations.

In one in whom it is feared, the surgeon should become apprehensive in

proportion as the muscular system becomes unsteady and tremulous, the

mind disturbed, and the individual sleepless.

Patients in a well-marked condition of delirium tremens may become

so uncontrollable and so lost to sensation of pain that it may be

practically impossible to enforce the physiological rest which their

surgical condition demands. The restraining sheet will answer for

general purposes, but the strait-jacket and even the most carefully

applied plaster splint or mechanical restraint will not always be

sufficient to carry out the indication.

Ingenuity may be taxed beyond its limit to enforce the needed rest, for

patients will tear off bandages and injure themselves in various ways.

=Treatment.=--The _local indications_ are in the direction of

_physiological rest_. _Constitutionally_ the indications are in two

directions: First, _to keep up nutrition_ and _excretion_; secondly,

_to properly medicate_. Nutrition is difficult unless excretion is

maintained. Hot-air baths, laxative enemas, preferably of cold water,

when necessary, and administration of a fluid and easily assimilable

diet are measures of the utmost importance. Should the case present

features of an acute alcoholic gastritis, stomach feeding may be

abandoned and the rectum utilized for this purpose. _Medication_

should consist mostly of stimulants, with such sedatives, laxatives,

diuretics, etc., as may be necessary. In surgical cases it is not wise

to abruptly deprive these patients of the alcohol which they have so

abused. Consequently in many instances a mild degree of alcoholic

stimulation, at least for a time, should be continued. Two stimulants

rank higher than all others as substitutes for alcohol, and in some

degree antidotes to its effect. These are _strychnine_ and _digitalis_.

The former should be given preferably subcutaneously; the latter by the

stomach if tolerated, otherwise by the rectum or beneath the skin. My

own preference for the use of digitalis is in the direction of large

and few doses. I have not hesitated in many instances to give 15 Cc.

of ordinary tincture, repeated once or twice at intervals of a few

hours, and then to discontinue it. The effect is to brace up the heart

and to equalize the circulation, while at the same time it acts as an

efficient diuretic. _Adrenalin_ may be necessary, but should be used

with discrimination.

Of the sedatives, bromides, chloral, and remedies of that class are

those most often resorted to, and should be given in doses sufficient

to meet the symptoms. They are all more or less depressant, and

stimulation by strychnine, etc., is necessary even while they are being

administered, in spite of the apparent physiological antagonism between

them. Opium is the remedy of choice, and is best given in the form of

morphine introduced beneath the skin.

The first indication is in the direction of ensuring rest and sleep,

even at the expense of inconvenience or misfortune in other directions.

I write this with a realizing sense of its significance, yet with

positive conviction as to its truth.

Upon the assumption that this form of delirium is a toxemia of

complicated type, only benefit can accrue, in aggravated cases, from a

free venesection, followed by intravenous infusion of a pint or more of

saline solution, at a temperature of 105° F.

TRAUMATIC OR POSTOPERATIVE MANIA.

It is difficult to distinguish this form of mania from that known

as _puerperal mania_, the two conditions being essentially similar.

This, too, is to be regarded as a complicated toxemia, in which

products of defective metabolism, of insufficient elimination, and of

phagocytic activity mingle in a blood whose corpuscular elements are

already much disturbed by injury or hemorrhage. Regarding these cases

from a surgeon’s standpoint, and carefully avoiding any attempt at

minute explanation of the phenomena, such cases are met with in the

practice of operating surgeons, as in the experience of obstetricians,

presenting themselves either as mild forms of harmless mental

aberration, or assuming almost any of the types of insanity as made

out and classified by experts in that subject. From the mildest mental

alienation up to intense and even homicidal or suicidal mania, one may

meet with all degrees of departure from the normal standard. Bowel

washing, hot-air baths, hepatic stimulants, and carefully regulated

nutrition will usually restore to the brain its natural food supply,

and hence its normal function. I have repeatedly seen much good result

from the exhibition of small doses (0.30 to 0.50) of potassium iodide.

TOXIC ANTISEPTICS.

As stated above, it is generally recognized that in people of peculiar

idiosyncrasies the administration of certain drugs ordinarily

considered harmless is followed by more or less toxic symptoms.

Obviously if this were universally the case, or true in the majority of

instances, the use of these drugs would speedily be abandoned. As it

is, it is well to have in mind the consequences which are occasionally

known to ensue, and perhaps to weigh in every case the chances as to

whether it is worth while to use a given substance of known occasional

toxic power as against another which is not known to possess it.

Of the less active antiseptic agents, _boric acid_ is considered

absolutely innocuous, yet is known sometimes to cause intestinal

disturbance, while in one instance serious toxic effects followed its

use. _Naphthalin_ will sometimes produce vertigo or vasomotor symptoms,

especially when administered internally. Many of the antiseptic

materials used are more or less irritating to the skin, and such local

expressions as _eczema_, etc., provoke little comment.

_Iodine_ is a drug whose activity should be borne in mind. Applied

upon the surface, it tans the skin and does no good. Injected in

solutions of varying strength into serous cavities (for example,

hydroceles, etc.) it gives rise to symptoms which may be alarming.

Fatal poisoning following its injection into an ovarian cyst has been

reported, and alarming symptoms have been produced by injection of the

ordinary solution into a hydrocele sac. Much of the virtue ascribed

to _iodoform_ is credited to the liberation of free iodine by its

decomposition. Whether or not this be true, iodoform is one of the

most frequently toxic of the antiseptic agents in ordinary use. In

mild cases it produces headache, restlessness, wakefulness, and often

a distinct taste of iodoform in the mouth. In more pronounced degrees

of poisoning there is fever, often with mental derangement which may

amount to delirium or even to acute mania, and may cause well-founded

suspicion of meningitis. Death after its use has repeatedly occurred

from syncope or in coma.

_Carbolic acid_ produces unpleasant effects, both upon patient and

operator, or with whoever it may come in contact. Aside from its local

effect upon the skin, which is most unpleasant, but which usually

passes away within a few hours, it seems to affect especially the

kidneys, causing often temporary albuminuria with discolored urine,

deranged secretion, and sometimes more acute forms of disturbance,

similar to those met with after its internal use. Carbolic poisoning

was observed most frequently during the era when Lister’s original

directions were scrupulously followed, and at a time before it was

learned that it is much better to remove dirt than to try to antagonize

its action. Eminent surgeons were compelled to discontinue its use

because of its unpleasant effect upon themselves as well as upon their

patients.

Among the powerful antiseptic agents in common use are the soluble

preparations of _mercury_, ordinarily _corrosive sublimate_, in

solutions of varying strength, which are used for irrigation,

douching, etc., and for preparation of dressings. An intense eczema

may follow its local use, and symptoms of mercurial poisoning may

appear in individuals of peculiar susceptibility to this drug.

Salivation, intestinal irritation, and other phenomena of mercurial

poisoning have been produced, with the result that the solutions and

preparations of corrosive sublimate are much weaker than those which

were used at first. The drug eczema produced by _corrosive sublimate_

interferes with one of the essentials of ideal wound healing--_i.

e._, physiological rest. The area involved should be protected with a

sterilized powder or by anointing it with sterilized ointment.

PART III.

SURGICAL PRINCIPLES, METHODS AND MINOR PROCEDURES.

CHAPTER XVIII.

DISTURBANCES OF BLOOD PRESSURE; SHOCK AND COLLAPSE.

The maintenance of the normal pressure of the blood is a material

factor in the welfare of surgical cases. Deviations in the direction of

lowered pressure constitute the most important features of _shock_ and

_collapse_. Prevention of loss of blood is but one of several complex

indications in prophylaxis and after-treatment.

Blood pressure is maintained in large part by the vasomotor system

of nerves, whose prime centre is in the gray matter of the fourth

ventricle, with subsidiary centres in the spinal cord and great

ganglia. Stimulation of these centres causes contraction of the

peripheral arterioles and increases intravascular pressure. If,

however, it be long-continued or excessive, these centres become

exhausted, vasomotor paralysis results, the arterioles dilate, and

pressure is lowered.

Three factors coöperate to maintain this pressure:

1. Regular and normal rhythmic heart action;

2. Normal vascular contractility;

3. Normal quantity of suitable fluid in the vascular system.

Departure from the normal in any one of these factors causes

perceptible disturbance, but when in all three of them it may prove

fatal. Whether this be caused by emotion, accidental injury, or

deliberate operation is of slight concern, as the effect is essentially

the same.

The pulse will usually tell its own story to the experienced observer,

but scientific accuracy in measuring blood pressure can only be

obtained by certain instruments of precision, such as the _tonometer_

or the _sphygmomanometer_, consisting of an air-containing armlet

which encircles the arm, a bulb by which the pressure of air can be

regulated, and the whole connected with a manometric gauge and mercury

tube. These instruments can be procured of the dealers, and their

employment during an operation gives the operator a continuous record

of the blood pressure, by which he may judge at any moment of the

degree of shock.

The normal blood pressure in healthy adults is 130 to 140 Mm. of

mercury in the tube. In children it ranges from 90 to 110 Mm. Females

have an average lower pressure of 10 Mm.

Excitement or slight stimuli will send the pressure up thirty or forty

points. It is also higher than the above average in arteriosclerosis.

In uremia it is always high. In cases of intracranial tension it is

also high, as the brain alone of all the organs of the body has no

complete vasomotor apparatus of its own; when it needs more blood this

has to be contributed from the general supply. When pressed upon by a

clot, depressed bone, or foreign body it becomes anemic, and on effort

to furnish the needed blood from other parts the vascular tonus is

increased. Cushing has shown the value of these estimations in cases

of _head injury_, for the rise of blood pressure may be regarded as an

indication for operation. In typhoid fever a sudden rise of pressure is

associated with perforation, or perhaps with the peritonitis which is

its immediate result. On the other hand, in this disease a sudden fall

of pressure is an indication of hemorrhage.

The course of events in surgical shock is about as follows: Injury to

afferent sensory nerves acts as a vasomotor stimulus after it reaches

the centre in the fourth ventricle; a reflex impulse is then sent out

which produces arterial contraction and raises the blood pressure.

When the abdomen is concerned the opening and handling of its contents

produce the same result through the splanchnic centres. If, however,

the stimulus is excessive, too often repeated, or too prolonged the

vasomotor grip is lost, the arterioles dilate, and the blood pressure

is reduced. A severe injury to any part of the body may produce this

effect without the preliminary rise. The popular impression that a

patient “bleeds to death into his own veins” has this to justify

itself, that the arterial tonus is lost and the blood is pumped through

the arterioles to accumulate in the capillaries and veins, especially

the abdominal, thus overloading the right side of the heart and giving

it a disproportionate amount of work.

Accompanying these circulatory disturbances are others, secondary and

unavoidable, as of respiration, which becomes rapid and enfeebled in

proportion to the degree of shock.

Any factor which tends to weaken the heart’s force favors both

phenomena. So important is the respiratory action that patients die

from cessation of respiration rather than from impairment of the

circulation. This shows the importance of maintaining artificial

respiration in cases of severe shock.

Cushing and Crile have studied the subject exhaustively in animals.

They have shown that certain injuries are likely to be followed by

well-marked reduction of blood pressure; for example, those of the

brain, the interior of the larynx, the abdomen and testicle, are often

followed by a marked reduction of pressure without any preliminary

rise. In other words, vasomotor paralysis is sometimes an almost

instantaneous effect of certain injuries. When most of the blood is

collected in the venous system and the central nervous system fails,

because of lack of blood supply, to respond to those normal stimuli

which are essential to heart action and respiration, the heart weakness

or heart failure is due, not alone to failure of its innervation, but

to its reduced output and its diminished content of blood on the left

side.

Crile has shown that the more abundant the blood supply to a given part

the more it contributes to production of shock; hence, the value of

cocainizing the interior of the larynx and the nerve trunks.

Aside from emotional causes--which are sometimes inseparable from even

surgical cases--the principal agencies in the production of surgical

shock and collapse are those which make a sudden and deep impression

through the medium of the sensory nerves upon the central nervous

system or the large sympathetic ganglia; ultimately upon the latter in

all serious cases. _Loss of blood, then, need not play a very important

role._

Weakened, anemic, or neurotic patients are predisposed by virtue

of these conditions, and also the young and aged. Fright combined

with injury increases the degree of the effect. Crile has shown that

trifling lesions of the interior of the larynx will cause symptoms

which do not occur in animals if the superior laryngeal nerves be

divided or if the parts be cocainized.

The upper portions of the abdomen are more sensitive in this respect

than are the lower, testicles particularly. The skin is more

impressible than the muscles or tissues beneath, save the nerve trunks,

which are very sensitive; the bones and large joints slightly so. After

shock has been once produced further injury causes a disproportionate

lowering of blood pressure.

So-called “concussion of the brain” is essentially a condition of

shock following injury to this particular part of the body. (See Head

Injuries.)

_Shock and hemorrhage are often closely associated_, and loss of

blood is doubtless a powerful factor in the production of the former,

especially in those already reduced or whose blood contains a lowered

percentage of hemoglobin. There are, therefore, great advantages in

entrusting an assistant with the duty of watching blood pressure during

serious operations.

The terms _shock_ and _collapse_ are nearly interchangeable, but, by

common consent, the latter is usually the name given to conditions that

are more sudden and overwhelming. Shock may be of all degrees--from

temporary faintness, from which the patient recovers within a few

moments, up to a condition of vital depression which terminates

fatally, there being no reaction in spite of all efforts to produce it.

=Symptoms.=--These vary to a considerable extent according as the

patient is or is not under a general anesthetic. The description of

_types_ and _symptoms_ includes an expressionless face, pallor of the

skin and mucous membranes, with corresponding coldness of the same,

_i. e._, reduction of surface circulation and heat; dilated pupils,

reacting slowly to light; irregularity of the heart’s action, with a

weak, irregular, thready, or almost imperceptible pulse; irregular

respiration, _i. e._, irregular both in rate and depth; mental

inactivity and apathy; loss of voluntary muscle movement; impairment of

superficial sensibility; reduction of body temperature; and nausea or

actual vomiting. These at least constitute the symptoms and form the

apathetic or torpid type of shock.

In the so-called erethistic type (Travers) the patients are restless

and excited, uncontrollable, with irregular pulse and breathing, often

with dilated pupils.

In a third type, described by Travers as the _delayed_, the symptoms

are as above detailed, but do not appear until some hours after the

cause which has produced them, which may be a concealed (internal)

hemorrhage. The delayed type is also seen in those who escape serious

accident with a minimum of physical harm.

As shock becomes more pronounced, mental depression deepens into coma,

or mental excitement subsides into it; the surface becomes colder and

bathed with perspiration, and death follows. These symptoms are those

generally noted, whether following injury to the head and denoting

so-called concussion of the brain, loss of blood, wound of the

abdomen with injury to the viscera, blows upon the testicles, gunshot

wounds or other accidents which are causes of shock. They follow also

after perforation of the bowel, as in typhoid fever or appendicitis;

depression following the receipt of bad news, or fright, etc.; in other

words, the physical condition is practically the same no matter what

the exciting cause.

=Diagnosis.=--Shock is mainly to be diagnosticated from fat embolism;

concealed hemorrhage as well as pulmonary edema and suppression of

urine are to be suspected. It is unquestionable that many patients have

died of fat embolism in whom the actual cause of death has not been

ascertained, yet has been ascribed to shock. (See Fat Embolism, Chapter

II.)

=Treatment.=--The treatment of shock consists essentially in measures

directed toward raising the lowered blood pressure. At the outset

reaction should not be established too quickly, lest it be succeeded

by overaction, with attendant disasters in the shape of secondary

hemorrhage, etc. Patients should not be expected to swallow nor act

as they would under other circumstances. They should not drink strong

liquors, for the irritating fluid may escape into the larynx and induce

coughing, which might prove fatal. The same is true of inhalations of

strong volatile stimulants, like ammonia. These measures, therefore,

should all be resorted to with great care and discretion. Warm,

stimulating drinks, if they can be swallowed, are useful; and whisky,

brandy, etc., should be given dilute and warm rather than strong and

cold. External heat is advisable, and can be supplied by immersing

the patient in a bath-tub of warm water, care being taken to keep the

face out of the water. When this is not at hand, bottles and other

receptacles for warm water may be used, but with caution, since too

much heat has been the cause of serious burns.

Numerous drugs have been recommended in the treatment of shock.

There are but two or three which are worthy of confidence. Crile, of

Cleveland, subjected a large number of animals to tests in regard to

the effect of various drugs in influencing blood pressure. He found,

for example, that alcohol apparently produces more depression, and

in deep shock is dangerous. Nitroglycerin and amyl nitrite seem to

increase shock and lower pressure. Digitalis may produce a temporary

rise in pressure, but in considerable doses impairs or arrests

respiration, and it seemed to him that cases of severe shock treated

with it did not live as long as the control animals. Strychnine has

been one of the main reliances in these conditions. Crile found that if

enough were given to cause increased excitability of the spinal cord it

raised the blood pressure, while small doses had little or no effect.

Pressure was raised by doses large enough to produce convulsions;

repeated smaller doses had little effect, tending rather to increase

shock.

These were the experimental results in the treatment of shock, and are

to be distinguished from what may be done with the same drugs in the

way of fortification and preparation as against shock. Thus strychnine

always exalts susceptibility of the cord of the medulla and digitalis

may temporarily supplement its use; together they may help to sustain

pressure or to fortify as against depressing agencies. They are like

whip or spur to a jaded horse.

Morphine alone, or in combination with ether as a general anesthetic,

reduces susceptibility to shock, and appears to be an equalizer of

pressure and a tranquillizer of an excited heart. Nitroglycerin and

the nitrites usually fail to raise or even sustain pressure. _Saline

infusion_ and _adrenalin_ are the _reliable and efficient means_ to

be used in combating shock and collapse; _they always raise blood

pressure_, and the latter is the most powerful of all known vasomotor

constrictors. Adrenalin always produces rise of blood pressure,

even after cocainization of the medulla and cord or destruction of

the medulla, division of the splanchnics, or arrest of the heart by

powerful electrical currents (2300 volts, alternating). Even after

death by decapitation and an interval of fifteen minutes, adrenalin

salt solution thrown into the veins causes a rise of blood pressure.

If this be combined with artificial respiration and rhythmic pressure

over the heart, resuscitation is possible in most extreme cases. In one

case, reported by Crile, a human heart which had stopped beating for

nine minutes was made to resume its pulsation for thirty-two minutes.

From all this it will appear that the heart stimulants, so called, have

a very limited applicability.

Crile further experimented by raising the atmospheric pressure

surrounding the animal, and found that blood pressure was somewhat

exalted. The reverse was also found to be true. When he so arranged his

experiment that an animal inhaled air under increased pressure he found

the tendency was rather to impairment of heart action, blocking the

circulation and reducing pressure. Changing the experiment and causing

the animal to breathe air at normal pressure while the body was under

increased atmospheric pressure, blood pressure was notably raised, but

respiration became labored and the heart’s action impaired. After death

the heart and the pulmonary vessels were found engorged.

This has its practical interest because it concerns not alone the

general treatment of shock, but the management of those cases where

the thorax must be opened, as in the surgery of the heart, the lungs,

the esophagus, etc., and the mechanical devices recently suggested

for maintaining differences of atmospheric pressure, and preventing a

traumatic collapse of the lungs.

These experiments also suggested the so-called “_pneumatic suit_”

devised by Dr. Crile, which is in effect a double-layered garment

of rubber cloth. The patient is enveloped in the suit, which can be

inflated with an ordinary bicycle pump, so that pressure is made upon

the surface of the body, and at the same time evenly distributed.

By such pressure accumulation of blood in the venous reservoirs is

prevented, and the emptying of the arteries, especially those in the

brain, is prevented. This is a more perfect and ideal application of

the idea underlying the practice of _bandaging the extremities_ or

raising them, in extreme conditions of shock; the former requires an

elaborate and expensive outfit, while for the latter purpose cotton

bandages or rubber may suffice. The latter, however, must be used with

great caution lest pressure be overdone. When the bandages are removed

they should be taken off slowly, and from one limb at a time, lest the

change be too abrupt.

Two other expedients are of the greatest value in conditions of

this kind; the first is _artificial respiration_. This cannot be

carried out, as is done on experimental animals, in a well-furnished

laboratory, by opening the trachea and making connection with a pump;

it must be effected by the usual methods, coupled with the aid afforded

by the improved Fell apparatus. If oxygen can be administered at the

same time it will enhance the effect.

The second expedient is _rhythmic pressure_ made over the lower part

of the thorax, or beneath the ribs, by which is produced a stimulus to

contraction of the heart. This may be made slowly at first, but may

approximate a rate corresponding to a slow pulse.

The temptation is to use the adrenalin solution too strong or in too

large doses. It may be administered in doses of 4 or 5 minims in a

small syringeful of salt solution, but when the symptoms are profound

and the case urgent, 300 to 500 Cc. of sterilized salt solution,

containing the same amount, should be injected beneath the skin into

the subcutaneous cellular tissue about the shoulder-blade, the buttock,

behind the breast, or into a convenient vein. Much larger amounts, even

up to 1000 Cc., may be used, but the adrenalin should never be mixed

until just before using it, as it is quickly oxidized and changed, and

should be used in the freshest possible condition. With salt solution

containing 1 to 50,000 of adrenalin and continuously administered,

Crile has kept a decapitated dog alive for over ten hours--that is,

the heart continued its action. One may agree with him, then, in the

statement that “_control of blood pressure is the control of life

itself_.”

Mathews, after a careful study of the osmotic behavior of blood plasma

and saline solutions, has shown that the ordinary salt solution, which

has been usually made in proportion of 6 to 1000, is not the best which

can be used for purposes of saline infusion. Many observers have added

potassium and calcium salts to such a mixture, the latter, especially,

because of its property of increasing the coagulability of the blood.

The following mixture meets the indications for what may be called

the “balanced” physiological solution: Sodium chloride 0.9, potassium

chloride 0.03, calcium chloride 0.02, water 100.[6]

[6] To the fluid for hypodermoclysis (salt solution) there may be

added a proportion of grape sugar, by which much is gained of true

nutritive value, which may be enhanced by the addition of pure

pepsin peptone free from albumose. Thus if every four hours there

be injected beneath the skin 100 Cc. of water containing 2 grams

each of grape sugar and table salt to 4 grams of pepsin peptone,

the necessity for further nourishment may be almost obviated, at

least for a period of two or three days at a time; as for instance

when intense nausea of severe peritonitis prevents the ingestion of

anything possessing food value. Credé recommends for the same purpose

a preparation containing soluble albumin in the strength of 95 per

cent., with traces of iron and salt. This preparation is called by

him kalodol, and much resembles blood albumin, which is why it is so

easily assimilated. According to Credé, four injections of kalodol a

day will suffice for ordinary needs.

It must not be forgotten that indiscriminate resort to intravenous

infusion may do great harm. It is a minor procedure which requires

skill. When the lungs are congested from the irritating effect of

ether, and the right heart is embarrassed, a too sudden flushing with

saline solution may further embarrass it or even check its activity. So

with a patient in the Trendelenburg posture, the intestines are crowded

up against the diaphragm and its natural downward play impeded, though

the brain is better supplied with blood in this than in any other

position.

Much may be done in the way of _prevention_ when shock can be foreseen.

This includes the general fortification of the patient by overcoming

any auto-intoxication which may have been previously noticed, by

improving elimination, and by stimulating the heart’s action with

strychnine, digitalis, cactus, etc. Atropine is especially a stimulant

to the respiratory centres.

Once the operation is begun, and remembering that the depressing

influences which tend to reduce blood pressure are transmitted through

the afferent nerves, we may take advantage of Crile’s suggestions and

temporarily paralyze them, by exposing them and injecting directly

into the nerve trunks two or three drops of 1 per cent. cocaine

solution. This should be done before division of the main trunks

and at a point above the line of section. It is possible during an

amputation, by taking a little extra time and pains, to “block off,” as

it is called, the nerves in this way and prevent their conveying any

depressing sensation. At other times, as in operations on the mouth,

and especially the larynx, cocaine solution may be used locally, as

by the spray, and the same effect produced. Cocaine seems to be a

protoplasmatic poison which inhibits nerve action.

In the description of the treatment of shock there has been little

reference made to the result of loss of blood as such. In cases where

this has already occurred, or cannot be prevented, it should be

atoned for by the infusion of saline solution, either by intravenous

introduction or by hypodermoclysis, _i. e._, its injection into the

loose connective tissues in various parts of the body. While a special

apparatus has been devised for this purpose, a sterile fountain syringe

with an ordinary aspirator needle will be found to be sufficient for

nearly all purposes.

The erethistic, or extremely restless type of shock, may be profitably

treated by small doses of morphine given subcutaneously.

The _question of immediate operation or delay_ should be carefully

considered. Shock is often alleviated by prompt removal of mutilated

limbs or parts whose fragments, while still connected with the trunk,

seem rather to perpetuate the condition, especially if the principal

nerve trunks are cocainized. In serious cases intravenous infusion

should be practised.

After commencing with the anesthetic, while scrubbing and cleansing

the field of operation it is advisable to scrub an arm where it may

be necessary to expose a vein, or the skin at several points, where a

needle may be entered, so that there may be no delay for this purpose

should infusion or hypodermoclysis be suddenly required.

CHAPTER XIX.

ABSTRACTION OF BLOOD; COUNTERIRRITATION; PARACENTESIS; TRANSFUSION;

CATHETERIZATION; SKIN GRAFTING; BANDAGING.

Abstraction of blood, usually of venous blood, known as venesection,

was a practice frequently indulged in years ago. At one time in the

history of medicine it seemed to be the measure regarded as a panacea

for all ills. The reaction from the period of excessive bloodletting

came during the previous century, and was so strong that the practice

was for a generation or so almost abandoned. The eminent surgeon S. D.

Gross wrote a paper entitled “Bleeding as a Lost Art.” Bloodletting is

an expedient of great value in a somewhat restricted class of cases,

but is capable of affording such relief in certain emergencies that

practitioners should be ready to resort to it at any moment when it may

be required.

After removal of a certain amount of fluid blood pressure is naturally

reduced and at the same time equalized, while when the right side of

the heart is overburdened with its task it is thus made to beat more

easily and regularly; thus indirectly there may be brought about a

subsidence of violent heart effort, a reduction of the respiration

rate, a lowering of temperature, and sometimes a diminution in the

activity of morbid processes which may be beneficial, and even

life-saving. Even after moderate bleeding, say a half-pint, the amount

of urine is increased and the proportion of solids raised. More air is

taken into the lungs, and oxygenation is thereby much improved.

The indications for venesection are:

Excessive vascular tension.

Intensity of pathological tissue activity which is leading to serious

disturbances.

The removal of a certain proportion of toxic material from the blood.

There may be added later the introduction of balanced physiological

salt solution as recommended in the treatment of shock, and of some of

the acute toxemias, _e. g._, delirium tremens.

The effect on an embarrassed and overfilled right heart of the

abstraction of blood is prompt. Nowhere is this more conspicuous than

in the early stages of pneumonia, and in some cases of heart failure

during administration of an anesthetic where a dilated heart seems

to become so overfilled as to be unable to empty itself. In profound

uremia, especially in puerperal eclampsia, the relief afforded by it is

usually immediate and permanent.

VENESECTION.

The question of the amount of blood to be withdrawn must be settled

at the time and for each individual case. The pulse is watched, as

well as the patient’s face; the best indications when to cease being

noted in this way. From 500 to 1000 Cc. may be removed according to

the condition of the patient and the degree of emergency. While the

operation is a trifling one, it should, nevertheless, be performed

with strict aseptic precautions. One of the veins at the bend of the

elbow, usually in the left arm, is commonly chosen, although in rare

instances, when there is intense cerebral venous congestion, the

external jugular may be selected. At the elbow the median basilic vein

crosses the brachial artery, being separated from it only by a thin

prolongation of the biceps tendon. It was especially in opening this

vein at this point with the old-fashioned lancet, which was plunged

perpendicularly to the surface and directly into the vein, that injury

to the artery occasionally occurred, thus leading to varicose aneurysms

and aneurysmal varices.

The skin should be thoroughly cleansed; a reasonably tight constriction

is made about the middle of the arm by a bandage, not so tight as

to completely occlude the radial pulse; the arm is allowed to hang

downward and the patient encouraged to grip some object in order to

better fill the vein. This soon becomes prominent, after which an

oblique incision is made through the skin above it, so that the vessel

itself is exposed. Then with a sharp bistoury the external surface

of the vein is pricked with the point, and a cut made outward. The

opening in the skin should be free; the skin may be frozen, or in very

sensitive patients local anesthesia may be first produced with cocaine.

By tightening and releasing the grasp, that is by closing and opening

the hand, the flow of blood may be hastened. When it is time to cease,

the bandage should be removed and an aseptic pad be applied over the

site of the wound, suitable pressure being made, and the arm kept at

rest for two or three days.

When the jugular or some other vein is selected the procedure is

essentially the same.

=Arteriotomy.=--Arteriotomy, or the opening of an artery for

bloodletting purposes, is resorted to only in rare instances, and

in an emergency. The temporal artery is the one usually selected

because of its accessibility and the ease with which its outflow can

be controlled. Its position is determined by its pulsation; it should

then be exposed by incision through the skin, and opened exactly as is

a vein, _not cut through_, lest it retract and furnish an insufficient

amount of blood. It should, however, be divided and tied before

application of the dressings.

=Cupping.=--By the application of “cups,” blood is drawn to the

surface, but ordinarily not abstracted, unless the surfaces have

been previously scarified or incised. _Dry cupping_ has the effect

of attracting blood to one portion of the body, thus drawing it

from another and congested part. It has the temporary effect of a

venesection. Cupping glasses are small tumblers which are rinsed in

alcohol; their edges are wiped and the remaining film within the

glass is ignited from a candle or flame. The glass is then instantly

applied to the affected area. The oxygen within the contained air is

sufficiently consumed to create a slight vacuum and the skin quickly

becomes congested, being sucked upward into the glass. These cups may

be allowed to remain for a few moments, or until they drop off. Care

should be exercised with alcohol and a lighted lamp around a patient

who may be unconscious or excitable, as serious burns have followed

carelessness in this regard. Small vacuum pumps, like the Allen

surgical pump, have been provided for this purpose, and give very

satisfactory results.

There was formerly employed for the purpose of _wet cupping_ a small

spring instrument, containing several sharp knives, by which a series

of incisions were made in order that blood might be drawn. This

instrument cannot be kept clean and is not used at present. When wet

cupping is desired the part should be scarified with a sharp knife and

the cup applied as above.

=Leeching.=--Leeches figure largely in literature of the past, but are

not often used, although they may be made effective, especially when

applied behind the ears in cases of cerebral congestion. The American

leech can be relied on only to abstract about a teaspoonful of blood,

while the Swedish will draw three or four times that amount. The region

to which they are applied must be washed, and, if necessary, shaved.

The part should then be smeared with milk, blood, or sugar-water. The

leeches should be put in a basin of fresh water, after which they are

placed upon a dry towel for two or three minutes. Each one is then

taken up in a small glass or test-tube and inverted over the spot

chosen. As soon as the animal fastens itself upon the skin the glass

may be removed. Leeches are often capricious and will sometimes wait

considerable time before attaching themselves. When full of blood

they usually relax and drop. If it be desired to remove them a little

salt will make them relax. Leeches should never be applied over loose

cellular tissue nor over superficial vessels or nerves. If used in the

interior of a cavity they should be prevented from passing too far.

COUNTERIRRITATION.

Counterirritation is a valuable means of accomplishing that which

is sometimes induced by leeches--namely, attracting blood to the

surface for the relief of deep congestion. In fact it comprises more

than this, since there is some deep influence exerted through the

medium of the nervous system; it not only equalizes the circulation,

but tranquillizes a disturbed innervation. The milder and more

domestic means include the use of the so-called rubefacients--hot

water, mustard, and turpentine. These are of little use in surgical

conditions which call for counterirritation; their use should be

controlled with caution lest mere counterirritation be converted into

actual burning.

By the use of _vesicants_ a blister is produced, _i. e._, an effusion

of serum and lymph beneath the superficial and outside of the deeper

layer of the skin. Mustard and cantharis are the principal vesicants in

common use. The former may be used in full strength, in which case it

is active, or it may be reduced with wheat flour or linseed meal. To

bring out the full strength of mustard, hot water should not be used in

its preparation, as it renders it almost valueless. A mustard paste or

plaster should be watched at intervals, and it should be removed when

the desired effect has been obtained--at all events, when the surface

to which it has been applied is covered with vesicles.

Cantharis, or Spanish fly, is used either in the form of the

cantharidal cerate or mixed with collodion, the latter being the

neatest and most pleasant preparation. Several layers are painted on

the surface where its effect is desired. This is then protected, and

vesication will be found to have been produced within an hour or two,

except where the skin is most resistant. The stronger chemicals, like

ammonia, chloroform, strong iodine, and nitrate of silver solutions,

will be found to be active blistering agents, but should be used with

caution.

Two other methods of irritation were at one time in favor--namely, the

_seton_ and the _issue_. The former consisted of a bundle of threads

or a wick, drawn into a large needle with a lancet-shaped point; the

skin was picked up into a fold, the needle made to traverse it, and the

wick was thus drawn through and cut off, so as to be left in place. The

issue was made by drawing a blister with a powerful agent, and then

preventing it from healing by the use of an irritating foreign body.

These procedures have been abandoned by the medical profession, but are

still in vogue among veterinary surgeons.

=The Actual Cautery.=--In some one of its improved forms the Paquelin

cautery has replaced all the old cruder methods of cauterization.

When properly employed its counterirritant effect can be made most

serviceable for the relief of pain, or for any desired form or

degree of counterirritation. Applied over the upper abdomen, with

the lightest possible touch, in such a way as to deserve the term

“_flying cautery_,” it will sometimes afford great relief in nausea and

vomiting, especially when these symptoms are purely reflex.

Used over the course of the larger nerves it does much to relieve the

pain of neuritis; while over swollen joints and swollen testicles it

affords great relief from the pain of chronic arthritis and chronic

or acute epididymitis. In deep-seated congestions and inflammations

_ignipuncture_ may be made with a small cautery point, by plunging it

through the skin into the underlying tissues, and into bone. The relief

of tension as well as the counterirritation will give great relief.

When practised in this manner local or general anesthesia may be used.

Except when thus used it will rarely be necessary to do more with it

than to disturb the exterior of the skin. When skilfully used this can

be done with the production of very little pain.

PARACENTESIS.

Paracentesis is the technical name given to the act of tapping, or the

withdrawal of fluid from any of the closed cavities of the body. It

includes _aspiration_, _tapping_, and _incision_.

=Aspiration.=--By aspiration is meant the removal of fluid without the

admission of air; it comprises the use of a suction apparatus, usually

known as an aspirator, which may be had in various forms and sizes. A

small so-called _exploring syringe_ will answer for small cavities,

while for large collections of fluid, such as may be met with in the

thorax, more elaborate apparatus is used, consisting of a suction pump

connected by tubing with a bottle in which the vacuum is produced. By

another tube this bottle is connected with a hollow needle used for

the withdrawal of the fluid. Absolute asepsis should be observed, even

in this minor procedure. The skin should be cleansed, and the needle,

instrument, and hands should be sterilized. The pain of puncture may be

prevented by use of the freezing spray, of cocaine injected locally,

or by touching the skin with a drop of pure carbolic acid. The vacuum

is commonly resorted to in the removal of fluid from the thorax,

the spinal and the cranial cavities, and from joints; also in small

collections of pus in any part of the body.

=Tapping.=--Tapping means a somewhat similar procedure with a larger

instrument known as a _trocar_ and a surrounding _cannula_, without the

aid of the vacuum. Precaution should be taken in every regard that the

instruments and the parts should be sterilized.

The trocar, inserted in the cannula, should be plunged quickly into the

cavity at the site selected. Considerable resistance will be offered

by the skin. If the trocar be small it is enough to anesthetize the

skin; if large, a small incision will permit of its better use. The

instrument makers have provided cannulas of various descriptions, to

which tubing may be attached, so that the fluid may be conducted into

a suitable receptacle, and wetting the patient avoided. It is well to

draw the skin aside and not to make the instrument pass directly into

the cavity to be tapped unless it contain pus and it be desired to

keep it open. If this precaution is taken the skin will cover the deep

opening after it slips back into its position, and will act as a valve

to prevent leakage. In this way infection may be avoided.

When fluid has ceased to be serous and has become purulent, as in

empyema, it is often so thick that it will not flow through any hollow

instrument. In such an event free incision should be made. When the

thorax is involved incision is made between the ribs, and in order to

maintain drainage a good-sized drainage tube should be inserted. This

at times may be so compressed between the ribs that an inch or more of

one rib should be exsected to provide against this possibility.

TRANSFUSION AND INFUSION.

Though much has been said concerning the indications for these

procedures no explicit directions have been given. While they are often

emergency measures they are, nevertheless, frequently practised. In

well-regulated institutions the conveniences are always at hand for

instant resort when needed; but it would be well for every general

practitioner to have ready at all times the few things that are

required, for at least hypodermoclysis. In country practice, however,

a clean fountain syringe, a suitable aspirator needle (both carefully

sterilized), some boiled water, table salt (when nothing else is at

hand), and soap and water for sterilization of the operator’s hands

and the patient’s skin are all that are necessary. In every outfit

there should be a needle which may be used for this purpose. It may

be carried in a glass tube, always sterilized, and ready for use. No

fountain syringe should be used which has not been freshly boiled,

except in an emergency. Tablets containing common salt in definite

amount, so that a solution of given strength can be made by adding them

to a definite amount of water, can be procured. With such a needle, a

few tablets, and a fountain syringe the surgeon is prepared for any

emergency.

For intravenous infusion for which no pressure is required, an ordinary

funnel, with rubber tubing attached, will be sufficient without the use

of a rubber bag.

The use of salt solution has supplanted the _transfusion of blood_.

This requires a source of blood which is not always at hand and an

amount of attention which can rarely be given in emergencies; moreover,

it has been shown that the injection even of defibrinated blood

is a dangerous procedure, because of liberation of hemoglobin and

destruction of white corpuscles, with the liability to coagulation of

the blood from increase of fibrin ferment, and the possible death of

the patient. Direct transfusion from another person into the veins of

the patient is also difficult, and has rarely been of service.

As already stated in the chapter on Shock, the best solution for

infusion is composed of calcium chloride 2 parts, potassium chloride 3

parts, sodium chloride 9 parts, sterile water, 1000 parts. The addition

of one part of sodium bicarbonate will sometimes prove of advantage,

while in diabetic cases this may be increased to three parts to a

thousand. It has also been suggested to add a small proportion of

sugar, even up to thirty parts, to this solution, in order to increase

osmotic action and better preserve the red corpuscles from injury. It

is supposed also to give a certain nutritive value.

When the fluid is injected into the venous system all that is desired

is that it barely enter; consequently the receptacle containing the

fluid should be held but a few inches above the level of the opening.

When hypodermoclysis is practised more pressure will be needed and a

greater difference of level should be maintained. In the veins the

amount injected should not exceed 100 Cc. each minute. From 500 to 1500

Cc. may be used altogether. There need be no hesitation in introducing

it at a temperature considerably above the body normal, and in cases of

shock it may be introduced even at 115° F. The character of the pulse

will afford the indication as to the amount of fluid to be used as well

as the wisdom of repeating the measure after an interval.

For _intravenous infusion_ a vein in the arm is usually exposed and the

needle point carefully inserted. It is an advantage to have for this

purpose a special needle, made with a blunted extremity, enlarged a

little, so that by the use of a temporary ligature the vein may be held

tightly around the cannula, for such it really is, and the escape of

fluid be prevented. After withdrawal of the needle a double ligature

should be placed for purposes of security. The limb should also be kept

at rest for a few days.

For _hypodermoclysis_ from 500 to 1000 Cc. may be employed; the

anterior abdominal wall, the flank, the thigh, and the retromammary

tissues are the best regions in which to inject the solution.

Absorption will be assisted by gentle massage. Local anesthesia by

the freezing spray, or by cocaine, will rob the procedure of its

discomfort. Adrenalin may be added to the solution, whose formula is

given above, in emergency cases where it seems to be especially needed.

In instances where infusion is practised for the purpose of washing out

the blood, _i. e._, in the acute toxemia of uremia, alcoholism, etc.,

nothing of the kind will be required; but in conditions of lowered

blood pressure, _i. e._, shock, it will prove of great value, as

already indicated.

CATHETERIZATION.

Catheters, as such, are intended for the withdrawal of urine from the

urinary bladder, or for the introduction and withdrawal of cleansing

fluids. They are made of metal, glass, gum, and silk, or other similar

material, in various sizes, while some are specially formed or bent

in order to pass more easily over the obstruction offered by a median

prostatic enlargement. Various forms are sold in the surgical depots,

from which the purchaser may make a choice. Next to the simple tubular

forms the elbowed or Coudé catheters are of the greatest value.

Catheters should be sterilized before use. Those used occasionally

should be cleaned after use and dried, while those in daily use may

be kept in an antiseptic solution after cleansing. The cleansing of a

catheter should include not only attention to the exterior, but also

removal from its bore of all clots, debris, etc. Some pressure behind

the fluid used for this purpose is advisable. A clean metal or glass

catheter may be sterilized in a flame just before use. All flexible

catheters should be boiled just prior to their insertion, or they

should be taken out of an air-tight receptacle in which they have been

kept in contact with some antiseptic, or in an antiseptic vapor. For

the latter purpose _paraform_ offers an excellent material, as there is

given off from it formaldehyde vapor, which is a powerful bactericide.

It comes in crystals and in tablets. Rubber catheters should be boiled

in a 5 to 10 per cent. solution of ammonium sulphate.

The urethra should also be cleansed, especially the meatus, in either

sex. Cases of cystitis may be directly traced to infection introduced

by a catheter, the result being the same whether the germs be not

removed from the instrument or are carried in by it from the anterior

urethra. This is particularly true in paralytics who have no power of

expelling the urine, and in prostatics who need regular catheterization.

The technique of using the metal catheter in the male is the same as

that of introducing a sound. A lubricant is necessary for the easy

introduction of the instrument, and a sterilized ointment or oil will

serve the purpose. Olive oil, mixed with iodoform, as often used, is

not sterile. The hands of the operator should also be clean, and no

part of a clean instrument should be allowed to come into contact with

any portion of the patient’s surface. On this account the parts exposed

should be covered with sterile towels.

The catheter being intended to afford relief with the least amount of

discomfort, a smaller instrument may be used than would be inserted

were it meant for the dilatation of a stricture. Occasionally, and in a

sensitive patient or hyperesthetic urethra, a little cocaine solution

may be used to advantage, especially if force or pressure need be made

in order to overcome spasm of the cut-off muscle. The metal instrument

is too rigid in some cases, while the gum catheter is too flexible.

Under these circumstances, the silk instrument may be used.

If the tip of the instrument be kept close to the floor of the urethra

it will rarely catch in any fossa or lacuna, particularly if the

size has been correctly chosen. When apparent obstruction occurs at

the triangular ligament the instrument should be withdrawn a little,

tilted differently, or lifted a little so that it is made to hug the

roof of the urethra rather than to press upon its floor. By a little

manipulation of the end of the instrument any obstruction at the neck

of the bladder may also be overcome. A sudden depression of the outer

end as the catheter reaches this part, or a little pressure by the

finger of the disengaged hand in the perineum, will give much help. It

is well, occasionally, to introduce one finger into the rectum in order

that by it the instrument may be better guided along its course. Only

in cases where there has been previous disease or where unsuccessful

attempts have already been made to pass an instrument will much real

difficulty be found; that is, only in those already suffering from

stricture, or from enlarged prostate with the difficulties which it

affords, will one have to resort to manipulation requiring more than

ordinary dexterity. In some of these cases even the expert is likely to

meet with difficulty, rarely with absolute disappointment. Should it

be impossible to empty a distended bladder with a catheter _suprapubic

puncture_ with the _aspirator needle_ should be made.

When difficulty is experienced it is enhanced by spasm of the deep

muscles, as a reflex from the soreness produced by repeated efforts and

by hemorrhage.

Hemorrhage from this source is rarely of serious character and quickly

ceases. In certain instances where it is aggravated much can be

accomplished by leaving the catheter _in situ_ for a few hours, or even

for two or three days.

False passages will occur sometimes in spite of at least ordinary care,

and are always serious in their nature. Extravasation of urine may

result, with more or less disastrous consequences, or speedy septic

infection may quickly terminate the life of the individual. They

are to be avoided, as far as possible, by the use of instruments of

large rather than of small size, with blunt tips, and by delicacy of

manipulation. For this purpose it is well to avoid the use of catheters

which require a wire stylet for the maintenance of their proper curve,

lest during manipulation the point of the wire may work injury. The

various accidents due to or connected with catheterization will be

dealt with in their proper places in connection with the surgery of the

urethra and bladder.

There are certain constitutional complications, however, which deserve

mention. One of these is known as _urethral fever_, which comes on

usually with a chill, followed by more or less rise in temperature,

and with general disturbance of the system. It is to be regarded

as a manifestation of septic intoxication, the hope being that the

disturbance may not go beyond this degree. In cases that have once

suffered from this intoxication precautions should be doubled. The deep

urethra should be irrigated before and after the withdrawal of the

urine, the patient should be kept in bed, and urotropin and quinine

may be administered before and after the discharge of urine. Much may

be done in the prevention of this as of other unpleasant occurrences,

such as pain, excitement, suppression of urine, syncope, etc., by the

previous use of cocaine and by due regard for gentleness. Should a

septic process be set up in the deep urethra it may lead to sapremia

of urethral origin, and to septicemia and pyemia. Septic complications

accompanied by any local indications, such as swelling, should make the

surgeon watchful for the time when an incision must be made for relief

of tension or escape of pus.

Postoperative suppression of urine, which may occur even after

catheterization, may be treated by giving 0.08 to 0.15 Cg. of sulphate

of sparteine every three or four hours (McGuire).

SKIN GRAFTING.

The whole method of skin grafting is based on the fact that if

epithelium be removed from any portion of the body and planted on

favorable soil elsewhere it will take root and grow, reproducing only

itself and no other kind of tissue. It is closely analogous to sewing

seed upon a favorable soil, or even to sodding. Furthermore it is not

necessary that epithelium be furnished from the individual upon whom

it is to be implanted; it may come from another of the same species or

even from a different species. Thus the skin of the frog has been used

for grafting upon human beings, and even the lining membrane of the

egg. Nor is it necessary that the epithelial cells should be apparently

alive when thus employed. Very thin shavings of human skin which have

been dried, or have been kept from decomposing by some antiseptic,

have been successfully used; nevertheless the ideal method consists in

taking what is needed from the individual who needs it.

The term skin grafting is now applied to the employment of very thin

layers of the epidermis, _i. e._, as thin as can be shaved off with a

sharp razor, and it does not apply to the autoplastic methods of skin

transplantation.

Hamilton, of Buffalo, and Reverdin, of Geneva, a number of years ago

independently discovered that minute particles of healthy skin might

be implanted upon healthy granulations and that from such minute

grafts epithelium would be produced and a fresh epidermal covering be

afforded. This method was in use for years and was a great advance on

what had previously been done. Then Hamilton, of Edinburgh, suggested

the use of thin slices of clean sponge, in order that thereby a trellis

might be offered for the growing and climbing granulation tissue; this

served a good purpose in many cavities. But the greatest advance came

when Thiersch demonstrated that large areas might be covered with skin

shavings, and that thus in a few days there would be accomplished

that which took weeks or months by older methods. His original plan

comprehended only the use of these grafts upon granulation tissue;

later it was found that they might be applied to fresh raw tissue, even

to denuded bone. Thus originated the so-called _Thiersch method of skin

grafting_.

The surface to which these grafts are applied must be thoroughly

cleansed as well as the surface from which they are removed. If an

ulcerated surface is to be prepared for grafting it should be scraped

thoroughly with a sharp spoon; all sloughing or suspicious tissue

should be carefully removed, and all oozing allowed to subside. Not

until the surface is prepared is it advisable to remove the grafts.

These are best removed by putting upon the stretch the skin of the

selected area, so as to render it taut and as nearly flat as possible.

The razor used for the purpose should be sterilized and sharp. Salt

solution may be allowed to drip upon the razor while the surgeon is

using it. It is rarely practicable to remove a strip over 5 Cm. wide

or 25 Cm. long. The endeavor should be to remove only the superficial

layer of the skin, and when properly done this removal should be

followed by but a trifling oozing of blood. If bleeding be profuse

the layer removed has been too thick. Grafts of sufficient number and

size are removed to nearly cover the desired area. The more completely

it is covered the more acceptable will be the final appearance of the

surface. If the grafts adhere, we may confidently rely upon their

furnishing enough fresh epithelium to fill in the irregular defects

between the edges. The grafts when cut should be raised with a razor

and a spatula and gently spread out upon the prepared surface, and so

pressed and treated that no air bubbles are retained beneath them. If

the surface be dry enough they will adhere to the very thin coagulum of

blood which glazes it, and after a few moments it will take friction to

disturb them.

Should the margin of the surface to be grafted be old and indurated it

is best to trim off any depression that exists, so that the new skin

may not be let in below the surface of the surrounding skin.

The _dressing_ should consist of a layer of sterilized oiled silk,

gutta-percha tissue, or green protective, laid on in strips, in order

that excessive fluid may escape between them. A little antiseptic

powder may be dusted upon the grafts, if such be the choice of the

surgeon, but if the operation has been properly managed this will

hardly be necessary. Careful regulated pressure should be made outside

of the protective, by cotton and a suitable dressing, and then the

part, if a limb, may be bound upon a splint in order to ensure

physiological rest. _Silver, tin, or aluminum foil_ also make a good

protective, and, on theoretical principles, are even better than the

textile materials.

Some surgeons leave these dressings for several days. I have found it

an advantage to remove them within thirty-six hours, as sometimes the

grafts appear to be macerated in the fluids and to lose their first

cohesion to the prepared surface. The main thing about the dressing

is that it should be non-adhesive and restful. After three or four

days, when the grafts have completely adhered, any ointment dressing

may be used. It may happen that only a portion of the entire number

of grafts serve their purpose, and that others fail to do their work.

Even when the failure has been apparently considerable it will often

be seen that individual epithelial cells have adhered and later will

grow. The unhealed portions of such a surface now fall within the

definition given earlier of an ulcer, and should be subjected to the

same treatment.

Grafting may be repeated as often as seems to be necessary. The best

surfaces from which to take the grafts are usually the outer aspects

of the arms and thighs. The places from which they are removed need

only the simplest antiseptic dressings. If the grafts have been of

sufficient thinness the scars left by their removal are scarcely

permanent and rarely disfiguring.

Wight, of Brooklyn, has suggested that advantage be taken of the

properties of high-frequency discharges from a suitable apparatus to

secure their hemostatic and coagulant effect. He has shown that such

electrical discharge will clot blood and coagulate albumin, this effect

being partly due to the formation of nitric acid from the air. In this

way it is theoretically possible to so seal the surfaces as to fix

grafts firmly in place. The apparatus calls for a pointed electrode,

passed at a distance of about 1 Cm. above the entire surface, until the

clot is firm and reasonably dry, all serum that is expressed in the

process being removed with sponges. Where the apparatus can be employed

this affords an effective way of fixing the grafts and preventing their

displacement.

Surface epithelium from an animal source may be used when necessary--as

from a young pig after it has left the packing-house, a young calf, or

some smaller animal. All that is required is _epithelium_. That from

a negro will reproduce only pigmented cells like the original. At the

time when amputating a limb about which there is still left healthy

unbroken skin, shavings may be removed from it and preserved for a week

or two between dry sterilized towels or in a weak antiseptic solution;

these may then be utilized for skin grafting during the ensuing few

days.

[Illustration: FIG. 30

Figure-of-8 bandage of leg.]

[Illustration: FIG. 31

Velpeau’s bandage.]

[Illustration: FIG. 32

Ascending spica bandage of the groin.]

BANDAGING.

Bandaging is a subject now taught so generally by actual demonstration,

and so simplified, that it scarcely seems necessary to more than

present a few illustrations showing how simple bandages can be applied

in the most effective manner.

The purposes of a bandage are either to afford means of retaining

splints and dressings, to exert pressure, or to afford physiological

rest. After every operation of importance it is necessary to apply and

retain an occlusive and aseptic dressing, under which the wound may

heal or into which wound discharges may be received; but the ideal

dressing affords more than this--it furnishes _support and rest._

[Illustration:

FIG. 33

FIG. 34

Spica bandage of shoulder.]

[Illustration:

FIG. 35

FIG. 36

Third roller of Desault’s bandage.]

There is danger in the injudicious use of any bandage, as by the

exertion of undue pressure it may interfere with wound healing, or may

even lead to gangrene. If applied loosely at the extremity and too

tightly above it will lead to venous obstruction and possibly secondary

hemorrhage. Moreover a bandage which seems properly arranged may become

so tight as to be painful and even unbearable after swelling has

occurred. There is but one safe rule, and that is to take note of the

appearance of the part as well as of the sensations of the patient. An

abdominal bandage may have been placed with a proper degree of snugness

at the conclusion of an operation, and yet be altogether too tight when

the abdomen becomes distended with a little gas. There is then always

room for discretion and good judgment in the matter of bandaging. It

may be necessary to apply a bandage quite firmly at first in order to

repress hemorrhage, with the intention to relax it after a few hours.

A splint may be a necessary feature in a surgical dressing; after

amputating at the lower part of the leg it is advisable to bind the

limb upon a splint in order that the necessary physiological rest

may be thus afforded. The first requisite of a bandage is not its

appearance but its effectiveness; a due regard for the esthetic in

surgery will, however, dictate that it be made as presentable as

possible.

[Illustration: FIG. 37

T-bandage.]

[Illustration: FIG. 38

Kelly’s bandage with perineal straps.]

For the roller bandages of cotton cloth, universally in use twenty-five

years ago, there have been substituted bandages of thin gauze or

crinoline, which have scarcely body enough to be applied, as was the

roller, or else of flannel, made wider and necessarily thicker, which

are more flexible, comfortable, and applicable.

[Illustration: FIG. 39

Barton’s head bandage as employed for suspension in applying

plaster-of-Paris bandage.]

Crinoline impregnated with starch is also in general use and makes a

serviceable bandage for head injuries. When prepared with plaster of

Paris it is capable of affording absolute support and even rigidity.

CHAPTER XX.

ANESTHESIA AND ANESTHETICS, GENERAL AND LOCAL.

To Oliver Wendell Holmes we owe the term _anesthesia_, as generally

employed and made to mean insensibility to pain, no matter how

produced. A more strict definition would limit the term to conditions

comprising not only insensibility to pain but loss of consciousness.

For mere loss of sensation we should, strictly speaking, use the word

_analgesia_. This is a distinction with a difference. Thus I have on

rare occasions seen a patient under chloroform absolutely oblivious to

pain but perfectly conscious, and chatting intelligently throughout

the operation. This is a rare phenomenon, but has been noted by

various observers. So after intraspinal cocaine injections we secure

complete analgesia of the lower portion of the body, but not complete

anesthesia, the former being what we are most anxious to produce.

The discovery of anesthesia is essentially to America’s credit. Long,

of Georgia, had produced anesthesia by ether as early as 1842; Jackson,

of Boston, also claims credit for the discovery; but to Morton, a

dentist of Boston, is undoubtedly due the honor of having introduced it

for surgical purposes. The first public demonstration of its properties

was made by Morton and Warren, October 16, 1846, in the Massachusetts

General Hospital. Chloroform seems to have been exploited independently

by Guthrie, of Sackett’s Harbor, N. Y., and Simpson, of Edinburgh, in

1847. It is a curious historical fact that the patient to whom Simpson

meant first to administer chloroform in his clinic did not receive it

because of some failure to have it on hand; she took ether instead and

died, presumably of the anesthetic. Had she died under the influence

of chloroform it would have been a serious setback to any general

appreciation of its merits. Nitrous oxide is also an anesthetic for

which America may take the credit. These are the three drugs in common

use today, although there are others which are coming into general

favor.

It can be stated as an axiom that when a surgeon tries to abolish

human sensibility, or pass an instrument through the human skin,

he introduces elements of danger which can never be certainly and

completely controlled--that is to say, the administration of an

anesthetic is never to be undertaken as a trifling matter, but should

be entered upon as carefully for a minor procedure as for a dangerous

and prolonged operation.

Anesthetics are sources of danger, not only for the moment while

they are in use, but because of the disturbances which may follow in

their train. These drugs should never be administered carelessly nor

thoughtlessly, nor by inexperienced individuals, but entrusted to the

wisest and the most discreet. More is expected of the anesthetizer

than that he shall barely keep the patient alive; he should be so

expert as to keep the patient safely on the side of complete anesthesia

and muscle relaxation. Nor should he be willing to yield to the

importunities of an impatient operator who may be continually appealing

to him to crowd the anesthetic. When thus given, and by an expert,

such postanesthetic distress as nausea, vomiting, coughing, etc., may

be avoided. So generally are these facts now realized and appreciated,

that in many of the large hospitals a regular anesthetizer is employed,

whose sole duty it is to administer the anesthetic for the attending

surgeons. The management of an anesthetic has much to do with the

allied subjects of the _preparation of the patient_, the _management of

shock or reduced blood pressure_, and the _status lymphaticus_, which

have already been considered.

Fatal accidents from anesthetics are the appalling ones which have

generally occurred in cases where it has been assumed that the patient

is in good condition, and where neither preliminary examination nor

preparation has been made. In the presence of unmistakable cardiac

disease, or of great arterial tension, the surgeon may, by foreseeing

the possibility of trouble, do much to prevent it; but when an

apparently healthy individual is placed upon the operating table

without attention to these matters it may happen that his heart will

stop as suddenly and unexpectedly as though it had been transfixed.

In other words, the accidents of anesthesia usually occur when least

expected; on the other hand, accidents will be few and far between when

all cases are handled as though promising to be severe ones.

The odor of most anesthetics is so distasteful to patients that they

inhale at first with difficulty and with signs of irritation. Much of

this can be guarded against by spraying the nasopharynx with a 1 or

2 per cent. solution of cocaine. This expedient will make anesthesia

much easier for them. The mouth should be examined; all false teeth or

foreign bodies, such as pins, chewing-gum, etc., should be removed.

Unpleasant burning of the sensitive mucosa of the nose and lips may be

avoided by anointing these parts with cold cream. Attention should be

given to the avoidance of irritation of the eyes or the careless escape

of an anesthetic into the conjunctival sac; with a struggling patient,

or a careless administrator, this may easily happen.

Circumstances which would justify the administration of an anesthetic

without the consent of the patient, or the friends or parents, occur

but rarely; still in an emergency case, with a patient incompetent to

decide for himself, the surgeon must assume the responsibility, in

which in all probability the law will sustain him.

The anesthetizer should always be accompanied by an assistant;

preferably in the case of a female patient, by a female nurse, who may

not only be of assistance to him at the time, but an actual protection

should the patient experience any erotic delusions during or after her

period of anesthesia. This applies equally well to dentists giving

nitrous oxide for the extraction of teeth, or physicians attending

cases of accident, convulsions, and the like.

The anesthetics in general use are ether and chloroform. If statistics

alone are appealed to it can be easily shown that ether is the safer

of the two by a large ratio. But the recovery of consciousness by no

means indicates the conclusion of the period of danger. The harm which

chloroform does is largely done promptly, whereas the unpleasant effect

of ether lasts through a much greater period, and the statistics which

give ether an advantage are in many respects fallacious. Chloroform is

doubtless the stronger and the more subtle agent of the two, and in

careless hands would, in all probability, become the more dangerous.

_But no anesthetic should be given carelessly_, and no one should

give it who cannot give it properly. There may be emergency cases,

especially in the rural districts, in which the surgeon may have to act

in the capacity of anesthetizer and operator as well, and where he may

have to transfer the inhaler to some lay assistant who knows nothing

of the action of these drugs. If this happen it would be safer to use

ether.

_When administered by a thoroughly competent person_ chloroform is the

safer anesthetic of the two, and is usually to be preferred. So largely

does the personal equation figure in this consideration that it seems

unnecessary to reproduce here statistical tables in regard to its

efficiency.

ETHER.

The writer’s intention is to confine his views on anesthesia to the

practical application of certain drugs whose chemistry, materia medica,

and ordinary therapeutic properties are appropriately treated of in

other works.

Ether anesthesia has by some been considered to be simply one form of

carbon dioxide poisoning; that it may be all of this, in certain cases,

may be granted; but it is certainly something more, as is shown, among

other things, by the peculiar odor which persists in the breath of

the patient for hours or even for days after its use. Various ways of

administering it have been recommended. Some give it well diluted with

air, and some give it as strong as a patient can possibly bear it, and

from the outset. Some keep mixing air with the vapor, while others have

devised inhalers, by which the same ether-ladened air is breathed over

and over again. These latter produce a certain degree of the carbon

dioxide poisoning above alluded to, and are not ideal even if effective.

Even when well diluted with air the vapor of ether causes irritation of

the air passages, in both the nose and throat, and leads quickly to a

sensation at first of oppression and then almost of suffocation, which

is trying to the self-control of intelligent patients and disturbing to

those having little or none. An inhaler saturated with ether should not

be pressed tightly over the patient’s face, as it is likely to produce

struggling to such an extent that weakened bloodvessels may give way

and by their rupture produce serious disturbance.

The first momentary period of irritation having subsided, there will

likely follow a few deep inspirations, and then perhaps a fixation

and immobility of the chest, so that for half a minute or a minute it

would seem as though the patient had _forgotten to breathe_ (Hare).

But deep respiration is quickly reëstablished, or may be stimulated by

slapping the chest, by a few movements at artificial respiration, or at

least by compressing the thorax. Then follows the period of “primary

anesthesia,” so called, or a period of excitement, during which the

patient may rave or become quite disturbed, and in a manner sometimes

quite at variance with his ordinary temperament. As this period

subsides the state of complete anesthesia begins, and when muscular

relaxation is complete, or even before, the surgeon may commence his

work. The respiration under complete anesthesia is usually deeper and

sometimes more rapid than in health, while as the muscles become more

relaxed a positively stertorous breathing is noted, along with an

increase in flow of saliva, due to the irritation of the ether vapor.

As anesthesia passes into complete narcosis, and this into asphyxia,

the color of the surface, especially of the face, changes to a cyanotic

hue, the skin becomes moist and clammy, and the pulse, which had been

accelerated, fails. The blood also becomes exceedingly dark from lack

of oxygen. Under these circumstances the heart may continue to beat

feebly for a short time after respiration has ceased. As Hare puts

it: “In producing its effects ether first attacks the perceptive and

intellectual cerebral centres, next the sensory side of the spinal

cord, next the motor side of the cord, then the medulla, and with this

last depression death ensues.”

Ether is more pungent and less agreeable to breathe than chloroform,

but the chief advantage usually connected with its use is its supposed

factor of safety.

On the other hand, the accidents which are due to ether are in a large

measure those common to the use of any anesthetic agent. Among the

most prominent is _arrest of respiration_, which may be caused either

by mucus or some foreign body in the air passages, or by the tongue

dropping back in the pharynx, and the impediment to respiration thereby

offered. When the cause of the difficulty is ascertained it is usually

easily removed. Should great pallor accompany these symptoms, then,

it is usually because the heart as well is at fault, and vigorous

stimulation of this organ should be promptly instituted.

Another disadvantage pertaining to ether results from the irritation

which its vapor produces in the bronchi and lungs, or in the kidneys

during its elimination. From the former may result bronchitis,

congestion, or even pneumonia; the latter more often of the catarrhal

type than of the croupous. As the result of renal irritation there may

be temporary albuminuria, or the congestion resulting may assume so

serious a type as to produce absolute suppression (_anuria_), which is

practically always fatal. Ether is said to be particularly undesirable

in cases of diabetes, because of the resulting acetonuria. Patients

have even been known to pass from anesthesia into diabetic coma.

It has been found that complications are more common in males than in

females, but more severe in the latter. Vomiting following the use of

ether is a frequent and most unpleasant sequel. It is to be prevented

by previous lavage, as well as by the same measure at the conclusion

of the operation. It will rarely subside when present until the ether

vapor has been eliminated. So far as it is possible to suppress it with

drugs probably 2 Gm. doses of chloral and one of the bromides, with

a little laudanum, given by the rectum in salt solution or a little

starch-water, will give the best results.

As already stated, it was formerly held that anesthesia was carbon

dioxide poisoning, plus something else which was vaguely described by

different authorities; much clearer notions now prevail regarding the

mechanism of anesthesia. A few years ago Meyer and Overton concluded

that anesthesia is produced by solution of the fatty constituents

of the cells by the anesthetic absorbed, this being true at least

with chloroform and ether, both of which are solvents of fat. The

absorbability of the anesthetic varies with the blood temperature,

this varying widely between the cold-blooded and warm-blooded animals.

They estimate that 1 part of ether to 400 parts of serum is necessary

for complete anesthesia in man, while one part in 4500 to 6000 parts

is a sufficient proportion of chloroform. According to these views

the dissolved fat is not removed from the cells, and no satisfactory

explanation yet accompanies this theory, even assuming its accuracy.

Of no small importance are the experiences of Snel, who found that

anesthetics decrease the bactericidal properties both of the blood and

of the tissues, but that this power is quickly recovered after the

elimination of the anesthetic. He furnishes reason for the theory that

the thus lowered resistance of the lungs is an important factor in the

production of the pneumonia which occasionally follows operations.

There is a belief that ether is more irritating to the kidneys than

chloroform. This, however, does not seem to be justified by evidence,

neither is the prejudice against the use of ether during the existence

of albuminuria or in the presence of casts. In the presence of a high

degree of albuminuria any anesthetic is dangerous, and here ether

would be the less desirable of the two. Nevertheless in ordinary mild

albuminuria one need not fear to give ether.

About twenty years ago it was suggested that ether anesthesia could

be induced by passing its _vapor into the colon through an ordinary

rectal tube_. There are many obvious reasons why it would be of great

advantage if anesthesia could be safely practised in this way, not only

in operations about the face and head, but because of the avoidance of

pulmonary and gastric irritation.

The method was to thoroughly empty the colon and then connect a rectal

tube with a receptacle containing ether, which was placed in warm water

and the vapor passed into the intestine. It was found that patients

could be readily anesthetized in this manner, but unfortunately it was

also found that a considerable degree of intestinal irritation was

produced.

The writer recalls one case in which this method was practised, which

terminated fatally within twenty-four hours after the operation, where

the autopsy disclosed a violent degree of acute colitis.[7]

[7] _Ether Narcosis by the Rectum._--Cunningham and Lahey have

revived the almost abandoned method of rectal ether narcosis, after

improving the technique. The rectal tube is introduced for ten to

fifteen inches and ether vapor is then forced in until considerable

gas is pressed around the rectal tube, keeping the forefinger in

the rectum opposite the tube until it causes pain and hastens the

expulsion of the rectal gases. It is essential that the rectum be

distended to the point of keeping closed around the tube, since

unless the gas normally in the bowel be first removed the patient

absorbs the ether much more slowly, presumably because of its

dilution. At the first introduction of the ether vapor the patient

may feel a natural discomfort and desire to defecate, but in a short

time this sensation disappears; the breath becomes ether-ladened

in from one to five minutes, he becomes drowsy, the breathing

stertorous, and he passes into complete surgical narcosis without any

excitement.

The apparatus used consists of a bottle seven inches in height, of

which five inches are used for ether space and the balance for vapor.

The afferent tube which leads to the bottom of the ether ends in a

bulb, with small perforations, so that the air escapes in several

bubbles. This bottle is placed in a water-bath at a temperature

between 80° and 90°. By keeping the ether warm, without boiling, the

air forced through it is more easily saturated.

The same care must be given to see that the tongue does not fall

over the larynx as when ether is given by the mouth. Should narcosis

be too pronounced the tube should be disconnected and ether gas

forced out of the bowel by abdominal massage. Oxygen may be given

through the same tube if desired, while artificial respiration and

stimulation are practised as usual when needed. After completion

of the operation the ether vapor should be completely expelled by

pressure.

The advantages of the method are that but a small amount of ether is

used, there is no stage of excitement, vomiting is rare, bronchial

secretion is prevented, and recovery is rapid. It has been shown that

six volumes per cent. of ether are required in the blood for the

production of complete anesthesia. The rapidity with which the latter

can be produced depends upon the rapid production of this percentage.

This result is attained more readily by the rectum than by the lungs.

For the production of narcosis by this method the rectum should be

previously and thoroughly emptied.

CHLOROFORM.

It is important that pure chloroform should be secured for anesthetic

purposes. It should be kept in dark bottles, and in the dark, as it is

liable to undergo decomposition in the presence of sunlight. It is less

volatile than ether, and mixtures of the two drugs are not stabile,

since the ether is likely to evaporate first. In its anesthetic effects

it resembles ether, acting first upon the perceptive and last upon the

motor centres.

The British Chloroform Committee estimate that from 1 to 2 per cent. of

chloroform in the inspired air is sufficient for anesthetic purposes,

and may be safely used; that 5 per cent. is more than adequate, and

that anything stronger than 2.5 per cent. is dangerous.

The _effect of chloroform upon the heart_ is to quicken and then

slacken it. The former action is due to a depression of the vagus

centre, while subsequent slowing is due partly to vagus stimulation

and partly to direct weakening of the heart muscle. While chloroform

does not materially affect the excitability either of the vagus or

accelerator nerves its main effect is on the strength of the heart

action, and is less marked on the auricles than on the ventricles.

Ether has a more marked tendency to raise blood pressure than

chloroform, while the latter is likely to be more responsible for

sudden falls in blood pressure even after its administration has ceased.

The question of the _relative dangers_ of the two drugs has engaged

the attention of investigators the world over, and one of the side

questions to be discussed is whether chloroform kills by arresting the

circulation or the respiration. Chloroform produces a fall in blood

pressure (see Chapter XVII) but as long as the blood pressure within

the brain, and especially the medulla, is maintained this effect is

of secondary importance; but when the respiratory centres lack their

natural stimulus, and respiration becomes irregular, then, as it

were, the patient “bleeds into his own vessels.” It is under these

circumstances that adrenalin produces its most marked and prompt effect.

The first effect of chloroform inhalations is to _raise blood

pressure_, but this is soon followed by lowered tension. The _pupils_

may dilate slightly at first, but usually contract and remain

contracted during anesthesia. _When they dilate suddenly means should

be adopted to avert the danger threatened_, as the relaxation of the

iris is the first visible relaxation of death. While the pupils react

to light there is little danger.[8]

[8] Lehmann believes it is a bad sign when a patient who is taking an

anesthetic keeps the eyes partially or completely open, or frequently

reopens them after being under the influence of the drug. He holds it

to be a premonitory symptom of more or less serious complications.

Death from chloroform usually occurs when it is assumed that no

accident is likely to happen, as when it is given to an athlete, or to

drunkards who are supposed to be secure from any reflex influences.

Patients with weak hearts can be conducted safely through a prolonged

anesthesia if there be time to prepare them. (See chapter on the

Preparation of Patients.)

The after-dangers of chloroform are smaller than those of ether, due in

part to the fact that a much smaller amount of the drug suffices; in

other words--that it is the stronger.

After anesthesia has been produced and the patient is unconscious it

requires but small additional amounts to maintain unconsciousness, as

it is necessary to add only as much as may be required to replace what

is lost by evaporation and exhalation. It is sometimes advantageous

to commence with nitrous oxide gas, for there are fewer unpleasant

reflexes, less salivation, and less disturbance of every kind. _Shallow

breathing may be improved at almost any time with a few drops of ether._

Many anesthetizers have a habit of testing the degree of anesthesia by

touching the cornea with their fingers. A piece of sterile gauze will

prove equally effective and less irritating.

When the mask upon which chloroform or ether is given is held over the

face free salivation will frequently be excited, and the patient will

be tempted to swallow as well as inhale. In this way the vapor of the

anesthetic is taken into the stomach as well as into the air passages,

and when the stomach is empty this comes into direct contact with the

gastric mucosa. This may produce not only irritation, but, in extreme

cases, gastritis. It has been suggested that to allow the patient to

drink a quantity of water at intervals before taking the anesthetic,

and especially a half-pint or more immediately before beginning it,

will be to permit of absorption and dilution of the anesthetic vapor

without their causing this irritation.

[Illustration: FIG. 40

Harcourt inhaler.]