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Full text of "Surgical diagnosis and treatment"

CONTRIBUTOBS TO VOLUME I. 

ABBE, ROBERT, M.D. 

BECK, JOSEPH C., M.D., F.A.C.S. 

BROWN, GEORGE VAN INGEN, A.B., D.D.S., M.D., 
F.A.C.S. 

CRILE, GEORGE W., A.M., M.D., F.A.C.S., F.R.C.S. (HON.) 

* 

GUSHING, HARVEY, M.D., Sc.D., F.R.C.S. 

GIBBON, JOHN H., M.D. 

JACKSON, CHEVALIER, M.D. 

JONAS, A. F., M.D. 

KAHLKE, CHARLES EDWIN, B.S., M.D., F.A.C.S. 

KANAVEL, ALLEN B., M.D. 

NUZUM, JOHN W., S.B., M.D. 

OCHSNER, ALBERT J., M.D., LL.D., F.A.C.S., F.R.M.S. 

PERCY, NELSON MORTIMER, M.D., F.A.C.S. 

SCHMIDT, EDWIN R., B.A., M.D. 

SCHMITZ, HENRY, A.M., M.D., F.A.C.S. 

SHAMBAUGH, GEORGE E., M.D. 

STANTON, E. MACD., B.Sc., M.D., F.A.C.S. 

TINKER, MARTIN B., M.D. 



o 



SURGICAL 



DIAGNOSIS AND TREATMENT 



BY AMERICAN AUTHORS 



EDITED BY 

ALBERT J. OCHSNER, M.D., LL.D., F.A.C.S., F.R.M.S. 

PROFESSOR OF SURGERY IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF ILLINOIS! 

SURGEON-IN-CHIEF TO THE AUGUSTANA AND ST. MARY'S HOSPITALS, 

CHICAGO, ILL. 



ILLUSTRATED WITH 562 ENGRAVINGS AND 
15 COLORED PLATES 



VOLUME I 





LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 



COPYRIGHT 

LEA & FEBIGER 

1920 



PREFACE. 



THE professional careers of the present leaders in surgery represent 
a period of advance in methods of diagnosis and treatment unequalled 
by the progress of many previous centuries. The atmosphere of 
spiritual and material progress in which they live enables these men 
to abandon precedent and accept new ideas. To them must be credited 
the introduction, the development and the adoption of many inno- 
vations far beyond the imagination of their predecessors. Their unself- 
ish devotion deserves and receives world-wide recognition. Therefore, 
it has seemed eminently proper to collect and, in their own language, to 
record in these volumes the conclusions of this group of contemporary 
workers who have so splendidly utilized their unusual opportunities 
to enrich surgical knowledge. 

At the present time it is deemed especially desirable to publish a 
comprehensive work emphasizing both surgical diagnosis and treat- 
ment ; because, on the part of the surgeon, there have lately been signs 
of relaxation on the side of diagnosis. To neglect the application of 
any resource in this, its most difficult department, would soon lose for 
surgery the enviable position won for it by the tireless efforts of a 
generation. 

This work in every sense reflects the current practice and thought of 
the most intensely active surgeons of this continent. Its chapters 
endeavor to tell the why and how in the solution of each surgical 
problem, and to bring the reader in touch with the actual experience, 
reasoning and practical methods of men eminent in all parts of the 
country. Each one describes intimately his methods of diagnosis, his 
plans for treatment before and after operation and gives his judgment 
regarding them. 

The reader may feel assured that he will find nothing here that 
smacks of what is copied from text-books; but only fresh material that 
represents the living work of today done by those whose powers of 
observation make their conclusions worthy of confidence. So far as 
possible, duplication has been avoided on the one hand, and on the 
other an attempt has been made to cover the entire field of general. 

(v) 



vi PREFACE 

surgery. Specialties have been invaded only so far as the general 
surgeon is justified in going when special skill is unavailable. 

In greater part the articles have been prepared during the strenuous 
years of the world war, which rendered the labor more arduous for 
contributors and publishers alike, but it has added immeasurably to 
the value of the work. With the exception of a few whose duties as 
teachers held them at their posts, all of the contributors were in the 
mjedical service of the Allied armies, and the material relating to war 
surgery has been written from the abundance of their recent experience. 

The editor desires to express his appreciation of the courtesies 
extended to him by all contributors as well as by the publishers. He 
especially wishes gratefully to record his obligation for help received 
from his assistants, Drs. Dennis W. Crile, Frank H. Doubler, O. E. 
Nadeau, John W. Nuzum and Erwin R. Schmidt. 

A. J. O. 
CHICAGO, 1920. 



CONTRIBUTORS. 



ROBERT ABBE, M.D., 

Senior Surgeon at St. Luke's Hospital; Consulting Surgeon to the Roosevelt, 
the Woman's, the Hospital for Ruptured and Crippled and the Babies' 
Hospitals, New York City; Associate Fellow of the College of Physicians of 
Philadelphia, etc. 

JOSEPH C. BECK, M.D., F.A.C.S., 

Associate Professor of Otolaryngology in the University of Illinois, Chicago, 
111.; Attending Otolaryngologist to the Cook County Hospital and the 
North Chicago Hospital, Chicago, 111. 

GEORGE VAN INGEN BROWN, A.B., D.D.S., M.D., F.A.C.S., 

Lieutenant-Colonel, Medical Reserve Corps, U. S. Army; Surgeon, U. S. 
Public Health Service, and Consultant in Plastic Surgery, U. S. Public 
Health Service at Milwaukee; Plastic and Oral Surgeon to St. Mary's 
Hospital and to the Children's Free Hospital and Columbia Hospital, 
Milwaukee, Wis.; Fellow of the American Medical Association; Member 
of the National Dental Association; Chairman of the Section on Oral 
Surgery of the Fourth International Dental Congress, etc.; formerly in 
charge of the Sub-section of Plastic and Oral Surgery of the Head Surgery 
Division of the Office of the Surgeon-General; Chief of the Maxillofacial 
Service at Walter Reed Hospital, Takoma Park, Washington, D. C. 

GEORGE W. CRILE, A.M., M.D., F.A.C.S., F.R.C.S. (Hon.), 

Professor of Surgery in the Western Reserve University, Cleveland, Ohio; 
Visiting Surgeon to the Lakeside Hospital, Cleveland, Ohio. 

HARVEY GUSHING, M.D., ScD., F.R.C.S., 

Professor of Surgery hi the Harvard University; Surgeon-in-Chief to the Peter 
Bent Brigham Hospital, Boston, Mass. 

JOHN H. GIBBON, M.D., 

Professor of Surgery in the Jefferson Medical College, Philadelphia; Surgeon 
to the Pennsylvania and Jefferson Hospitals, Philadelphia, and Consulting 
Surgeon to the Bryn Mawr Hospital, Bryn Mawr, Pa.; Late Colonel in the 
Medical Corps of the United States Army. 

CHEVALIER JACKSON, M.D., 

Professor of Laryngology in the Jefferson Medical College, Philadelphia. 

A. F. JONAS, M.D., 

Head of Surgery in the Medical Department of the State University; Surgeon 
at the Nebraska State University Hospital, the Nebraska Methodist Episco- 
pal Hospital, and the Wise Memorial Hospital, Omaha, Neb.; Chief Surgeon 
of the Union Pacific Railroad, Omaha, Neb. 

CHARLES EDWIN KAHLKE, B.S., M.D., F.A.C.S., 
Chicago, 111. 

(vii) 



viii CONTRIBUTORS 

ALLEN B. KANAVEL, M.D., 

Professor of Surgery in the Northwestern University Medical School; 
Attending Surgeon at the Wesley Memorial and Cook County Hospitals, 
Chicago, 111. 

JOHN W. NUZUM, S.B., M.D., 

Associate in Anatomy and Pathology in the University of Illinois, College of 
Medicine, Chicago*; Chief Surgical Assistant to Drs. A. J. Ochsner and 
Nelson Percy at Augustana Hospital, Chicago; formerly Director of the 
Laboratories in the Cook County Hospital, Chicago, 111. 

ALBERT J. OCHSNER, M.D, LL.D., F.A.C.S., F.R.M.S., 

Professor of Surgery in the Medical Department of the University of Illinois; 
Surgeon-in-Chief to the Augustana and St. Mary's Hospitals, Chicago, 111. 

NELSON MORTIMER PERCY, M.D., F.A.C.S., 

Associate Professor of Clinical Surgery in the University of Illinois College of 
Medicine, Chicago; Attending Surgeon to the Augustana and St. Mary's 
Hospitals, Chicago, 111.; Fellow of the American Surgical Association. 

EDWIN R. SCHMIDT, B.A., M.D., * 

Chief of Resident Staff of the Augustana Hospital, Chicago, 111.; Captain, 
Medical Corps, V. S. Army. 

HENRY SCHMITZ, A.M., M.D., F.A.C.S., 

Professor and Head of the Department of Gynecology in the Loyola University 
School of Medicine; Attending Surgeon at St. Mary's of Nazareth Hospital; 
Attending Gynecologist at the Cook County Hospital and the Frances E. 
Willard National Temperance Hospital, Chicago, 111. 

GEORGE E. SHAMBAUGH, M.D., 

Professor of Otology and Laryngology in the Rush Medical College; Otologist 
to the Presbyterian Hospital, Chicago, 111. 

E. MACD. STANTON, B.Sc., M.D., F.A.C.S., 

Surgeon to the Ellis Hospital, Schenectady, New York. 

MARTIN B. TINKER, M.D, 

Lieut.-Colonol in the Medical Reserve Corps of the United States Army; 
Chief of Surgical Service at the U. S. General Hospital No. 26, Fort Des 
Moines, Iowa; Formerly Assistant Professor of Surgery at Cornell Univer- 
sity, Ithaca, New York. 



CONTENTS. 



SURGICAL PROGNOSIS 17 

BY E. MACD. STANTON, B.Sc., M.D., F.A.C.S. 

TECHNICAL EFFICIENCY '...., 77 

BY ALBERT J. OCHSNER, M.D., LL.D., F.A.C.S., F.R.M.S. 

ASEPTIC AND ANTISEPTIC TECHNIC . ." 79 

BY ALBERT J. OCHSNER, M.D., LL.D., F.A.C.S., F.R.M.S. 

ANESTHETICS AND ANESTHESIA 93 

BY EDWIN R. SCHMIDT, B.A., M.D. 

SHOCK AND HEMORRHAGE 117 

BY JOHN W. NUZUM, S.B., M.D. 

INFLAMMATION AND HEALING OF WOUNDS 125 

BY JOHN W. NUZUM, S.B., M.D. 

SURGICAL FEVER AND INFECTIONS . 131 

BY JOHN W. NUZUM, S.B., M.D. 

POSTOPERATIVE TREATMENT 139 

BY JOHN H. GIBBON, M.D. 

VACCINES 163 

BY A. F. JONAS, M.D. 

BLOOD TRANSFUSION 187 

BY NELSON MORTIMER PERCY, M.D., F.A.C.S. 

EFFICIENCY OF RADIUM IN MALIGNANT DISEASE .... 209 
BY ROBERT ABBE, M.D. 

DEEP ROENTGENTHERAPY 235 

BY HENRY SCHMITZ, A.M., M.D., F.A.C.S. 

(ix) 



x CONTENTS 

INJURIES AND DISEASES OF THE SKULL AND ITS COVERINGS 263 
BY CHARLES EDWIN KAHLKE, B.S., M.D., F.A.C.S. 

DIAGNOSIS AND TREATMENT OF TUMORS, INFLAMMATIONS 

AND ABSCESSES OF THE BRAIN 327 

BY ALLEN B. KANAVEL, M.D. 

THE PURPOSE AND TECHNICAL STEPS OF A SUBTEMPORAL 

DECOMPRESSION 407 

BY HARVEY GUSHING, M.D., Sc.D., F.R.C.S. 

SURGICAL COMPLICATIONS RESULTING FROM SUPPURATIVE 

MIDDLE-EAR DISEASE 449 

BY GEORGE E. SHAMBAUGH, M.D. 

* 

SURGERY OF THE NOSE AND THROAT 473 

BY JOSEPH C. BECK, M.D., F.A.C.S. 

SURGERY OF THE MOUTH AND FACE 535 

BY GEORGE VAN INGEN BROWN, A.B., D.D.S., M.D., F.A.C.S. 

MAJOR OPERATIONS ON THE MOUTH 655 

BY ALBERT J. OCHSNER, M.D., LL.D., F.A.C.S., F.R.M.S. 

SURGERY OF THE NECK 669 

BY MARTIN B. TINKER, M.D. 



DIRECT LARYNGOSCOPY, BRONCHOSCOPY AND ESOPHAGOS- 

COPY 735 

BY CHEVALIER JACKSON, M.D. 



SURGICAL DISEASES OF THE THYROID AND PARATHYROID 

GLANDS 771 

BY NELSON MORTIMER PERCY, M.D., F.A.C.S. 

THE DUCTLESS GLANDS 811 

BY GEORGE W. CRILE, A.M., M.D., F.A.C.S., F.R.C.S. (HoN.) 

SURGERY OF THE THYMUS GLAND 821 

BY ALBERT J. OCHSNER, M.D., LL.D., F.A.C.S., F.R.M.S. 



SURGICAL PROGNOSIS. 



BY E. MACD. STANTON, M.D., F.A.C.S. 

IN surgery the relation between cause and effect, the operation and 
its result, is usually so definite that the subject of prognosis assumes 
a position of far greater relative importance than in most other 
branches of medicine. A thorough knowledge of surgical prognosis 
is the most essential single requisite for a sound surgical judgment, 
and, no matter how great the surgeon's diagnostic ability or how 
excellent his operative technic, his ultimate standing as a surgeon 
will be determined very largely by the standard of surgical judgment 
which characterizes his work. 

When we attempt to deal with the general aspects of surgical prog- 
nosis it is well for us to bear in mind that there are two distinct mental 
processes by which the surgeon may arrive at the approximate prognosis 
of the individual case. 

First, h may ascertain the results previously obtained in similar 
cases, beginning with the average results obtained in all those indi- 
viduals who have suffered from the same disease and proceeding 
ultimately to the results obtained in smaller groups of cases more 
nearly approaching in their various details the character of the case 
under consideration. This first or comparative method necessitates 
an intimate knowledge of the statistical data having to do with the 
prognosis of each separate disease. The specific portions of our 
knowledge concerning this phase of prognosis are far too complex in 
their detail to be encompassed in the limits of this chapter. 

The second method depends chiefly upon a careful study of the 
individual patient with special reference to each one of those factors 
which may be ascertained to have a distinct bearing on the outcome 
of the case. These factors, which have to do principally with the 
general condition of the patient and the dangers and complications 
incident to all surgical diseases and operations, can be discussed to 
advantage in a chapter devoted expressly to this purpose. 

STATISTICS IN PROGNOSIS. 

Because statistics play such an important part in all discussions 
pertaining to the subject, it may be well to emphasize several 
facts concerning the value of and the limitations of statistics in 
prognosis. Statistics properly handled are essential for determining 
many of the most important truths concerning prognosis. That 
2 (17) 



18 SURGICAL PROGNOSIS 

they are not always properly interpreted, and that both medicine 
and surgery have been abundantly burdened with figures of doubtful 
or even negative value means only that due care should be used in 
drawing conclusions from this kind of data. The man with a thorough 
knowledge of the subject at hand and a fair sense of mathematical 
proportion usually finds little difficulty in ascertaining the important 
points demonstrated by the statistical data presented. 

The most common error arising from the use of medical as well as 
other statistics comes from a failure to recognize the fact that gener- 
alities, no matter how true they may be in themselves, are not meant 
to be applied directly to specific instances. For example, statistics 
collected from all over the world show that, taken as a whole, the 
operative mortality in acute appendicitis has borne a quite definite 
relationship to the day of the disease on which the patient has been 
operated. That these figures do show certain great truths concerning 
the mortality of acute appendicitis is proved by the fact that the 
results are essentially uniform for large group^of cases compiled from 
clinics in no way connected with one another. Yet because there 
has been an average mortality of say 8 per cent, for patients subjected 
to operation during the third day of the acute attack, it does not 
mean that this figure represents the true prognosis in the majority of 
individual third-day appendix cases. As a matter of fact a perfectly 
accurate individual prognosis under the circumstances existing at the 
time the patients were operated upon would have been wholly favor- 
able in 92 per cent, of the cases, and entirely unfavorable in 8 per 
cent. The absurdity of predicting one chance in twelve of death 
for each individual third-day appendix case because that may have 
been the average for cases operated during the third day of the attack 
is self evident. 

It is a fact to be regretted that much of the available data purporting 
to show the results obtained in the many special fields of surgery has 
emanated from the clinics of those who have devoted particular 
attention and skill to the special line of work, the results of which, 
they have reported. Just in so far as these reports represent the 
exceptional rather than the average results they are liable to be 
misleading. Such statistics should be interpreted as representing 
what can be accomplished under exceptional circumstances rather 
than as a fair estimate of the results to be expected under ordinary 
conditions. The true prognosis and the permanent standing of a 
surgical procedure are determined not by the exceptional results 
which may be obtained by some master in a particular line of work, 
but by the average results which are obtained by other surgeons 
using the same methods. 

The introduction of a standard case-record system for hospitals 
complying with the standardization requirements of the American 
College of Surgeons has been a notable advance which is bound to 
result in the accumulation of much needed data pertaining to the sub- 
ject of surgical prognosis. The summary card recommended by the 



STATISTICS IN PROGNOSIS 19 

College is admirably adopted to the purpose of collecting end-result 
data. 

Data as to end-results is best attained by means of letters sent to 
the patients at regular intervals following the operation. In the case 
of general hospitals treating large numbers of charity patients the pro- 
portion of answers received to these letters is often disappointing. On 
the other hand in private practice we have for a number of years 
received more than 90 per cent, of replies to the following letter: 

SCHENECTADY, N. Y. 

"It is now just a year since your operation, and as I am anxious to keep track of 
the results obtained in all cases operated by me, I will appreciate the favor if you will 
fill out the answers to the following questions and return this letter in the enclosed 
stamped envelope. 

After the operation were you cured of the trouble from which you sought relief? 

If cured, how long after the operation was it before you recovered your strength? 
If not entirely cured, what symptoms referable to the old condition still persist? 



Were there any ill effects referable to the operation itself? 

If so describe briefly what they were 

Please note any other points of interest concerning the results of your operation 
not covered by the above questions 

If you are not certain concerning the answers to the above questions you can call 
on your family physician for advice or you can telephone me or call at my office at 
any time during office hours. 

Very sincerely," 



The system introduced by the American College of Surgeons is 
resulting in the collection of an enormous amount of data pertaining 
to the late results following operations. However my own end-result 
studies, carried out over a period of thirteen years, have convinced me 
that the chief reason for our present-day lack of end-result knowledge 
is not so much the lack of data as that surgeons have not as yet 
devised a uniform and satisfactory system for reporting the data 
which they have been able to collect. Surgical literature is full of com- 
munications dealing in a general way with the subject of end-results, 
in which it is evident that the author is in possession of considerable 
data which he has finally despaired of presenting in other than the 
most general terms. 

Some time ago I found that I had several thousand histories with 
end-result records extending over fairly adequate periods of time, 
but that whereas these records had been collected with, let us say, one 
unit of energy on my part, when I came to study any one group of 
cases it took several units of time and energy to put the data into form 
suitable for study and comparison. In some groups it was impossible 
to classify the results according to the usually attempted standards. 
Also, I found that no two surgeons adopted the same standards in 
reporting their cases, so that it was impossible to compare small groups 
from different sources or to combine them into larger series of greater 
statistical value. 



20 



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SURGICAL PROGNOSIS 



The real reason for this difficulty lies in the fact that surgeons have 
tried to state the end-results in terms such as "cured," "improved," 
etc., without reference to the time element. Actually, our patients 
are cured, or whatever the result may be, for variable periods of time, 
and it is just as absurd to try to state end-results in terms ignoring the 
element of time as it would be to attempt to state the area of a plot 
of ground in terms of one dimension. 

All of the major difficulties of presenting the end-results disappear, 
if we tabulate the results in terms of the time the patients have been 
traced following the operation, together with their state of health for 
the time periods. By this method the " cured" column becomes " years 
cured" and the term "years" is also added to the other divisions. It 
is also of advantage to add the headings "years operated" and "years 
traced" as illustrated in the accompanying table, which shows the 
results of tabulating 20 exophthalmic goitre cases operated by myself. 

The mortality may be recorded either as "years dead" or by simply 
giving the number of deaths. In the cases here reported the operative 
and late deaths are given in separate columns, also the expected mor- 
tality in normal individuals for the same period is indicated. 

TABLE I. RESULTS FOLLOWING OPERATIONS FOR EXOPHTHALMIC 

GOITER. 



pflftp 


Years Deaths. 


v^aSC 

No. 


i ears i ears \ ears satis- i ears 
op. traced. cured. factorily improved. umm ~ 
improved. e _ 


Late. 


2 


10 3 3 


3 


10 10 8 


1 


1 


4 


9 1/12 ' glO/12 7 4 /12 1 6 /'2 








5 


811/12 8*/i2 en/12 


6 /12 


1 






6 


810/12 


810/w 7>%2 


1 








7 


8Vi2 


8 2 /i2 6 2/12 2 










8 


711/,2 73/i 2 6 9 /12 6 / 










9 


78/i 2 1 


6 /12 


6 /12 






12 


6 8 /, 2 


6Vl2 J 5 


1 "A, 










13 


6/12 


5 / 5 '/i2 












16 


51U/ 12 


9 /12 


9 /12 










18 


5 8 / 12 


4/12 










1 




19 


5/12 


* / ** 

5/u 




1/12 


4 








21 


5 4 /12 


5/w 


4 4/, 2 


1 










28 


4 6 /12 


3 7 /12 














30 


3/12 


2'/12 


. 


.... 


2^/12 





1 




32 


3/12 


3 6 /12 




2 */12 


6/ w 






1 


33 


30/12 


3 4 / 




3 4 /12 










40 


2/w 


1 8 /12 


Wu 








41 


2/ii 


l n /12 










1 




42 


2V.2 


1 




1 










43 


!/ 


I'/* 


. . 


/ 


/12 








44 


1 */12 


1 7 /12 




1 */l* 


4 /W 








45 


1 8 /12 


1 / 




1 1 /12 


Vu 








47 


1 6/ 12 


1 


8 /n 


|/tl 










49 


1 


1 


9 /n 












Total 


136 / 107 Vw 50/w 


20 / 


223/ 12 


2/I2 


3 


2 



THE PROGNOSIS OF ALL SURGICAL DISEASES 25 

The advantages of this system of recording end-results are quite 
obvious. No matter how complicated the postoperative history, it can 
be readily subdivided and classified into the appropriate periods. 

It is not necessary for the surgeon to trace each case to the time of 
reporting his results. If he has lost track of his patient soon after 
operation this fact is clearly shown by his figures and the value of the 
data may be judged accordingly. This method of completing end- 
result statistics is illustrated by Table I. 

Formerly the most difficult of all cases to classify were the exoph- 
thalmic goiter cases. This was because almost no single case could be 
placed under a single heading. By the method here outlined even the 
exophthalmic goiter cases can be readily classified. The table shows 26 
cases operated, a total of 136 T 5 2- years and traced 107 f-% years. Of 
this time 50 T 2- years or 47 per cent., of the total traced postoperative 
time the patients have been cured. An additional 20 T 5 2- years, or 
9 per cent., of the time the patients have been satisfactorily improved, 
making 66 per cent, of truly satisfactory results. 22 T 3 2- years, or 21 
per cent., credited in the improved column, represent improvement 
to such an extent that the patients feel well repaid for their operations. 
Only 2 T 6 2- years, or 2 per cent, of the postoperative time, has been 
passed as unimproved. 

In this series there are 3 early postoperative and 2 late deaths. The 
expected mortality for normal risks of the average age of the patients 
in this series is 0.963, or not quite 1 normally expected death. 

GENERAL FACTORS INFLUENCING THE PROGNOSIS OF 
ALL SURGICAL DISEASES. 

Age. The influence of age on surgical prognosis is most important 
at the two extremes of life. The fact that the effect of age on the 
mortality of surgical diseases is essentially the same as the effect of 
age on disease in general enables us to make use of the enormous data 
collected by life insurance companies. Chart I has been compiled 
from the standard mortality tables of the life insurance companies 
for the purpose of graphically representing the effect of age on mor- 
tality. Although the data used for these tables is not obtained from 
surgical experience we believe that the curves here reproduced do 
show better than any other data available the effect of age per se 
upon the mortality factor in surgical prognosis. 

An infant during the first year of life is a poor surgical risk. In 
general mortality statistics, most of the deaths are due to nutritional 
disorders not directly associated with surgical conditions, but never- 
theless infants suffering from surgical diseases demanding operations 
at this early age are usually in a condition making them particularly 
liable, not only to the dangers incident to the operation itself, but to 
all the incidental dangers of this delicate age as well. 

The general mortality of the second year is only about one-fourth 
that of the first year, and the prognosis continues to improve until, 



26 



SURGICAL PROGNOSIS 



at about six years of age, the special dangers of early infancy and 
childhood have largely disappeared. Nevertheless, actuarial figures 
show a continued improvement up to the age of twelve. The mor- 
tality from all causes during the years from ten to fifteen is decidedly 
less than in any other period of years allotted to man. 

Before passing to the consideration of the middle and later periods 
of life, it may be well to mention certain points of special surgical 
importance having a bearing on the prognosis of the early years of life. 



AGE 



70 80 90 



10 20 30 40 50 




FIG. 1. Relation of age to mortality risk. 

Surgeons generally agree that children, and especially infants, bear 
hemorrhage badly. Yet when we take into consideration the natur- 
ally bloody character of a large proportion of the operations of general 
surgery undertaken on infants and children, and the proportionate 
amounts of blood available for loss in children and adults, it is diffi- 
cult to prove a much greater relative inability to withstand hemorrhage 
in the younger patients. Certainly in the absence of other factors to 
produce or continue shock, the recovery of the average child from the 
effects of hemorrhage after such operations as tonsillectomy or staphyl- 
orrhaphy is very rapid. 

Nearly all surgeons agree that children are particularly susceptible 
to shock, and this fact should always be borne in mind when operating 
on children. Nevertheless, operative interference of such magnitude 



THE PROGNOSIS OF ALL SURGICAL DISEASES 27 

as to be commonly associated with serious shock is seldom really 
imperative during childhood. In cases requiring extensive operative 
work the conditions are usually such that all need not be done at 
one time. Children much better than adults can afford the extra 
time consumed by operations carried out in several stages. 

The susceptibility of the young baby to all those conditions inter- 
fering with its nutrition is known to all mothers, and the intensity 
of the metabolic processes throughout childhood make children, as a 
rule, more susceptible than adults to interference with their nutri- 
tion. Yet, if children are not too unruly, those suffering from intra- 
peritoneal infections may be kept for a week or more on the Murphy 
drip, without food or drink by mouth, and after the cause of their 
illness has been successfully dealt with, it is remarkable how quickly 
they regain their weight and strength. 

The prognosis of surgical tuberculosis is very much better in chil- 
dren than in adults. If the part can be kept at rest, bone tuberculosis, 
as a rule, heals spontaneously in children, while in adults radical 
excision of the diseased structures is usually required in order to 
effect a cure. Lymph gland tuberculosis in children heals sponta- 
neously or after the simple removal of the more extensively involved 
glands, while in adults recurrences after operation for tuberculous 
lymph nodes are the rule, unless all of the glands in the region of the 
involvement are removed as well as the focus of primary infection in 
the tonsils or elsewhere. 

In children the increased risks due to alcoholism and other excesses 
may be eliminated from our reckoning. 

The child recovers very rapidly from the nervous phenomena 
accompanying the operation and postoperative neurasthenia is almost 
never seen. 

Thrombosis and embolism are very rare after operations during 
childhood. 

During middle life the mortality curve shows a gradually increasing 
risk with each succeeding year until in the forties the curve begins 
to ascend more rapidly. It is well to note that between forty-five 
and fifty-five years there is practically a 60 per cent, increase in the 
male mortality rate. These are the years which represent the period 
of the menopause in women. It is "the critical period for women" 
in the minds of the laity and most of the profession. But a careful 
examination of the table shows the rise in female mortality during 
this period is just as gradual as it was before. Much more startling 
is the appearance of the increase in the male mortality. Certainly 
this is man's critical period. The old doctrine that he too had a great 
climacteric is most strikingly shown. In the ten years from forty-six 
to fifty-six the gain in mortality per mille per annum formates is 6.32, 
while for females it is only 3.47. What are the causes for this greatly 
increased mortality among men? It is because his dissipations now 
begin to make themselves felt especially alcoholism. The syphilis 
of his youth is just drawing its last check. The hardships of his 



28 SURGICAL PROGNOSIS 

occupation have now begun to bankrupt him. This is the period 
when habits and excesses begin to have a special importance in surgical 
prognosis. 

After fifty the normal death-rate increases so rapidly that it is 
practically doubled with each succeeding decade. Thus, at fifty it 
is 13.01 per mille for males, at sixty it is 23.67, at seventy it is 55.64 
and at eighty 124.93, or at the latter age approximately twenty times 
the normal death-rate for fifteen years of age. 

In those past middle life, the effects of age on the individual prog- 
nosis must be estimated in conjunction with a knowledge of such 
ascertainable facts as the blood-pressure, the general condition of the 
heart and arteries, the findings of the urinary examination and the 
previous habits of the patient. 

Sex. The sex of the patient concerns more closely the incidence 
than it does the prognosis of surgical diseases. Most surgeons are 
convinced that women are, as a rule, better risks than men, and 
there is considerable data purporting to sho 1 ^ that the operative 
mortality in diseases of certain organs not related to the sex of the 
patient, e. g., gall-bladder surgery, is very much higher in the male 
than in the female. A study of this data, however, seems to show that 
the increased mortality in men occurs chiefly in the surgery of organs 
liable to be damaged by alcoholism and other excesses, and that males 
whose general resistance has not been undermined by irregular living 
are quite as good risks as females. Women are much less likely to 
be handicapped by these excesses. 

The other noteworthy effects of sex on the prognosis have to do 
with the conditions involving especially the sex organs and will be 
discussed under the diseases of these organs. 

Constitution. As regards operative mortality there is little to 
choose between the slender, weak-muscled, nervous patient and the 
heavy, strong-muscled, calm, physically perfect individual. If any- 
thing, the advantage is liable to lie with the apparently weaker indi- 
viduals unless the inferiority be due to actual disease. In them the 
technical part of the operation is usually easier, they seem to be 
better able to handle infection when it is present, and, as a rule, 
they are less liable to postoperative pneumonia and similar compli- 
cations. 

The great danger with the constitutionally weaker class of indi- 
viduals lies not so much in the mortality as in the temptation con- 
stantly presented to the surgeon to try and accomplish the impossible 
in the way of making well and strong those who are fundamentally 
defectives. As W. J. Mayo has recently emphasized, the surgeon 
must not expect to make the man who is thin and six feet high into 
one who is fat and five feet six inches high by any operative procedure. 
Yet, if we study the history of surgery, especially during the past two 
decades, we cannot help but be impressed with the fact that many 
surgeons have been, and for that matter still are, actively engaged 
in trying to make over the thin, nervous, droop-bellied, visceral- 



THE PROGNOSIS OF ALL SURGICAL DISEASES 29 

sensitive woman into a strong normally innervated individual, usually 
by taking a tuck or two in the auxiliary supports of whatever organ 
may strike the fancy of the operator. The wise surgeon, who values 
his end-results and his lasting reputation as much as his mortality- 
rate and record of operations performed, places a very high value 
on the factor of "constitution" in so far as it may effect the final 
results of his work. 

Neurotic Temperament. The question of the nervous weakling has 
for years been one of great practical importance in surgery. The 
many terms which have been used to describe this class of patients 
illustrates the confusion which exists regarding them, and yet in 
general, the neurotic individual is not difficult to recognize. Most 
of them are physically below the average, and yet comparatively 
few actually show well-marked evidences of disease. Their com- 
plaints are always out of proportion to the objective evidences of 
gross pathology. 

Many of these neurotic patients seem to be endowed with an 
abnormal visceral sense which makes them subjectively conscious of 
the workings of their internal organs and these visceral sensations 
come to occupy a large sphere in their mental processes. It is these 
visceral hypersensitives who make up a large proportion of the doubt- 
ful cases which the surgeon is called upon to diagnosticate and treat. 
Others are acutely sensitive beyond normal limits to all sorts of 
painful stimuli, and still others, the true neurasthenics, appear to be 
simply in a state of chronic nervous exhaustion. All of these types 
are continually seeking cure by surgical means, and operations devised 
for the purpose of curing them are continually being described. 

In studying the history of surgical attempts to cure these cases 
we find surgeons at one time directing their efforts against the ovaries, 
while at another period uterine antiflexion was supposed to be the 
really important factor, and at still another period movable kidneys 
were looked upon as the most important cause of trouble to say 
nothing of the chronic appendix. Recently tucking up the intestines 
was in great favor with a few operators, while others turned to 
resections of the colon. These periods of operative experimenta- 
tion are mentioned because the fact should not be lost sight of that 
the surgeons were in each period dealing with essentially the same 
class of patients, and at no time have any considerable proportion of 
these patients been permanently benefited by surgery. The prog- 
nosis as regards mortality in these patients is usually excellent, but 
as regards cure from the viewpoint of the patient and the patient's 
relatives and friends these operations have been almost uniformly 
failures. 

Surgically the nervous weakling should receive the same considera- 
tion as any other patient, no less and no more. Above all, real physi- 
cal findings of disease should be the basis for operation and not the 
patient's account of his or her subjective sensations. It is seldom 
necessary to operate for pain alone. The subjective pain of the 



30 SURGICAL PROGNOSIS 

patient must be substantiated by some objective finding of the surgeon. 
Yet frequently we find surgeons operating for pain which they do not 
know to exist. 

SPECIAL CONDITIONS AFFECTING SURGICAL PROGNOSIS. 

Obesity. Overweights are poor life insurance risks in almost direct 
proportion to the degree of excess weight, and the same handicap 
applies to these patients as surgical risks. A moderate amount of 
excess fat, as a rule, has little effect on the prognosis other than to 
increase the technical difficulties of the operation. With greater 
degree of obesity many difficulties and even dangers begin to make 
themselves manifest. 

Excessive quantities of fat not only increase the technical difficulties 
of the operation, but the very presence of the fat in excessive quan- 
tities renders these patients bad subjects for either general or local 
anesthesia. The respiration is usually interfered with, and they take 
the anesthetic badly causing cyanosis, venous stasis and increased 
hemorrhage. Later these patients are particularly prone to develop 
postoperative pulmonary complications. Acute cardiac dilatation is 
a complication which may be encountered, especially if the patient 
be kept for any length of time in the Trendelenburg position. Fat 
embolism is another complication which probably occurs more fre- 
quently than is generaly recognized. 

Fat is essentially a tissue of low vitality. Adipose tissue and 
obese individuals in general are notoriously little resistant to infection. 
Experimental observations have shown fat to be the least resistant 
tissue in the body to infection, and this has been abundantly confirmed 
clinically. It is likewise a particularly slow-healing tissue, the fat 
itself acting much as a benign foreign body while the repair proceeds 
chiefly from the interlobular connective-tissue septa. Whereas the 
serum exuded between two cut surfaces is an essential element in the 
healing process, oil pressed out from the fat and collecting between 
cut surfaces must first be removed before repair can proceed. 

Ventral hernias and similar postoperative partial failures are more 
common after operations on the obese. This is due largely to 
the fact that the incision is called upon to support excessive strains 
incident to the increased weight while at the same time the tissues 
used in closing the wound are often so infiltrated with fat that they 
are soft and yielding. Another reason is that surgeons are prone to 
forget the slow repair in these patients. Obese patients should be kept 
in bed after laparotomies until adequate time has elapsed for the union 
of the slow-healing tissues. 

Alcoholism. The chronic alcoholic is a peculiarly unreliable surgi- 
cal risk. All that life insurance companies say concerning the dangers 
of chronic alcoholism may be repeated with special emphasis as 
applying to the effect of alcoholism on operative prognosis. 

These patients almost uniformly take an anesthetic poorly, and 



SPECIAL CONDITIONS AFFECTING SURGICAL PROGNOSIS 31 

they are also notoriously bad subjects when it comes to resisting an 
infection of any kind. Postoperative pneumonia is a particularly 
dangerous complication for them. 

The liability of the chronic alcoholic to develop delirium tremens 
after even minor accidents or operation is known to every hospital 
attendant. Particularly is this so after fractures, where it is possible 
that fat emboli, which in other patients would produce no symptoms, 
may play a part in the etiology. 

The worst subject is usually the alcoholic between forty-five and 
sixty years of age. By this time many of the chronic alcoholics have 
reached a condition of general disintegration, when some otherwise 
minor disease is all that is necessary to carry them off, and if this 
trouble happens to be of a surgical nature they are very likely to be 
added to the surgeon's list of failures. 

The alcoholic who survives sixty seems often to be made of tougher 
material than the average man, so that among old men alcoholism 
would appear to have less effect on the operative prognosis than it 
does among the middle-aged. 

Heart Disease. The laity and many general practitioners lay 
special stress on the dangers of general anesthesia in the presence 
of valvular heart disease. This belief is probably handed down 
from the days of relatively frequent chloroform fatalities. Certainly 
experience today, with ether given by the open drop method, is to 
the effect that well-compensated valvular lesions add very little if any 
risk to the anesthetic. Myocardial degenerations are, on the other 
hand, of considerable importance. 

Willius, 1 in a recent paper, summarizes the experience of the Mayo 
Clinic as to the operative risk in cardiac cases as follows : 

I. The decision of operability in cardiac disease depends on the 
factors as follows: (1) The immediate operative risk, (2) the probable 
improvement of the heart after operation, (3) the patient's relative 
chance for length of life or general health with and without operation, 
and (4) in less serious conditions, whether the operative relief will 
justify the added risk. 

II. Cases in which the heart permits the patient to go about in rela- 
tive comfort, or in which it can be sufficiently restored by treatment to 
allow this, usually are considered safe for operation. 

III. Malignancy complicated by heart disease is usually considered 
operable if a fair hope of cure is offered. 

IV. The best measure of operative risk is a good clinical impression 
of the patients' ability to stand physical strain, supplemented by a 
careful history and a thorough physical examination. 

V. Preoperative medical therapy and rest combined with surgical 
and medical correlation after operation, is of paramount importance. 

VI. The general tendency is to require too great a margin of cardiac 
safety in surgical work. 

1 The Operative Risk in Cardiac Disease, American Journal of Surgery, Oct.. 1918. 



32 SURGICAL PROGNOSIS 

Renal Disease. The relationship of renal disease to surgical prog- 
nosis is one which must be approached with great caution. Albumin 
and casts are such frequent accompaniments of so many conditions 
requiring surgical treatment that they in themselves have little 
influence on the prognosis. On the other hand grave renal disease 
may be an almost absolute contra-indication to operation. In general, 
it may be said that the dangers depend upon the evidences of renal 
insufficiency rather than upon the results of the urine examination. 
Elective operations in the presence of demonstrable renal insufficiency 
should, as a rule, be approached with great caution or abandoned 
entirely, but if the condition of the patient be such as to actually 
demand operative interference the renal lesion may usually be dis- 
counted as a contra-indication to operation. The dangers of operating 
in the presence of uremia or on parts edematous with chronic renal 
disease cannot, of course, be overestimated. 

The relation of renal disease to the surgery of the urinary tract 
will be discussed under the chapter dealing witfe this subject. 

High Blood-pressure. High blood-pressure is a symptom which 
should be given due weight in so far as it indicates grave cardiovascular 
or renal disease. 

Low Blood-pressure. A markedly low blood-pressure is always a 
dangerous prognostic sign in surgical cases. During and following 
operations it is a symptom of shock. Previous to an operation it 
may signify shock or hemorrhage or some grave asthenic condition. 
Except for the purpose of preventing further active hemorrhage, 
operations should very rarely be undertaken if the systolic blood- 
pressure is under 100 mm. Hg. A blood-pressure below 90 mm. Hg 
is almost a positive contra-indication to active operative interference. 

Low Pulse-pressure. The pulse-pressure should equal approximately 
one-third of the systolic pressure. In shock, grave hemorrhage and a 
number of other conditions affecting seriously the prognosis, the pulse 
pressure is found to be low in relation to the systolic. Patients having 
a pulse pressure of less than one-third of the systolic pressure should 
always be viewed with suspicion. A sudden fall in pulse-pressure during 
the course of a disease or following an operation is a grave prognostic 
sign. 

Diabetes. Diabetics are notoriously bad surgical risks. Wound in- 
fection, non-healing and diabetic coma are the three dangers peculiar 
to operations on diabetic patients. Of these coma is by far the most 
frequent and the most difficult to prevent. Karewski reports 136 
operations on diabetics with a mortality of 20 per cent, and of these 
78 per cent, died in coma. 

Sepsis and non-healing can be very largely controlled by the use of a 
rigid aseptic technic and great care to avoid unnecessary trauma to the 
tissues. 

For many years surgeons generally have held to the belief that 
if the diabetic patient could be rendered sugar-free, an operation 
could then be performed with relative safety. This idea was based 



SPECIAL CONDITIONS AFFECTING SURGICAL PROGNOSIS 33 

largely on the work of Phillips 1 who in 1902 reported a large series of 
cases from the literature showing a mortality of 36.37 percent, in cases 
not subjected to preoperative treatment and 17.7 per cent, in treated 
cases. More recently it has been show a that the well-known dangers 
accompanying attempts to render the urine sugar-free in medical 
practice hold with equal force in surgical work and that preoperative 
dietary treatment unless it is surrounded with all the safeguards known 
to the medical treatment of this disease is likely to actually increase 
the dangers of coma. 

The dangers of operating in the presence of diabetes can scarcely 
be overestimated and yet under certain conditions the diabetic seems 
to offer but a moderately increased operative risk. Fifty per cent, of 
the postoperative coma cases reported by Karewski were in so-called 
mild diabetics and it may be said that the factors governing the selec- 
tion of safe operative risks in the presence of this condition are not yet 
fully understood. In general it may be said that no diabetic should 
be operated, except in the gravest emergency without first demon- 
strating the patient's ability to maintain a sugar-free urine without 
developing any of the well known acidosis complications of the disease. 

Acidosis. This term has been used to designate conditions varying 
in importance from the slight increase in the H-ion concentration of the 
blood which follows severe exercise to the grave acid intoxications of 
the type encountered in diabetic coma. Theoretically acidosis explains 
certain phases of the abnormal physiology encountered in many serious 
conditions. As a rule the underlying causes of the acidosis are readily 
recognizable and when acidosis is demonstrable in the presence of these 
causes the prognosis is serious and when possible the operation should 
be postponed until the acidosis can be remedied. Occasionally the 
surgeon encounters patients suffering from a grave acidosis without 
the underlying disease being apparent. 

Russ 2 states that the warning signs in such cases are: 

1. A history of unaccountable headaches, vertigo, attacks of 
dyspnea, occasional nausea or vomiting, an unreasonable dread of 
the operation, tachycardia and other nervous symptoms. 

2. A peculiar sweetish odor to the breath, suggesting the odor of 
rotten apples. In some cases this is marked and unmistakable. 

3. The presence in the urine of the acetone bodies. 

He further says that to disregard these warning signs is to subject 
the patient at best to (1) an anesthesia requiring large amounts of 
ether or chloroform and attended with struggling and great rigidity 
of the muscles, difficult breathing, a rapid pulse and nausea and 
followed by a prolonged and nerve-racking convalescence, with per- 
sistent vomiting, restlessness, dyspnea, a rise in temperature and 
much suffering; or, if less fortunate, to (2) the certainty of a fatal 
termination, preceded by nausea, air-hunger, persistent vomiting, a 

1 Surgical Aspects of Glycosuria and Diabetes, Lancet, 1902, i, 1308-1386. 

2 Acidosis as a Complication after Surgical Operations, Jour. Am. Mod. Assn., 1913, 
Ixxxi, 1618. 

3 



34 SURGICAL PROGNOSIS 

rise in temperature, great nervousness and followed by coma and 
death in from ten hours to two or three days. 

The writer 1 has had one postoperative death due to this cause, 
and can recall three other deaths which were pirobably due to this 
condition. As a complication in surgical work acidosis is undoubtedly 
rare and the data so far available concerning it is by no means conclu- 
sive, and yet as surgeons learn to eliminate the more common causes of 
failure these rare conditions assume greater relative importance. 

Intestinal Auto-intoxication. Few subjects in medicine or surgery 
have been, more written about with less clear understanding than 
has the question of auto-intoxication of intestinal origin. Some even 
claim that the victims of this condition are bad general surgical risks 
prone to all sorts of complications. It would seem, however, that in 
all but the most severe grades of the condition its effect on the imme- 
diate operative prognosis is of but very slight importance. 

It is in connection with the question of the ultimate prognosis of 
operations performed for other conditions and those directed toward 
tha relief of this condition that the subject of intestinal auto-intoxica- 
tion assumes great practical importance. That the surgical end-results 
in cases operated for the various phases of so-called auto-intoxication 
have up to the present time been often unsatisfactory is generally 
accepted. Furthermore, it seems highly probable that the results 
will remain unsatisfactory until some really definite knowledge is 
obtained concerning the etiology of the condition. Up to the present 
time no really definite proof of the actual existence of intestinal 
auto-intoxication as a clinical entity has ever been demonstrated. Is 
the constipation which is usually present the cause of the diseased 
condition or is the primary disease or defect, whatever it may be, the 
cause of the intestinal derangement? In spite of much literature on 
the subject this question has not yet been answered. 

Hemophilia. This rare condition may lead to serious or even fatal 
hemorrhage after operation which under other circumstances would 
be considered most minor surgical procedures. Within recent years 
excellent results have been reported from the use of alien or human 
serum injections or better the transfusion of whole blood given with 
the idea of adding to the blood of the hemophiliac those substances 
essential for thrombus formation which are ordinarily lacking in the 
blood of these patients. 

In this connection it might be well to emphasize a point concerning the 
use of serums or blood in general to control the hemorrhagic tendencies 
associated with this and other conditions, and that is that thrombus 
formation and even ordinary coagulation are very complex processes. 
Recent investigations have shown that they are really resultants of the 
action of many substances, and that because borrowed serum supplies 
the missing link in one case is no reason why it should be expected to 
give equal results in other cases of diverse origin. The outcome in 

1 Analysis of Deaths in 1573 Surgical Operations, Albany Med. Ann., August, 1914, 
p. 432. 



SPECIAL CONDITIONS AFFECTING SURGICAL PROGNOSIS 35 

one case may be excellent and in another altogether disappointing, 
depending upon factors, as yet none too well understood, and requiring 
careful study in each individual case before any operative procedure 
should be undertaken. 

Jaundice. Jaundice in itself indicates the presence of a serious 
pathological condition so that, irrespective of the special dangers 
incident to the jaundice per se, the prognosis in the presence of jaundice 
should always be guarded. Aside from the dangers incident to those 
pathological conditions which may be primarily responsible for the 
jaundice, there are two additional special dangers which must always 
be reckoned with when operating on these patients. The first is 
referable to the liver itself and is probably the result of an interference 
with the liver function due to a sudden relief of pressure in the biliary 
ducts. The phenomenon is undoubtedly similar in kind to the renal 
failure frequently noted after suddenly relieving the urinary pressure 
in long-standing cases of urinary obstruction. The danger of this 
grave complication is always present when operating on the biliary 
tract in the presence of obstructive jaundice. A fatal postoperative 
termination, the direct result of hepatic failure, is an almost invariable 
rule in cases in which the obstruction has persisted until only a clear 
watery fluid is found in the bile ducts at operation. 

The second danger associated directly with jaundice is hemorrhage. 
Operations performed in the presence of jaundice are, under certain 
circum stances, liable to be followed by prolonged oozing from vessels 
which under ordinary conditions would scarcely bleed at all. Jaundice 
is not always associated with this tendency to hemorrhage. The 
majority of jaundiced patients coming to operation are not noticeably 
bad bleeders, and yet in these patients the possibility of this dangerous 
condition must always be borne in mind. 

The causes of the hemorrhagic condition associated with jaundice 
are not well understood. In general it bears a relation to the dura- 
tion and intensity of the jaundice but this relationship is not fixed 
and there may be wide fluctuations in the hemorrhagic tendency in 
individual cases without known cause. These patients frequently 
bleed to death from simple trocar punctures. In deeply jaundiced 
patients with evidences of purpura the danger of hemorrhage has 
usually been considered, along with the other dangers associated 
with this condition, almost an absolute contra-indication to operation. 
In these cases the operative mortality is so high as to be prohibitive 
while under conservative treatment a fair proportion ultimately clear 
up provided the obstruction be not due to malignant disease. 

Within recent years Munro, 1 Moynihan 2 and others have claimed 
good results in the way of controlling the hemorrhage by the injection 
of alien serum before and after the operation, and equally good results 
have been claimed from the similar use of blood or serum obtained 
from normal individuals. The factors governing success or failure 

1 Boston Med. and Surg. Jour., March 25, 1909. 

2 British Med. Jour., October 2, 1909. 



36 SURGICAL PROGNOSIS 

are not thoroughly understood and frequent failures are reported 
alongside of the successes. 

The writer 1 has had one death from anaphylactic shock following 
the use of rabbit's serum in a case of jaundice. 

Anemia. If we exclude from consideration at this time the acute 
anemias, the result of sudden hemorrhage, it may be said that the 
effect of anemia per se on the operative prognosis is in almost direct 
proportion to the grade of the anemia. The lesser grades of anemia 
have little direct effect on the prognosis other than to indicate the 
possibility of a more prolonged postoperative convalescence. The 
more severe grades of anemia affect the prognosis in two ways: In the 
first place the presence of a well-marked anemia is usually of itself an 
indication of the presence of some serious disease capable of causing 
the anemia. In the second place the more severe grades of anemia 
considerable increase the dangers accompanying any operative pro- 
cedure. Mikulicz believed that no operative work requiring a general 
anesthesia should be undertaken in a patienrwith less than 30 per 
cent, of hemoglobin. Certainly no operation should be undertaken 
in the presence of extreme anemia unless the patient is suffering from 
some form of continuing hemorrhage not controllable by non-operative 
means. In most cases of severe anemia it is better to keep the patient 
under conservative treatment until the condition of the blood can be 
improved to such an extent as to make the operation safe. In all cases 
of severe anemia the possible use of blood transfusions should always 
be kept in mind. 

This does not, however, mean that a patient who is already a 
reasonably good operative risk should be kept for a long time under 
conservative treatment subject to the dangers of the disease itself 
if a more rapid improvement could be confidently predicted after 
operation. As a rule, if the hemoglobin is over 50 per cent, the special 
dangers due to the anemia are not such as to warrant prolonged 
delay unless there is little danger in delaying the operation and the 
general condition of the patient is improving at least approximately 
as rapidly as could be expected after operation. 

Acute Bronchitis. In the writer's experience ether given to patients 
suffering from acute bronchitis has almost invariably resulted in an 
exacerbation of the pulmonary trouble. This exacerbation is always 
distressing to the patient, if not actually dangerous, and should be 
avoided if possible by postponing the operation until such time as 
the patient has recovered from his bronchitis. If the patient with 
acute bronchial trouble must be operated some form of anesthesia other 
than inhalation ether anesthesia should be selected if possible. Local 
novocain or spinal anesthesia are the methods usually selected. 

In contrast to acute bronchial infection the more chronic pulmonary 
troubles, even those associated with empyema and pulmonary abscess, 
are often but little influenced by the anesthetic. 

1 An Analysis of Deaths in 1573 Surgical Operations, Albany Med. Ann., August, 
1914, p. 442. 



PROGNOSIS OF THE OPERATION ITSELF 37 

Surgeons differ in their opinions concerning the dangers of operat- 
ing in the presence of pulmonary tuberculosis. It is certain, however, 
that a general anesthetic never does the condition any good, and that 
following operations exacerbations of the pulmonary lesions are 
frequently noted due either to the anesthetic or to a postoperative 
period of lowered immunity against the disease. 

THE PROGNOSIS OF THE OPERATION ITSELF. 

Accidents and Complications Associated with Surgical Operations. 
Every surgical operation has associated with it a certain element of 
risk, (1) as regards tha life of the patient, and (2) as regards the danger 
of unforeseen complications resulting in a more or less serious disability 
directly traceable to the operation. The danger may be so slight as 
to be almost negligible, nevertheless, it is the duty of the surgeon in 
each individual case to carefully estimate the risks involved before 
undertaking any operative procedure no matter how simple or how 
extensive it may be. This is necessary not only that he may arrive 
at a correct decision for or against the operation, but because the more 
carefully the estimate is made the better will the surgeon be prepared 
to avoid those complications which are liable to interfere with the 
results of the operation. 

In order to get a clear understanding of the factors influencing the 
prognosis of the operation itself it is necessary to discuss separately 
each of the accidents and complications which may interfere with the 
outcome of the operation. The list is a formidable one, and unless 
the reader constantly bears in mind the fact that he who is forewarned 
is forearmed, it is difficult not to overestimate the combined dangers 
associated with most surgical operations. 

Table II has been prepared for the purpose of showing the mortality 
of a number of typical operative procedures. This table was purposely 
compiled from data representing the work of surgeons of concededly 
more than average ability so as to show what can be accomplished 
at the present time. Similar compilations from the reports of many 
of the smaller hospitals throughout this country would seem to show 
that the average mortality of the average operator is at least two 
and in some cases three times that shown in the table. 

The influence of the disease itself on the operative mortality is well 
illustrated in the results of operations for hernia and appendicitis. 
Only 13 patients died following 5984 operations for non-strangulated 
hernia or 1 in 460 patients operated upon, while among 694 patients 
operated upon for strangulated hernia at St. Thomas' Hospital 
(London) 1 between 1900 and 1909 there were 120 deaths or 1 in 5.8. 
Following 3584 operations for interval and chronic appendicitis in 
several American hospitals there were only 5 deaths or 1 death in 717 
operations. After 9440 operations for acute appendicitis reported in 

i Battle, W. H.: Lancet, October 12, 1912, p. 999. 



38 SURGICAL PROGNOSIS 

the last few years by individual operators in this and foreign countries, 
there were 687 deaths or 1 death in 13.6 cases. All studies of the mor- 
tality following operations for acute appendicitis show that the great 
majority of the deaths occur in cases accompanied by peritonitis at the 
time of operation. 

TABLE II. 

Character of operation. Operation. Deaths. Proportion. 

Radical operations for non-strangulated hernia 5984 13 1 in 460.0 

Operations for strangulated hernia . . . . 694 120 1 in 5.8 

Laparotomies for chronic appendicitis . . . 3584 5 1 in 7 17.0 

Laparotomies for acute appendicitis . . . 9440 687 1 in 13.6 
Laparotomies for miscellaneous gynecological 

affections 2497 33 1 in 76.0 

Abdominal hysterectomies for myoma . . . 1843 73 1 in 25.6 

Abdominal myomectomies 453 17 1 in 26.6 

Laparotomies for gall-stone disease . . . 5051 197 1 in 25.6 
Operations for non-perforated duodenal or 

pyloric ulcer 1417 26 1 in 54.5 

Suprapubic prostatectomy 1442 95 1 in 15. 2 

Perineal prostatectomy 1000* 61 1 in 16.4 

Operations on kidney and ureter .... 705 14 1 in 50.0 

Radical operations for carcinoma of the breast 1063 3 1 in 354.0 

Thyroidectomy for simple goiter .... 1893 6 1 in 315.0 
Operations for tuberculous cervical lymph 

nodes 465 1 1 in 465.0 

Partial gastrectomy for carcinoma . . . . 234 31 lin 7.6 

Partial resection large intestines for carcinoma 159 26 1 in 6.1 

Anesthesia. In estimating the effect of the anesthetic on the 
operative prognosis it is necessary to consider both the immediate 
dangers occurring during the administration of the anesthetic and the 
more remote effects of the anesthetic such as the lowering of the vital 
powers of resistance against infection, the relation of the anesthetic to 
postoperative lung complications, and the effect of the anesthetic on 
such organs as the kidneys and liver. 

Although carelessness or incompetency in the administration of any 
anesthetic makes that individual anesthesia dangerous, it has been 
abundantly proved that with a competent anesthetist the immediate 
dangers due to the anesthetic itself, when employing one of the stand- 
ard methods of local or general anesthesia, is so slight as to constitute 
almost a negligible factor in the prognosis of the individual case. 
Table III, compiled by Dr. James T. Gwathmey 1 shows the relative 
proportion of fatalities to the number of anesthesias in 278,945 cases 
reported from American sources. 

Ether. In more than half of the anesthesias reported in this table 
ether was given by the open drop method with a mortality of one 
death in 5623 cases. This figure is considerably higher than that 
given in the much quoted statistics of Hewett, i. e., 1 death in 16,302 
ether anesthesias, but the higher death-rate undoubtedly is much 
nearer the true average under ordinary conditions. The facts are 
that the risk is not definable in terms of statistics but rather in terms 
of the skill and care of the anesthetist. Ether properly administered 

1 Jour. Am. Med. Assn., 1912, lix, 1846. 



PROGNOSIS OF THE OPERATION ITSELF 



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40 SURGICAL PROGNOSIS 

is so safe that series of 15,000 or even 20,000 consecutive cases without 
an anesthetic death are not uncommon. The writer has never wit- 
nessed an ether fatality in the hands of a competent anesthetist, and 
yet I have personal knowledge of 7 ether fatalities in the hands of 
students or inexperienced internes representing a mortality of about 
1 in 500 for ether anesthesias given by incompetent anesthetists. 

Chloroform. The figures given for chloroform, i. e., 1 death in 2408 
anesthesias agree approximately with other statistics from general 
sources although chloroform statistics vary greatly. Lawrie 1 reports 
30,000 chloroform anesthesias without a death. In some British 
hospitals the death-rate is said to be as high as 1 in 250 cases. German 
statistics give 1 in 2200. U. S. Army figures give 4 deaths in 3931 
operations. Hewett reports 214 deaths in 676,767 administrations, 
or 1 in 3162. 

Nitrous Oxide and Oxygen. The figures given for nitrous oxide and 
oxygen, i. e., not any deaths in 8585 anesthesias show the possibilities 
of this form of anesthesia, which is undoubtedly one of the safest of 
the general anesthetics in the hands of the experts, and at the same 
time one of the most dangerous when used by the novice. The attempt 
a few years ago to make general use of this form of anesthesia certainly 
resulted in a very much higher death-rate than that shown by the 
figures here quoted. 

Spinal Anesthesia. Babcock, 2 in a summary of the subject of spinal 
anesthesia, gives the following conclusions based on a personal experi- 
ence of over 5000 cases: 

"In our personal experience ether and spinal anesthesia have been 
about equally dangerous, ether M>m exigencies compelling a profound 
narcosis or an imperfectly trained anesthetist; spinal anesthesia from 
an unwise selection of patients and an imperfect knowledge as to 
the physiological action of the drug. With careless or unskilled 
use, spinal anesthesia is doubtless much more dangerous than 
ether. 

" The morbidity of spinal anesthesia as expressed by nausea, vomit- 
ing, headache, backache, postoperative pain, and albuminuria is less 
than that from ether. 

"Ocular palsy may result from spinal anesthesia where contaminated 
or deteriorated solutions are used. A lateral deviation of the needle 
with injury to a nerve root may be followed by severe neuritis and 
secondary palsy. 

"Secondary degeneration of the spinal cord from the chemical 
action of stovain, properly introduced within the arachnoid in human 
beings, for purposes of spinal anesthesia is doubted. 

"Functional or neurotic symptoms occur after spinal anesthesia as 
they do after etherization, and may, to the annoyance of the surgeon, 
be attributed by the patient to the injection. 

1 Bull. Johns Hopkins Hosp., January, 1895. 

2 The Dangers and Disadvantages of Spinal Anesthesia, New York Med. Jour., 
November 8, 1913. 



PROGNOSIS OF THE OPERATION ITSELF 41 

"If a steel needle be used it may be broken under the skin during 
the injection. 

" Danger symptoms may follow if the patient be moved immediately 
after the injection or if the proper posture to prevent the anesthetic 
from reaching the upper nerve roots be not maintained for at least one 
half hour after the injection. 

"Repeated intradural injections seem to be harmless. 

"Spinal anesthesia is dangerous in circulatory subtension, conditions 
greatly depressing the respiratory centers, shock, collapse, advanced 
myocardial disease, and large intrathoracic effusions. It is more 
dangerous for operations upon the upper abdomen than those upon 
the lower. It does not obviate the danger of sudden cardiac arrest 
in operations for large uterine fibroids." 

The experience of Babcock and a number of other surgeons who 
have had extensive experience with this form of anesthesia has proved 
that in expert hands its dangers are very slight. Equally good results 
have not, however, been obtained by surgeons who have attempted to 
make occasional use of spinal anesthesia. 

The Remote Effects of Anesthetics. With the gradual elimination of 
the more immediate dangers associated with anesthesia surgeons 
have begun to pay more attention to the influence of the anesthetic 
on the postoperative morbidity and mortality, especially as regards 
its influence on the kidneys, liver, lungs and the central nervous 
system, and also as regards its effect on the vital forces concerned in 
the resistance against infections. 

Effect of Anesthetics on the Kidneys. At least one-third of all ether 
anesthesias are followed by albumin and casts in the urine, persisting, 
as a rule, for several days. Animal experiments have shown that 
ether when administered in sufficient quantities to produce general 
anesthesia is a distinct irritant to the kidneys in approximately direct 
proportion to the amount of anesthetic employed and the duration of 
the anesthesia. Clinical experience has, however, demonstrated that 
in the great majority of surgical patients the slight effect of the ether 
on the kidneys is of little or no prognostic significance. 

Chloroform is generally understood to be distinctly less irritating 
to the kidneys than ether. 

Nitrous oxide is said to have practically no effect upon the kidneys. 
It has, however, a marked effect in cases suffering from arteriosclerosis. 

Cocain and its derivatives used as local anesthetics have no effect 
upon the kidneys. 

Cases of anuria following operations other than those on the urinary 
tract are very rare, and it is now known that many cases of anuria 
following operations on the urinary tract, which were formerly ascribed 
to the anesthetic, were in fact due to causes entirely apart from the 
anesthesia. 

The Effect of Anesthetics upon the Liver. The general effect of the 
several anesthetics upon the liver is probably not essentially different 
from that exerted by them upon the kidneys. In most cases it is of 



42 SURGICAL PROGNOSIS 

little known importance. Within recent years a number of writers 
have reported cases of so-called delayed chloroform poisoning accom- 
panied by very serious pathological changes in the liver simulating 
those found in acute yellow atrophy. This condition is, however, so 
rare as to have practically no influence on the prognosis of chloroform 
anesthesias. 

The Effect of Anesthetics upon the Lungs. Postoperative lung com- 
plications are among the most frequent and serious of the postoperative 
sequels, yet the exact role played by the anesthetic in these cases is still 
open to question. Attempts to show any well-marked difference in 
the frequency of the more serious pulmonary complications following 
the use of different forms of anesthesia have not yielded conclusive 
results. 

Ether is generally conceded to be the most irritating of the general 
anesthetics, and the minor grades of bronchial irritation are certainly 
relatively more frequent after ether anesthesia. 

The Effect of Anesthetics upon the Nervous System. Notwithstanding 
the fact that the physiological activities of certain portions of the 
nervous system are profoundly altered during all forms of anesthesia, 
actual injury to the nerve cells or nerve fibers does not seem to occur 
under ordinary circumstances. In fact the state of physiological rest 
enforced by the anesthesia seems to protect those portions of the ner- 
vous system acted upon by the anesthetic from the fatigue changes of 
overstimulation which would otherwise result from the operative 
manipulations. 

The Effect of Anesthetic upon Immunity Factors. This is one of the 
most important questions related to anesthesia, and yet it is one 
concerning which there is very little definite data available. There 
is, however, abundant clinical evidence to show that a prolonged 
ether anesthesia has a decidedly deleterious effect on those complex 
immunity factors which go to make up the body's power to resist 
infection. The effect is probably similar in kind to that observed after 
an alcoholic debauch, when it is a well-known clinical observation 
that there is a temporary reduction of the natural immunity against 
the pyogenic infections as well as gonorrhea, typhoid and probably all 
other infections. 

There is practically no data concerning the effect of chloroform on 
immunity. 

Nitrous oxide and the local anesthetics are said not to appreciably 
lessen the natural powers of resistance. 

Postoperative Nausea and Vomiting. The surgeon is liable to give 
scant consideration to the nausea and vomiting which so frequently 
accompany anesthesia, and yet to the patient it is usually one of the 
most distressing features of the operation and one which cannot be 
entirely ignored in considering the postoperative prognosis. With 
ether it can only be reduced by shortening, as much as possible the 
duration of the anesthesia, and by giving the least possible amount of 
the anesthetic. 



PROGNOSIS OF THE OPERATION ITSELF 43 

While it is undoubtedly true that chloroform gives rise to nausea 
and vomiting far less frequently than does ether, it is claimed by some 
that when these symptoms do occur following chloroform anesthesia 
they are of a much severer type. After nitrous oxide nausea and 
vomiting are of almost negligible importance. 

Hemorrhage. Dieffenbach has said: "From the behavior of a 
surgeon in cases of severe hemorrhage are we able to judge of what 
metal he is made." 

The intelligent management of hemorrhage demands more than the 
mere technical ability to control bleeding vessels. Ideal surgery would 
be bloodless, or nearly so, yet a certain and sometimes considerable 
loss of blood is the price which must be paid for the successful comple- 
tion of many operations. Along with the technical ability to control 
hemorrhage it is most important that the surgeon be able to estimate 
at any instant the balance between blood assets and actual or probable 
blood losses in the patient he is operating. A great many operations 
have been incompletely performed because the surgeon became fright- 
ened in the presence of an amount of hemorrhage, which under the 
circumstances, was of little relative importance. On the other hand, 
many patients have lost their lives because the operator failed to rea- 
lize the immediate importance of what under other circumstances 
might have been a relatively unimportant loss of blood. 

The amount of blood which can be lost without death ensuing has 
been the subject of extensive observation and experimentation. The 
total quantity of blood in the body has been determined as amounting 
to approximately 7.7 per cent, (one-thirteenth) of the body weight. 
That is, a man weighing one hundred and fifty pounds has approxi- 
mately five quarts of blood. The amount which can be lost depends 
upon a number of factors, so that it is impossible to say that 10 or 20 
or 40 per cent, can bs lost without death ensuing. 

The immediate source of danger from hemorrhage is the fall of 
blood-pressure to a point at which the circulation cannot be main- 
tained. Up to a certain point the effect of the loss of blood on the 
blood-pressure can be neutralized by a general contraction of the 
peripheral vessels, but the mechanism by which this adaptive process 
is carried out requires an appreciable element of time for its consum- 
mation. Sudden hemorrhages are, therefore, much more serious in 
proportion to the amount of blood lost than are slow hemorrhages 
which allow time for the adaptive mechanism to keep up with the loss 
of blood. "The effect upon the blood-pressure is most sudden in 
venous hemorrhage from the large venous trunks because the quantity 
of blood supplied to the heart is more immediately reduced, the cardiac 
output being directly proportional to the venous pressure. The 
blood-pressure is only a quarter of a pound to the square inch in the 
veins, whereas in the arteries it amounts to four pounds to the square 
inch or from ten to sixteen times that in the veins." 

The sudden gush of blood, even though it be controlled before the 
total loss has reached an otherwise considerable amount is always 



44 SURGICAL PROGNOSIS 

dangerous because of the collapse which is liable to ensue. On the 
other hand, during the course of a prolonged operation a much greater 
total loss of blood may be borne by the patient without producing 
serious symptoms. 

Individual patients undoubtedly vary greatly as regards their 
ability to withstand hemorrhage. Women, as a rule, withstand 
hemorrhage better than men, and hemorrhages from the uterus often 
seem to be borne better than equally rapid and severe hemorrhages 
from other sources. Children may die after losing relatively small 
amounts of blood and old people are particularly susceptible, probably 
because their sclerotic vessels do not aid in the adaptive contraction 
of the peripheral vessels. 

The best guide to the immediate prognosis in cases of recent hemor- 
rhage is the blood-pressure, for if this be maintained it matters little 
what the red cell count or the hemoglobin index may be. 

The anemia resulting from hemorrhage is usually of minor impor- 
tance. The loss of 50 c.c. which is a fair average for an ordinary 
operation is immediately replaced out of the reserve fund of the vascu- 
lar system (Arneth). In surgical conditions it is very seldom that 
over 3 per cent, of the blood is lost (Crile) and after severe hemorrhage 
the regeneration is usually complete in from nineteen to twenty-four 
days (Lyon). Regeneration is said to be most rapid in adult males 
(Matas). Exhaustion of the blood regenerating organs, the result of 
long-continued hemorrhages previous to the time of operation, may 
greatly retard the process of regeneration. Likewise the presence 
of any systemic disease ordinarily accompanied by anemia will retard 
the regeneration of blood lost at the time of operation. 

Secondary Hemorrhage. The elimination of sepsis, the selection of 
more suitable ligature materials, and a better understanding of the 
principles governing the ligation of vessels has very largely eliminated 
the dangers of secondary hemorrhage in most fields of surgery. There 
are today, however, certain operations which are followed by secondary 
hemorrhages with sufficient frequency for this complication to have a 
definite influence upon the prognosis of these operations. 

Few surgeons of experience but have encountered secondary hemor- 
rhages following amputation of the cervix. These hemorrhages are 
seldom rapidly fatal and can be readily controlled in the great majority 
of cases. 

Considering the large number of tonsil operations performed, 
dangerous secondary hemorrhages are rare and when they do occur 
they can usually be brought under control without great difficulty. 

Hemorrhage following goiter operations is nearly always due to 
slipping of the ligature applied to the superior thyroid. This accident 
is usually caused by including fibers of the overlying muscle in the 
ligature. The accident is very serious and can only be avoided by 
faultless primary ligation of the vessel. 

Secondary hemorrhage following prostatectomy is relatively fre- 
quent and always of serious import owing to the difficulty of controlling 



PROGNOSIS OF THE OPERATION ITSELF 45 

it and the fact that prostatic cases are usually very poor subjects for 
hemorrhage. 

Nephrotomy is not infrequently followed by secondary hemorrhage 
which may be rapidly fatal. It is always difficult to control and often 
requires secondary nephrectomy. 

Hemorrhage after gastro-enterostomy and similar operations on the 
gastro-intestinal tract constitutes one of the chief dangers in this 
field of surgery. These can only be avoided by most careful suturing. 
Crile has recommended the use of the shoemakers' stitch in intestinal 
work because of the control it gives of the vessels in the intestinal wall. 

No discussion of hemorrhage is complete without calling attention to 
the results obtained by direct transfusion in the treatment of these 
cases. Many cases are lost that might be saved by timely transfusion. 
In our experience the citrate method has been entirely satisfactory and 
quite as easy to give as, an intravenous injection of salvarsan. When 
possible the donor should be selected according to approved compat- 
ability tests. When these tests have not been possible we inject very 
slowly 5 to 10 c.c. of the citrated blood of the donor into the recipient 
and then wait five or six minutes. Symptoms of incompatability 
develop very promptly and are readily recognizable so that if no 
reaction develops in five or six minutes it is usually quite safe to pro- 
ceed with the injection of the maximum quantity of blood. 

Shock. "Shock may be defined to be a depression of the vital 
powers, induced suddenly by external injury, and essentially dependent 
upon a loss of innervation." (S. D. Gross.) 

In the more than half a century which has elapsed since the publi- 
cation of Gross's System of Surgery our conception of shock has not 
materially changed or have we greatly increased our knowledge of the 
elemental causes of shock. "Shock may be produced by a great 
variety of causes, some of a bodily, others of a mental character; some 
external, others internal. It may be purely nervous, or partly nervous 
and partly hemorrhagic, that is, dependent upon the conjoined loss 
of nervous and sanguineous fluids. The nature and extent of shock 
are greatly influenced by the state of the general health at the time 
of the accident, the amount of injury, the importance of the part more 
directly assailed, and, also, in a special manner, by the idiosyncrasy of 
the individual. There are some persons, soldiers, for example, of the 
most undoubted courage, men who would not hesitate to face the 
mouth of the cannon, who fall into a state of the most profound pros- 
tration from the most trifling accident; who turn pale and tremble 
like a leaf; whose minds are perfectly bewildered, and who are, as it 
were, completely stunned, from injuries so insignificant as not to affect, 
in the slightest degree, ordinary persons. Such' an occurrence can 
only be explained by a reference to idiosyncrasy; and it has its counter- 
part in those persons who, although extremely plethoric, faint from 
the slightest loss of blood, or even from the mere sight of that fluid. 
There are other persons, on the contrary, whom hardly any accident, 
however sever 3, can shock; they are insensible to pain; their nervous 



46 SURGICAL PROGNOSIS 

system is obtuse; nothing affects them, either bodily or mentally; a 
severe blow may stun them, but the effect is transient; in a few minutes 
they are completely restored to consciousness and power. Here, 
again, is an example of idiosyncrasy, a peculiarity of organization; 
in the former case, the individual is all nerve, all sensibility; in the 
latter, all blood, all muscle. 

" Mental shock is often extremely severe, and is occasionally followed 
by the worst consequences, especially when it occurs during the 
progress of a severe illness, or after a severe surgical operation. Fright 
is perhaps the worst of the causes of mental shock. The effect of terror, 
in suddenly exhausting nervous power, is well illustrated by the history 
of those persons, who, being sentenced to be bled to death, actually 
died on hearing water trickling into the basin, which they supposed 
to be blood issuing from their veins, after the arm had been slightly 
pricked, although no vessel had been opened. It is related of Dessault 
that he one day lost a patient, about to be lithotomized, from sheer 
fright. The man, who was very cowardly, tainted and died under 
the impression that the operation was progressing, when this dis- 
tinguished surgeon was, in fact, only tracing with his nail the line of 
the intended incision on the perineum. 

"Mental and corporeal shock are often combined; and, when this 
is the case, it is not uncommon to see the former predominate, in a 
very marked degree, over the latter. The soldier on the field of 
battle may suffer from bodily shock induced by a severe wound; he 
may feel that he is badly hurt, but still he is sanguine of recovery, and 
cheerfully and manfully bears up under his affliction. The surgeon 
examines his wound and perceiving its grave character, informs him 
that it will probably cost him his life. Instantly the case assumes a 
different aspect; the system is overwhelmed with perturbation and 
excitement; the vital powers are depressed to the utmost; and death 
takes place perhaps several days sooner than it would otherwise have 
done." (Gross.) 

During the World War, the opportunities for observing and studying 
shock were almost unlimited. As a result of these observations we 
have learned to differentiate more sharply between the true surgical 
shock resulting from traumatism, psychical shock and hemorrhage. 
At present it would seem that the best working hypothesis explaining 
the phenomena attending shock is that the underlying cause of shock 
is due to a diminution in the normal alkalinity of the Vood. This 
hypothesis gives a rational basis for the prevention and treatment of 
shock which has apparently stood the tests of experience as encountered 
in war practice. 

In accident and military surgery shock is still encountered with 
much the same frequency as in the time of Gross, but today serious 
life-threatening shock has been, to a very great extent, eliminated 
from deliberately planned operative surgery. This improvement is 
due to a better understanding of the mechanism of shock and how to 
avoid the causes responsible for its production; also, to the fact that 



PROGNOSIS OF THE OPERATION ITSELF 47 

surgeons have learned what may and what may not be done under 
given circumstances without producing dangerous shock. In the 
writer's experience shock, apart from hemorrhage, has been responsible 
for a mortality of less than .one-fifth of 1 per cent, in patients subjected 
to deliberate operative procedures, and not over 2 per cent, of major 
operative cases have suffered from shock of a degree sufficient to cause 
the least anxiety as to the outcome. In order to get the best results 
it is necessary for the surgeon not only to know the usual causes of 
shock and how to, as far as possible, avoid them, but he should in each 
individual case in which shock is at all liable to be an important factor 
make a careful estimate of the shock risk and plan every detail of 
the operation accordingly. 

Patients differ greatly as regards susceptibility to shock, the special 
dangers occurring largely in those handicapped by readily recogniz- 
able impairments which make them especially susceptible to the 
action of shock-producing causes. Different regions and organs of the 
body also show different degrees of susceptibility. 

Temperament. Experimental investigations have shown that noxious 
impulses transmitted through the nervous system are the immediate 
cause of shock and practical experience has shown that the high-strung, 
acutely sensitive individual is more susceptible to shock than is the 
phlegmatic type of patient. 

Frightened patients are particularly bad shock risks, and most 
students of this subject believe that fright itself is an important 
element in the production of shock. 

Previous Nerve Exhaustion. Many look on shock as essentially a 
phase of nerve exhaustion and certainly patients who from overwork 
or worry have exhausted their reserve of nervous energy are more 
susceptible to shock than is the man or woman who has lived a rational 
life keeping each bodily function up to a normal standard of activity. 
Crile says that the worst risk is probably the overworked surgeon, 
about fifty years of age. Work short of actual exhaustion is, how- 
ever, not a handicap, because the industrious and those who have 
by their daily life accustomed themselves to overcoming the lesser 
trials of every-day existence are, other things being equal, far better 
shock risks than are the idle luxurious type of loafers. The hard 
working laundress is, as a rule, a better shock risk than is her idle 
employer. 

Age. Surgeons are generally agreed that children are more sus- 
ceptible to shock than adults yet this increased susceptibility is very 
difficult to estimate. It has been said that could the infant be operated 
on in its own ratio, that is to say, by Lilliputian surgeons, using infan- 
tile instruments, etc., and exposing only proportionate areas to heat, 
cold and traumatism the results might not be disproportionate to 
those obtained in the adult. This is impossible. Therefore, from the 
practical standpoint, the infant and child require a special estimate 
of the shock risk and very frequently the institution of special pre- 
cautions to guard against the danger of shock. 



48 SURGICAL PROGNOSIS 

Old people may not be particularly susceptible to shock as measured 
by the ordinary standards of pulse and blood-pressure, yet in them 
shock is relatively much more dangerous than in the young or middle- 
aged because of their lack of "come back" or power to recover from 
what in individuals with normal hearts and bloodvessels would amount 
to only temporary disability. Serious shock may come on during 
operations on the aged without its being recognized either by the 
surgeon or the anesthetist. This is partly because it is difficult to 
recognize pulse quality in the presence of arteriosclerosis, partly 
because the increase in pulse frequently does not keep pace with the 
degree of shock in the aged as it does in the young, and partly because 
of a failure to realize that a blood-pressure of 100 to 110 mm. is a 
serious matter in a patient whose "normal" pressure is 160 to 170 mm. 
or over, while in a younger individual a fall in blood-pressure to 100 
mm. or even lower would be of little relative importance. 

Sepsis. Patients suffering from any form of sepsis should be looked 
upon as having an increased susceptibility tc^shock, and yet in these 
cases it is probable that the postoperative symptoms often ascribed 
to shock are really the result of increased toxin absorption incident 
to manipulating infected tissues and the breaking down of natural 
barriers against absorption. 

The collapse which frequently follows the curettage of a septic uterus 
is not shock but toxemia. Likewise the grave symptoms which 
formerly followed extensive intra-abdominal manipulations in the 
presence of acute infection were in part due to shock and in part to 
sudden toxin absorption. 

Recent Severe Illness. A typical example of increased susceptibility 
to shock is seen in patients who have only partially recovered from a 
severe illness and who are operated "before they have had time to 
regain their strength." 

The patient, who lying quietly in bed, has a normal temperature 
and normal pulse of fair volume but who has only recently recovered 
from the acute stage of a serious gall-bladder or renal or other form of 
infection is a handicapped risk as regards shock a risk relatively safe 
within certain limits but a very bad risk when these limits are exceeded 
by a careless or too radical surgeon. 

In the writer's personal experience instances of unlocked for shock 
have been confined largely to this class of cases, among which may be 
mentioned secondary operations for osteomyelitis, nephrectomies and 
operations for pelvic infections in which neither the operative manipu- 
lations nor the hemorrhage were sufficient to account for the degree 
of shock produced. The possibility of the shock-like symptoms being 
due to embolism should always be considered in this class of cases. 

Cachexia. One of the most serious of the predisposing causes to 
shock is that little understood state of metabolic perversion occurring 
in the course of malignant disease which is known under the general 
term cachexia. The vital impairment in this class of patients is 
difficult to estimate. Operations in them are usually of necessity 



PROGNOSIS OF THE OPERATION ITSELF 49 

severe. Increased susceptibility to shock is the rule, but the most 
important factor in connection with the prognosis in these cases is 
the fact that, while they may exhibit only a relatively slight increased 
susceptibility to shock, their power to react and recover is often almost 
nil. Like the senile individuals, only often to a greater extent, they 
have no "come back." 

Brain Surgery. First among the operations especially liable to be 
accompanied by ^shock are those involving portions of the central 
nervous system. Even the jarring, incident to chiselling through 
the skull may produce shock. Sponging of the exposed meninges is 
another cause. Horsley, 1 Gushing 2 and others have pointed out the 
dangers incident to increased intracranial pressure. 

Laryngeal Operations. In such operations as intubations, laryngot- 
omies, laryngectomies, intralaryngeal operations of all sorts, opera- 
tors have reported instances of sudden collapse or death. According 
to Crile, this is due to reflex inhibition of the heart and of the respira- 
tion from mechanical stimulation of some part of the superior laryngeal 
nerve and may be wholly obviated by previously administering a 
physiological dose of atropin or by applying a local anesthetic to the 
nerve endings in the laryngeal mucosa or by injecting the trunk of the 
nerve with novocain. 

Intrathoracic Operations. Sudden changes in intrathoracic pressure 
such as occur on opening empyemata, or to an even greater extent 
when the normal pleural cavity is opened, are always liable to be 
accompanied by serious shock. 

Blake 3 has summed up the experience gained in the War as follows : 

"One of the most striking observations was in regard to wounds 
opening the pleural cavity the so-called sucking wounds. It was 
noticed that with such a wound a man got along fairly well for a short 
time and then rapidly went into shock and died. The reason was, as 
we have seen in the explanation of shock, a lack of oxidation due to 
inadequacy of respiration. If the admission of air through the wound 
were stopped, these cases did as well as those with non-sucking wounds. 
It became the rule, therefore, to close such wounds as soon as possible, 
even if they were only provisionally sewed together and had to be 
operated on and reclosed later. It was found that if shock could thus 
be prevented the patient could subsequently withstand a formal 
operation in the course of which the wound of the chest wall could be 
excised and enlarged, the lung withdrawn if necessary, the wounds in 
the latter also excised and sutured, and the chest finally closed. Closure 
of the chest, if only for a day or two to enable the vital functions to 
become readjusted, was found imperative." 

Abdominal Operations. "In abdominal operations the amount of 
shock depends in direct ratio upon the trauma and exposure. This 

1 British Med. Jour., 1890, iv, 1286. 

2 Bull. Johns Hopkins Hosp., 1901, i, ii, 290. 

3 The Influence of the War upon the Development of Surgery, vol. Ixix, May, 1919, 
p 459. 

4 



50 SURGICAL PROGNOSIS 

territory bears a rich supply of vasomotor nerves, and the effect of a 
given operation upon the vasomotor center is the sum of the exposure 
to the air and the intensity and number of mechanical contacts with 
the abundant nerve supply of this territory." (Crile.) 

Operations in the region of the diaphragm, the common bile duct, 
the pancreas and all operations involving extensive traumatism of 
the mesentery (intestinal resections) are especially shock-producing. 
Operations below the pelvic brim are, as a rule, less shock-producing 
than those in the upper abdomen. 

Operations on the Extremities. In operations upon the extremities 
shock may be almost entirely avoided if care be taken to prevent 
hemorrhage and to either avoid injuring the larger nerve trunks or to 
block the nerves by intraneural injections of novocain. Nerve block- 
ing should be employed in all operations upon the extremities likely 
to be accompanied by shock. 

Wound Infection. The whole science of modern surgery has devel- 
oped around the fact that except in war stfrgery it lies within the 
power of the surgeon to prevent wound infection in all but a very 
small minority of the cases he is called upon to treat. In general it 
may be said that the prognosis as regards infection is, in the individual 
patient, what the surgeon himself makes it, and yet experience has 
always shown that no surgeon has been able to entirely eliminate this 
complication from his work. 

Infection always increases the postoperative morbidity and prolongs 
the period of convalescence. Not infrequently it serves to defeat the 
purpose of the operation and occasionally an accidental infection 
results in the death of the patient. Most of the postoperative com- 
plications leading to more or less serious permanent disability are the 
result of infection. 

Statistics dealing with the frequency of wound infections have 
for the most part been published with the idea of proving the superior- 
ity of some particular aseptic or antiseptic technic, yet when we 
attempt to compile and compare these results it is evident that the 
averages as reported for the different methods are very nearly the 
same provided the character of the operative work is of approximately 
the same nature. 

Beckman 1 reports 1.9 per cent, of infections in a series of 5835 
operations and 1.7 per cent, of infections in another series of 6825 2 
operations performed at the Mayo Clinic. This (2 per cent.) is about 
the average frequency as reported from various sources. 

Operations on the Extremities. This field of surgery offers ideal 
opportunities for the carrying out of an approved technic, and ortho- 
paedic surgeons have abundantly demonstrated that in civil practice 
the incidence of infection following operations on the extremities is 
almost entirely under the control of the operator; also, that there is no 
special liability to infection in operations involving bones and joints 

1 Collected Papers by the Staff of St. Mary's Hospital, 1912, pp. 738-747. 
'Ibid., 1913, pp. 776-782. 



PROGNOSIS OF THE OPERATION ITSELF 51 

provided the manipulations do not endanger the vitality of the tissue. 
When infections do occur, however, as the result of operations involv- 
ing bones or joints the prognosis as regards the effect of the complica- 
tion on the outcome of the operation is usually much more serious than 
after operations limited to the soft tissues. 

An exception to the above rule regarding the relative freedom 
from infections in operations on the extremities is apparently encoun- 
tered in the operative treatment of fractures. The peculiar liability 
of compound fractures to serious infection and the disastrous conse- 
quences of the same has been recognized since the earliest times. 
Within recent years this has been again emphasized in connection with 
the open treatment of fractures. In this field of surgery, especially 
when buried metal splints are employed, even the slightest grades of 
infection, such as would be scarcely demonstrable in abdominal 
surgery, are fraught with the most serious consequences. Lane has 
demonstrated that infection can be avoided but the standard neces- 
sary for success is entirely different from that ordinarily attained by 
the average general surgeon, and failures in this field of surgery have 
been frequent and serious. 

Operations of the Head, Face and Neck. The face and scalp are 
particularly resistant to infection. Scalp wounds, even those the 
result of accident, seldom become infected. Operative wounds in 
the region of the mouth, even though they be made through fields 
impossible of sterilization, heal by first intention in the great majority 
of cases. 

Although the technical difficulties of maintaining absolute asepsis 
during operations upon the neck are considerable, infection in this 
region is rarely encountered and the occasional infection which does 
occur is seldom of much importance. Beckman reports only 26 
infections in 2785 operations for goiter, or less than 1 per cent., and 
none of these resulted seriously. 

The Breast. Practically all surgeons report a very low incidence 
of infections following amputation of the breast. The Halstead type 
of breast amputation exposes a large surface to possible infection, 
the field is frequently difficult of sterilization and closure of the skin 
defect often necessitates tension on the sutures There may be some 
sloughing of the skin but noteworthy infection is seldom encountered. 

Hernia. Beckman reports 31 infections in the course of 623 opera- 
tions for inguinal hernia (4.9 per cent.). This proportion seems high 
and yet it is approximately the average as reported by other surgeons. 
Hilgenreiner 1 has reported 4.2 per cent, infections in 1000 operations 
for hernia performed between 1901 and 1910. Sertoli, 2 from Ceci's 
Clinic, reported that in 1509 operations for non-strangulated hernia, 
the wound suppurated in 90, or 6 per cent. A few have reported better 
results but many more have admitted an even higher percentage of 
infection. 

1 Beitr. z. klin. Chir., December, 1910. 
Arch. f. klin. Chir., 1909, No. 2. 



52 SURGICAL PROGNOSIS 

Ventral and umbilical hernias apparently exhibit about the same 
tendency to infection as do inguinal hernias. Femoral hernias are, 
on the other hand, rarely accompanied by infection. 

Whether the liability to infection in hernias be due to the difficulty 
in sterilizing and dressing the field, or to the suture tension necessary 
to close the defects, or to the necessity of using slowly absorbable 
suture material, the fact should always be borne in mind that hernia 
operations are for some reason particularly liable to infection. 

Gynecological Operations. Laparotomies for tubal and ovarian 
conditions, shortening the round ligaments and other minor gynecolog- 
ical conditions are seldom accompanied by infection. Subtotal hys- 
terectomy adds a slight risk possibly due to increased traumatism 
and possibly due to opening the cavity of the uterus. On the other 
hand, total abdominal hysterectomy yields a large percentage of 
infections (7 per cent. Beckman), due to the fact that the vagina often 
harbors virulent organisms in cases requiring total hysterectomy, while 
at the same time unavoidable trauma incidenUto the operation leaves 
a field susceptible to bacterial invasion. 

In spite of the fact that it is impossible to secure an actually sterile 
field in vaginal operations, infections interfering with the results of 
operations on the cervix or perineum are seldom encountered, although 
perfect primary union in the sense used when speaking of abdominal 
wounds is frequently not obtained. Formerly the writer used great 
care in sterilizing the vagina but in a certain percentage of cases it 
was apparent that the normal harmless bacteria inhabiting this region 
were removed only to have it reoccupied soon after the operation by new 
species toward which the body had not had an opportunity to develop 
an immunity. During the past six years I have made no effort to 
sterilize the vagina other than a simple cleansing with soap and water, 
and I am certain that the healing in vaginal cases has been far better 
than when we disturbed the truce existing between the body and the 
normal vaginal flora. 

Intestinal Tract. The danger of infection by intestinal bacteria in 
all operations on the intestinal tract is self-evident. Under ordinary 
conditions in otherwise clean laparotomies the incidental removal of 
the appendix seems to approximately double the liability to infection. 
In this connection it is worthy of note that whereas most surgeons use 
great care in handling the stump of the appendix itself most of them 
fail to appreciate the fact that the needle and suture used in inverting 
the stump is usually promptly infected by passing it through all coats 
of the cecum, and that the suture and the objects coming in contact 
with it should thereafter be looked upon as infected. With proper 
attention to this detail, we believe that the extra risk, due to appen- 
dectomy in otherwise clean cases, can be eliminated. 

Beckman reports 5.7 per cent, of infections in 750 operations on the 
stomach, and according to data from other sources from 5 to 10 per 
cent, would seem to be a fair average. These infections in stomach 
cases rarely result in fatal complications, but they do frequently result 
in ventral hernia. 



PROGNOSIS OF THE OPERATION ITSELF 53 

Operations on the large bowel are accompanied by some infection 
in a large percentage of cases, and in the surgery of the large intestine 
more frequently than in any other branch of abdominal surgery, 
infection is liable to lead to fatal complications. 

The Peritoneum. The ability of the peritoneum to resist infection 
is not surpassed by any other tissue in the body. In estimating the 
possibilities of a peritoneal infection occurring as the result of an 
operation, laparotomies may be divided into three classes: (1) Those 
cases in which the operation is performed for a condition other than an 
active infection, and in which no infected cavities are invaded during 
the course of the operation. In this group are included hernia opera- 
tions, many gynecological, a certain proportion of gall-bladder opera- 
tions and other miscellaneous laparotomies. (2) Operations in which 
no active infection is present but in which infected or possibly infected 
cavities are invaded during the course of the operation. Appendec- 
tomies, hysterectomies, operations upon the gastro-intestinal tract 
and some of the operations on the biliary and urinary tracts should 
be included in this group. (3) Operations undertaken for the relief 
of active intraperitoneal infections. 

In the first group serious accidental infection of the peritoneum is 
one of the rarest accidents in surgery. In the second group note- 
worthy peritoneal infection is only very rarely encountered in simple 
appendectomies, gall-bladder operations or hysterectomies. With 
good technic it is also rare after operations on the stomach and upper 
intestinal tract. On the other hand, operations involving resection 
of portions of the large intestine are frequently accompanied by 
serious peritoneal infection. In the third group modern technic aim- 
ing to protect and assist the peritoneum in its fight against the already 
existing infection has to a considerable extent lessened the danger of 
the infection being spread as the result of the operation. In these 
cases the danger is greatest during the height of the infection and 
decreases rapidly after the subsidence of the acute stage of the inflam- 
matory process, so that in subacute and chronic cases abscesses may 
be opened and drained through incisions opening into the general 
peritoneal cavity with surprisingly little danger of extending the 
area of infection. 

Except after operations on the large intestine cases of postoperative 
general peritonitis, such as were rather frequently encountered by 
the pioneers in abdominal surgery, are now almost always due to 
gross accidents, such as overlooking rents or fistulous openings in the 
intestines, faulty intestinal suturing or improperly placed drainage, 
allowing pus, bile or urine to escape directly into the peritoneal cavity. 

Incisions Made for the Purpose of Treating Infections. In operations 
undertaken for the treatment of acute inflammatory conditions the 
incisions are necessarily exposed to infection, and the question of the 
extension of the infection to such incisions is of considerable practical 
importance. In general it may be said that if the primary focus of 
infection is thoroughly drained, that portion of the incision which is 
sutured at the close of the operation will heal by primary union. 



54 SURGICAL PROGNOSIS 

In the writer's experience abdominal drainage cases operated during 
the acute stages of an intraperitoneal infection have yielded a much 
higher proportion of wound infections than have cases operated after 
the subsidence of the acute stage, even though pus was encountered 
at the time of the operation. This is probably due chiefly to the fact 
that in the later operations an acquired immunity has been developed 
against the organisms responsible for the infection. At a still later 
period the pus may be sterile or the organisms may have lost their 
virulence. 

A considerable proportion of the more troublesome wound infections 
has been in patients operated for acute intraperitoneal lesions in which 
the abdomen was closed without drainage, or in abscess cases in which 
the drainage was carried through a lateral stab wound without pro- 
viding for adequate drainage of the principal incision. In the first 
group the peritoneum has had no difficulty in overcoming the infection 
which in less resistant tissues has been sufficient to break down the 
abdominal incision. In the second class of 6"ases the closure of the 
chief incision with the use of a lateral stab wound for drainage has not 
only been unsatisfactory as regards healing but has resulted in more 
ventral hernias than would probably have occurred had the drainage 
been brought out through one end of the original incision because 
without drainage the chief incision has broken down. 

Accidental Wounds. Infection in wounds of the industrial accident 
type is dependent upon a number of factors. Cuts and simple lacera- 
tions are much less liable to become infected than are open wounds 
accompanied by considerable crushing of the soft parts. The char- 
acter of the surroundings in which the accident happens is also a very 
important factor. The grease and dirt of the machine shop is seldom 
the habitat of virulent, pathogenic organisms. On the other hand, 
street dirt usually contains organisms capable of causing infection. 
Ambulances, doctors' offices and dispensaries are always dangerous 
localities, and before an accident case is allowed to enter any one of 
these highly infected regions open wounds should always be covered 
with a sterile first-aid dressing. 

The possibility of effectually sterilizing the field of traumatism 
after an accident is a question still open to discussion. Some surgeons 
believe in very vigorous use of mechanical and antiseptic methods of 
cleansing the wound. Others believe that the really essential point 
is to preserve the vitality of the tissues and that whatever is done in 
the way of a toilet of the wound the tissues should not be subjected 
to further mechanical or chemical traumatism. The success attend- 
ing the use of tincture of iodin in these cases is probably dependent 
largely upon its simplicity and relative harmlessness as compared 
with more complicated methods formerly employed. 

In general it may be said that a surprisingly large percentage of 
accidental wounds heal without suppuration and that in the absence 
of pathogenic germs gaining access to the wound after the patients 
come under treatment, serious infections are but seldom encountered. 



PROGNOSIS OF THE OPERATION ITSELF 55 

War Wounds. One of the lessons of the late World War was the fact 
that civil experience and war experience are entirely different as regards 
the frequency of wound infections. The great liability of infection 
and the factors governing the same will be described in other chapters 
of this book. 

Postoperative Pulmonary Complications. Postoperative pulmonary 
complications may be classified in five groups (Beckman) : 

1. Acute Postoperative Congestion of the Lungs. This condition is 
characterized by an excess of secretion in the air passages. It is usu- 
ally most noticeable immediately after the operation and subsides in 
a few hours. As a rule, it has little or no effect on the prognosis. 

2. Pleurisy. This is a relatively frequent minor complication. 
The symptoms last from a few days to a week, rarely longer. Serious 
results are very rarely observed. 

3. Bronchitis. This is the most frequent of the postoperative pul- 
monary complications. The acute symptoms usually subside in a 
few days and serious results are rarely encountered, although the 
discomfort produced by the coughing is often considerable. Occa- 
sionally the extra strain placed on the suture line in abdominal cases is 
the cause of a subsequent ventral hernia. 

4. Bronchopneumonia and 5, Lobar Pneumonia. Pneumonia is one 
of the most serious of the postoperative complications. Clinically it 
is often difficult to separate the two forms of the disease, and in most 
of the statistical studies dealing with pneumonia as a postoperative 
complication no attempt has been made to separate them. The 
frequency of this complication varies in statistics from different 
sources due probably in a large measure to the different character 
of the material analyzed in compiling the statistics. 

In America postoperative pneumonia is a rare complication. Thus, 
Beckman, 1 Anders 2 and Miller 3 report 37,132 operations followed by 
103 cases of pneumonia, or 1 case of pneumonia for each 360 cases 
operated. Beckman and Anders report 24 deaths from pneumonia 
following 30,132 operations, or 1 death for each 1255 cases operated. 

These results are in sharp contrast to the often quoted statistics 
of Mikulicz, 4 Henle, 5 Gibele 6 and Czerny, 7 which may be summarized 
as follows: 

Mikulicz 1278 operations with 110 pneumonias. 

Henle 1987 " " 145 

Gebele 1196 " " 54 

Czerny . . 1300 52 

1 Northwestern Lancet, May 15, 1911; Ann. Surg., 1913, vii, 718-729; Collected 

Papers by the Staff of St. Mary's Hospital, 1913, pp. 784-785. 

* University Med. Mag., Philadelphia, 1897-1898, x, 641-666. 
8 Kelly and Noble's Gyn. and Abd. Surg., 1910, ii, 35. 

4 Pneumonie, Verhand. d. XXX Kongr. der Deutsch. Gesellsch. f . chir. Centralbl. f. 
Chir., 1901, No. 29, p. 16. 

8 Ueber Pneumonie und Laparotomie, Arch. f. klin. Chir., xliv, Heft 2. 

Beitr. z. klin. Chir., xliii, Heft 2, 251-318. 

7 Cited by Miller in Kelly and Noble, loc. cit. 



56 SURGICAL PROGNOSIS 

The great majority of the above operations were laparotomies and 
Continental surgeons only a few years ago insisted that pneumonia 
was to be expected after laparotomy in about 5 per cent, of the cases. 
This figure is certainly from five to ten times greater than the average 
American frequency following abdominal operations. Robb and 
Dittrick, 1 after 1007 abdominal operations, found only 3 cases of 
pneumonia, while Mallett, 2 after 1700 laparotomies found 7 cases of 
pneumonia. 

The exact relationship between the anesthetic and the pulmonary 
group of postoperative complications has never been definitely deter- 
mined. The terms "ether pneumonia" and "ether bronchitis" are 
.very frequently used. Yet before the discovery of anesthesia, lung 
complications caused a high mortality after operation, and modern 
statistics dealing with the frequency of these diseases fail to show any 
clearly defined relationship between the anesthesia and the pulmonary 
complication. 

The figures reported by Mikulicz 3 are typical. He states that at 
the Breslau Clinic in 1005 laparotomies and operations for strumous 
affections under general anesthesia there was a pneumonic morbidity 
of 7.5 per cent, with a mortality of 3.4 per cent. In 273 cases operated 
under local anesthesia (Schleichs's method) there was a morbidity of 
12.8 per cent, and a mortality of 4.8 per cent, due to pneumonia. 
These results do show that great care should be exercised in placing 
the blame on the anesthetic, yet local anesthesia was used in a con- 
siderable proportion of these 273 cases because of the known liability 
of the individual cases selected to pneumonia if operated under general 
anesthesia. The pulmonary mortality might have been considerably 
higher under general anesthesia. I know of no trustworthy statistics 
on this subject comprising large groups of similar cases operated under 
different methods of anesthesia. 

As a matter of fact the incidence of postoperative pneumonia depends 
very largely upon* the age and general condition of the patient and the 
character of the disease for which the patient is operated. Fatal 
pneumonia may follow the simplest operation on a patient in the 
prime of life and apparently in the best of health, but such accidents 
are extremely rare. Past middle age the danger of pneumonia increases 
directly with the age of the patient until in the very old the danger 
becomes so great as to be one of the chief causes of surgical mortality. 
Likewise in the severely septic and the debilitated from any cause, 
particularly alcoholism, the dangers of pneumonia are greatly increased. 
Operations on the stomach and gall-bladder are said to be specially 
liable to be followed by pulmonary complications. 

The inspiration of material into the lungs during an operation 
greatly increases the danger of bronchopneumonia. 

1 Cited by Miller, loc. cit. 

2 Am. Jour. Obst., April, 1905, p. 516. 

8 Pneumonie, Verhand. d. XXX Kongr. der Deutsch. Gesellsch f. Chir. Centralbl. f. 
Chir., 1901, No. 29, p. 16. 



PROGNOSIS OF THE OPERATION ITSELF 57 

TABLE IV. SHOWING RELATIVE FREQUENCY OF THE DIFFERENT 
PULMONARY COMPLICATIONS. 

Bronchitis. Pneumonia. Pleurisy. 

Miller 18 17 16 

Robb and Dittrick 18 3 9 

Armstrong 1 19 20 5 

Beckman 72 56 55 

127 96 85 

Embolism. With the gradual reduction of operative mortality due 
to other causes, embolism has assumed a place of constantly increasing 
relative importance, until today it is one of the important causes of 
surgical mortality. 

The great majority of cases of fatal postoperative embolism are 
due to the sudden plugging of a vessel of the lung (pulmonary embo- 
lism) with a clot originating in the field of operation or femoral vein. 
Occasionally the clot may originate in a vessel other than the femoral 
at some distance from the field of operation or in the heart itself. 
Occasionally the clot may lodge in the brain (cerebral embclism) or in 
the heart (cardiac or coronary embolism) . Embolism involving other 
organs notably the kidneys, spleen or intestines is frequently observed 
at autopsy but is seldom recognized clinically. The smaller pulmon- 
ary emboli, such as are so frequently found at autopsy, are probably 
responsible for many cases of so-called pleurisy. Fat embolism and 
air embolism will be discussed under separate heads. 

Wilson 2 calls attention to the following general considerations 
concerning the subject of postoperative embolism: 

"1. Following operation, particularly on the blood vesssls, aliment- 
ary canal and genito-urinary organs (both male and female), from 
1 to 2 per cent, of all cases give more or less distinct clinical evidence 
of emboli, above 70 per cent, of which are in the lungs. 

"2. As nearly as can be observed from the incomplete and neces- 
sarily inaccurate data at hand, about 10 per cent, of postoperative 
emboli which give clinical symptoms of diagnostic significance cause 
sudden death. 

"3. Where postmortems are made on cases of fatal postoperative 
embolism, the source of the emboli can be definitely determined as 
venous thrombosis in about 80 per cent, of the cases, as cardiac throm- 
bosis in 10 per cent, of the cases, while 10 per cent, are scattering or 
undeterminable. 

"4. Though there must be more or less formation of venous thrombi 
at the site of every extensive surgical opera jion, yet it is probable 
that the long, loosely-formed thrombi from the medium-sized veins 
are those chiefly concerned in embolism, and especially in fatal 
embolism. 

1 Lung Complications after Operations with Anesthesia, British Med. Jour., 1906, i, 
1141. 

2 Fatal Postoperative Embolism, Ann. Surg., December, 1912. 



58 SURGICAL PROGNOSIS 

"5. When large, loose thrombi are once formed in a resting patient, 
any unusual exertion or change of position may cause a dislocation of 
large masses which become dangerous emboli." 

The mortality from embolism, based on the 63,573 operations 
reported by Wilson is 0.07 of 1 per cent., or 1 death in every 1352 
operations. When the cases are grouped according to the anatomical 
regions on which the preceding operation was done, they are found 
to be as follows: 

After 1372 operations on bloodvessels, 2 deaths, or 0.14 of 1 per cent. 

After 3266 operations on the thyroid, 2 deaths, or 0.06 of 1 per cent. 

After 2281 operations on the mouth, 1 death, or 0.05 of 1 per cent. 

After 2391 operations on the stomach or duodenum, 3 deaths, or 
0.12 of 1 per cent. 

After 4597 operations on the gall-bladder, 9 deaths, or 0.19 of 1 per 
cent. 

After 389 operations on the small intestine, 1 death, or 0.26 of 1 per 
cent. * 

After 9908 operations on the appendix, 4 deaths, or 0.04 of 1 per 
cent. 

After 2530 operations on the colon and rectum, 5 deaths, or 0.20 of 
1 per cent. 

After 4501 operations on hernia, 5 deaths, or 0.11 of 1 per cent. 

After 900 operations on the kidney, 1 death, or 0.11 of 1 per cent. 

After 601 operations on the prostate, 4 deaths, or 0.66 of 1 per cent. 

After 7993 operations on the uterus, tubes and ovaries, 10 deaths, 
or 0.13 of 1 per cent. 

After 1346 operations on the breast, no deaths. 

After 449 vaginal hysterectomies, no deaths. 

After 1712 abdominal hysterectomies, 5 deaths, or 0.29 of 1 per 
cent. 

These figures in themselves fail to show any particular liability to 
embolism in any special field of operative work except possibly opera- 
tions on the prostate and supravaginal hysterectomy. In this con- 
nection it has long been known that cases of prostatectomy and 
operations for uterine myomata are especially liable to be followed 
by pulmonary embolism. 

The frequency of fatal embolism as given by Wilson is, for the most 
part, lower than that given by others who have studied the subject. 
While the material analyzed is not strictly comparable, the discrepan- 
cies in the data from different sources is best indicated in the following 
manner : 

Wilson, 63,573 operations, 47 deaths from emboli. 

Oppenheim, 1 6871 operations, 23 deaths from emboli. 

Wilson, 9908 operations on appendix, 4 deaths from emboli. 

Howard, 2 3774 operations on appendix, 8 cases of pulmonary embo- 
lism. 

1 Berl. klin. Wchnschr., 1902. 

Phlebitis and Thrombosis, 1906, p. 41. 



PROGNOSIS OF THE OPERATION ITSELF 59 

The following figures show the recognized frequency of embolism 
as reported from different sources: 

Per cent. 

Gebele, 1 1196 laparotomies, embolism in 1.17 

Lowen, 1 1203 laparotomies, embolism in 0.75 

Wolff, 1 1806 operations, embolism in 0.49 

Bibergeil, 1 3909 laparotomies, embolism in 0.30 

Albanus, 1 1140 laparotomies, embolism in 0.20 

Sorrenburg, 2 2000 appendix operations, embolism in 5 . 30 

Oppenheim, 3 6871 operations, embolism in 0.82 

Kro nig, 4 391 myoma operations, embolism in 0.50 

Burkhardt, 4 236 myoma operations, embolism in 5.00 

Frieberg Klinic, 4 2265 laparotomies, embolism in (deaths) . . . . 0.10 

v. Winczel, 5 836 laparotomies, embolism in 1.20 

Stanton, 6 1573 operations, embolism in (deaths) 0.13 

Sertoli, 7 1543 herniotomies, embolism in (deaths) 0.20 

Fat Embolism (Traumatic Lipemia). Fat embolism is a possible 
complication after all bone injuries and after orthopedic operations 
and manipulations." In the past it has been looked upon as a patho- 
logical curiosity, and yet the observations of Warthin 8 and others 
would seem to indicate that a fairly large proportion of the deaths 
following traumatisms and commonly ascribed to such causes as shock, 
heart failure, acute cardiac dilatation, cerebral hemorrhage, pneu- 
monia, sepsis, insanity, alcoholism, etc., are really examples of fat 
embolism. Out of 12 cases of fatal traumatic lipemia autopsied by 
Warthin the real cause of death had been suspected in only 1 case, 
and yet all had occurred in the services of clinicians of the highest 
standing. 

Bissell 9 in a review of clinical and experimental data from the Mayo 
Clinic has shown that fat embolism is one of the really important causes 
of serious postoperative complications often closely simulating simple 
shock. 

Air Embolism. This accident is so rare as to have practically no 
effect on prognosis. Nevertheless, its possibility should always be 
borne in mind when operating in regions where there may be a negative 
venous blood-pressure during inspiration. 

With the patient lying flat on the operating table the region of 
danger is practically limited to the subclavian and the lower third 
of the jugular veins. With the head elevated to the semi-sitting 
posture the danger in head and neck operations is considerably 
increased. In this position air embolism may follow opening one of 
the cranial sinuses as well as any of the large venous trunks of the neck. 

1 Quoted by Beneke, Die Embolie, in Krehl and Morehead, Handbuch der Allgemeinen 
Pathologie, 1913, Pt. 2, vol. ii. 

2 Arch. f. klin. Chir., 1902, vol. Ixviii. 8 Berl. klin. Wchnschr., 1902. 
4 In Aschoff and others, Beitr. zur Thrombosfrage, Leipzig, 1912. 

6 Thrombose und Embolie nach Gynakologischen Oper., Beitr. z. klin. Chir., 1913, 
Ixxxiv, 37-46. 

6 Albany Med. Ann., August, 1914. 7 Arch. f. klin. Chir., 1909, No. 2. 

8 Traumatic Lipemia and Fatty Embolism, International Clinics, 1913, 23d series, iv, 
171-227. 

9 Pulmonary Fat Embolism, a Frequent Cause of Postoperative Surgical Shock. 
Collected papers of the Mayo Clinic, ix, 1917, 535-559. 



60 SURGICAL PROGNOSIS 

With the patient in the Trendelenburg position air embolism may 
follow gynecological operations, but this is very rare. 

Of 33 cases collected by Cauty, 1 in 1876, the point of entrance 
was in the external jugular nine times, in the axillary eight times, 
in the internal jugular five times, in the subscapular three times, 
in the facial occipital, anterior jugular and anterior thoracic, each 
twice. The accident occurs with the greatest frequency after opera- 
tions for the removal of tumors from the neck and axilla. 

Cases have been reported from the use of air dilatation in the 
bladder, uterus and the knee-joint. 

The recent extensive use of intravenous medication has yielded an 
occasional fatality from air embolism. 

Embolism Due to Miscellaneous Causes. The use of paraffin injec- 
tions to correct nasal deformities has resulted in a number of reported 
cases of paraffin embolism. The use of Beck's paste in the treatment 
of sinuses has also been followed by symptoms of embolism. Intra- 
muscular injections of oily suspensions of ntercury and other sub- 
stances has occasionally resulted in embolism. 

Phlebitis. Its comparative frequency and distressing after-results 
combine to make phlebitis one of the most troublesome of the post- 
operative complications. It is also met with after labor, occasionally 
after non-operative traumas and after certain of the infectious diseases, 
notably typhoid fever. 

In 232 cases collected by Cordier 2 the vessels involved were as 
follows: 

The left saphenous or femoral vein affected 213 

Both rifcht and left veins affected 8 

The right veins alone affected 11 

The proximal part of vein first affected 182 

The distal part of vein first affected 36 

Schenek 3 reports 566 cases following 49,161 operations (1.15 per 
cent.) which gives a general idea of its frequency. 

In surgical work it occurs most frequently after laparotomies and 
hernia operations, and only rarely after extraperitoneal operations as 
is shown by the following data compiled by the writer. 

Operations. Phlebitis. Per cent. 

Laparotomies 17,090 280 1.63 

Herniotomies 1,669 13 0.8 

Miscellaneous extraperitoneal operations . 6,121 8 0.13 

All authors agree that it is several times more frequent following 
operations for myoma uteri than any other laparotomies. 

The 232 cases collected by Cordier occurred after the following 
operations the number of times stated: 

1 Arch. d. Physiol., 1876. 

1 Phlebitis Following Abdominal and Pelvic Operations, Jour. Am. Med. Assn., 1905, 
xlv, 1792-1797. 

1 Thrombosis and Embolism Following Operations and Childbirth, Tr. Am. Gynec. 
Soc., 1913, xxxviii, 295-311. 



PROGNOSIS OF THE OPERATION ITSELF 61 

Hysterectomy for fibroids so-called aseptic cases . 69 

Abdominal and pelvic operations character not stated 56 

Appendectomy mostly so-called aseptic cases 27 

Oophorectomy cystic, cirrhotic, etc 16 

Pelvic operations character not stated 9 

Vaginal hysterectomy for cancer 9 

Nephrorrhaphy 9 

Vaginal operations character not stated 8 

Suspension of uterus 7 

Cholecystotomy 4 

Hernia 4 

Ectopic pregnancy 4 

Alexander's operation 3 

Splenectomy 1 

From various sources the writer has compiled the following figures 
which give an approximate indication of the relative frequency of 
phlebitis after several frequently performed operations: 

Operations. Thrombosis. Per cent. 

Operations for myoma uteri 3,416 108 3.1 

Intraperitoneal pelvic operations other than 

for myoma . 1,369 15 1.1 

Appendectomy 5,959 77 1.6 

Operations on gall-bladder 821 4 0.46 

Operations on stomach and intestines . . 689 2 0.3 

Operations for inguinal hernia 1,323 9 0.67 

Operations for ventral hernia 243 4 1.6 

Operations for femoral hernia 103 0.0 

Labor 96,000 381 0.4 

Ultimate Prognosis. There is very little data available concerning 
the ultimate prognosis of crural thrombosis. Schenek studied the 
late histories of 29 patients, 8 of them had symptoms for about four 
months and subsequently no trouble; 2 had some difficulty in walking 
for about twelve months and then completely recovered; 19 never 
fully recovered, being troubled with swelling and with more or less 
pain after being on their feet more than usual. On the basis of these 
cases, he assumes that about 65 per cent, of the patients never fully 
recover, and that if complete restoration is to follow it will come before 
the end of the first year, by which time the collateral circulation is as 
completely established as it ever will be. 

Without quoting definite figures other surgeons express essentially 
the same opinion concerning the ultimate effects of phlebitis. 

There is considerable divergence of opinion concerning the frequency 
of embolism in cases with phlebitis. Among the 233 cases studied by 
Cordier there were 6 cases with pulmonary symptoms possibly refer- 
able to emboli and three cases of sudden death. The same operations 
which are most frequently followed by phlebitis are also the ones 
most frequently followed by embolism although the two complications 
may not occur in the same patients. Clinics reporting a high fre- 
quency of phlebitis also have a high frequency of embolism, showing 
that there is a common etiological factor for the two. It is worthy of 
note that, in spite of a general belief in the infectious origin of throm- 
bosis, most cases occur following so-called aseptic operations, and 



62 SURGICAL PROGNOSIS 

recent investigations Kronig, Aschoff, v. Wenszel all agree that 
blood stasis is probably a more important etiological factor in phlebitis 
than is infection. 

Peritoneal Adhesions. The real importance of adhesions as a cause 
of distressing symptoms following laparotomies is difficult to estimate. 
Probably the majority of abdominal surgeons consider them as among 
the greatest evils associated with their work. Many believe that 
they are the principle cause of invalidisrri following laparotomies. 
On the other hand, it is very easy to overestimate the importance of 
postoperative adhesions. Their presence is by no means confined to 
the unsuccessful cases and their almost constant presence after laparot- 
omies makes them a most convenient excuse for the surgeon seeking 
to justify a poor result. 

In this connection it is a fact worth noting that patients oper- 
ated for definite pathological conditions of a character constantly 
associated with adhesions, such as appendicitis with abscess, 
pelvic inflammatory conditions and acute cliolecystitis, seldom com- 
plain of serious symptoms due to this cause, while the neuras- 
thenic operated for what amounts to practically nothing is more than 
likely to be greatly troubled with "adhesions." An extensive study 
of the causes of poor end-results in abdominal surgery seems to indicate 
that while adhesions are frequently of great importance they are 
altogether too frequently used as a refuge behind which the surgeon 
hides his mistakes in diagnosis and surgical judgment. 

Experience has . taught that although the factors underlying their 
formation are fairly well known, those determining the persistence of 
adhesions are as yet very imperfectly understood. The average case 
of severe pelvic or appendiceal peritonitis has most extensive adhe- 
sions during and immediately after the attack yet a few months later 
there may be scarcely any to be discovered anywhere in the abdomen. 
On the other hand, every surgeon of experience knows that after 
operations which were performed for non-inflammatory conditions, 
where every form of traumatism or infection could be ruled out, 
where no packings or drains were used, where no reaction of any kind 
was observed, in short in cases where the conditions were apparently 
ideal as regards their avoidance, very extensive adhesions not only 
develop but persist in spite of every effort to get rid of them. 

In general it may be said that the immediate formation of peritoneal 
adhesions after operation is in direct proportion to the amount of 
sepsis, the raw areas left by operative procedures, the injury to peri- 
toneal surfaces resulting from contact with gauze pads and drams, 
the minor traumatisms incident to operative manipulations and the 
injury due to chemicals and exposure to drying. The primary fibrin- 
pus variety which form over practically all injured peritoneal surfaces 
immediately after an operation are an essential part of the repair 
process which makes intra-abdominal surgery possible. In so far as 
they represent repair of unnecessary damage they are to be avoided, 
but in themselves they have little influence on the outcome of the 



PROGNOSIS OF THE OPERATION ITSELF 



63 



operation. Most of these adhesions disappear by resolution and the 
majority of those which undergo organization are soon reabsorbed. 
The trouble is that all of them may not be reabsorbed and that in 
the present state of our knowledge it is almost impossible to predict 
which will be permanent and which will not. Very extensive experi- 
mental work designed to determine the laws governing their formation 
and persistence has served to emphasize the fact that results even 
under experimental conditions are extremely variable. The literature 
and experimental data has been reviewed by Richardson 1 to whom we 
are indebted for many of the references quoted below. 

In estimating the possibility of troublesome adhesions in the indi- 
vidual patient it is necessary to consider each of the several possible 
causes of adhesions, such as blood clots and free blood in the peri- 
toneum, sutures, ligatures, etc., which may be present in the case at 
hand. 

Blood Clots and Free Blood in Peritoneum. The relation of free blood 
in the peritoneal cavity to adhesion formation is a question about 
which a final verdict has not yet been given. PenzokU 2 published, in 
1876, the results of a very elaborate experimental research into the 
fate of large amounts of blood in the peritoneal cavity, showing that 
it is absorbed. Wegner, 3 in 1877, and later Vogel, 4 observed the same 
thing experimentally, v. Dembowski, 5 in 1888, reported the results 
of a large number of carefully executed experiments on adhesion 
formation in the peritoneal cavity, and concluded with reference to 
blood clots, that they do not provoke adhesions. Fromme 6 reported 
a few years ago the results of very elaborate and painstaking experi- 
ments on rabbits designed to test (1) the effect of blood alone, and 
with serous defects in the peritoneal cavity; and (2) of infected blood 
alone, and with serous defects; using for this test pure cultures of 
common bacteria. He concluded that in the vast majority of cases 
neither blood alone nor with peritoneal defects produces adhesions. 
Furthermore, some of the cases with infection added showed none, 
although the majority of these did develop adhesions, especially those 
with raw peritoneal surfaces. Other investigators have reached the 
same conclusions. Flateau 7 leaves all blood in the peritoneal cavity 
in cases of ruptured extra-uterine pregnancy except that which escapes 
as a result of necessary operative manipulations. He condemns all 
efforts to remove it on the ground that it is impossible to get it all 
out, and that attempts to do so only serve to prolong the operation 
and to injure the peritoneum. Baisch, 8 on the basis of his experi- 
mental work, concurs with the view that the peritoneum is capable 

* Studies on Peritoneal Adhesions, Ann. Surg., 1911, liv, 768-797. 

2 Deutsch. Arch. f. klin. Med., 1876, xviii, 542. 

3 Arch. f. klin. Chir., 1877, xx, 51. 

4 Deutsch. Ztschr. f. Chir., 1902, Ixiii, 296. 
6 Arch. f. klin. Chir., 1888, xxxvii, 745. 

6 Ztschr. f. Geburtsh. u. Gynak., 1907, lix, 313. 

7 Miinchen. med. Wchnschr., 1904, li, 42. 

s Beitr. z. Geburtsh. u. Gynak., 1905, ix, 437. 



64 SURGICAL PROGNOSIS 

of absorbing large amounts of blood without resulting adhesions, if 
intact, but finds that whenever a serosa-free surface is present it 
always leads to adhesions. 

The facts seem to be that blood alone in the peritoneal cavity 
seldom causes adhesions, but in the presence of infection or peritoneal 
trauma blood helps materially to cause the production of adhesions. 

Sutures and Ligatures. The relation of sutures and ligatures in the 
peritoneal cavity to adhesion formation has been carefully studied 
by a number of investigators. Hallwacks, 1 as early as 1879, showed 
that non-absorbable sterile ligatures in the peritoneal cavity were first 
surrounded by a circumscribed inflammatory zone and finally covered 
by a thin layer of granulation tissue which served to encapsulate the 
suture material which might finally become disintegrated through the 
action of the tissue juices and leukocytes. Rosenberger, 2 Tillmans, 3 
TenBrink, 4 Kelterborn 5 and others later confirmed these observations. 

On the other hand many observers have noted firm adhesions in the 
region of heavy silk ligatures, and in the presence of low-grade infec- 
tion non-absorbable suture material often causes adhesions to persist. 

Mechanical Injury. All investigators agree that mechanical injury 
sufficient to destroy the endothelium of the peritoneum results in 
primary adhesions over the injured areas, but experimental as well as 
clinical results differ widely as to the character of injury necessary to 
cause permanent adhesions. Pankow, 6 in testing the relationship of 
denuded peritoneal surfaces to adhesion formation, was able to produce 
adhesions in only one-half of his cases by stripping the parietal peri- 
toneum sufficiently deep to cause multiple punctiform hemorrhages. 
Franz found no adhesions following aseptic peritoneal defects. Sanger 7 
concluded from operations in which portions of the parietal peritoneum 
were resected, that one wound surface is sufficient to produce adhe- 
sions, which inevitably follow, and that it is not necessary for two 
such areas to lie together for their formation. 

Air Drying. Very elaborate and interesting experiments have been 
carried out to ascertain the effect of air on the peritDneal endothelium 
and its relation to adhesion formation. The results of these experi- 
ments as well as clinical observations show that drying may so injure 
the peritoneum as to cause temporary adhesions, but it is doubtful 
whether these adhesions are ever permanent except in patients having 
a special tendency toward the formation of permanent adhesions. 

Infection. Adhesions are the most important means of defense 
against infection in the peritoneal cavity and at some period during 
each case of intraperrtoneal infection which recovers they are practi- 
cally coextensive with the infection. With the elimination of the 
infection these adhesions usually rapidly disappear by resolution and 

1 Arch. f. klin. Chir., 1879, xxiv, 122. 2 Ibid., 1880, xxv, 771. 

3 Virchows Arch., 1879, Ixxviii, 437. 

Ztschr. f. Geburtsh. u. Gynak., 1898, xxxviii, 276. 

'Centralbl. f. Gynak., 1890, xiv, 913. 

Ztschr. f. Geburtsh. u. Gynak.. 1907, lix. 313. 1 Ibid., 1884, xxiv. 1. 



PROGNOSIS OF THE OPERATION ITSELF 65 

reabsorption except in the immediate vicinity of persisting foci of 
infection. Thus during the acute stage of a diffuse peritonitis of 
appendicular origin, the fibrinous adhesions are encountered every- 
where, while ten days later with the subsidence of the diffuse lesion 
it is the rule to find only a narrow zone of organizing adhesions walling 
off a peri-appendicular abscess. With the drainage of the abscess 
even these adhesions usually disappear except in those cases in which 
the appendix still retains some active infection. In these cases the 
zone of adhesions is soon limited to the immediate neighborhood 
of the appendix and even these will usually soon disappear if the 
appendix is removed. There is still some controversy as to whether 
peristalsis is necessary for the freeing of adherent surfaces, but it 
seems probable that peritoneal rest during the acute stage and active 
peristalsis after the acute stage has passed in the means best calcu- 
lated to get rid of adhesions. In patients not exhibiting a special 
tendency to adhesion formation continuing irritation is undoubtedly 
the chief cause of persistent adhesions. Extensive adhesions per- 
sisting in relation to a tube, ovary, gall-bladder, uterus or cervical 
stump usually signify that trouble still exists in these organs sufficient 
to prevent the reabsorption of the adhesions. 

Cauterization by Heat. Nothing illustrates the variability of factors 
governing adhesion formation better than the results following the use 
of the thermocautery in the peritoneal cavity. Thus Spiegelberg and 
Waldeyer, 1 v. Dembowski, 2 Franz 3 and Maslowski 4 found that it 
produces adhesions. Baisch 5 and Kelterborn, 6 on the other hand, 
were unable to confirm this work. TenBrink 7 produced adhesions 
with the cautery only when infection was present. Kiistner 8 reports 
in detail a case in which a large ovarian cyst, with many pelvic adhe- 
sions, was removed, the actual cautery being used to sever the adhe- 
sions and also the pedicle of the cyst. At a second operation fourteen 
months later for postoperative hernia no adhesions were found where 
the cautery had been used. A possible explanation of these conflicting 
reports has been given by Vogel. He found that a superficial burning 
of the peritoneum generally gives rise to adhesions, but that none 
occur after a thorough cauterization with the formation of a thick 
eschar. 

Prevention of Adhesions. The best way to prevent adhesions is to 
avoid as far as possible all those causes which are known to favor their 
production. As far as possible all defects in the serosa should be 
covered by peritoneal flaps or grafts. However, in doing this great 
care must be used to maintain normal relationships, to avoid undue 
tension and to select proper suture material else the attempt to prevent 
adhesions may actually determine their formation under unfavorable 

1 Virchows Arch., 1868, xliv, 69. 2 Arch. f. klin. Chir., 1888, xxxvii, 745. 

3 Ztschr. f. Geburtsh u. Gynak., 1902, xlvii, 64. 

4 Arch. f. klin. Chir., 1868, ix, 527. 

5 v. Vleits: Ztschr. f. Geburtsh. u. Gynak., 1890, xx, 384. 

6 Centralbl. f. Gynak., 1890, xiv, 913. . 

7 Ibid., 1898, xxxviii, 276. 8 Ibid.. 1890. xiv. 425. 

5 



66 SURGICAL PROGNOSIS 

circumstances. Many other plans have been devised for preventing 
adhesions, chief among which may be mentioned the interposition of 
non-absorbable or slowly absorbable substances such as silver foil, 
Cargyle membrane, animal, vegetable and mineral oils and even gases 
and liquids. All of these special methods have had their advocates 
but none have stood the test of time and most of them have been 
definitely proven to be worse than useless. 

In conclusion it is well to emphasize the fact that adhesions do 
not always cause noteworthy trouble, and that possibly the best way to 
avoid unpleasant after-results, such as are usually ascribed to them, is 
to make sure that the operation actually cures the original lesion for 
which the patient is operated. Troublesome adhesions are particu- 
larly prone to develop around persisting foci of low grade infection. 
It is equally important for the operator to so arrange the position of 
the organs at the close of the operation as to insure normal relationships 
one to another in case adhesions do form subsequently. 

Postoperative Intestinal Obstruction. Intestinal obstruction may 
be either an early or late complication following abdominal operations. 

Cases occurring immediately or within a few days following lapa- 
rotomy have usually been classified under the following heads: 

1. Septic ileus such as accompanies a septic peritonitis. 

2. Paralytic ileus. 

3. Mechanical ileus usually due to adhesions and conditions result- 
ing therefrom. 

Today the term postoperative obstruction is largely limited to the 
third group of cases due to mechanical causes which may make them- 
selves manifest at any time following a laparotomy. 

Cases of postoperative obstruction coming on immediately or a 
few days after operation were formerly of frequent occurrence and 
constituted one of the chief causes of mortality in abdominal surgery. 
In our experience and probably that of most surgeons in this country 
this form of postoperative ileus has almost entirely disappeared. 
Beckman reports only 3 cases of postoperative obstruction occurring 
during convalescence in the course of 4764 abdominal operations. 
During the past eleven years the writer has had no deaths from this 
cause and only 1 case requiring secondary operation. 

Simplification of operative procedures, the application of better 
judgment as to what not to do when working in the presence of recent 
adhesions and inflammatory exudates, and the general introduction of 
more rational lines of postoperative treatment are the three chief 
reasons for the lessened incidence of this complication. It seems 
probable that the introduction of more rational lines of postoperative 
treatment is the principal reason for the reduction. The withholding 
of cathartics until normal bowel movements are obtained by enema, 
followed by the withholding of food and drink by mouth and the use 
of proctoclysis in patients with suspicious symptoms were important 
steps in the elimination of this complication. Another advance of 
almost equal importance has been the introduction of the prompt use 



PROGNOSIS OF THE OPERATION ITSELF 67 

of the stomach tube whenever postoperative cases became nauseated 
or distended. 

As practically all statistics purporting to show the frequency of 
early postoperative obstruction are based on the results obtained 
during the period when early catharsis was supposed to be an essential 
element of after-care, they are entirely misleading as regards the 
present time. Late cases of complete obstruction occurring months 
or years after operation are very rare considering the great number 
of patients now living upon whom laparotomies have been performed. 
Nevertheless, every surgeon doing an active practice meets with an 
occasional case of complete obstruction and numerous cases of lesser 
grades of obstruction developing months or even years after operation. 

Adhesions are the primary cause of the great majority of all cases 
and adhesions involving the small bowel are far more liable (93 per 
cent. Woolsey) to cause acute obstruction than are those involving 
the large bowel. In a considerable percentage of cases it is found 
that the adhesion causing the obstruction has fixed a loop of small 
intestine in a grossly abnormal location in the abdomen. This cause 
of postoperative obstruction can be largely avoided by using care 
not to disturb the normal relationships of the organs during the 
placing of or removal of tampons or drains. 

As a rule, cases developing acute intestinal obstruction after con- 
valescence from the original operation should be operated upon imme- 
diately, because, even if they do obtain relief from enemas, there is 
almost no likelihood of the cause of the obstruction disappearing, and 
even if the acute attack is relieved the condition will almost certainly 
reappear. In any case operation should not be delayed more than a few 
hours. The mortality, if operated during the first twenty-four hours, 
is only nominal, while after twenty-four hours it rises very rapidly. 
Naunyn, in a study of 288 cases of acute obstruction found the mor- 
tality in cases operated the first or second day to average 25 per cent., 
while if operation was delayed to the third day or later the mortality 
was from 60 to 65 per cent. 

The indications for immediate operation are less definite in cases 
occurring within a week or ten days following the primary operation 
because secondary operations performed at this time have a high 
mortality, and if they can be avoided the chances are that the adhe- 
sions causing the obstruction will be ultimately absorbed. 

Secondary operations for the relief of obstruction occurring during 
early convalescence have a mortality of from 25 to 50 per cent., while 
wound infections and ventral hernias are particularly frequent in 
those who recover. Such operations are plainly to be avoided if 
possible, and yet to procrastinate when radical interference is demanded 
is usually fatal. In our own experience the following rule has always 
served to differentiate between the cases which have demanded opera- 
tion and those which could be cured by conservative treatment. If 
no plainly evident results are obtained from two or three enemas 
given at intervals of two to eight hours, depending on the urgency of 



68 SURGICAL PROGNOSIS 

the symptoms, the obstruction is probably complete, and the patient 
should be operated before alarming symptoms set in. On the other 
hand, if each enema does yield a little result in the way of gas or 
fecal matter it has invariably been our experience that the acute stage 
of the obstruction will clear up without operation and a recurrence 
of the trouble has very rarely been noted. 

LITERATURE. 

Funk: Ueber Ileus Nach Laparotomie, Deutsch. med. Wchnschr., 1905. 

Sonnenburg: Ueber Postoperation-Ileus, Berl. klin. Wchnschr., 1907, Bd. i. 

Winternitz : Ueber operative Behandlung des postoperativen Ileus, Miinchen. med. 
Wchnschr., 1900, Bd. ii. 

Martin: Postoperative Ileus, Deutsch. med. Wchnschr., 1907, Bd. ii. 

Busch: Ueber postoperative Ileus, Berlin, 1912. 

Funk: Acute Postoperativen Intestinal Obstructions, Jour. Indiana State Med. 
Assn., 1913, vi, 433-449. 

McGlannan, A.: Intestinal Obstruction: A Study of 181 Cases, Tr. South. Surg. 
and Gynec. Assn., 1912, xxv, 26-51. 

Woolsey, G.: Postoperative Intestinal Obstruction, ^Tr. Am. Surg. Assn., 1910, 
xxviii, 270-298. 

Acute Dilatation of the Stomach. Since the attention of the pro- 
fession was forcibly called to this condition by Thompson, 1 in 1902, 
this rare but serious postoperative complication has been frequently 
recognized by all surgeons. It is also met with after labor and in many 
non-surgical diseases of the asthenic type. Within recent years the 
more severe cases have largely disappeared from clinics where the 
stomach tube is used to treat postoperative vomiting. Equally bril- 
liant results are often obtained by having the patient lie on his stomach 
until the symptoms pass away. 

Postoperative Ventral Hernia. Abel 2 examined 586 patients some- 
time after laparotomy and found that ventral hernias had developed 
in from 9 to 20 per cent, of the scars depending upon whether the 
incision had been closed by approximation of the anatomical layers 
or by through and through sutures. Harrington 3 studied the post- 
operative condition of 236 patients operated for appendicitis; 85 
were completely closed at the time of operation and of these 3.5 per 
cent, showed subsequent hernia; 88 were sutured down to the drainage 
tube or almost completely closed and of these 12.5 per cent, developed 
hernia; 63 were treated by the "open method" and 20 per cent, devel- 
oped hernia. Since the time when the above figures were compiled' 
the results have been greatly improved, but ventral hernias still 
constitute one of the chief causes of unsatisfactory end-results after 
laparotomies. Recent literature contains many references to descrip- 
tions of technical procedures designed to prevent or cure this condi- 
tion but no comprehensive studies dealing with the frequency of this 
complication under modern conditions. 

The following statements concerning the incidence of ventral hernias 

1 Acute Dilatation of the Stomach, London, 1902. 

2 Archiv. f. Gynekologie, 1898, Ivi, 956-750. 

3 Quoted by Murphy in Keen's Surgery, iv, 793. 






PROGNOSIS OF THE OPERATION ITSELF 69 

are based very largely on a personal study of the known end-results 
following approximately 2000 laparotomies : 

After abdominal incisions of approved type, closed in such a manner 
that the anatomical structures are held in normal relationship one 
to another while healing by first intention, there is no noteworthy 
weakening of the abdominal wall. Any cause which interferes with 
the union of properly approximated surfaces predisposes to ventral 
hernia. Chief among these causes may be mentioned infection, early 
excessive strains on the incision, drainage, nerve injuries and obesity. 
In the average clean case the union at the end of two weeks should be 
sufficiently strong to withstand the strains of ordinary life, but from 
four to six weeks should elapse before hard manual labor is undertaken. 
In obese individuals and those suffering from constitutional defects 
such as marked anemia, jaundice, etc., due allowance should be 
made for delayed repair even though it be by first intention. If the 
incision has been infected the danger of subsequent hernia may be 
considerably reduced by insisting that no strain be placed on the 
wound for at least ten weeks after it has closed. 

Ventral hernias following primary union of undrained abdominal 
incisions are very rare and when they do develop they are almost 
always the result of abnormal strains being placed on the sutures soon 
after the operation. Excessive postoperative coughing, especially in 
upper abdominal incisions, has been followed by ventral hernia in a 
number of patients who must certainly have escaped had it not been 
for the coughing. Obese patients may develop ventral hernia with- 
out the presence of any other demonstrable cause. In these cases the 
tissues which are relied upon to give strength to the incision are often 
themselves weakened by fatty infiltration, repair is slower than in 
normal individuals, the line of the incision must usually bear its 
share of the excessive weight, increased postoperative intra-abdominal 
tension is particularly common, and finally there is the well-known 
susceptibility to infection. 

In the great majority of cases infection is the chief cause of subse- 
quent yielding of the abdominal scar. With or without drainage 
frank infection involving the suture lines of the fascial layers results 
in ventral hernia in a very large proportion of cases. In mildly 
infected wounds not accompanied by frank suppuration along the 
fascial layers hernias are frequently determined by excessive coughing 
or other strains subjected to the wound before firm union has been 
completed. 

Drainage per se predisposes to hernia in direct proportion to the 
size of the drains employed. While drained cases are very much 
more likely to be followed by ventral herria than are clean undrained 
cases, the infection which necessitates drainage rather than the drains 
themselves is responsible for the resulting hernias in most instances. 

In the writer's experience, rectus and midline incisions, in which 
drainage not over 3 cm. in diameter was employed and in which 
primary union of the remainder of the incision was obtained, have 



70 SURGICAL PROGNOSIS 

yielded not over 3 per cent, of hernias and these have been of almost 
no practical importance. On the other hand, if in drainage cases 
the closed portion of the incision has suppurated, hernias have devel- 
oped in a considerable proportion of the scars depending upon the 
extent and duration of the suppurative process. Incisions which 
were packed open with little or no effort to obtain prompt closure have 
nearly all resulted in ventral hernias. 

Harrington reported 3.5 per cent, of hernias developing in incisions 
for appendicitis which were completely closed at the time of opera- 
tion. At first sight this figure seems high but it corresponds with our 
own observations in cases operated for acute intra-abdominal condi- 
tions. In my experience ventral hernias have been particularly fre- 
quent after operations for acute appendicitis in which the conditions 
within the abdomen did not demand drainage but in which the tissues 
of the abdominal wall were unavoidably infected during the operation 
causing a subsequent suppuration in the undrained iacisioh. Similarly, 
infection in the main incision has been muofe more frequent when 
drainage was carried through a lateral stab wound than when it was 
brought out through the primary incision. Because of this fact, in the 
cases examined, lateral stab drains have been a cause of rather than 
a means of preventing ventral hernia. Data obtained from other 
sources would seem to confirm this view which is contrary to that held 
by many surgeons. 

Although the theoretical advantage of the muscle splitting incisions 
of the McBurney type are well known, it is a fact worth noting that 
while the writer has never used this incision in operating for acute 
appendicitis and although it has not been commonly employed by other 
surgeons whose results we have had the opportunity to observe, 
nevertheless, a very considerable proportion of the most troublesome 
ventral hernias which have come under observation have followed 
so-called McBurney incisions. This point is of sufficient practical 
importance to warrant careful study of much more data before 
expressing a definite opinion. In so far as our own observations go the 
muscle-splitting incisions of the McBurney type are definitely more 
prone to give ventral hernias than are the incisions which depend upon 
the accurate suturing of fascia layers for their postoperative strength. 

The end-results of secondary operations for ventral hernias depend 
largely upon the size of the hernia. Small hernias are easily cured 
while wide hernias have so far been followed by a large percentage of 
recurrences. Coley 1 reports 10 known recurrences following 61 oper- 
ations for ventral hernia (16.4 per cent.) which is about the average 
reported by other surgeons. The introduction of the imbrication 
method of closing small and medium-sized hernias has apparently 
given better results than the old edge-to-edge approximation of the 
anatomic layers, and the use of the silver wire filigree has yielded good 
results in many cases previously inoperable. 

1 Progressive Medicine, June, 1913. 



PROGNOSIS OF THE OPERATION ITSELF 71 

Cystitis. Cystitis is one of the most frequent and distressing of 
the minor postoperative complications. It is particularly frequent 
after gynecological operations, and after pan-hysterectomy for cancer 
cystitis is so frequent and serious a complication as to have a decided 
bearing on the prognosis of the operation. Hemorrhoid and hernia 
operations as well as simple appendectomies are also often followed 
by cystitis. Its occurrence after such operations may mean that the 
patient has been relieved of one condition only to be left with a much 
more troublesome and possibly even dangerous infection of the bladder. 

The causes responsible for postoperative cystitis are none too 
well understood. Formerly surgeons were agreed that infection 
introduced through catheterization was the immediate cause of the 
infection. More recently it has been recognized that this simple 
explanation is insufficient and that it is the abnormal condition of 
the bladder necessitating the catheterization which is probably the 
most important factor in causing the cystitis. The normal bladder 
is not easily infected even by catheterization. On the other hand, 
after certain operations, especially those involving the immediate 
neighborhood of the bladder, this organ becomes highly susceptible to 
infection which may develop with or without catheterization. 

In attempting to reduce the frequency of this complication in our 
own cases it soon became apparent that extreme care used in catheter- 
izing cases of postoperative retention had little effect on the frequency 
of cystitis. Likewise there was little or no demonstrable benefit 
from the prophylactic use of urinary antiseptics administered by 
mouth. 

On the other hand, in the writer's experience cystitis as a post- 
operative complication has been practically eliminated since adopting 
the plan, in all cases of postoperative retention, of frequent catheteri- 
zation followed each time by the injection into the bladder of one 
ounce of saturated boric acid solution which is allowed to remain 
until the next catheterization. This method of prophylaxis is simple 
and harmless and has apparently proved to be of real value. 

Injury to the Ureter. In 4086 major operations in the gynecological 
service of the Johns Hopkins Hospital studied by Sampson, 1 there 
were 32 known instances of injury to the ureter occurring during 
operation. A ureter was clamped sixteen times; a portion of the ureter 
was intentionally excised six times; a ureter was incised three times, a 
ureter was completely divided three times and the blood supply was 
so interfered with as to cause a subsequent ureteral fistula seven times. 
The ureter was tied or clamped three times in 50 abdominal hyster- 
ectomies for carinoma of the cervix; once in 26 combined abdominal 
and vaginal hysterectomies for carcinoma; three times in 63 vaginal 
hysterectomies for carcinoma of the cervix; four times in 516 hystero- 
myomectomies; twice in 276 hysterosalpingoophorectomies for pelvic 
inflammatory disease; once in 63 repairs of vesicovaginal fistula; once 

1 Ligation and Clamping of the Ureter as Complications of Surgical Operations, Am. 
Med., 1902, iv, 693-700. 



72 SURGICAL PROGNOSIS 

in 100 fixations of the kidney and once in a combined vaginal and 
abdominal colpohysterectomy for carcinoma of the vagina. 

In a series of 310 intra-abdommal pelvic operations performed by 
the writer the ureter was injured twice. Once in ligating a deep 
pelvic vessel a ureter was punctured by the suture in such a way 
as to allow the urine to escape into the general peritoneal cavity with 
a fatal result. In the second case a portion of a ureter which was 
adherent to an intraligamentary cyst was excised along with the cyst. 
In this patient immediate nephrectomy was followed by recovery. 
In two other cases ureteral fistula developed following the removal 
of gauze packs which had been placed against the exposed ureter. 

Although injury to the ureter is one of the rare surgical accidents, 
it is nevertheless of sufficient frequency to make it one of the most 
important single complications liable to be encountered in gyneco- 
logical work. 

Postoperative fistulse developing in the presence of infection are 
followed by ascending infection and pyelontphrosis in a very large 
proportion of cases. 

Divided ureters implanted into the intestine always result in ascend- 
ing infection and the same may be said of the great majority of cases 
where the ureter is implanted into the bladder. 

Uretero-ureteral anastomosis is sometimes successful but is more 
often followed by hydronephrosis and infection. 

Permanent ligation of the ureter results in an atrophy of the kidney 
without recognizable clinical symptoms in the majority of cases, 
although in some cases ligation is followed by hydronephrosis. 

Parotitis. At the present time parotitis is a rare postoperative 
complication. 

Stephen Pagent, in investigating the causes in 101 cases, found that 
in 50 cases parotitis arose after disease or temporary derangement of 
the generative organs ; 23 cases of parotitis arose after disease or injury 
of the abdominal wall, peritoneum or pelvic cellular tissue; 18 cases 
arose after disease or injury to alimentary canal; 10 cases arose after 
disease or injury of the urinary tract. 

In our experience it has usually followed operations for some form 
of acute intraperitoneal infection. It is an exceedingly distressing 
complication which may occasionally determine a fatal termination 
in patients already handicapped by serious illness. 

Postoperative Intestinal Fistulas. Postoperative intestinal fistulse 
occur most frequently after operations for acute appendicitis. They 
are also met with after operations for pelvic infections and after other 
intra-abdominal operations undertaken for the relief of long-standing 
infection. Sometimes they follow leakage from the suture lines after 
intestinal anastomoses. 

Chronic tubercular infections within the abdomen are very fre- 
quently accompanied by small fistulse into the intestines which may 
not be discovered until a fecal fistula has developed. 

The great majority of fecal fistulse close spontaneously. Serious 



PROGNOSIS OF THE OPERATION ITSELF 73 

complications are seldom encountered unless the fistula be in the 
duodenum or jejunum when the loss of semidigested food through the 
fistula may interfere with the nutrition of the patient. In appendix 
cases and after pelvic operations the fistulse usually close spontaneously 
in from ten to fourteen days. Fistulse in cases of tuberculosis are 
always serious but some of them close spontaneously. Those follow- 
ing anastomosis operations usually spell failure although occasionally 
one may close without further operative interference if there be no 
obstruction at or distal to the anastomosis. When an ordinary 
fecal fistula fails to close spontaneously the failure is usually due to 
some obstruction in the intestine distal to the fistula. 

In the past leakage from the intestine has often been caused by 
gauze packs placed against suture lines, appendix stumps or weakened 
intestinal walls. Others have been due to pressure necrosis from 
glass or stiff rubber tubes. 

During the past few years the incidence of fecal fistula has been so 
markedly lessened as to make worthless all of the older data con- 
cerning the frequency of this complication. 

Nerve Injuries. Injuries to important nerves often mar the results 
of otherwise successful operations. Only extreme care and a thorough 
knowledge of anatomy will suffice to avoid these injuries. Facial 
paralysis following mastoid operations and operations in the upper 
cervical and parotid regions is relatively frequent and of great impor- 
tance. Injury to the spinal accessory is a common complication of 
operations in the cervical region. Abdominal incisions should be 
so planned as to avoid injuring the nerve supply to the abdominal 
muscles as otherwise serious weakness of the abdominal wall may 
result. Injuries and operations on the extremities are always liable 
to be accompanied by serious nerve injuries. Suture of the divided 
nerves yields good results in many cases but the process of repair is 
very slow and the percentage of failures is high. 

Musculospiral paralysis due to the arm resting over the edge of the 
operating table while the patient is under the anesthetic is one of the 
most distressing of the avoidable postoperative complications. With 
constant attention to details this complication can be avoided, but 
with the least carelessness it may occur with considerable frequency. 
The patient, operated for some minor disability and left with a painful 
crippled arm for six months or a year after the operation, is a sad 
victim of misplaced confidence. 

Scars. The possibility of unsightly scars must always be borne in 
mind, especially when operating on the face and neck. Scars may 
have little bearing on the postoperative result viewed from a purely 
scientific standpoint, but the talkative woman who has been relieved 
of a disfiguring goiter and left with a slight scar visible only, on party 
occasions, is prone to forget the goiter and dwell on the disfigurement 
caused by the scar. 

Artificial Menopause. In women who have had both ovaries 
removed before the period of the natural menopause, there results an 



74 SURGICAL PROGNOSIS 

artificial menopause characterized by phenomena similar to those 
seen at the natural menopause, only often in a peculiarly exaggerated 
form. 

Gynecologists still differ in their opinions concerning the effect of 
the removal of the uterus with the preservation of one ovary on this 
condition, but most surgeons have long been convinced that the 
preservation of an adequate amount of ovarian tissue is the essential 
factor in avoiding these phenomena. Dickinson, 1 after studying 164 
cases, arrives at the following conclusions: 

"Conservation of the ovarian structures after hysterectomy show 
four-fifths of the patients free from marked disturbance of the surgical 
menopause. The results are somewhat better where both ovaries 
remain than where one is left or resections are made. 

"Where disturbances do occur their character is less severe and 
more gradual than after bilateral removal of the ovaries. In married 
women conservation shows nearly uniform persistence of sexual 
desire." ^ 

To preserve the functional activity of the ovary its circulation must 
not be impaired. Removal of the tube frequently compromises the 
blood supply and barring definite evidences of disease the tube should 
be preserved when the ovary is preserved in doing a hysterectomy. 

The disorders of the artificial menopause are flashes or flushes of 
heat, palpitations, hysteroneuroses and physical disturbances. The 
flushes come on, as a rule, within a few weeks after operation and 
persist for periods of time varying from a few months to several years. 
Their intensity grows less, usually, in a few months. They frequently 
appear even forty to fifty minutes while the patient is awake, and 
are sometimes preceded by a slight faintness, chilly sensations or 
dizziness. The patient feels that she is pale and that the blood is 
leaving the surface of the body. This is followed by a wave of heat 
which rushes over the surface of the body, particularly the face and 
neck, causing burning, tingling and flushing of these parts, and this 
is succeeded by sweating. The patient may complain of her heart 
beating very forcibly, the thumping of which she can hear. The 
flushes are nervous phenomena, the vascular system responding to 
the same sort of stimulus which causes blushing. 

Palpation and tachycardia, which may or may not accompany 
the flushes or may appear independently, are likewise due to a disturbed 
nervous system. 

The hysteronervous and psychic phenomena are those of other 
forms of neurasthenia, but are frequently seen in women who have 
previously been free from them. 

Many surgeons believe that the morbidity due to the artificial 
menopause is not to be compared to the bad results following attempts 
at conserving one or both ovaries. The viewpoint of surgeons 
opposed to conserving the ovaries has been recently emphasized by 
Polak, 2 who found that 43 women in whom both ovaries were removed 

1 Tr. Am. Gynec. Soc., 1911, xxxvi, 324. Ibid, i, 329. 



PROGNOSIS OF THE OPERATION ITSELF 75 

were completely relieved of all pelvic pain and symptoms, only 3 
suffered from flushes, and only 1 suffered from marked nervous phe- 
nomena. Of 32 women in whom one or both or a part of one ovary 
was saved 5 had enlarged tender ovaries which caused them pain; 
3 of the 32 women suffered from nervous phenomena which could 
hardly have been worse. 

Postoperative Susceptibility to Fatigue and Postoperative Neuroses. 
Following the average clean laparotomy the histological processes 
of repair are essentially completed by the end of the second week, 
and by the end of the third week there is seldom any objectively 
demonstrable reason why the patient should not return to his usual 
routine of daily work. As a matter of fact, the patient is almost never 
able to do this. The patient operated upon for some relatively minor 
ailment is weak out of all proportion to any objectively demonstrable 
cause. There may not have been a degree of temperature nor any 
noteworthy acceleration of the pulse, theie may have been no loss 
of weight and he may look the picture of health, yet the inability to 
carry on sustained effort may be even more pronounced and may 
persist for a much greater length of time than after a really serious 
medical illness of approximately equal duration. The patient inter- 
prets his condition, not in terms of pain or other phenomena directly 
referable to the operation itself, but in terms of weakness. He feels 
compelled to wait weeks or even months to "recover his strength." 

In the light of our present knowledge this postoperative susceptibility 
to fatigue can best be explained as the result of a profound impression 
on the central nervous system or the central nervous system plus 
associated organs controlling psychic and possibly muscular activities. 

In this connection it should always be borne in mind that a surgical 
operation is, for possibly the majority of patients, a great crisis in 
their lives. Fear, worry, anxiety and physical suffering are super- 
imposed one upon another and crowded into an interval of a few 
days or hours in such a way as to tax the strongest nervous system. 
It is, therefore, little wonder that the strain leaves an impression on 
the nervous and psychic centers of a considerable proportion of 
patients. The phenomena referable to this strain usually disappear 
slowly but certain effects may persist in the form of more or less 
permanent neuroses. 

Crile and his followers believe that the phenomena under considera- 
tion are the result of exhaustion beyond the limits capable of prompt 
repair of those organs whose function is that of converting latent 
energy into kinetic energy in response to adaptive stimuli. They 
also claim that the changes incident to the exhaustion are demonstrable 
histologically by structural alterations in the cells of these organs, the 
degree of pathological alteration being directly proportionate to the 
degree of overstimulation due to noci impulses. According to them 
the cells of the central nervous system are chiefly affected but the 
suprarenals, liver, thyroid and muscles may also be involved in the 
changes incident to the exhaustion of overstimulaticn. Whatever the 
final verdict concerning the histological aspects of the subject may be, 



76 SURGICAL PROGNOSIS 

there is no questioning the fact that increased susceptibility to fatigue 
is readily demonstrable after the majority of surgical operations and 
after many non-operative traumas, especially those accompanied by 
considerable fright. 

In the great majority of cases this condition amounts only to a more 
or less prolonged period of weakness ; the patients subsequently stating 
that following the operation it took six weeks, six months or even a 
year to recover their strength. Nevertheless, in considering the 
prognosis of an operation the surgeon must always bear in mind the 
possibility of producing a true postoperative neurasthenia or even 
hysteria and very rarely insanity. 

The postoperative neuroses are not different in kind from the well- 
known traumatic neuroses. It is noteworthy, however, that whereas 
the traumatic neuroses have been fully recognized for many years, 
surgeons have, for the most part, failed to recognize the fact that 
many of the neuroses following operation were the direct result of 
the pain, fear, anxiety and other noxious influences incident to the 
operation itself, and that the operation was often the principal and 
not infrequently the sole cause of the trouble, even though there were 
no demonstrable anatomic defects resulting from the surgical manipu- 
lations themselves. 

Not only is it important to avoid the so-called noci-association before 
and during operations, but it is equally important that following an 
operation or injury the patient's mental attitude be guided into proper 
channels. The man or woman who has received an ordinarily unimpor- 
tant injury but who looks forward to a substantial compensation for 
"permanent injury to the nervous system" is almost invariably placed 
in a mental attitude which continues the traumatic neurosis until after 
the litigation is ended. Likewise the patient who has undergone an 
operation and later develops the mental attitude of self-pity for each 
little ache and pain is almost sure to continue in a state of more or less 
pronounced "shell-shock." If, on the other hand, the patient can be 
brought to think constantly of how fortunate he or she is that the opera- 
tion is passed, that no serious, life-threatening conditions such as cancer 
were found, and to interpret each little ache and pain as only a natural 
step in the convalescence, from a condition which might have been 
infinitely worse, then in our experience the recovery from the nervous 
manifestations is prompt and positive. We believe that this question 
of abnormal mental attitude is so important a factor in most cases of 
traumatic and postoperative neurosis that the effort to develop a 
correct mental attitude has for years formed the chief basis for our 
therapy in these cases. 

It is a noteworthy fact that patients operated for real pathological 
conditions, be it a pelvic abscess, a cancer of the breast, an empyema 
of the gall-bladder or an acute appendix, seldom suffer from postopera- 
tive neurasthenia ; while the patient whose abdomen is explored without 
positive findings is more than likely to suffer from nervous symptoms 
greatly exaggerated by the operation. 



TECHNICAL EFFICIENCY. 

BY ALBERT J. OCHSNER, M.D. 

THE idea of attaining technical efficiency has invaded almost all 
fields of human activity. In the industries this has taken so important 
a place that corporations employ efficiency experts in order to be 
enabled to meet competition. 

In surgery, little attention has been given to this field, although 
here and there individual surgeons have grasped the idea and have 
developed systems far in advance of others in this direction. 

Several elements are involved in the development of efficiency. 

1. Concentration. Concentration of attention and energy are of 
primary importance. If the surgeon regularly concentrates his atten- 
tion upon the work before him, his assistants and nurses will soon 
acquire the same characteristics, and an endless waste of time can be 
eliminated. 

2. Preparation. If the operation has been thoroughly planned and 
everything is in readiness not only for the operation but also for 
possible emergencies and for the surgical dressing, much efficiency 
will result. 

3. System. The surgeon who has observed a large number of 
capable surgeons operate, can avoid a vast amount of unnecessary 
manipulation because he can develop a system which will eliminate 
everything useless in all of the methods observed and at the same time 
he can adopt all of the points which make for efficiency. 

4. Constancy of Working Plan. By developing a working plan 
which is constantly in use in a hospital all of the persons involved, 
operator, assistants, anesthetist and nurses know what will be expected 
of them and will be ready to do their part promptly and efficiently, 
while a rattle-brained operator who does the same things in a number of 
different ways, according to the whim that strikes him, cannot count 
on efficient cooperation. 

5. Limited Number of Assistants. Clinics in which a large number 
of assistants and nurses are involved in each operation must lack 
efficiency because everything handled is likely to pass through a 
number of hands, and at each handling there is an opportunity for 
loss of time, infection and error. 

6. Instruments. It is much more likely to develop a high degree 
of efficiency if the surgeon and each assistant handles the instruments 
which he uses rather than to have them passed to him by a nurse or 
another assistant, because it requires but one mental act and one motion 
for each change of instruments, provided they are always placed in the 

(77) 



78 TECHNICAL EFFICIENCY 

same relative position when these are not handed to the surgeon by a 
second person. On the other hand, if they are handed by a nurse or 
an assistant, whenever the surgeon decides upon the next step, if the 
assistant happens to have thought of exactly the same step he may 
anticipate the operator; if, however, the surgeon must call for the 
instrument, or if the wrong one is handed to him, there is a loss of 
time and energy, and usually some mental irritation, all of which 
conditions do not make for efficiency. 

Automatic Action. Everything that we do really very well we do 
more or less automatically, and, other things being equal, the more 
we can introduce this element into surgical technic the greater will be 
our efficiency. 

Arrangement of Operating Room. Much can be accomplished to 
increase efficiency by carefully studying the arrangement in the 
operating room. By studying the motions required in doing surgical 
work and observing the distances to be traveled in accomplishing the 
work, one can arrange the furniture and apparatus in the operating 
room so as to reduce to a minimum the waste of energy required and 
this will of course increase the efficiency. 



ASEPTIC AND ANTISEPTIC TECHNIC. 



BY ALBERT J. OCHSNER, M.D. 

THE practice of antiseptic surgery was based upon the knowledge 
that suppuration and inflammation occur only in the presence of micro- 
organisms in the tissues involved and upon the supposition that these 
microorganisms should be destroyed by the introduction of some sub- 
stance or some combination of substances which has been demon- 
strated to possess the power of destroying microorganisms or to inhibit 
their growth or their power of reproduction to a sufficient extent to 
enable the tissues to destroy them. Aseptic surgery, on the other 
hand, attempts to accomplish the same result by keeping wounds free 
from microorganisms to a sufficient extent to enable the tissues to 
destroy the very small number which may*obtain entrance into the 
wound, notwithstanding any precautions that may be taken. 

When we come to consider the practical details of accomplishing 
these objects, however, so many conditions have a definite and impor- 
tant bearing upon the results in wound-healing that it is quite worth 
while to go into details. 

These will be considered in an intensely practical way in order to 
give them the position they deserve in the planning of actual surgical 
work. 

At the present time aseptic methods are almost universally employed 
in the treatment of wounds that are made by the surgeon in tissues 
which are not already infected. This is proper because'none of the anti- 
septics can in any way benefit the tissues of wounds which are free 
from infectious material, while undoubtedly many of the antiseptic 
substances which have been introduced into practice . have harmful 
effects upon the tissues. 

It is at the same time possible to prevent the introduction of micro- 
organisms into these wounds to so great an extent that the slight 
number which may be introduced accidentally can be easily disposed 
of by the natural action of the tissues, provided these tissues be given 
a fair chance to defend themselves against these intruders. 

We must then provide against the introduction by contact of micro- 
organisms into the uninfected wounds. The fear of infection from 
microorganisms in the air has been proved to be unfounded. Exposing 
culture plates in an operating room will demonstrate that the air 
practically always contains microorganisms, the number varying with 
the amount of dust present; but even in operating rooms, in which a 
large number of microorganisms are present in the air, infection of 
wounds will not occur provided precautions are taken against contact 
infection. 

(79) 



80 ASEPTIC AND ANTISEPTIC TECHNIC 

I recall some notable examples in my personal observation which 
may serve as illustrations. While serving in the capacity of surgical 
assistant in one of the clinics connected with a medical college thirty 
years ago, when this subject was in its developmental stage, I had an 
opportunity to observe the work of two of the members of the hospital 
staff who were at the same time members of the surgical faculty of the 
college. 

One of these surgeons performed his operations in the hospital 
operating room, which was cleaned and disinfected with the most 
scrupulous care. Everyone in the operating room wore a sterilized 
gown and every possible precaution was taken to prevent air and 
contact injection. Before important operations the air was sprayed 
at times by means of an atomizer with 5 per cent, carbolic acid solution. 
The conditions, in other words, were quite as perfect for performing 
an aseptic or antiseptic operation as they are now in our modern 
hospitals. 

The other surgeon performed his operations in a public amphi- 
theater with five hundred seats, most of which were usually filled with 
students and practitioners. These surgical clinics were conducted 
three afternoons each week, while on the opposite days the same 
amphitheater was used by the professor of anatomy in the demon- 
strations upon the cadaver. 

The dissecting room was located in the story above the amphi- 
theater, and many of the students came directly from their dissections 
to the surgical clinic without stopping to change their clothing. 

Occasionally the amphitheater was swept and dusted. The floor of 
the operating pit and the surrounding woodwork were washed with 5 
per cent, carbolic acid before the operations, and everything that was 
likely to be touched by any one connected with the operation was 
covered with sterile sheets. During each month more than one 
hundred operations were performed in this operating room. The 
assistants and nurses, instruments, ligatures and sutures and supplies 
for both surgeons were supplied by the hospital and were identical. 
In the one case the wounds healed by primary intention almost without 
exception, not even a stitch abscess being present ; in the other instance 
absolutely aseptic healing was practically unheard of, there being at- 
the very best a few stitch abscesses. 

The surprising feature being that all of these infections occurred in 
the practice of the surgeon whose work was done in an ideally prepared 
operating room while none occurred in the dirty college clinic room. 

It is needless to state that when the surgeon who conducted the 
public clinic performed his private operations in the aseptic operating 
room in the hospital on the alternate days that the wounds made there 
also regularly healed by primary union. 

These observations were most convincing of the fact that there is 
no infection in surgical practice except contact infection, to which 
should be added infection from saliva thrown into the wound by 
speaking while facing the operation wound. 



ASEPTIC AND ANTISEPTIC TECHNIC 81 

The observation described above confirmed a similar observation 
I had made in two foreign clinics in which two gynecological surgeons 
were working in adjoining buildings. One of these operated in a large 
amphitheater open to all students and visitors ; these were not required 
to take any antiseptic precautions. The second clinic could be visited 
by only a few visitors each day and all had to be covered with sterile 
caps and gowns. The former I visited daily, the latter rarely, because 
special permits were difficult to obtain; but I visited the necropsy 
every morning, and to my amazement I never saw a cadaver that had 
been operated in the former clinic who had died from peritonitis during 
a period of two semesters, while the latter clinic furnished a con- 
siderable number of these cases, so much so that one morning when 
the old professor of pathology saw the professor of gynecology enter 
the necropsy while he was personally making the rounds, greeted his 
colleague with the enthusiastic exclamation, "Ah, Colleague! here we 
again have one of your wonderfully typical cases of peritonitis." This 
observation was made more than a third of a century ago and the inter- 
vening years have convinced me that the former surgeon did nothing 
which could cause contact infection because his attention was centered 
upon essentials while the patients of the second suffered because his 
attention was so thoroughly filled with many non-essential details 
that in some way he overlooked some element which resulted in contact 
infection. 

There can be no doubt but that practically in every case of infection 
the microorganisms determining the kind of infection were placed in 
the wound by some object which in turn had come in contact with 
infectious material, and that if such conditions are established that this 
cannot happen, that then the wounds will remain aseptic. 

A most perfect system has been developed, for example, by Sir 
Arbuthnot Lane in connection with his operations upon bones. In 
these operations the following procedure is employed: (1) All instru- 
ments, sponges, ligatures, sutures and dressings are prepared so that 
they are absolutely sterile. The surgeon's hands are covered with 
sterile rubber gloves. The skin is rendered sterile so far as this is 
possible. After the primary incision through the skin, its edges are 
covered with sterile towels fastened in place by means of suitable clamps 
in order to prevent infection of the wound by transfering staphylococci 
which had not been removed from the skin at the time of its disinfec- 
tion. The knife with which the skin incision was made is then laid 
aside, and from this time on no one except the operator touches 
either instruments or wound except with instruments or sterile 
sponges. 

In this manner infection can be prevented with certainty. There 
is no reason why most of the other operations could not be done 
according to this perfect system although this is not necessary in most 
cases because primary healing of wounds occurs regularly if every one 
connected with the operation is surgically clean. It is, however, far 
better to err on the safe side than to expose the patient to even a slight 

VOL. I 6 



82 ASEPTIC AND ANTISEPTIC TECHNIC 

infection by overlooking any detail. The following bacteria give rise 
to infection of wounds: 

1. The pyogenic cocci. 

Staphylococcus pyogenes aureus. 
Staphylococcus pyogenes citreus. 
Staphylococcus epidermidis albus. 

2. Streptococcus pyogenes. 
Streptococcus hemolyticus. 

3. Bacillus coli communis. 

4. Bacillus pyocyaneus, produces bluish green pus. 

5. Pneumococci. 

Other bacteria occasionally found in suppurating wounds. 

Bacillus typhosus. 

Micrococcus tetragenus. 

Bacillus diphtherise; Klebs-Loeffler bacillus. 

Gonococci. 

Bacillus of tetanus. 
Gas Gangrene: 
B. aerogenes capsulatus; B. welchii. 

Vibrion Septique. 

Bacillus edematicus; bacillus of malignant edema. 
Of these the Staphylococcus aureus and albus are the most common 
and at the same time the least harmful; the latter of these is almost 
universally found in healthy skin, frequently located too deeply to be 
reached and destroyed by the antiseptics commonly in use for disin- 
fecting the field of operation. One is consequently likely to carry 
some of these bacteria into the wound from the exposed wound edges 
unless the wound itself is protected by fastening aseptic towels along 
the skin edge of the wound before manipulating the deeper tissues. 

As a matter of fact, wound infection during the operation is almost 
always due to the fact that some one person connected with the 
handling of the wound or some of the articles coming in contact with 
it does not give his undivided attention to the work in hand. An 
excellent illustration to prove this theory can be found in the fact 
that whenever some new method is on trial at any hospital so that 
the interest and attention of the entire staff is centered upon the details 
of the operations, one is sure to find an absence of infection, while 
slight infections will again occur after the interest has worn off. 

The tissues, are, however, capable of disposing of a considerable 
number of microorganisms, providing favorable conditions are estab- 
lished while under unfavorable conditions the same number of 
microorganisms will give rise to stitch abscesses or more serious 
complications. 

The conditions which favor infection due to a number of micro- 
organisms which would not ordinarily cause trouble are: (1) the 
presence of dead space; (2) blood clots; (3) traumatism of tissues; 
(4) drawing of sutures too tightly; (5) grasping large portions of tissues 
at bleeding points and tying ligatures around these too tightly; (6) 



TECH 'N 1C Of ASEPTIC OPERATION 83 

tissues poorly supplied with blood; (7) bandages applied too tightly 
interfering with circulation; (8) ragged edges of wounds; (9) carelessly 
placed drainage tubes or gauze tampons interfering with the circulation; 
(10) badly planned skin flaps. 

Ordinarily portions of the body which are especially well supplied 
with blood show great resistance against infection. Among these we 
may enumerate the tissues of the face, especially the lips and cheeks 
and the tongue. The peritoneum is very resistant to infection; this 
is also true of the mucous membranes. Whenever there is accumu- 
lation in a cavity lined with mucous membrane such as the urinary 
bladder, the pelvis of the kidney or the gall-bladder, the mucous mem- 
brane becomes infected. This is also true of the serous membranes 
of the joints. Willems has shown that if open infected joints are 
moved actively or passively every two hours, the synovial membrane 
will recover because this will prevent an accumulation of septic fluid; 
on the other hand, if the same joint is held quiet so that the fluid 
can accumulate there will be a destructive inflammation. 

Medullary tissue of the bone is very susceptible to infection. This 
is also true of loose connective and adipose tissue. 

The condition of the patient affects the susceptibility to infection. 
The following classes of patients lack resistance: 

1. Patients exhausted from fatigue or exposure to cold and wet. 

2. Diabetics and nephritics. 

3. Those weakened from disease. 

4. Those weakened from intemperance. 

5. Those weakened from extreme old age. 

TECHNIC OF ASEPTIC OPERATION. 

In my practice aseptic surgery was substituted for antiseptic surgery 
in the year 1888 as a result of the following observation: 

On the same day my chief, Professor Charles T. Parkes, operated 
upon a number of patients, among them three in whom he performed 
abdominal sections and one in whom he made a complete removal 
of the breast. As chief of his clinic I had superintended all of the 
antiseptic preparations and directed every detail, so far as handling of 
instruments, sponges, sutures, ligatures and antiseptic solutions were 
concerned. 

The abdominal wounds healed without a drop of pus while the 
breast wound showed a considerable amount of irritation, which, 
however, subsided shortly. This difference in the action of wounds 
made under the same careful supervision attracted my attention 
and resulted in a careful review of each step of the operations, and 
this resulted in the discovery that the only difference in the methods 
applied consisted in the fact that the breast wound had been carefully 
irrigated with a solution of corrosive sublimate, which could, of course, 
not be applied to the abdominal wounds. 

A further examination of previously operated cases showed that in 



84 ASEPTIC AND ANTISEPTIC TECHNIC 

a very large number of abdominal sections we had experienced no 
infections, all wounds having healed in an absolutely aseptic manner, 
while in the other wounds we had observed some disturbance in a few 
cases. 

Abandoning the use of antiseptic material in all clean wounds the 
healing immediately became uniformly perfect. We continued the 
use of antiseptics in presumably infected wounds, probably to the 
detriment of the patient, because as we have abandoned this practice, 
our results became more and more satisfactory. 

Our present method of treating infected wounds is fully discussed 
in the section on Military Surgery, so it need not be repeated here; 
suffice it to say that before the war for a number of years our faith in 
the value of antiseptic substances had dwindled down to a kind of 
superstitious belief that there is some virtue in tincture of iodin which 
we apply in the preparation of the skin in the field of operation and in 
the treatment of compound fractures. Dakin's solution and dichlora- 
mine-T we have adopted during the war. The application of these 
antiseptic substances have been described elsewhere in this work. 

Preparation of Hands. The first important point to be borne in 
mind regarding the preparation of the hands of surgeon, assistant and 
nurse refers to general cleanliness. 

The hands should be kept away from unclean materials. A surgeon 
who is careless about handling unclean things is much more likely to 
be a carrier of microorganisms than one who is habitually clean. 

Again, it is important to keep one's hands covered with smooth 
non-irritated skin which will shed dirt more easily than a roughened 
skin. If any particular substance causes an irritation of the surgeon's 
skin that substance should be discarded permanently, because of all 
the substances in use there is not a single one that is indispensable. 
This can be easily proved by the fact that if a surgeon washes his 
hands carefully with soap and sterile water and does not use a single 
one of the many antiseptic substances that have been lauded, his 
wounds will heal without infection, provided he eliminates all other 
sources of contact infection. 

We have proved this fact in a large number of consecutive cases. 

Still almost every surgeon has some special antiseptic lotion which 
he has used for a long time and in which he has a kind of faith akin to 
superstition, and whose systematic use gives him a feeling that he has 
done his utmost, a kind of virtuous feeling. So long as the substance 
is quite harmless it seems entirely proper to continue its use indefinitely. 

It is certainly important that the surgeon develop an antiseptic 
conscience, and it is quite important to develop a degree of enthusiasm 
upon this subject in everyone connected with making of wounds and 
caring for them, and it seems necessary to have some superstition or 
other to maintain the necessary attention, concentration and enthu- 
siasm. 

The important points in rendering the hands aseptic consists in 
careful washing, preferably first in a deep basin filled with warm water, 



TECH NIC OF ASEPTIC OPERATION 85 

with the use of a soft cloth and an abundance of green soap. We have 
found that the skin becomes clean much more rapidly when the hands 
are scrubbed in this manner under water than when this is done under 
the stream of a faucet. 

After the hands have been thoroughly washed in this manner the 
nails are cleaned with a blunt-pointed instrument and then these are 
brushed thoroughly with a soft brush under water. The forearms 
should be washed to a point above the elbows in the same manner. 
The forearms and hands are then washed under a stream of sterile 
water, in order to wash away the soap. After this has been done it 
does not matter what further steps are taken so long as the substance 
used does not harm the skin. Alcohol is probably as desirable as any 
substance, because it dissolves any fatty substance which may not 
have been dissolved by the soap. A solution of 1 to 2000 of bichloride 
of mercury in water may be employed safely unless the skin is sensitive 
to this solution, which is the case only very rarely. A J per cent, of 
formalin in water may be used, but this is exceedingly irritating to 
the skin in many cases. 

It is important that the hands be washed thoroughly. Of course, 
an active person can clean his hands as thoroughly in one-tenth of the 
time that it will require a phlegmatic, slow moving person to accom- 
plish the same end, but it may be well, in a surgical clinic, to have a 
regular time of at least five minutes to be devoted to preparing the 
hands before operations. During the time consumed in doing this the 
person's attention should be directed upon the result to be accom- 
plished. Too often too little attention is given to this, and the matter 
of preparing the hands proceeds as a kind of ceremony instead of making 
it an important matter of business. 

In case the surgeon's hands become rough or irritated it is practically 
always possible to determine the cause of this irritation. It is usually 
best, under this condition, to have the surgeon take a vacation from 
his work in order to permit the skin to become quite normal. Upon 
resuming his work he should use only soap and sterile water for a 
number of days. Then if the skin shows irritation he should discard 
the use of the kind of soap he is using and should use only pure castile 
soap, which is made of vegetable fats, such as olive oil, and which 
practically never causes irritation. 

If the soap and water do not cause any irritation of the skin he should 
use only one other substance for a period of a month, preferably grain 
alcohol. If this causes irritation it should be discarded, if not any 
other substance desired may be added for the next month. In this 
manner the irritating substance can be readily discovered and none of 
these substances are necessary and may be discarded without causing 
any harm. 

It is well to bear in mind that the denatured alcohol in the market 
at the present time may contain some irritating substance which has 
been introduced for the purpose of changing pure alcohol into the 
denatured product. 



86 ASEPTIC AND ANTISEPTIC TECHNIC 

The most common of these substances are formaldehyde and some 
of the coal-tar products. Camphor is the least irritating substance, 
which is in common use for the purpose of producing denatured alcohol. 

Rubber Gloves. It is important to disinfect the hands with exactly 
the same care whether or not rubber gloves are used because a tear 
may occur in the glove or the necessity may arise for the removal of 
the glove during the operation, in order to increase the acute sense of 
touch, and in either case, if the hands were not absolutely clean, an 
infection might result. 

Ordinarily an operation can be performed nearly as rapidly and as 
well if the surgeon's hands are covered with gloves, and as these can 
be thoroughly disinfected by boiling, they are, of course, readily ren- 
dered absolutely sterile. 

There is an advantage in the use of rubber gloves which is not fully 
appreciated. The surgeon is much more likely to tie his ligatures and 
sutures tightly enough to cause pressure necrosis, working with bare 
fingers because the gloves cause the ligature iff slip while tying, giving 
the patient the additional protection against too tight sutures and 
ligatures. 

It is of special importance always to wear gloves in operating upon 
patients with infected wounds and in dressing infected wounds. 

In the latter case it is well, even if gloves are being worn, to handle 
all infected substances with forceps, because it establishes the habit 
of keeping one s hands out of unclean substances, and it is specially 
important to have the assistants and nurses to become habitually 
clean. 

Everyone should habitually remain clean before, during and after 
operations and dressings and at all other times, and when accidentally 
the hands are soiled, they should be rendered surgically clean at once 
during operations or dressings, and as nearly as possible so at all 
other times. 

It has been proved, by means of a long and carefully carried out 
series of experiments by Sprengel, that sterile gloves on the surgeon's 
hands which have come in contact with pus can be rendered sterile 
again by simple washing with hot water while still on the hands of 
the surgeon. The knowledge of this fact may serve to save time, 
for the patient occasionally, when a few minutes wasted, may be of 
importance, but, as a rule, it is such a simple matter to change the 
soiled gloves for clean ones that this plan should be preferred. 

Disinfection of Skin Preliminary to Operation. Before every opera- 
tion if his condition permits it is well to give the patient a warm 
tub bath, using a good quality of soap and a large soft wash cloth 
made out of Turkish towelling, because in this way the loose epi- 
dermis and the excretions from the sebaceous glands of the skin can 
be removed. 

Two precautions should be taken, however: (1) the bath tub should 
be thoroughly scrubbed with soap or some cleaning powder and hot 
water and then with some disinfectant, preferably with J per cent. 



TECH NIC OF ASEPTIC OPERATION 87 

solution of formalin in water, because if this or some similar plan is 
not carried out bath tubs are likely to become a source of infection. 
As a further precaution the nurse who prepares the bath should be 
instructed invariably to run boiling water into the tub until a sufficient 
amount has accumulated approximately to give the bath a proper tem- 
perature after cold water has been added. The hot water should remain 
in contact with the tub for several minutes before the cold water is 
added. 

A second precaution should be borne in mind, namely, that it is not 
safe for patients who are accustomed to wearing woollen undergar- 
ments and woollen night garments to be placed in what in some 
stupidly conducted institutions are known as regulation sterile garments 
for surgical cases. The patient should be placed in clean underclothing 
of the type to which he has been accustomed; these need simply be 
freshly laundried, but need not be surgical aseptic. 

Many so-called ether pneumonias undoubtedly result from neglect- 
ing this precaution or from failing to protect the patient properly when 
transported to or from operating rooms and during the time taken to 
perform the operation. 

The day before the operation it is well to wash the field of operation 
and a large area surrounding the field with soap and warm water, 
preferably using a large piece of sterile gauze as a wash cloth. It is 
usually well to shave this entire surface at the same time and then to 
wash it with alcohol and to apply a sterile dressing in a manner to 
prevent the patient from touching the surface. 

This can also be postponed until the patient is taken to the operating 
room. In this case, however, it is better to wash the entire surface with 
benzine first, then to dry it perfectly, permitting all of the benzine to 
evaporate, then to wash with alcohol and then to apply a mixture of 
tincture of iodin, U. S. P., and grain alcohol in equal parts to the sur- 
face, which should be permitted to dry before the operation is begun. 

Another simpler method which has given equally satisfactory results 
consists in simply washing the field of operation with soap and warm 
water immediately before the patient is taken to the operating room 
and then washing the field of operation and the surrounding areas with 
benzine very carefully, and drying the surface in order to prevent irri- 
tation from the benzine, and then to paint the entire surface with the 
tincture of iodin and alcohol mixture described above. There is some 
danger of blistering of the skin especially if the second method described 
has been used, but if one is careful to dry the surface and to prevent the 
benzine from running into any creases of the skin, or to moisten the 
sheet underneath the patient, there is little danger from this source. 

We have, however, abandoned the use of benzine and soap and water 
at the same time, and have simply, of late, in cases which for any 
reason could not receive any preliminary preparation on the day pre- 
ceding the operation, washed the surface with benzine, then shaved the 
surface dry, then again washed it with benzine and then we have 
applied the tincture of iodin and alcohol mixture immediately before 
beginning the operation. 



.. f 



88 ASEPTIC AND ANTISEPTIC TECHNIC 

Disinfection of Instruments. All instruments after being used 
should be carefully washed with a brush in lukewarm water and soap. 
It is best not to use cold water, because this is likely to roughen the 
nurses' hands, neither should hot water be used, because this will 
coagulate the blood on the instruments and will make the washing more 
difficult. 

Instruments should never be permitted to stand in water, because 
this causes rusting. 

After washing the instruments they should be boiled for one-half 
hour in water to which half an ounce of bicarbonate of soda in the form 
of ordinary baking soda has been added to the gallon of water. This 
will prevent rusting. They should be dried out of the hot water and 
placed in a case protected from dust. Before using these instruments 
again they should be boiled again in the same alkaline solution for 
two to five minutes. 

Knives and scissors should be washed with special care then carefully 
wiped with 95 per cent, alcohol and then Soiled for two minutes. 
Long-continued boiling oxidizes the sharp edge of the instruments. 
The precaution should be taken never to lay down soiled knives or 
scissors without having wiped them clean with a moist, gauze sponge. 
This can be done without loss of time during operation. Instruments 
will be improved if rubbed with liquid paraffin when put away. 

Preparation of an Operating Room. Ideal temperature is 80 F. 
Close all windows and keep closed during operation. Disinfect 
floors, tables, stands, etc., with phenol, solution of 5 per cent., or 
formaldehyde solution | per cent. Dust carefully electric lights and 
doors with moist cloth. Cover radiators with sheets. Place sterile 
scrub basins, soap, brushes and nail cleaner in scrub stands. Bring 
in all necessary supplies, such as linen, solutions, etc., to be used during 
day's operation. 

After-care of Operating Room. Ventilate well by opening all windows 
Remove all supplies. Wash all stands, tables, windowsills, etc., with 
soap and water, to which ammonia has been added. The floor is 
mopped with an antiseptic solution after scrubbing with soap and 
water. 

Instruments. Wash in lukewarm water, as hot water coagulates 
blood. All instruments, with the exception of those having cutting 
edges, should sterilize at least twenty minutes. Needles and scissors 
are sterilized five minutes only, to prevent cutting edge from becoming 
dull. To prevent instruments from rusting and also to soften water 
add sodium bicarbonate, 1 per cent. Instruments from septic oper- 
ations must be taken care of separately. Use distilled water for 
sterilizing instruments whenever possible. 

Disinfection of Catheters. Rubber catheters to be boiled for ten 
minutes only. Filiform bougies, silk catheters and hard-rubber cath- 
eters are washed thoroughly with green soap and then with a saturated 
boric acid solution, then suspended in tall glass jars in the fumes of 
formaldehyde, produced by pouring formaline upon cotton placed in 



TECH NIC OF ASEPTIC OPERATION 89 

the bottom of the jars. Ordinary catheters (rubber) can be preserved 
dry or suspended in the same manner. 

Directions for Preparing Catgut. Unchromicized Catgut. (a) Keep 
in ether in a tightly stoppered bottle for thirty days. Shake con- 
tainer daily. Change the ether at the end of the first fifteen days. 

(6) Keep in the following solution for one month, transferring to 
another jar. Alcohol, 95 per cent., 1 ounce; bichloride of mercury, 
1 grain. At the end of thirty days transfer to alcohol, 95 per cent. 

(c) Storage Solution. Iodized solution. Can be kept in this solution 
indefinitely. lodoform powder, 1 ounce; ether, 5 ounces; alcohol, 
14 ounces. As solution evaporates add ether until all iodoform powder 
at the bottom of the jar has been dissolved. 

Chromicized Catgut. In ether for thirty days, changing at the end 
of the fifteenth day. Shake container daily. 

Solution A. 

(a) To mix chromic acid solution for catgut: Chromic acid, one 
part; distilled water, five parts, dissolve carefully. 

Solution B. 

(b) Take solution A, one part; glycerin, sterile, five parts. 
NOTE. Pour solution A into solution B, slowly stirring all the 

time. 

(c) Take solution B and soak catgut from twenty-four to thirty-six 
hours, according to resistance desired. Twenty-four hours resist ab- 
sorption for seven to fifteen days. Thirty-six hours resist absorption 
for fifteen to twenty-five days. 

(d) Take catgut out of solution B, rinse quickly in sterile water to 
free from the chromic acid solution. Stretch and rub quickly with a 
hard, sterile towel. Wind on glass rods or slides and preserve in the 
following for thirty days: carbolic solution, 95 per cent., one part; 
glycerin (sterile), five parts. 

(e) At the end of thirty days keep in a storage of iodized solution. 
Preparation of Silkworm Gut. Place in coils by winding four 

strands around two fingers and twisting ends around the coil three 
times. Place coils in a piece of gauze, attaching a forceps and sterilize 
for forty-five minutes. Preserve in the following solutions for: Bi- 
chloride of mercury, 1 to 2000; phenol solution, 5 per cent. Purchase 
hard-twisted sewing machine silk, as it is the strongest made. 

Preparation of Horsehair. 1. Scrub thoroughly with green soap 
and hot water. This should be done away from the operating room as 
horsehair may contain tetanus bacilli. 

2. Boil for sixty minutes in a 1 per cent, sodium bicarbonate solution. 

3. Change the water and allow to boil for another ten minutes. 

4. Immerse in ether for twenty-four hours to remove fat. 

5. Wind in coils of four strands each and for final sterilization boil 
fortv-five minutes. 



90 ASEPTIC AND ANTISEPTIC TECHNIC 

6. Preserve in any of the following solutions: Bichloride of mercury, 
1 to 2000; carbolic acid, 5 per cent.; alcohol, 95 per cent. 

Preparation of Gutta-percha. 1. Cut gutta-percha into squares 
6x6. 

2. Disinfect a glass table porcelain tray or platter. 

3. Take a square piece of the rubber protective and place it smoothly 
on the surface. 

4. Have in readiness a basin of cold water (sterile), green soap, 
bichloride of mercury, 1 to 500, and a phenol solution, 5 per cent. 

5. Scrub up hands surgically clean and wear sterile gloves. 

6. Scrub tissue well on both sides with brush and green soap. 

7. Place in a basin of cold sterile water. 

8. Then transfer to basin of bichloride of mercury, 1 to 500, to 
remain twenty minutes. 

9. Then transfer to basin of phenol solution, 5 per cent., for another 
twenty minutes. 

10. Change gloves to another sterile pair. 

11. Place protective between folds of gauze and keep in a storage 
solution of boric acid, 4 per cent. 

12. Cigarette drains must be handled carefully, as they tear easily. 

13. Make up not more than two dozen at one time. 
Preparation of Rubber Tubing. 1. Scrub well with green soap and 

water to remove all white coating that is present. 

2. Boil for ten minutes in a 1 per cent, sodium bicarbonate solution. 

3. Scrub again if any of the white coating remains. 

4. Roll in a coil and place in a jar of cold water and allow to sterilize 
by boiling for forty-five minutes. 

5. Preserve in alcohol, 95 per cent.; bichloride of mercury, 1 to 
1000; formalin solution, 1 to 1000. 

6. Resterilize and change the solution once weekly. 

NOTE. All glass drainage tubes are taken care of in the same 
manner. 

Bartlett's Method of Preparing Catgut. 1. The strands are cut into 
convenient lengths, say thirty inches, and made into little coils about 
as large as a silver quarter. These coils in any desired number are then 
strung like beads onto a thread so that the whole quantity can be 
conveniently handled by simply grasping the thread. 

2. The strings of catgut coils are dried for four hours at the following 
temperatures: 160, 180, 200, 220, one hour each, the changes in 
temperature being gradually accomplished. 

3. The catgut is placed in liquid albolene, where it is allowed to 
remain until perfectly "clear," in the sense that the term is used in the 
preparation of histological specimens. This is usually accomplished 
in a few hours, though it has been my custom to allow the gut to 
remain in the oil overnight. 

4. The vessel containing the oil is placed upon a sand-bath and the 
temperature raised during one hour to 320 R, which temperature is 
maintained for a second hour. 



DISINFECTION OF SURGICAL DRESSINGS 91 

5. By seizing the thread with a sterile forceps the catgut is lifted 
out of the oil and placed in a mixture of iodin crystals, one part in 
Columbian spirits (deodorized methyl alcohol), one thousand parts. 
In this fluid it is stored permanently and is ready for use in twenty-four 
hours; the thread is then cut and withdrawn. 

DISINFECTION OF SURGICAL DRESSINGS. 

Manufacturers have produced many high-pressure steam sterilizers 
for the disinfection of surgical dressings, which are thoroughly reliable. 

It is necessary only to place the dressings to be sterilized in suitable 
containers and to carry out the directions which come with the sterilizer 
in use in order to secure perfectly sterilized dressings. 

The dressings should be handled with the greatest care, to guard 
against contamination at all times, because persons who are careless 
in the manipulation of dressing material before sterilization are not 
likely to use the necessary care of the same materials after sterilization 
has been accomplished. 

It is important to place the various articles in convenient bundles 
in order to reduce the likelihood of contamination as well as to reduce 
unnecessary waste. 

Gauze pads should be carefully folded in case they are to be used 
for sponges, or for tampons or for pads to be used in performing 
abdominal sections, in order to prevent the ra veilings from remaining 
in the wound. 

The pads should be placed in uniform bundles and these folded in 
pieces of muslin or in towels folded so as to completely protect the 
contents against contact infection. The cover should be held in place 
by means of pins, and the size, number and kind of dressing should be 
noted on the cover by means of a lead-pencil, which will not be erased 
during the process of sterilization. 

These bundles are then packed loosely into a metal container so 
constructed that it does not interfere with the steam being forced 
through the dressings. 

It is wise to place a glass tube containing substances which change 
color upon being heated to 100 C. in the center of the bundles, in order 
to be certain that all portions of the package have been touched with 
live steam. 

Half an hour will suffice to sterilize surgical dressings in an apparatus 
containing high-pressure superheated steam, but it is better to leave the 
dressings in the sterilizer at least one hour and then to turn off the 
steam and permit the heat of the apparatus to accomplish thorough 
drying of the dressings. 

The same method will suffice for the sterilization of towels, gowns 
and operating suits. 

These should also be placed in bundles and covered with muslin 
covers or they may be placed in muslin bags properly labelled and 
passed through the sterilizer. 



92 ASEPTIC AND ANTISEPTIC TECHNIC 

Resterilizing Used Dressings. Before the great war many hospitals 
destroyed all dressings after they had been once used. This resulted 
in an enormous waste of material, but for the sake of being absolutely 
safe, and because in most instances the cost did not fall upon the 
person who wasted the material, little attention was paid to the possi- 
bility of eliminating this item of waste. 

During and since the war many hospitals have proved the safety 
and the economy of resterilized dressings. 

Usually only dressings which have not been directly soiled with pus 
are resterilized. These dressings are first washed with cold water until 
they are free from blood, then they are boiled for half an hour in a 
steam laundry machine, in which the water is kept at the boiling-point 
by the forcing of live steam through the apparatus for half an hour. 

Then the dressings are placed in a centrifugal drier, which removes 
the greater portion of the water. They are then placed in a drier 
heated to a high temperature by means of iron tubes carrying super- 
heated steam. Then these dressings are sterilized on two or three 
successive days, according to the method described above. This 
method is known as fractional sterilization. The method is safe even 
if dressings are resterilized which have been saturated with pus during 
their previous use, but it does not seem wise to save such dressings for 
fear of harm coming through carelessness on the part of some member 
of the personnel. 

In institutions in which resterilization is practised it is wise to pur- 
chase a good quality of gauze, because this can be resterilized many 
times while the poorer qualities speedily become stringy and useless. 

Of course, the muslin covers used to protect dressings, towels, 
aprons, etc., must be sterilized with the same care as their contents, 
although this is not necessary theoretically, because these are sub- 
jected to the sterilization each time their contents undergo this process; 
but the nurse or other person preparing dressings should not handle 
anything which has been used in the operating room unless it has 
previously passed through the laundry except the material be new and 
have not come in contact with anything which might cause contami- 
nation. 



ANESTHETICS AND ANESTHESIA. 



BY E. R. SCHMIDT, B.A., M.D. 

Introduction. From the earliest practice of the medical art, the 
relief of pain has been one of the principal efforts of the physician. 
His primitive attempts varied from the inhalation of fumes to the 
use of weird incantations and hypnotic spells. These eventually led 
him to the discovery of ether, chloroform and nitrous oxide gas. To 
this trio more recent years have added a variety of other more or less 
efficient anesthetics by which the field and scope of anesthesia have 
been steadily enlarged until today they have become an essential 
factor in surgery. Under their benign influence not only has incalcul- 
able human suffering been alleviated, but the science and skill of the 
modern surgeon has mounted to its present high level. 

With the discovery of ether, chloroform and nitrous oxide, general 
anesthesia was established. Ether has enjoyed a much wider use than 
any other single anesthetic. Chloroform was much more popular in 
England and on the continent, than in the United States; however, 
there has been a decline in its use abroad and ether has been substituted. 
The reason for the employment of chloroform in the United States 
is explained by the fact that students are generally taught that it is 
the anesthetic of choice in obstetrical practice, and having thus become 
accustomed to its use they are disposed to continue it in their general 
surgery. However, the fact that our medical schools are insisting upon 
a year's internship in some good hospital will undoubtedly reduce the 
amount of chloroform employed. 

With the work of Reclus local anesthesia had its beginning. It 
rather slowly won its way at first, but during the last two decades 
improved methods of administration have added greatly to its popu- 
larity and enlarged its sphere of usefulness. In skilled hands local 
anesthesia will suffice for almost any operation. 

The results of the War on anesthesia have not been marked. Local 
anesthesia has been used with greater freedom. There have been 
some new appliances developed for the administration, suitable for 
emergency work and under the circumstances that existed, but whether 
they will find a place in civil practice is yet to be seen. 

GENERAL ANESTHETICS. 

Anesthetics are for general or local effect and their combined use 
is not unusual in modern practice. General anesthesia is a state of 
unconsciousness, with more or less complete loss of the perception of 

(93) 



94 ANESTHETICS AND ANESTHESIA 

pain and relaxation of the voluntary musculature, produced by the 
inhalation of ether, chloroform or nitrous oxide gas. Each of these 
anesthetics differs slightly from the others in its effect. It is a well- 
known fact that nitrous oxide and oxygen do not cause the complete 
relaxation of the voluntary musculature that attends the adminis- 
tration of ether or chloroform. This is especially noticeable in abdom- 
inal operations, and in setting fractures. 

Ether. Ether is volatile and inflammable, and the vapors, which 
are about two and a half times as heavy as air, are dangerously explosive 
when mixed with air. It is soluble in water (1 to 10) and readily 
soluble in alcohol. It is the anesthetic par excellence, and its use is more 
general than that of any other anesthetic agent. In using ether, one 
must be certain that it contains as few impurities as possible. Some 
of these impurities are alcohols, peroxide, aldehydes, acids and fusel 
oil. These with the exception of alcohol increase the irritation to the 
mucous membrane of the respiratory tract. It is impossible to test 
each package before using it, but it is possible to obtain ether free 
from these impurities from a reliable chemical manufacturer. How- 
ever, the fact that it has been obtained from a reliable firm does not 
indicate that no attention need be paid to the ether. One must always 
be guided by the results. The amount used, the course of the anesthesia 
and the after-effects, such as nausea and gas pains, are a good index 
to its value. 

Ether depresses all parts of the central nervous system, causing loss 
of sensation, loss of consciousness and abolition of the reflexes. The 
vital centers of the medulla are involved very late in the poisoning, 
making its use much safer than that of any other anesthetic. The 
respiration is affected first. Later there is a depression of the vaso- 
motor center and consequent fall of blood-pressure. Ether does not 
produce a marked effect on the heart. Its first action is a moderate 
reflex stimulation, but in poisonous doses it depresses the heart. 

The irritating action of the ether vapor on the mucous membrane 
of the respiratory tract and on the kidneys is a well-known fact. With 
the careful administration, that prevents an over-concentration of the 
vapor, this irritating action on the respiratory tract can be reduced a 
good deal, and also by using as small an amount as possible the renal 
irritation will be lessened if not avoided. 

Chloroform. Chloroform is a heavy, clear, colorless and mobile 
liquid, of a characteristic odor and a burning, sweetish taste. It is but 
slightly soluble in water (1 to 200), but is miscible in all proportions 
with alcohol. It rapidly deteriorates under the influence of heat, 
light, and air. Hence it should be stored in a cool, dark place, in well- 
stoppered brown bottles. 

Under chloroform the anesthetic state is more dangerous than with 
ether, as there is a gradual, but progressive, fall of blood-pressure 
even if the administration is carefully managed. The fall is due to 
depression of both the cardiac muscle and the vasomotor center. The 
respiratory center is also depressed, but later than the vasomotor 



GENERAL ANESTHETICS 95 

center and the cardiac muscle, so that if respiration ceases, resusci- 
tation is more difficult than when a like accident occurs under ether. 

The irritant action on the kidneys and mucous membrane of the 
respiratory tract is about the same as with ether. There may be a 
delayed poisoning, due to prolonged administration, which may occur 
several days later. This produces a fatty degeneration, especially in 
the liver. The irritant action of chloroform is especially marked in the 
first stage, when most of the fatalities occur. The use of morphin 
and atropin preliminary to the anesthesia reduces this danger. 

Ethyl Chloride. Ethyl chloride was first used by Hegfelder in 1848. 
It is a colorless, volatile liquid, having an agreeable odor and a sweetish, 
burning taste. It induces anesthesia promptly, but, like chloroform, 
the danger of stoppage of the heart and the depression of the vital 
centers limit its use. 

The pulse and respiration are at first accelerated, but when the 
stage of anesthesia is reached they should be normal. The induction 
is rapid, usually two or three minutes sufficing. There is very little 
excitement. Muscular relaxation is not as complete as with ether or 
chloroform. Too concentrated vapor is dangerous, as respiration may 
cease and the diaphragm go into a state of spasm. Prolonged adminis- 
tration lowers blood-pressure, causes cyanosis and asphyxia, and may 
produce death from respiratory failure. 

Its use as an anesthetic is safer than that of chloroform but not as 
safe as ether. For short operations it is a quick and pleasant anesthetic. 

Nitrous Oxide and Oxygen. Nitrous oxide has been used alone as an 
anesthetic, but in combination with oxygen it has become much more 
popular. Nitrous oxide is a colorless gas. It has a pleasant odor and 
a sweetish taste. It should contain 95 per cent. N 2 and no solids, 
other oxides of nitrogen or organic matter. It is stored in steel cylinders 
of various sizes in which it has been liquefied under pressure. 

The anesthesia induced is rapid and pleasant. There are no definite 
stages, as in ether and chloroform, and the patient passes quite rapidly 
into a state of surgical anesthesia. By varying the amount of nitrous 
oxide and oxygen given, the depth of the anesthesia can be regulated. 
The elimination through the lungs is quite rapid, so that a patient 
deep in anesthesia will soon awaken if given oxygen or air. The per- 
centage of nitrous oxide is gradually increased from 2 or 3 per cent, at 
the beginning to 10 per cent, as the case may demand. The longer the 
anesthesia lasts the greater should be the percentage of oxygen. 

The muscular relaxation in nitrous oxide and oxygen anesthesia is 
not as complete as with ether or chloroform, hence it is less desirable 
for abdominal or fracture work. Crile believes that it produces less 
shock, less nausea, and less lowering of vital resistance to infection 
than does ether. 

The administration of morphin previous to the anesthetic, or using 
ether with the nitrous oxide and oxygen, will aid in procuring muscular 
relaxation. 



96 ANESTHETICS AND ANESTHESIA 

The striking phenomena during its administration are asphyxia, 
stertorous respiration, cyanosis and even convulsions, dilatation of the 
pupils, rapidity of the heart, and swelling of the tongue. 1 Slowness 
of the heart is a danger sign. If nitrous oxide causes death, it does so 
by asphyxia, or by asphyxia and cardiac inhibition. 

Mixtures. Mixtures were introduced in an effort to reduce the mor- 
tality due to ether and chloroform. Schleich said that the further the 
boiling-point of an anesthetic was below the human temperature the 
less could be introduced into the body by inhalation. With the boiling- 
point about 98.5 F. the lungs can regulate the elimination, so that 
about as much is exhaled as is inhaled. When the boiling-point is about 
149 F., as in the case of chloroform, more is inhaled than is exhaled 
and anesthesia is rapid; an excess is readily accumulated, so attempts 
were made to secure mixtures with a boiling-point that would give an 
ideal anesthetic. 

Ether and Chloroform. These may be used in varying proportions. 
Hewitt employs a mixture of two parts of chforoform and three parts 
of ether. Three parts of ether and one part of chloroform, constitute 
the Vienna mixture. 

Alcohol and Chloroform. By adding alcohol to the chloroform, 
Sansome thinks the evaporation of the chloroform is reduced, and, as a 
result, there is less concentration. One part of alcohol and four parts 
of chloroform are used. 

Alcohol, Chloroform and Ether. This may be used as a mixture of 
one part of alcohol, two parts of chloroform and three parts of ether. 
Its action is that of chloroform and ether. The materials do not evapo- 
rate at the same rate, so that one does not know how much of either 
the patient is inhaling. 

Billroth's mixture consists of one part of alcohol, one part of ether 
and three parts of chloroform. 

Schkich's Mixture. 

SOLUTION No. 1 (BY VOLUME). 

Chloroform 5is3 

Petroleum ether gss 

Sulphuric ether x gvi 

SOLUTION No. 2. 

Chloroform 5iss 

Petroleum ether 5ss 

Sulphuric ether gv 

SOLUTION No. 3. 

Chloroform . . . 5j 

Petroleum ether gss 

Sulphuric ether gij 

No. 1 is for light anesthesia, No. 2 for medium and No. 3 for deep 
anesthesia. Petroleum ether has no anesthetizing power. Meltzer 
has shown that it is dangerous and tends to paralyze the respiratory 
muscle. The use of mixtures has never gained a wide popularity. 

i Hewitt: British Med. Jour., February 18, 1899. 



GENERAL ANESTHETICS 97 

Preparation of the Patient for Anesthesia. An operation is just like 
a chain and the results that the surgeon obtains are dependent on the 
weakest link in his chain. Every patient should have preparation for 
an operation, and especially if a general anesthetic is to be given. In 
an emergency where there is immediate surgical intervention, this is 
oftentimes impossible. The preparation should not be too prolonged 
unless there is some special reason, as in a very toxic hyperthyroidism, 
where the preparation for operation may include preliminary treat- 
ment extending over some time. Prolonged preparation has a bad 
effect on the patient, as there is always an operation staring him in the 
face. 

The following routine has been found very successful at the Augus- 
tana clinic. A careful history and physical examination are made and 
recorded. The physical examination should be made the day before 
operation, so as to be certain that nothing new has developed. The 
urine is examined very carefully for albumin, sugar, diacetic acid, casts 
and blood. A red and white blood-count is made, the percentage of 
hemoglobin determined and the systolic and diastolic blood-pressure 
taken and recorded. The afternoon before the operation the patient is 
given a warm bath if the patient's condition permits it. In order to 
clean the gastro-intestinal tract, early in the afternoon preceding the 
operation, oleum ricini (two ounces), either in the foam of beer or 
orange-juice, is given. It is given early so that the effects of the 
cathartic will be over early in the evening and the patient secures a good 
night's rest. Of course, in acute abdominal conditions one should 
never give any cathartic. The following morning the patient receives 
a soapsuds enema. 

If the patient has been on a full or modified diet, the evening meal 
preceding the operation is limited to broth. The next morning no 
food is taken before the operation. If there is food in the stomach, 
or, in cases of obstruction, when there is liable to be some retention 
of food, the stomach is thoroughly washed out with water at a tempera- 
ture of 105 to 108 F. 

In operations that may be prolonged and in thyroidectomies, the 
patient receives morphin, grain J, and atropin, grain T -J~Q- one-half hour 
before commencing the anesthesia. This permits a prolonged adminis- 
tration of the anesthetic. Less of the anesthetic will be used and the 
patient will take it better. Also in alcoholic and very robust patients 
morphin and atropin aid the anesthetic. The fact that morphin and 
atropin have been administered to the patient should be recorded, so 
that the anesthetist is aware of it, as the pupillary reaction will be 
changed and less anesthetic will be necessary to keep the patient under. 

Anesthetist. The anesthetist should be a medical man if it is possible, 
or a carefully trained woman, preferably a nurse. The best anesthe- 
sias are conducted by women at the present time, because it is possible 
to select women with the highest degree of intelligence and judgment 
for this work, while medical men possessing these qualities can almost 
never be induced to elect anesthesia as a specialty. Unless the person 

VOL. I 7 



98 ANESTHETICS AND ANESTHESIA 

giving the anesthetic makes a profession of this work the anesthetic 
may be poorly given and the patient suffer as a consequence. 

Dr. Price defines an anesthetic as an agent by which the patient is 
carried to the edge of death and held there while the surgeon does his 
work. To accomplish this requires skill, knowledge and practice. 
There is no doubt but that a layman can learn to administer an anes- 
thetic, and in the majority of instances do it very well. While in France 
the author knew a medical corps sergeant who was able to procure 
excellent anesthesia with any kind of an anesthetic. He had adminis- 
tered anesthetics many thousand times and studied the subject thor- 
oughly from even' angle. But to give an anesthetic is only a part of 
the task. 

The personal bearing of the anesthetist, his confidence in himself, 
his method of preparing for work, help a great deal toward a successful 
anesthesia. The anesthetist must be able quickly to understand his 
patient. A young boy or girl must be differently handled from a man 
or woman. The patient must not be frighterfed. All these particulars 
noted and deftly handled by the anesthetist enhance the prospect of a 
good result. 

For emergency there should always be at hand a mouth gag, tongue 
forceps, artery forceps and gauze for wiping mucus out of the mouth. 
A towel or two should be convenient in case the patient vomits. A 
hypodermic, in working order, strychnin, brandy, camphorated oil 
and caffein citrate should be ready. A tank of oxygen, ready for admin- 
istration, should be accessible. It is a good plan, when using the open- 
drop method of inhalation, to have another dry mask in reserve. 

When women patients are being anesthetized a third person should 
be in the room. This is an invariable rule. It is a well-known fact 
that while receiving an anesthetic women may have erotic sensations, 
and on awakening have declared that they were raped. 

After the patient is asleep it is the duty of the anesthetist to carry 
the anesthesia along in a way to help the surgeon as much as possible. 
This means he must know the operation. For instance, when the 
abdomen is being opened, to prevent the intestines from protrud-. 
ing, thus increasing shock, the patient must be relaxed and asleep. 
Then he uses as little anesthetic as possible, just enough to keep the 
patient unconscious while the abdomen is closed and the dressing put on. 
The patient is now almost conscious. During this time he should be 
kept warm, and to avoid paralysis, the arms should be prevented 
from hanging over the edge of the table. The patient should be accom- 
panied by the anesthetist to his room and left in the care of a nurse. 

Methods of Administration of Anesthetics. Open-drop Method. 
This is the most commonly used method. By means of a wire mask 
covered with two layers of gauze, so that the vapors are not too dense, 
ether, chloroform and ethyl chloride and the various mixtures of alcohol, 
chloroform and ether can be administered. 

There are many masks on the market. A very satisfactory one 
is the Esmark mask. It is necessary that the mask when applied to 



GENERAL ANESTHETICS 99 

the face, covers the nose and mouth, that it fits the contour of the face 
snugly, and that on crossing the bridge of the nose there is no pressure. 
The gauze should not be too thick or else the vapor may become too 
dense and the patient will choke and struggle. One cannot say how 
thick the gauze should be, because of the difference of the mesh and 
texture of the gauze. A very good method is to take a small piece of 
stockinette, such as is used for plaster-of-Paris work, slip it over the 
frame and then adjust the frame. Take a small piece of surgical 
gauze and wind it around the edges, so that it will rest easier on the 
face. By varying the amount of ether dropped on the mask one can 
regulate the density of the vapor and the depth of the anesthesia. For 
each administration a dry piece of stockinette and a sterile frame are 
used. The stockinette can be sterilized and used many times. In 
order to protect the patient's face and eyes a drop of sterile oleum 
ricini is dropped in each eye and a piece of protective tissue, which has 
a V cut out of the middle, so that it fits over the bridge of the nose, is 
put over the eyes. 

Open-drop with Posture. In the clinic at the Augustana Hospital 
the open-drop method with posture has been used very successfully 
for many years. This is especially applicable to operations on the head 
and neck. The patient is thoroughly anesthetized in the prone position 
with ether by the open-drop inhalation method. Then the patient is 
taken into the operating room and the head of the operating table is 
elevated about 35 degrees. The patient will remain in a state of surgi- 
cal anesthesia for from one-half to three-fourths of an hour without 
further administration of ether. As an adjunct these patients receive 
J grain morphin and T ^Q grain atropin one-half hour before operation. 
This continuance of anesthesia is possible because, as a result of the 
elevation of the head, there is an anemia of the brain. This method is 
of great value in thyroid operations, because a small amount of ether 
is used and the shock is less. In other operations on the neck and head 
the anesthetist is removed from the field of operation. This method is 
used only with ether. 

Intratracheal Insufflation Anesthesia (Method of Meltzer and Auer). 
This method is of value when operations are performed on the head 
and neck. The anesthetist is out of the way and is not so likely to 
contaminate the field of operation. The patient is first anesthetized 
in the usual position with ether. When unconscious the head is dropped 
over the edge of the table and a flexible rubber tube, smaller in diameter 
than the trachea, is passed into the trachea. This should be done by one 
with experience, and should be under the guidance of the eye. The tube 
should reach almost to the tracheal bifurcation. 

To supply the ether vapor under pressure one can use a foot bellows, 
allowing the air to pass through a container with ether. This is the 
simplest. A more complicated apparatus has been devised by Dr. 
Elsberg, of New York. An electric motor is used instead of the foot 
bellows to furnish the stream of air. The air before entering the trachea 
is warmed by passing through hot water. This supplies a constant 



100 ANESTHETICS AND ANESTHESIA 

stream of air under pressure. During expiration the lungs force the air 
out of the trachea around the rubber tube. Care must be taken that 
the pressure is not too high and that no ether is sprayed into the 
trachea. Ether can be administered intratracheally without a positive 
pressure. A very simple way is to attach to the rubber tube inserted 
into the trachea a long rubber tube with a glass funnel. Over this 
funnel a few layers of gauze are placed, and on these ether is dropped. 
This is very simple, and one who knows how to give ether by the drop 
method can readily use this. 

Intrapharyngeal Administration. Where the tubing would interfere 
with operations on the mouth the ether can be given intrapharyn- 
.geally. Two soft-rubber catheters are put into the nose, one on each 
side, and pushed back until the ends reach the pharynx. The two 
outer ends are connected by means of a glass Y-tube, and the long 
rubber tube with large glass funnel is attached. This allows the 
anesthetist to keep away from the field of operation and leaves the 
mouth empty. 

Of course, where hot irons and fire are used in an operation around 
the neck or head, ether and chloroform are dangerous. The air pas- 
sages must be kept free. If the jaw sags or the tongue drops back 
an aseptic assistant must hold the jaw forward. Mucus should be 
wiped out of the mouth. A very good precaution to prevent much 
secretion of mucus and to reduce the amount of ether needed is to give 
the patient J grain morphin and T ^ grain atropin one-half hour 
before operation. 

Intravenous Administration. For intravenous administration, ether is 
used. Under the influence of J grain morphin and T ^ grain atropin, the 
patient is brought to the anesthetic room. A needle such as is used in 
giving intravenous saline solutions is inserted into a vein of the forearm. 
To the needle is attached a rubber tube which has a glass Y-tube at 
its end. Two tubes are attached. One leads to a glass container, 
having a 5 per cent, solution of ether in normal saline; the other goes 
out to another container, with only normal saline. Each of these tubes 
has a screw stop-cock on it, so that the flow from the two containers 
can be shut off or regulated as desired. All the air should be out of the 
tubes before starting. By turning the stop-cock on the tube leading 
to the container with the ether in solution the anesthesia can be begun. 
As soon as the anesthesia is complete the flow can be decreased to just 
enough to keep the patient properly anesthetized. If the patient is 
too profoundly anesthetized, salt solution can be run in until the 
second stage of anesthesia returns. By regulating the flow from the 
two solutions the desired degree of anesthesia can be obtained. 

Kuemmel says there is no postoperative headache, vomiting or 
nausea. He claims that it is specially efficacious in wasted, weak 
individuals, patients who have lost a good deal of blood and those 
that are extremely exhausted. 

It is contra-indicated in arteriosclerosis, myocarditis, cholemia and 
plethoric patients. Edema of the eyelids or conjunctiva are signs for 
discontinuing the flow of both solutions. 



GENERAL ANESTHETICS 101 

x 

This method, as in intratracheal administration, keeps the anesthe- 
tist out of the way, the respiratory passages are not irritated as much 
and the air passages are free for the surgeon. Usually ten minutes 
suffice to produce anesthesia and from 200 to 300 c.c. of the solution 
or about 10 to 15 c.c. of ether. 

Rectal Administration. The utilization of the colon for the absorp- 
tion of ether fumes necessitates for rapid absorption an empty colon. 
This is accomplished by giving oleum ricini, ounces two, twenty-four 
hours before the operation. Twelve hours later a high soapsuds enema 
is given and repeated the next morning before operation. In giving 
the anesthetic, oleum ricini (sterile) is dropped into each eye and then 
both are covered with protective tissue. This is necessary to prevent 
any trauma during anesthesia. 

Around the rectum vaselin is spread so as to prevent irritation of the 
skin. The jaws should be held during the anesthesia, so as to prevent 
the tongue from obstructing the air passage. The apparatus necessary 
is a rectal tube, a rubber tube leading to a wide-mouthed bottle, with a 
snugly fitting rubber stopper which has two perforations. Through the 
stopper are two glass tubes, one reaching to the bottom the other reach- 
ing just through the stopper. A rubber tube leading from a foot 
bellows is attached to the glass tube reaching to the bottom of the 
bottle. The air bubbles through the ether and becomes saturated with 
ether vapor. The short glass tube is attached to a tube leading to the 
rectal tube. The rubber stopper must fit snugly; buc it should not be 
firmly fixed, for it acts as a safety-valve. If pressure is too high it will 
come out and prevent too much tension being put on the colon. 

The wide-mouthed bottle, which should be at least 30 cm. deep, so 
as to allow the air to go through a long column of ether, should be kept 
at a temperature from 80 to 100 F. This can be accomplished by 
keeping the bottle in a water-bath and regulating the temperature of 
the water by a thermometer. This causes the ether to evaporate fast 
enough to produce anesthesia and supplies a warm, less irritating gas 
to the bowel. By raising and lowering the temperature of the water 
the ether may be made to evaporate faster or slower. 

On passing the rectal tube, all the gas in the colon is let out, and by 
attaching the apparatus, ether fumes are sent into the colon. At first 
there may be some colicky pains, but as the patient comes under the 
influence of ether the pressure may be increased until a state of sur- 
gical anesthesia results. By supplying from time to time more ether 
vapor the patient is kept under. If anesthesia becomes too deep, dis- 
connect the tube from the rectal tube and allow the gas to escape. 
This can be aided by making gentle pressure on the abdomen. 

The amount of ether used is small, one to four ounces sufficing for 
most anesthesias. Anesthesia can be induced in from five to fifteen 
minutes. 

There is less irritation of the respiratory tract, and a patient comes 
out of the anesthesia soon after stopping the ether vapor. Since less 
mucus, ladened with ether has been swallowed there will be less nausea 



102 ANESTHETICS AND ANESTHESIA 

and vomiting. For abdominal operations this method is undesirable 
because of the distention of the colon with ether fumes. 

In head and neck operations it keeps the anesthetist away from the 
field of operation. In asthenic cases and bad risks, especially in pul- 
monary tuberculosis and chronic affections of the respiratory tract, 
rectal anesthesia will reduce the irritation to the respiratory mucous 
membrane. 

Oral Administration. Gwathmey and Karsner 1 found that general 
analgesia was much safer than general anesthesia.. They use 50 per 
cent, ether in some bland oil, such as liquid petroleum. It may be 
sandwiched between mouthfuls of port wine, taking away the unpleas- 
ant taste. There is no deleterious effect on the stomach, and the nausea 
and vomiting are absent. It is used for painful dressings. 

Closed Method. The closed method of administering an anesthetic 
is not generally used except with nitrous oxide and oxygen. Ether 
has been given a good deal this way. It is said to reduce acapnia, 
lessen postanesthetic nausea and practically abolish lung complications. 
In addition the amount of ether used is much less than in the open 
drop method. 

There are many closed inhalers on the market. The principle is the 
same as the one used in the Teter apparatus for nitrous oxide and 
oxygen. The air is exhaled into a rubber bag and then inhaled. Fresh 
air may be introduced at any time. During the passage of the air from 
and to the rubber bag the ether is added. Dr. Rice 2 furnishes the ether 
vapor by allowing oxygen to bubble through ether and enter into the 
bag. 

One objection to this method is the apparatus. The more simple 
the thing is, the better it is. By putting a towel over the mask used 
in the open-drop inhalation method a semiclosed method results. 
Gwathmey in his book on Anesthesia says that in the closed method 
there is an anoxemia and a danger of too concentrated ether vapor. 
The excess of carbon dioxide stimulates respiration, and an overdose 
of the ether is very likely. This, of course, must be regulated by 
admitting free air from time to time. 

With nitrous oxide and oxygen the mask is put over the face, so as 
to cover the nose and mouth. Nitrous oxide is run into the rubber 
bag and the patient breathes it in. If the patient is difficult to put to 
sleep the bag may be a little overdistended. In about two or three 
minutes the anesthesia will be completed. As the patient is going 
under, oxygen may be added. The amount and proportion of oxygen 
and nitrous oxide used will be determined by the condition of the 
patient. Ether may be added when the anesthesia is prolonged, or 
complete relaxation of the voluntary musculature is required. 

Sequence Administration. The preliminary stage with some anes- 
thetics is annoying to patients, especially if they have to take ether a 
second time. To obviate this, other anesthetics have been used for 

1 British Med. Jour., March 2, 1918. 

2 American Year Book of Anesthesia and Analgesia, 1915. 



GENERAL ANESTHETICS 103 

the initial stage and then followed by ether. The most commonly 
used are nitrous oxide and oxygen followed by ether. Chloroform 
may be used because it is more pleasant and ethyl chloride may be 
employed. These are usually administered by the open-drop method. 
Oral analgesia and intravenous or rectal anesthesia may be used to 
induce the anesthesia which is then completed with ether by the 
open- drop method. 

Choice of Anesthetic. The choice of an anesthetic depends on 
several factors. The prime factor is the safety of the patient. McGrath 1 
reports 49,057 anesthetics with ether and no fatalities. At the Augus- 
tana Hospital there have been over 20,000 ether anesthesias with no 
fatality. This makes no fatality in almost 70,000 ether administrations. 
There are many statistics on the mortality due to anesthetics, and they 
vary greatly. This variation may be due to two things: (1) the anes- 
thetic itself, or (2) the administration of the anesthetic. Both of these 
conditions can be controlled. A good grade of the drug must be used 
and one expert in its administration must give it. 

Ether is used more generally than any other anesthetic. It gives 
complete unconsciousness and a relaxation of the voluntary muscula- 
ture. In acute respiratory diseases, chronic bronchitis, obstruction 
to the air passages, arteriosclerosis, hypertension and atheroma the 
use of ether is more dangerous. Since ether affects the respiratory 
center before it does the vasomotor center and cardiac muscles, it is 
much easier to give, and easier for a patient to recover if too much has 
been given. 

Chloroform has a pleasant, sweetish odor and is agreeable to take. 
In obstetrical work it may be administered with relative safety. 
Because of the danger of reflex stoppage of the heart, late poisoning 
and the early depression of the vasomotor center it is more dangerous 
than ether. It has an irritating effect on the mucous membrane of the 
respiratory passages. It is much more dangerous in shock than ether. 
In acute pathological processes in the lungs, emphysema, pulmonary 
tuberculosis, in marked kidney diseases, in valvular disease of the heart 
with hypertension and myocardial disease, chloroform should not be 
used. 

Ethyl Chloride. Ethyl chloride has the same disadvantage for general 
use as chloroform. Great care must be exercised in giving it. The 
vapor must not be too concentrated and a semiclosed method used in 
its administration. It is easy to give an overdose and cause death by 
respiratory failure and spasm of the diaphragm. 

Nitrous Oxide and Oxygen. Nitrous oxide and oxygen combined, make 
one of the safest anesthetics. Because of an incomplete relaxation of the 
voluntary muscles it is less desirable than ether. It should not be used 
in plethoric patients, in myocardial disease, valvular heart disease or in 
any case with obstruction to the respiratory passages, severe anemia, 
hypertension, diabetes, and status lymphaticus. It necessitates a much 

1 Collected Papers of Staff of St. Mary's Hospital, Mayo Clinic, 1913. 



104 ANESTHETICS AND ANESTHESIA 

more complicated apparatus, and as the gas is in steel cylinders, its 
transportation is more difficult. For these reasons nitrous oxide and 
oxygen have not been used generally except in extracting teeth, open- 
ing abscesses and in operations that are short and where muscular 
relaxation is not essential. It is often used in combination with ether, 
and, in the hands of an expert, a very safe and satisfactory anesthesia 
can be secured. 

COMPLICATIONS. 

The postoperative complications that occur are due to (1) condition 
of the patient; (2) anesthetic given and (3) operation performed. 

If the patient is in a very poor physical condition, the anesthetic 
poorly given and an extensive operation performed, it stands to reason 
that complications will be met. Cutler and Morton, 1 using the statistics 
of operation at the Massachusetts General Hospital (3490 cases), 
came to the following conclusions regarding the predisposing factors 
causing postoperative complications: * 

1. Poor general condition; age, anemia, alcoholism, arteriosclerosis, 
a weak myocardium or chronic infections of the lungs. 

2. Oral sepsis: carious teeth, septic tonsils. 

3. Badly given anesthetic, forced, aspiration of mucus, unnecessary 
intubation of esophagus, vomiting on table with aspiration of vomitus. 

4. Presence of septic foci. 

5. Too radical operations that open, unnecessarily, pathways to the 
neighborhood of the lungs and the lungs themselves. 

6. Operations in the epigastrium carry the added danger of lung 
complication through ease of vascular and lymph extension. 

7. Exposure to cooling fluids or to draughts (vasomotor disturb- 
ances) . 

8. Postoperative pain resulting in hypostasis from poo expansion. 
They further noted that 1 in every 54 patients operated upon devel- 
oped postoperative lung condition and that 1 in 106 died. 

There are a good many factors entering in. 

The lung complications, such as lobar pneumonia, bronchopneu- 
monia, bronchitis, pleurisy, empyema, pneumothorax, mediastinitis, 
pulmonary embolism, and lung abscess are most common. By giving 
the anesthetic carefully, using as little as is necessary and not forcing 
the anesthesia, there is much less irritation. Morphin and atropin 
will diminish the secretion of mucus and less anesthetic will be required. 
The treatment immediately after operation is most important. If 
possible, changing the position of the patient every two or three hours 
will prevent a hypostatic congestion. The Fowler position will also 
help, and the patient's head should be elevated 12 to 18 inches when- 
ever any evidence of pulmonary irritation follows an operation. This 
plan of treatment almost entirely eliminates postanesthetic pneumonia. 

Nausea and vomiting are chiefly due to swallowing mucus laden 

Surg., Gynec. and Obst.. December, 1917. 



COMPLICATIONS 



105 



with ether, but there may be some regurgitation from the duodenum. 
By washing the stomach the- nausea and vomiting are relieved. Pre- 
venting the excessive secretion of mucus and having the gastro-intes- 
tinal tract clean will reduce the nausea and vomiting. The patient 
should be almost or wholly conscious when put to bed after an oper- 
ation. He should be able to cough up any vomited material that 
might otherwise go down the trachea, and expel excessive secretions 
that may collect in the respiratory tract. Drinking hot water tends to 
dilute the mucus and wash it out of the stomach. 

Anuria occurs occasionally after an operation. One must first be 
certain that it is an anuria and not simply an inability to void. This 
can be done by catheterization. Care must be exercised in catheter- 
izing a patient, so as not to infect the bladder and produce a cystitis. 
If an anuria exists the fluid intake should be increased by means of 
hypodermoclysis, proctoclysis and water by mouth. Water is the best 
diuretic. Stimulate elimination through the skin by hot packs and 
electric lights, through the gastro-intestinal tract by means of saline 
cathartics, if it is permissible. In abdominal operations, cathartics 
immediately and for several days after anesthesia, are contra-indi- 
cated. Diuretics, such as diuretin and caffein citrate, may aid. As 
a final resort the capsules of the kidneys may be split. This may prove 
successful when all other measures fail. 

Inability to void the urine after an operation is due to a reflex 
spasm of tjie internal sphincter. Increasing the fluid intake, as 
described under anuria, will sometimes aid. Usually there is plenty of 
urine secreted. Running water in the room, applying a hot pack to 
the perineum or allowing the patient to sit up will often correct this 
trouble. Giving the patient an acid, so as to increase the acidity of the 
urine, will cause irritation at the internal sphincter and the urine may 
be voided. As a last resort the patient should be catheterized. Usually 
one catheterization will suffice. If not the patient must be carefully 
watched and should be catheterized every twelve hours. Catheteriza- 
tion must be performed with surgical asepsis, and even then occa- 
sionally a cystitis results. 

Gas pains are prevented by a thorough preliminary preparation. 
The gastro-intestinal tract is clean and there is no opportunity for stag- 
nation and fermentation. Limiting the diet to broth the evening before 
operation is important. 

Backache may be complained of by the patient. This is usually 
located in the lumbar and sacral regions. Dr. Dunlop 1 believes it is 
due to the posture on the operating table. There is a strain due to 
lack of support to the lumbar curve and a strain of the iliosacral syn- 
chondrosis results. Placing a small pillow under the back during 
operation will obviate this. 

Nephritis is usually transient if the kidneys are normal. Giving the 
patient water to drink, preferably distilled, as soon as possible and 

1 New York Med. Jour., July 10, 1909. 



106 ANESTHETICS AND ANESTHESIA 

continuing to force it for a time, will soon clear up this condition. 
If the process in the kidney is chronic, water, together with diuretics, 
should be employ ed. Diaphoretics and cathartics when indicated 
may be given. Usually their use is limited. Because more ether than 
chloroform is generally given the irritant action of ether seems to be 
greater. When a patient has chronic nephritis the function of the 
kidneys should be carefully studied before operation. 

The degree to which a patient is shocked depends chiefly on the 
patient's physical condition before operation. A prolonged operation, 
with a great deal of traumatism to the tissues, exposure of and hand- 
ling of the intestines, a poor anesthesia, an excessive dose of the 
anesthetic or exposure to cold during the operation conspire in 
producing shock. 

This condition will be proclaimed by a low blood-pressure, poor 
heart action, with a weak, small and rapid pulse, pallor, cold sweat, 
feeble respirations. The patient may be conscious or unconscious. 

The treatment consists in prevention. Trfe surgeon must be able 
to judge how much he can do without shocking tbe patient. The oper- 
ation should be as short as possible. No unnecessary trauma or hand- 
ling of the intestines should be done. If the intestines are exposed 
they must be covered with gauze moistened in hot saline solution. If 
possible they should remain in the abdomen. There should be as 
little loss of blood as possible. The anesthetic should be given by an 
expert and just as little used as is required to perform the operation. 
Care must be exercised in choosing an anesthetic. 

During the operation the patient should be kept warm on the operat- 
ing table. Whole blood transfusion by the Percy method, hypodermoc- 
lysis of saline solution, elevation of the foot of the bed and applica- 
tion of external heat, by means of blankets, hot-water bottles, and 
electric lights, tend to combat shock. 

LOCAL ANESTHETICS. 

Local anesthesia was practised in ancient times by the inunction of 
various narcotics. There was little progress made in this art until 
the latter part of the nineteenth century. 

In 1884 Karl Koller, of Vienna, demonstrated the effects of cocain 
as a local anesthetic before the Ophthalmological Congress at Heidel- 
berg. Later, Merling discovered Alpha and Beta eucain, and stovain 
was synthetically produced by Fourneau. Since that time the scope 
and use of local anesthesia has slowly increased. The introduction of 
the syringe in 1845 by F. Rynd, of Edinburgh, contributed an impetus 
to this method of anesthesia. 

In 1884 Halstead and in 1885 Corning demonstrated clinically the 
value of cocain. Hall and Halstead also demonstrated that injecting 
a nerve trunk caused a sensory paralysis in its course. This work was 
expanded by Crile, Cushing, and Matas. The development of anoci- 
association by Crile has given an added value to local anesthesia. 



LOCAL ANESTHETICS 107 

During the last two decades its use has become more general, until 
now, in the hands of a skilled operator, any operation may be per- 
formed under local that has been done under general anesthesia. 
There are none of the accidents that happen during the use of a general 
anesthetic and no postanesthetic complications except vomiting and 
pneumonia. The only disadvantage is the fact that the patient is 
conscious and may become alarmed. However, this factor together 
with a perfect injection depend on the skill and ingenuity of the oper- 
ator. Some men are so skilled, can so dominate the consciousness of 
their patients that they are able to do almost any operation. Farr 1 
cites 77 cases in children, and almost every part of the body was 
operated upon. He says the psychic element is not so important, and 
sometimes restraint is necessary. The anesthesia must be complete 
and the surgical technic refined. 

The scope of local anesthesia has been broadened by the knowledge 
that viscera innervated by purely visceral nerves are insensitive, and 
sensation exists only in those that receive branches from the somatic 
nerves. Lennander 2 shows that the parietal peritoneum is sensitive to 
pain but not to touch. The intestine, stomach, edges of the liver, 
mesentery, gall-bladder, urinary bladder, kidney parenchyma, lung, 
anterior wall of the trachea, testicle and epididymis are insensitive, 
but the coverings of the testicles and epididymis are sensitive. 

Action. Local anesthetics produce anesthesia over a limited area 
in three ways: (1) by an anemia of the capillaries supplying the nerve 
endings; (2) by direct action on the nerve-endings; (3) by direct action 
on the nerve fibers. It has been shown that by injecting normal saline 
under pressure, anesthesia will result. No doubt, in different local 
anesthetics, their effectiveness depends on whether they act in all 
three ways or in only one or two. 

The action may be intensified in various ways. Corning, and Oberst, 
of Halle, by applying a tourniquet proximal to the area anesthetized, 
increased the anesthesia because of the increase of the anemia. Braun 
used adrenalin with his injecting solution and prolonged the anesthesia, 
due to the greater anemia. 

It is to Schleich that we owe the introduction of weaker solutions 
and a greater use of local anesthesia. There is thus less danger of 
poisoning and a greater area is anesthetized. Reclus, Schleich, Braun, 
and Puchet showed clinically that a large quantity might be injected, 
but that If to 3 grains of cocain is the maximum. 

Preparation of Solutions. As a result of the work of Schleich, 
weaker dilutions of the agent are used. It is preferable to use salt 
solution as the diluent, for if the solution is not isotonic there will be 
an irritation and traumatism of the tissues. Following the injection 
there will be a reaction. 

The solution prepared must be sterile. Some drugs, such as cocain, 
break down upon heating, so a sterile solution must be prepared by dis- 

1 Interstate Med. Jour., February, 1919. 

2 Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1902, Bd. x, Hefte 1 und 2. 



108 ANESTHETICS AND ANESTHESIA 

solving the sterile cocain in sterile water. Fresh solutions should be 
prepared often, as it soon deteriorates. Stovain, novocain and alypin 
may be boiled and a sterile solution obtained. 

The addition of adrenalin intensifies the action by increasing the 
local anemia, and thus reduces hemorrhage during the operation. The 
disadvantage of using adrenalin is that there may be delayed bleeding. 
Usually ten minims of a 1 to 1000 solution of adrenalin to 100 c.c. 
of solution is sufficient. 

T. Sollman 1 finds the alkalinization increases the efficiency from two 
to four times. The anesthetic salts may be mixed with an equal volume 
of 0.5 per cent, sodium bicarbonate solution without loss of efficiency 
and one-half of the anesthetic is saved. 

Eggleston and Hatcher 2 find that the toxicity of the different drugs 
varies and depends on the rate of their absorption and elimination 
from the system. Using epinephrin delays the absorption, gives the 
system more of a chance to eliminate and so reduces the toxicity. The 
elimination is due to destruction of the drug iff the liver. 

They find that death is due to paralysis of the heart and respiratory 
center. By artificial respiration and intravenous injection of epineph- 
rin the patient may be carried along until the system has had a 
chance to eliminate some of the drug. They advise using epinephrin 
in solution of alypin, apothesin, beta-eucain, nervanin, procain (novo- 
cain) stovain and tropacocain, as it delays the absorption and allows 
time for destruction of the poison. It prolongs the anesthesia and 
reduces the amount of the anesthetic required. 

Morphin and Atropin. As an adjunct to all local anesthesia the 
use of morphin and atropin is indicated. By depressing the higher 
centers the perception of painful stimuli is not so acute and an anes- 
thetic that might have been a failure is a success. It is also easier for 
the surgeon to dominate the situation and gain the confidence of the 
patient. For adults J grain of morphin and a T ^ 7 grain of atropin are 
used. For children the dose is reduced to 3^ or T V grain of morphin 
and y-J-^ to YTRF grain of atropin. 

Cocain. Cocain is derived from several varieties of cocoa. It forms 
colorless prisms and has a slightly bitter taste. It is slightly soluble 
in water (1 to 600), freely so in alcohol (1 to 5). In fixed oils it is 
soluble, but insoluble in petrolatum and lard. The hydrochloride 
that is most commonly used, is freely soluble in water. On boiling it is 
hydrolized into egonin, benzoic acid and methyl alcohol. 

If too large a dose is used or a person has an idiosyncrasy for it, 
symptoms of poisoning develop. At first there is a stimulation of the 
different segments of the central nervous system. The exaltation in 
the brain has usually passed into depression by the time the spinal 
segments are reached, so that there may be a mixture of depression 
and stimulation. Muscular irritability, loss of sense of fatigue, 
increased psychte activity and insomnia are evidence of stimulation. 

1 Jour. Am. Med. Assn., January 26, 1918. 
1 Ibid., October 25, 1919. 



LOCAL ANESTHETICS 109 

Somnolence, stupor and coma show that depression has set in. Respira- 
tion may be of the Cheyne-Stokes variety, and is usually quickened. 
Later, respiratory paralysis may set in. The heart-rate is increased 
at first but later becomes weak, and the blood-pressure falls as vaso- 
motor paralysis appears. 

Cocain, in addition to its anesthetic effect is a vasoconstrictor and 
is often used in nasal work to shrink the mucous membrane. 

Eucain. There is an alpha and a beta eucain. The beta compound 
is less irritating and toxic than the alpha. It has the same anesthetic 
action as cocain, but instead of vasoconstriction it produces a slight 
vasodilatation. The salts of eucain are fairly soluble in water, espe- 
cially the hydrochlorate and the lactate. It is a synthetic preparation 
and derived from benzoyl. Its action is said to be slower than that of 
cocain or novocain but after its action has begun the anesthesia lasts 
as long. It is far less toxic than cocain. 

Tropacocain. Tropacocain is derived from the same source as cocain. 
It is benzoyl tropin and its action is similar to cocain. However, its 
induction of anesthesia is quicker and does not last as long as cocain. 
It is about one-half as toxic. It has no vasoconstrictor or vasodilator 
action. It has been used for the most part in spinal anesthesia. 

Stovain. Stovain is also a benzol derivation. It is readily soluble 
in water and has been used a great deal in spinal anesthesia. It can 
be heated to 120 C. before it begins to decompose. There is some 
irritating action on nerve tissue, and the anesthetic effect is less intense 
and of shorter duration than that of cocain. When injected into tissues 
at first there is a slight, burning pain, then anesthesia follows. Fol- 
lowing the anesthesia there is often an inflammatory reaction and if 
strong solutions up to 10 per cent, are used there may be marked 
tissue necrosis. 

Novocain (American Procain). Novocain hydrochloride was intro- 
duced by Einhorn in 1905. It is less irritating and toxic than cocain 
or eucain. It is soluble in water in equal parts and 1 to 30 in alcohol. 
Heating to 120 C. will not decompose it, and it may be kept in solution 
for a long time. In anesthetic action a 1.25 per cent, solution has the 
same effect as a 1 per cent, solution of cocain, and has about of the 
toxicity of cocain. The anesthetic action will not last as long as cocain. 
However, by adding adrenalin its action is intensified so as to make it 
equivalent to cocain and while the action is not so rapid it may last 
longer. There is no vasomotor disturbance, irritation of the tissues 
or postanesthetic inflammation. In the eye its action is much slower, 
but it does not damage the cornea as does cocain. 

Alypin. Alypin, a derivative of the benzoyl group, was introduced 
by Imperes. It is readily soluble in water and alcohol and is not decom- 
posed by boiling. It is a white, crystalline powder. The anesthetic 
power is about the same as that of cocain. Injection of alypin causes 
a slight burning sensation and some hyperemia. Its anesthetic action is 
of shorter duration than cocain, but the addition of adrenalin will 
prolong its action . There is less irritation and toxicity than with cocain . 



110 ANESTHETICS AND ANESTHESIA 

In the eye there is no drying of the cornea, no dilatation of the pupils 
nor changes in accommodation and tension. Cocain in the hands of 
the skilled has proved far superior. Drs. Bransford Lewis and Willy 
Meyer recommend alypin in the genito-urinary tract. Dr. Meyer 
uses a 2 per cent, solution for instillation. 

Anesthesin. Anesthesin has found its greatest use in topical appli- 
cation. It is a fine, white crystalline powder and melts at 90 C. 
Prolonged boiling will cause decomposition. It is non-irritating and 
almost non-toxic. It is insoluble in cold water, but slightly soluble in 
warm and hot water. It is soluble in alcohol, ether and benzin, but 
less so in fatty oils. 

If left on a surface undisturbed its anesthetic action reaches its 
maximum in ten minutes and lasts for hours. This has a varied use 
in otalgia, painful open wounds, continued vomiting, itching, vesical 
and rectal irritations and ulcers. 

Apothesin. Apothesin is an American product. It occurs in small, 
snow-white crystals and melts at 137 C. It Dissolves in alcohol and 
water and is slightly soluble in acetone and ether. There is very 
slight irritation and no toxic effect. The action is quite rapid and lasts 
for some time. During the war, because of a scarcity of foreign-made 
local anesthetics, apothesin came quite widely into use. It has been a 
very efficient agent, and in its toxicity and slight irritating effects it 
resembles novocain. 

Quinine Salts.* The hydrochloride of quinine and urea is the most 
soluble of the quinine salts. Its anesthetic effect is not so rapid in 
infiltration and in topical application, but its effect lasts a great deal 
longer than cocain, novocain, or eucain. There is no diffusion of the 
anesthetic action, and vasodilatation favors capillary oozing. Follow- 
ing the injection and depending on the concentration there is some 
induration. As a local anesthetic agent it can be used for almost any 
operation. The serious drawback is this hard swelling and a capillary 
oozing from the wound. This prevents rapid healing by first intention. 
Dr. F. W. Parham 1 calls attention to tetanus following the injection 
of quinine solution for malaria. Dr. C. W. Allen, discussing it in his 
book on Local and Regional Anesthesia, thinks there is a necrosis of 
the tissue with a suitable place for the tetanus spore to develop; 
because of low toxicity and of long-lasting anesthesia the quinine salts 
are often used in local anesthesia. 

Dr. C. W. Allen, 2 quoting from Piquaud and Dreyfus, 3 says that 
cocain is the most powerful of all local anesthetics, but its high toxicity 
renders it dangerous; a safe dose should not exceed 14 to 15 eg. in 1 to 
200 solution, care being taken to maintain the recumbent position 
during and after its use. Dr. Allen says further: 

"Beta-eucain appears to present no advantage over cocain; it is 
equally as toxic, much less anesthetic, and more irritant. 

"Alypin should be proscribed in view of its toxicity and irritability 
qualities. 

1 New Orleans Med. and Surg. Jour., October, 1913. 

2 Ix>c. cjt, 3 Jour. Phys. et Path gen., January, 1910- 



LOCAL ANESTHETICS 111 

"Stovain presents considerable advantage over cocain; it is two times 
less toxic, and a safe dose is placed at 30 eg. of a 1 to 200 solution. 

"The irritant action following its use and its weaker anesthetic 
power can be largely overcome by using it in normal salt solution and 
in slightly greater strength. 

"Novocain appears at the present time the most commendable of 
local anesthetics; its feeble toxicity permits large doses to be used 
without inconvenience; it has considerable anesthetic power; it is non- 
irritant and not a vasodilator. .The only inconvenience is that its 
action is comparatively a little shorter than cocain, but this can be 
overcome by the addition of adrenalin, which produces a prolonged 
anesthesia of slightly more marked degree without increasing its 
toxicity." 

Methods of Administration. Topical Application. For anesthetiz- 
ing mucous membranes topical application may be used. On unbroken 
skin the local anesthetic has no effect. For this kind of an anesthesia 
the strength of the solution is greater than that used for other methods. 
Cocain is generally used, although Sollman 1 says that beta-eucain, 
alypin and tropocain are very useful. A 5 per cent, solution may be 
used for local application to the mucous membrane. Epinephrin 
should be added to the solution, about 10 mimins for every 100 c.c. of 
solution. Care must be exercised in its use in the urethra, for it seems 
that absorption here is very rapid. In nasal work the strength of solu- 
tion should be 1 per cent, with the adrenalin. This method is a very 
excellent one as a preliminary step to injection. 

Infiltration. This method is the most widely used. Necessary for 
this method is a set of good hypodermic needles of various lengths 
and a good syringe. Many syringes have been invented, such as self- 
filling, those that deliver the solution under a constant pressure, etc. 
But a convenient apparatus consists of a syringe that is air-tight, the 
size varying from 1 to 20 c.c., and several hypodermic needles of various 
lengths. 

Reclus first introduced this method. The skin should be injected 
first. This is done by introducing the needle into the skin itself, inject- 
ing the solution so that it is under pressure and produces wheals. By 
pushing the needle along and injecting the solution at a constant pres- 
sure a series of wheals are produced. When the full length of the needle 
has been inserted, withdraw it and reinsert it in the skin just inside of 
the last wheal and continue the injection. If the operation extends 
deeper, by means of a larger needle, layer by layer of the deeper struc- 
tures are injected, so that all the structures that are to come in contact 
with the knife are anesthetized. 

Regional Anesthesia; Bier's Intravenous Anesthesia. This method 
was introduced by Bier in 1908. It is applicable to operations on the 
limbs when infiltration would not be successful. It is not widely used. 

The limb is elevated and an Esmarch bandage put on, beginning 

Jour. Am. Med. Assn., January 26, 1918, 



112 ANESTHETICS AND ANESTHESIA 

at the distal end and wound proximally. Above this bandage a tour- 
niquet is applied. The Esmarch is removed. Another tourniquet is 
put distal to where the operation is to be performed. Into the veins, 
which have been marked, 50 c.c. of a J to | per cent, of novocain 
solution are injected. Anesthesia will be quite rapid, but one must 
wait until the field of operation is anesthetized. There may be a motor 
paralysis in the peripheral part of the limb, but that soon disappears. 
Bier before closing the wound moves the peripheral bandage and loosens 
the proximal, so that the arteries are open, but the veins still compressed. 
As much as possible of the solution is washed out of the wound. If 
much anesthetic has been used the veins can be washed with normal 
saline and a good deal of anesthetic will escape through the wound. 
In diabetes and arteriosclerosis it is contra-indicated. 

Perineural Method. The nerve supplying the sensory filaments to 
the area which is to be operated has the anesthetic agent infiltrated 
around its sheath. This in from ten to thirty minutes will completely 
block all sensory stimuli. The nerve is not injured and this is a simple 
method of procuring anesthesia. 

Endoneural Method. Crile 1 found that by injecting cocain directly 
into a nerve trunk, anesthesia of the part supplied by the nerve quickly 
resulted. In promptness it has the advantage over the perineural 
method, but it can only be used in large nerves. The nerve must be 
exposed to be certain that the injection is made into the nerve itself. 
Sometimes a neuritis follows the injection. The blocking of the sensory 
stimuli is complete. 

Spinal Anesthesia. This method of anesthesia was introduced by 
Corning in 1885. Some years later it was taken up by Bier and made 
more familiar to the medical profession. Spinal anesthesia, as all other 
methods, has a place in the practice of medicine and surgery. In the 
hands of a surgeon who has had experience with its use it is quite 
efficient. Sometimes in the hands of the enthusiast its use is overdone. 
Oftentimes in attempting this method of anesthesia a partial failure 
will result and a general anesthetic must be given. 

In hypertension, aneurysm, cardiac decompensation, eclampsia, 
nephritis, labor and arteriosclerosis it may be the method .of choice. 
Because of the vasomotor relaxation it is contra-indicated in conditions 
of hypotension. In operations above the costal arch, superficial infec- 
tion near the point of injection, lesions of the spinal cord, in athletic 
individuals and for light anesthesia, spinal anesthesia is contra- 
indicated. Care and good judgment must be used in the selection of 
patients suitable for spinal anesthesia. 

Attempts have been made to regulate the height of the anesthesia 
by means of varying the specific gravity of the solution injected. A 
5 per cent, solution of glucose, glucose solution with alcohol, using spinal 
fluid as a diluent, have been employed. At the present time the 5 per 
cent, glucose solution is used much more abroad while the tendency in 
the United States is to prefer spinal fluid. 

1 Jour. Am. Med. Assn., February 22, 1902. 



LOCAL ANESTHETICS 113 

Many different drugs have been used, cocain being the first. At 
the present time most of them have been discarded with the exception 
of stovain, tropocain and novocain. These in the experience of men who 
have tested spinal anesthesia widely, have the least deleterious effects. 
The novocain comes in what is known as tablet "A." It contains 
If grain of novocain and ^ir grain of suprarenin. 

Orth and Miiller 1 prepare their solution in the following manner: 
An ordinary test-tube, cork to stopper and beaker are boiled fifteen 
minutes in water free from bicarbonate of soda. They specify this 
because novocain and adrenalin preparations are chemically affected 
by alkalies. These utensils are then rinsed in freshly distilled water. 
About 3 c.c. of freshly distilled water are poured into the test-tube, 
boiled a few minutes and allowed to stand until ready for use. A 
color of a faint rose or a brownish red is the result of decomposition of 
the suprarenin by oxidation. Only clear and colorless solutions are to 
be used. When ready for use the solution is brought to the boiling- 
point six to eight times to sterilize. It is not boiled continuously as 
the active principle of suprarenin would thereby lose its effect. The 
solution is then poured into the beaker, from which it is drawn into a 
syringe. The specific gravity of this solution is approximately that of 
the spinal fluid, 1.008. In giving the fluid, about 7 c.c. of spinal fluid 
are withdrawn and mixed with the 3 c.c. of novocain solution and then 
slowly injected. 

Barker 2 uses a solution isotonic with the blood. It consists by weight, 
of 5 parts of stovain, 5 parts of glucose and 90 parts of distilled water. 
He uses, on the average, 1 c.c. of the solution and injects it directly 
into the spinal canal without withdrawing any spinal fluid. It is in- 
jected very slowly. Barker does not use adrenalin. 

The site of injection has varied from between the fourth and fifth 
lumbar to high in the dorsal region. At the present time high injec- 
tions are coming more and more into disfavor, and only the low 
injections in the region of the lumbar vertebrae are used. It is less 
dangerous, and, if a higher anesthesia is desired, changing the position, 
using more solution and using a solution of low specific gravity will 
give it. 

Usually the region between the third and fourth lumbar vertebrse 
is chosen. Whether the patient sits up or lies down depends upon the 
operator. The usual way is for the patient to lie on the side, flex the 
knees on the abdomen and the head on the chest. The region of the 
back is prepared with the usual surgical care. The needle is inserted 
in the midline and just below the spine of the third lumbar vertebra. 
The needle should be sharp, the bevel on the end short and the diameter 
about TQ inch and 5 to 6 inches long. It may be of platinum or gold, 
as they are flexible and stand boiling without becoming rusty. The 
needle with the stylet is introduced until it suddenly seems to go easier. 
The stylet is withdrawn and spinal fluid will usually drop out. We 

1 A Plea for Spinal Anesthesia, St. Paul Med. Jour., July, 1917. 

2 British Med. Jour., March 16, 1912. 
VOL. i 8 



114 ANESTHETICS AND ANESTHESIA 

are now in the subarachnoid space and ready to withdraw spinal fluid 
to mix with the solution. 

Anesthesia begins to show itself very soon in the following order: 
" Perineum, external genitalia, posterior surface of the thighs, legs, feet, 
anterior surface of the thighs, umbilicus and costal arch." (Orth and 
Miiller.) The surgeon must be careful in each individual case to see 
that the field of operation is fully anesthetized before beginning. The 
untoward effects reported are many : headaches, ocular palsies, collapse, 
meningitis, retention of urine, chills, elevation of temperature, incon- 
tinence of urine, paraplegia, pains in the back and legs, nausea, vomit- 
ing, sweating, dimness of vision and dyspnea. These are unpleasant 
complications and can be obviated to a great degree, (1) by using a 
low puncture; (2) by injecting the solution slowly, so as to permit 
rapid absorption; (3) by using drugs which have not deteriorated. 
Orth and Miiller 1 found that headaches and the untoward effects in the 
use of novocain and suprarenin occurred usually when the solution 
was reddish or brownish. This was due to decomposition of the supra- 
renin. They also insist on the use of distilled water to rule out any 
foreign bodies. 

From statistics one finds that spinal anesthesia has a fairly high, 
mortality. Tuffier 2 notes three deaths in 2000. Perkins 3 finds in a 
series of collected cases 16 deaths in 2345 cases. Although in special 
cases it may be the anesthetic of choice, it cannot compare with ether 
for general use. It should be undertaken only by men of experience. 

Paravertebral Anesthesia. To circumvent some of the ill effects of 
special anesthesia, para vertebral injection of the spinal nerves has 
been used. Corning, in 1885, attempted to inject close to the spinal 
canal. Selheim, in 1905, injected the roots of the lower dorsal and the 
ilio-inguinal and iliohypogastric nerves. The solution usually used is 
1 to 1J per cent, novocain with adrenalin. Some observers, especially 
Muroya, use a 5 per cent, gelatin with adrenalin in normal saline to 
delay absorption. 0.4 to 0.8 gm. of novocain is the amount that is 
usually needed. 

The inter vertebral foramina are protected by the lateral projections 
of the transverse processes. As the anterior and posterior roots come 
out of the inter vertebral foramina they join, and from the anterior 
branch a filament runs to join the sympathetic system. The object 
in paravertebral anesthesia is to inject, just before they divide, so as 
to catch all the fibers. After determining what segments are to be 
anesthetized, these segments must be located on the vertebral column. 
After definitely locating the segments one is ready to inject. Allen 4 
gives the following method for finding the point of injection: "A 
vertical line is drawn down the tips of the spinous processes and lateral 
measurements are made from this line; the free intervals between the 

1 Loc. cit. 

2 La Presse Medicale, 1901, Iv, 190. 

' New Orleans Med. Jour., January-September, 1902. 
Local Anesthesia, 1918, 2d edition, p. 494. 



LOCAL ANESTHETICS 115 

transverse processes are about one inch on each side. While the con- 
formation of the vertebrae in the dorsal and lumbar regions is quite 
different this measurement holds good along the entire dorsal and 
lumbar regions. As the intervertebral foramina are shielded posteriorly 
by the lateral projections of the articular processes a point about J 
inch farther out, making 1J inch from the midline, is best selected 
as the point of puncture, so as to enable the needle to be directed 
upward and inward toward the intervertebral foramina. The average 
interval between the transverse processes in the dorsal region is ^ inch, 
while the midpoint of this^pace lies in a vertical line about 1 inch from 
the midpoint of the space above and below it. 

" In the lumbar region the free space between the transverse processes 
is from J to f inch and the distance from the midpoint of one space 
to that of another is 1J inch." 

Untoward effects such as one finds in spinal anesthesia have been 
noted. This is due to the fact that while injecting, some of the solu- 
tion enters the spinal canal. Lawen and Gaza, in experimenting with 
epidural injections in animals, found that colored solutions entered the 
spinal canal and would ascend, so that care must be exercised while 
injecting. The injection should be made at the site of the union 
of the anterior and posterior branch before the branch to the sym- 
pathetic ganglia is given off. Too much pressure should not be exerted. 

This method is used also in the cervical region. Braun, following the 
method of Heidenhain, injected in a line drawn from the transverse 
process of the atlas to the transverse process of the sixth vertebra. 
By inserting the needle straight in, the nerves can be reached and 
anesthesia produced. When the midline structures are involved 
both sides of the neck are injected. 

Parasacral Anesthesia. Over the lower end of the sacrum, just 
lateral to its junction with the coccyx, a long needle is inserted. This 
follows up the sacrum until it runs into the lowest sacral foramen. 
As the needle is introduced the solution is slowly injected. As each 
foramen is reached more solution is injected. This is continued until 
the solution has been injected on each side. Just before finishing, 
several cubic centimeters are injected between the coccyx and the 
rectum. This injection furnishes a sufficient block for prostatectomies 
and minor operations on the rectum. Novocain and adrenalin, f to 
1.05 per cent, is used in making this injection. 



SHOCK AND HEMORRHAGE. 



BY JOHN W. NUZUM, B.S, M.D. 

Introduction. The importance of traumatic shock as a most serious 
complication attendant on a certain proportion of surgical operations 
and frequently associated with various wounds and injuries of the 
body, has led to an extensive investigation of the mysterious nature of 
wound shock and methods of combating the same. 

The recent world war has afforded unparalleled opportunities to 
surgeons for the study and investigation of both shock and hemorrhage. 
As a direct result several of the older conceptions relative to the 
causation of shock must now be discarded and a standardized method of 
treatment has been definitely established on a sound basis. I propose 
to discuss briefly the various theories of the etiology of shock, together 
with the symptoms, diagnosis, prophylaxis and treatment. 

Definition. Shock may be defined as a general bodily state following 
various surgical operations and wounds characterized by a persistent 
low arterial blood-pressure, rapid, thready pulse, pallor, sweating and 
shallow, rapid respiration. Primary wound shock refers to those 
patients in whom the onset of the typical symptoms occurs suddenly, 
associated with the constant low systolic blood-pressure. Secondary 
shock is confined to those cases in whom all the symptoms of shock 
manifest themselves only after a longer or shorter period of continu- 
ous hemorrhage, exposure to cold, complicating infections, etc. All 
observers agree that the one common pathognomonic finding in shock 
is the persistent low systolic blood-pressure. Hemorrhage when severe 
presents a clinical picture quite similar to shock. Dr. W. J. Mayo, 1 
from his wide surgical experience believes that perfect hemostasis is 
positive prophylaxis against surgical shock, and states there is no 
surgical shock with perfect hemostasis. 

In both shock and hemorrhage there is an insufficient circulation of 
blood; in each severe damage may result to the vital cells of various 
essential organs; and in both conditions the essential problem is the 
rapid restoration of a normal blood-pressure. It is common knowledge 
that shock may be induced by rough handling, tearing and pulling of 
the body tissues, by prolonged exposure of the abdominal viscera, by 
traumatism to the mesentery of the bowel and by prolonged anesthesia. 
Numerous experimental studies of shock have been made in animals, 
apparently with the view of discovering a single cause for a condition 
now known to be instituted or aggravated by a variety of causes, at 
least in man. 

1 Quoted by Bissell: Surg., Gynec. and Obst., 1917, xxv, 8-22. 

(117) 



118 SHOCK AND HEMORRHAGE 

The Critical Level of Blood-pressure. Fraser and Cowell 1 have 
reported a large series of blood-pressure determinations made in shock 
cases among the soldiers in France. They found that moderate cases 
showed a systolic pressure of approximately 90 mm. of mercury while 
severely shocked patients had systolic pressures varying from 40 to 
not more than 70 mm. With the falling arterial pressure it is very 
essential, from a therapeutic point of view, to know at what level in 
the blood-pressure scale the oxygen supply to the tissues become 
insufficient. It has been found that this "critical level" of systolic 
pressure is approximately 80 mm. of mercury and a fall below r this point 
maintained for any considerable time results in an inadequate oxygen 
supply to the tissues. The nerve cells are early affected by this anemia; 
later the vasomotor mechanism suffers, and if the arterial pressure is 
not restored before too long a lapse of time no known treatment will 
suffice to save the patient's life. 

Theories of Etiology of Shock. Nerve Exhaustion Theory. G. W. 
Crile, 2 as a result of extensive investigations o the blood-pressure and 
nerve cells in shocked animals, states that "the most vital effect of 
shock is the impairment of the vasomotor mechanism." He believes 
that exhaustion of the cells in the brain, liver and suprarenal glands 
constitutes shock. Crile 3 and Dolley have shown that histological 
changes can be demonstrated in the nerve cells of shocked animals, 
which they attribute to the afferent impulses reaching the nerve 
cells from stimuli induced by trauma, fear, emotions, etc. On this 
basis Crile has developed his theory of anoci-association or nerve-block- 
ing, with which all surgeons are familiar. It should be stated that 
those who dispute the evidence of histological changes in the nerve 
cells of shocked animals claim that similar histological changes are 
within the limits of normal variations, 4 and that these same alterations 
in the nerve cells are the result of low blood-pressure rather than its 
cause. 5 

The Acapnia Theory. Henderson 6 advanced the theory that shock 
was the result of a reduction of the carbon-dioxide of the blood, a 
condition known as acapnia. In support of his argument he produced 
a shock-like state in animals by vigorous artificial respiration. He 
believed that the diminished CO 2 content of the blood produced in 
the above manner was the prime factor in the production of shock. 

Fat Embolism. Porter, who was one of the first Americans to visit 
the battlefields of France in order to study shock in the front-line 
trenches, has brought evidence to show that shock may be produced 

1 A Clinical Study of Blood-pressure in Wound Conditions, Jour. Am. Med. Assn., 
1918, p. 520. 

2 Volumes on Surgical Shock; Blood-pressure in Surgery; Anoci-association. 

3 Anoci-association, Philadelphia, 1913. 

* Allen: Proc. Soc. Exper. Biol. and Med., 1915, xii, 96: Kocher, R. A.: The 
Effect of Activity on the Histological Structure of Nerve Cells, Jour. Am. Med. Assn., 
July 22, 1916, p. 278. 

8 Cannon, W. B.: A Consideration of the Nature of Wound Shock, Jour. Am. Med. 
Assn., March 2, 1917, pp. 611-617. 

Am. Jour. Physiol., A Series of Papers, 1908-1910. 



THEORIES OF ETIOLOGY OF SHOCK ll 

in animals by the intravascular injection of fat or oil. In his paper 
on "Shock at the Front" 1 he wrote as follows: "I have myself ex- 
amined more than a thousand wounded. Save a few wounds of the 
abdomen, in which the bloodvessels or their nerves in that great 
vascular region were probably directly injured, there has been no case 
of shock except after shell fractures of the thigh, and after multiple 
wounds through the subcutaneous fat. In these, closure of the capil- 
laries by fat globules is known to take place. This is strong support 
for my discovery that shock may be produced in animals by injecting 
fat into the veins." 

Porter advocated the rebreathing of expired air as a preliminary 
measure to improve the circulation before surgical operations in badly 
shocked soldiers. His plan was to increase the excursions of the 
diaphragm so as to pump the blood out of the great splanchnic vessels 
back into the heart. 

Bissell 2 has observed six instances of fatal postoperative fat embolism 
in the necropsy service of the Mayo Clinic, and concludes that " deaths 
clinically supposed to be due to surgical shock are due, in so far as this 
experience goes, to pulmonary fat embolism and its attendant blood- 
pressure phenomena." 

Several investigations have brought forward evidence to disprove 
the fat-embolism theory of shock, and have pointed out a possible 
danger in the rebreathing of expired air as advocated by Porter. Thus, 
Cannon 3 quotes: "English surgeons of extensive experience at casualty 
clearing stations in the recent war, who have performed many hundreds 
of abdominal operations on patients in all degrees of wound shock, 
have testified that on opening the abdomen they have not found any 
primary splanchnic congestion." 

Furthermore, as regards the possible dangers of rebreathing expired 
air, "The testimony of Marshall, who as an expert anesthetist in a 
casualty clearing station has had large experience, is pertinent . . . 
the most important consideration in anesthetizing patients suffering 
from hemorrhage or shock is to avoid anything in the nature of asphyxia; 
indeed, that if such a patient becomes cyanosed he loses ground that 
can hardly be recovered." 

Finally, McKibben 4 reports the presence of fat in the vessels of all 
animals examined whether shocked or not and no quantitative or quali- 
tative differences were noted between the fat in the vessels of shocked 
animals and those of normal animals. 

Suprarenal Exhaustion. It is known that the medullary portions 
of the suprarenal bodies possess a blood-pressure-raising constituent, 
and the theory has been advanced that exhaustion of the glands leads 
to shock with consequent low blood-pressure. As opposed to this 

1 Shock at the Front, Boston, 1918. 

2 Pulmonary Fat Embolism: A Frequent Cause of Postoperative Surgical Shock, 
Surg., Gynec. and Obst., 1917, xxv, 8-22. 

3 Statement by Wallace, Fraser and Drummond: Lancet, London, 1917, ii, 727. 

4 A Note on Intravascular Fat in Relation to the Experimental Study of Fat Embo- 
lism in Shell Shock, Am. Jour. PhysiOl., 1919, xlviii, 331. 



120 SHOCK AND HEMORRHAGE 

theory, Mann 1 has shown that total suprarenalectomy does not pro- 
duce the state of shock. 

The Cardiac Failure Theory. Arguments that the heart itself is 
the offending organ in shock would seem to be disproved by the 
repeated observations on the slowing of the rapid heart action and the 
resumption of its normal function following massive transfusion of 
blood in patients suffering from shock due to hemorrhage. 

Shock as Exemia. After an intensive study of shocked troops 
on the battlefields, Cannon 2 offers an additional conception of 
the causation of shock which demands critical analysis. He believes 
that the low blood-pressure of shock is explicable as a consequence of 
blood being stagnant in some part of the vascular system, a condition 
to which he has given the name of "exemia," meaning "drained off 
blood." This exemic blood is not in the abdominal veins as formerly 
supposed, but is stagnant in the capillary beds. He has demonstrated 
that the capillary blood in shock may be so concentrated that a cubic 
millimeter by actual count may contain as hjgh as two and one-half 
million more of red blood cells than simultaneous venous blood counts. 

Furthermore, in cooperation with Bayliss, Cannon has shown that 
shock may result from tissue injury. Thus " the crushing of the muscles 
of the hind leg of an animal is followed by a fall of arterial pressure 
reaching a shock level in about one hour. This effect occurs even 
though the nerves to the leg are severed ; it is therefore not of nervous 
origin. If the bloodvessels (iliac artery and vein) of the leg are tied 
and the muscles injured by blows the pressure drops only after the 
blood flow is restored. And if a shock pressure is produced by muscle 
injury, tying the vessels may be followed by a steady rise of arterial 
pressure to the normal level." 

As a result of these important observations, Cannon has arrived at 
the following conception of wound shock: "There are primary wound 
shock with rapid lowering of arterial pressure, and secondary wound 
shock with toxemia and hemorrhage and subsequent lowering of the 
pressure." 

Various causes in combination, some nervous, others chemical and 
each associated with a reduction of arterial pressure, and all exag- 
gerated by hemorrhage, result in a state of collapse attended by a low 
blood-pressure. Sweating occurs with loss of fluids and loss of body 
heat. Along with hemorrhage, absorption of the toxic products con- 
tained in the tissue juices of the injured muscles effect a concentration 
and stagnation of the blood in the capillary beds. With the fall of 
pressure acidosis supervenes roughly proportionate to the drop of 
pressure. 

The condition of the shocked man tends to become acute unless the 
absorption of the toxic products of muscle injury are counteracted. 

1 Shock during General Anesthesia, Jour. Am. Med. Assn., August 4, 1917, p. 371. 

* A Consideration of the Nature of Wound Shock, Jour. Am. Med. Assn., March 2, 
1918, pp. 611-617. Reports of Special Shock Investigation Committee of the Medical 
Research Committee of Great Britain a series of six papers. 



PROPHYLACTIC TREATMENT OF SHOCK 121 

Operative treatment is imperative at the earliest possible moment. A 
shattered, useless limb must be amputated. A tourniquet should be 
applied as near as possible to the zone of injury and amputation done 
proximal to the constrictor before removal of the same. It is vital 
that the blood volume and blood-pressure be raised above the critical 
level by transfusion before the existing anemia of the nerve centers 
leads to a permanent paralysis. After too long a period of anemia 
recovery is not possible by any known method of treatment. 

It is obvious, from the many diverse theories on the causation of 
shock and the voluminous literature relative to experimental produc- 
tion of shock and its clinical manifestations, that the real etiological 
factors still remain to be discovered. However, it must be admitted 
that vital information, more especially as regards treatment and 
prophylaxis, has accrued from the careful and tedious investigations 
made during the recent world war. Fat embolism does not explain all 
of the cases; loss of vasomotor control with stagnation of blood in 
the great splanchnic vessels, a theory which had gained considerable 
prominence, could not be confirmed by English surgeons performing 
many hundreds of abdominal sections on soldiers in all stages of wound 
shock; while Cannon's notion of stasis of blood in the capillary bed 
with toxic absorption of the products of injured muscle tissue has yet 
to be confirmed. 

It seems fair to assume that each of these different factors may play 
a role in certain cases of shock, some instigating, others merely the 
result of a state of traumatic or surgical shock. 

Diagnosis. The diagnosis of surgical shock calls for but brief 
comment. Indeed, surgeons with but limited experience, if alert, 
recognize the typical syndrome in its early stages when appropriate 
treatment can be best instituted. The characteristic pallor, sweating, 
rapid weak pulse, subnormal temperature, shallow rapid breath- 
ing and a falling blood-pressure constitute a clinical picture which 
can hardly be misinterpreted. When the condition develops subse- 
quent to a prolonged or severe operation, or supervenes rapidly after 
a severe hemorrhage, the diagnosis is evident and the indications for 
treatment are both definite and urgent. 

Hemorrhage. Severe hemorrhage must be differentiated from shock, 
although the differential diagnosis is of little moment, because the 
treatment of both conditions is identical and because a hemorrhage 
so often instigates the shock state. In sudden, severe hemorrhage, as 
when a large artery is severed, the skin becomes cold, clammy and pale, 
the respirations are gasping and the temperature of the body sub- 
normal. The body tissues suffer from anemia, the patient often com- 
plains of a sensation of suffocation (air hunger) and becomes extremely 
restless. The pulse is very rapid and weak and death quickly ensues. 
During the hemorrhage the blood-pressure rapidly falls below the 
so-called "critical level." 

Prophylactic Treatment of Shock. For many years Dr. A. J. Ochsner 
has insisted that careful attention to details, namely, avoidance of 



122 SHOCK AND HEMORRHAGE 

exposure of the body to cold, gentle manipulation of tissues, clean, 
sharp dissection, nerve-blocking by Crile's method, careful hemostasis, 
etc., are little things of big moment to the patient. Minor details, 
such as avoiding useless trauma to tissues occasioned by the prolonged 
pull of retractors, preliminary elevation of the foot of the operating 
table to facilitate gravitation of the small bowel upward out of the 
operative field in pelvic operations, elevation of the head of the table 
to prolong cerebral anemia and diminish the amount of ether required 
in thyroidectomies, all of these seemingly insignificant details serve to 
increase the margin of safety for the patient. 

Treatment. There is abundant evidence to prove conclusively that 
exposure to cold has a very marked effect on instigating and increasing 
the state of shock. Accordingly, every effort must be made to restore 
the body heat to the normal temperature. Avoid exposure of the body. 
Apply external heat by means of hot-water bottles. Wrap the patient 
in warm blankets. Administer hot drinks to restore the body fluids 
and increase the blood volume. Mprphin should be given in large 
enough doses to keep the patient quiet. The systolic blood-pressure 
readings are usually low r . With a systolic pressure below the " critical 
level," namely, 80 to 90 mm. of mercury, a blood transfusion should be 
instituted without delay. It is common knowledge that blood trans- 
fusion is the specific treatment for shock secondary to hemorrhage and 
the clinical improvement is both rapid and certain, provided the 
oxygen deficiency of the tissues has not existed for too long a time. A 
small percentage of patients will require repeated transfusions if the 
blood loss has been severe. 

Transfusion of blood is indicated in patients who have lost con- 
siderable blood during a prolonged or severe operation in whom the 
blood-pressure tends to remain low in spite of supporting treatment. 
Cases of secondary anemia, with suppurating w r ounds and sinuses, 
often make a rapid convalescence after repeated transfusions. For 
several years it has been the practice at the Augustana Hospital to 
group the blood of a large number of available individuals in good 
health who have a negative Wassermann test and are desirous of 
giving their blood for a small fee. In this way donors properly grouped 
are always available for any emergency. The technic employed is the 
massive transfusion of whole blood by means of Dr. Percy's modi- 
fication of the Kimpton paraffin tube method. Amounts of blood 
varying from 500 to 1000 c.c. can be transfused within a period of 
five to six minutes. This method has been shown to yield a smaller 
percentage of reactions than the citrate method and possesses the 
additional advantage that the patient receives the blood without the 
addition of any chemical agent in as near the normal state as possible. 
The technical details o* this method are discussed by Dr. Percy in 
another chapter. It should be emphasized at this point, that the 
splendid clinical results obtained by blood transfusion therapy in 
thousands of soldiers suffering from shock and hemorrhage, with 
an enormous saving of lives, has established this method of treatment 
on a sound and popular basis. 



SUMMARY METHODS FOR COMBATING SURGICAL SHOCK 123 

Bayliss 1 has introduced the infusion of a 6 per cent, solution of gum 
acacia in 0.9 per cent, sodium chloride as a substitute for blood trans- 
fusion when blood is not available in sufficient quantities. He advo- 
cates infusion of 500 c.c. amounts by the intravenous route within a 
period of twenty minutes. This solution has the advantage over normal 
salt and adrenalin infusions, in that it does not leave the bloodvessels 
rapidly and it restores the blood-pressure by increasing the total blood 
volume. It has the disadvantage that, unlike blood, the oxygen carriers 
or red blood cells are not increased by this solution. However, surgeons 
who have had experience w r ith the gum-salt infusion method report 
that fatalities were not uncommon some of which must be attributed 
to the solution. As regards the use of various drugs, namely, strychnin, 
camphorated oil, etc., little need be said except to point out that their 
effect at best is very transitory and there is probably very little to 
commend them. 



SURGICAL OPERATIONS IN RELATION TO SHOCK. 

Finally, we come to a consideration of the treatment of those cases 
of shock in whom injuries or disease demand surgical procedures as a 
life-saving measure. It is well known that operations on patients in 
the shock state or those who have recently recovered from a severe 
hemorrhage are attended by grave dangers, due primarily to the low 
blood-pressure. These cases . do not stand ether anesthesia well. 
Clinical observations have demonstrated that the anesthetic of choice 
is nitrous oxide and oxygen in the ratio of three parts of nitrous oxide 
to one part of oxygen. Morphin should be given before operation, and 
great care is essential that cyanosis and deep anesthesia be absolutely 
avoided, as they precipitate an additional fall in an already low blood- 
pressure. Exactly the same precautions relative to the gentle handling 
of tissues, avoidance of exposure to cold, etc., apply here. If ampu- 
tation of an extremity is imperative a tourniquet should be applied 
proximal to the lesion and removed only after the amputation has 
been completed. 

SUMMARY OF METHODS FOR COMBATING SURGICAL SHOCK. 

For those patients in the shock state who demand surgical treatment 
as a life-saving measure the following suggestions are pertinent: 

1. The anesthetic of choice is nitrous-oxide-oxygen gas. It should 
be administered by a skilled anesthetist and great care taken to avoid 
cyanosis. 

2. Avoid unnecessary exposure of the patient's body during oper- 
ation. All surgical manipulations must be conducted with the greatest 
degree of gentleness and care must be exercised to avoid those factors 
which precipitate or aggravate the general shock state, viz., rough 

1 Intravenous Injection in Wound Shock, London, 1918. 



124 SHOCK AND HEMORRHAGE 

handling of tissues, prolonged exposure of the bowel or other viscera, 
needless handling of the intestines, pulling on the mesentery, etc. It 
goes without saying that all surgical procedures should be conducted 
as rapidly as is consistent with good surgery. 

3. Transfusion of blood is specific for the treatment of shock second- 
ary to severe hemorrhage. There is also good reason for believing 
that transfusion of whole blood may act as a prophylactic against the 
development of shock in patients subjected to prolonged or severe 
operations. Certain it is that patients respond in a most striking and 
beneficial manner after a transfusion performed either during or at 
the completion of such an operation. 

4. Postoperative care of the shock patient demands the application 
of external heat. The body should be wrapped in warm woollen 
blankets. Hot-water bottles, carefully protected, should be applied 
to the patient's body. Hot drinks may be given by mouth. 

5. The blood-pressure and blood volume must be restored. Saline 
hypodermoclysis is often a valuable adjunct ^vhen transfusion is not 
possible. 

6. The more common drugs employed to combat shock, such as 
strychnin, camphorated oil, adrenalin solution, etc., all have the prac- 
tical objection that their action is at best but transitory. Morphin 
by hypodermic injection is of definite value in many cases. It 
diminishes the amount of anesthetic required and subdues the use- 
less muscular exertions of the restless patient. It blocks the passage 
of external pain stimuli to the higher cerebral centers. 



INFLAMMATION AND HEALING OF WOUNDS. 

BY JOHN W. NUZUM, B.S., M.D. 

Definition. Inflammation may be defined as the series of phenomena 
which follow local injury to the tissues of the body. It is a complex 
vascular and cellular response on the part of the tissues involved, 
whereby the blood serum and blood corpuscles are mobilized at the 
site of injury in order to engage and destroy the invading bacteria, 
overcome the infection, aid in removing the inflammatory debris 
and ultimately prepare the field for reparative processes of healing. 

Sir John Sanderson defined inflammation as "the succession of 
changes which occur in a living tissue when it is injured, provided that 
injury is not of such a degree as at once to destroy its structure and 
vitality." Professor Adami's definition is as follows: "The series of 
changes constituting the local manifestation of the attempt at repair 
of actual or referred injury to a part or briefly the local attempt at 
repair of actual or referred injury." 

Formerly inflammation was considered by pathologists as a destruc- 
tive and harmful process, but subsequent bacteriological studies have 
proved conclusively that the tissue response in inflammation is largely 
of a protective nature and represents the body defences against invasion 
by various microorganisms. It should be clearly understood that 
repair goes hand-in-hand with inflammation and constitutes the end- 
picture of the phenomenon. 

Etiology. The causes are both numerous and varied, and may be 
subdivided into: 

(a) Predisposing causes, such as general debility, senility, cardiac 
and renal disease, syphilis, gout, rheumatism, tuberculosis or infectious 
diseases in general, all tending to lower the normal bodily resistance. 

(b) Exciting causes are injuries and infections. Accordingly the 
inflammatory irritants may be classified as mechanical, such as wounds 
or contusions of the body; chemical, such as burns by acids or alkalies; 
thermal, as exposure to the rays of the sun (dermatitis solare or sun- 
burn); freezing the exposed parts of the body; and specific inflam- 
mations of the tissues as, for example, erysipelas which is caused by the 
presence of the streptococcus in the subcutaneous lymphatics. Some 
authors believe that all inflammatory processes are the result of 
microorganisms or the toxins produced by the bacteria which lead to 
necrosis of the tissue cells of the host. However, it would seem that 
while bacteria probably are responsible for the greater number of 
inflammatory processes, such is not always the case. 

(125) 



126 INFLAMMATION AND HEALING OF 

Pathology of Inflammation. The pathology of acute inflammation 
may be conveniently considered under the following heads, viz.: (1) 
circulatory changes; (2) migration of blood corpuscles and fluids into 
the tissues; (3) changes in the perivascular tissues. When pathogenic 
staphylococci gain access to the deeper tissues of the body and are 
able to multiply in sufficient numbers to set up an acute inflammatory 
reaction the process may be described as follows: 

1. The circulatory changes consist of a transitory contraction of the 
bloodvessels of the affected part followed by a dilatation of the vessels 
with an acceleration of the velocity of the blood stream (active hyper- 
emia) . Later the blood stream becomes slower and eventually an actual 
stagnation of the blood current results in a condition of passive hyper- 
emia. With the slowing of the blood the leukocytes tend to separate 
from the central or axial stream and come to roll along and accumulate 
against the walls of the bloodvessels (margination) . The leukocytes 
and platelets tend to associate at the periphery while the red cells gain 
the axial portion of the blood stream. 

2. Exudation, or the passage of the constituents of the blood through 
the vessel walls, begins as soon as a passive hyperemia has been 
established . The polymorphonuclear leukocytes insinuate their pseudo- 
podia between the endothelial cells lining the vessels and rapidly 
worm their way through the vessel walls to gain access to the adjacent 
perivascular tissues in large numbers. The plasma of the blood 
passes into the surrounding tissues in excess of the amount required 
to nourish the tissue cells, and since it is not carried away sufficiently 
rapid by the lymphatics, an inflammatory edema results. The red 
cells and blood platelets, lacking ameboid movements, are carried 
through the vessel walls by diapedesis. Finally, there is a marked 
increase in the total number of the leukocytes, both in the inflammatory 
zone and also in the general blood stream (leukocytosis) . 

3. Changes in the Perivascular Tissues. With the myriads oi 
leukocytes mobilized in the zone of inflammation the combat for 
supremacy ensues between the invading bacteria and the defensive 
white blood corpuscles. Many of the polymorphonuclear leukocytes 
exert a phagocytic function engulfing the bacteria and destroying 
them while others are disintegrated and liberate thrombokinase, which 
acts on the fluid present in the tissues to form the delicate meshwork. 
The leukocytes perform additional important service, not alone destroy- 
ing the invading microorganisms but acting as scavengers they digest 
the dead tissues and pass back into the circulation through the 
lymphatics; if suppuration ensues they become pus cells. At the same 
time the liquor sanguinis present in the tissues at the site of injury pos- 
sesses both bactericidal and antitoxic properties against the bacterial 
invaders. Finally, the area is cleaned of debris, the fibroblasts pro- 
liferate to form new connective tissue, new capillaries develop to 
vascularize the newly formed connective tissue and healing may be 
said to be well advanced. Thus it seems that acute inflammation repre- 
sents a protective process whereby Nature pours large numbers of 



VARIETIES OF INFLAMMATION 127 

cells and quantities of fluid into the inflammatory zone to meet and 
destroy invading microorganisms, neutralize bacterial toxins and 
furnish digestive ferments to liquefy and facilitate disposal of the 
inflammatory debris. 

VARIETIES OF INFLAMMATION. 

Varieties of inflammation may be subdivided into acute forms, with 
sudden onset and severe course; subacute, with insidious onset and 
milder type and chronic inflammation of low grade and long duration. 

Parenchymatous refers to involvement of the parenchyma or secret- 
ing cells of an infected organ as contrasted with interstitial inflam- 
mation where the connective-tissue cells are affected. Traumatic, 
due to an injury; specific infective, due to various microorganisms; 
serous, with profuse serous exudation; purulent or suppurative, char- 
acterized by excess of pus; hemorrhagic, associated with bloody exu- 
date; catarrhal, as in inflammation of mucous membranes; pseudo- 
membranous, characterized by the presence of a false membrane formed 
from the tissues rather than from the exudate; gangrenous, with 
necrotic foul-smelling exudation; metastatic, as in inflammation at a 
distant point from the original focus through blood-stream dissemi- 
nation, etc. 

Symptomatology. The local symptoms are pain (dolor), heat, 
(calor), redness (rubor), swelling (tumor), and disturbance of function 
(functio laesa). 

Pain of acute inflammation is of slow onset, constantly present in 
the same location, and is increased by palpation of the affected area or 
by allowing the part to be placed in a dependent position. This pain 
is due to the pressure of the inflammatory exudate on the terminal 
nerve endings and probably also to the tissue changes resulting from 
the presence of bacterial toxins. Heat is due to the increased amount 
of blood brought to the affected part. Redness is due to the increased 
blood content. In acute inflammation the skin may be a livid scarlet 
red but w r ith older cases it fades into a dusky purple hue. Swelling 
results from exudation and varies greatly in different parts of the body. 
Disturbance of function results directly from the pain and swelling of 
the inflamed parts. 

The constitutional symptoms naturally vary greatly with the sever- 
ity and location of the lesion. In mild cases slight or none are present, 
while in severe inflammations chills, fever and even prostration are 
often seen. 

Treatment. Treatment resolves itself into local and constitutional. 
Local treatment has three main things in view, namely: (1) removal of 
the cause of the inflammation; (2) rest of the affected part; (3) reduc- 
tion of the swelling and hyperemia, with relief of pain. Causative 
bacteria are removed by thorough drainage of suppurating wounds, 
with deep pockets, and especially is drainage important where the pus 
is under great pressure. Rest of the affected part is essential as it 



128 INFLAMMATION AND HEALING OF WOUNDS 

greatly diminishes the amount of blood to the inflamed area, lessens 
the pain and decreases both the spread of the inflammation and the 
danger of general sepsis. In inflammation of the extremities, elevation 
of the arm or leg after the proper application of a hot boric-acid-alcohol 
dressing, extending well beyond the area involved proximal as far as 
the body, not only lessens the swelling and decreases the pain, but 
tends to hasten convalescence and to prevent widespread dissemination 
of the invading bacteria in the blood stream. 

Hot and cold applications as the patient desires may be valuable 
in relieving tumefaction and pain in earlier stages of inflammation. 
Bier's "passive hyperemia" treatment is based on the belief that the 
increased number of blood corpuscles and the excess of blood serum 
exert favorable action on inflammatory processes. He advocates 
obtaining this increased hyperemia either by constriction above the 
zone of inflammation or by a suction apparatus. Constitutional treat- 
ment demands the use of tonics together with proper dietetic manage- 
ment and plenty of sunshine and fresh air in trie chronic inflammatory 
processes, which may prove to be of tuberculous, luetic or rheumatic 
origin. Finally, I wish to emphasize the splendid results obtained in the 
treatment of inflammations and infections by the application of the 
simple therapeutic light as employed at the Augustana Hospital. The 
rapidity with which inflammatory processes subside and the great 
comfort and diminished pain afforded the patient convinces one of the 
practical value of this simple measure. 

HEALING OF WOUNDS. 

The repair or healing of wounds is a normal physiological process as 
contrasted with inflammation, which is distinctly a pathological 
process. Repair goes on hand-in-hand with inflammation. Within 
twenty-four hours the edges of a wound may be glued together by 
fibrin and mitotic figures can be demonstrated in the connective 
tissues. In the repair of tissues the parenchyma cells play but little 
part, the connective tissues play the chief role. Indeed, it may be 
stated as a general rule, that the more highly specialized the tissue the 
less its power of regeneration. 

Before repair begins, large amounts of inflammatory debris must 
be removed. The polynuclears and large mononuclear cells present 
in the inflammatory exudate act as scavengers, engulfing bacteria, 
digesting dead tissues and picking up fragments to eventually make 
their way to the dilated lymphatics. The lymph glands act as mechani- 
cal and chemical filters and thus protect the blood stream from noxious 
material. Gradually the field of inflammation is cleared up and the 
way paved for healing. 

The phenomena of repair may best be studied in the healing of a 
surgical incision. When an incised wound heals without suppuration 
the process is called "primary union" or healing by first intention. 
Within twenty-four hours the wound edges are glued together by 



HEALING OF WOUNDS 129 

fibrin. The leukocytes have largely removed the inflammatory 
debris. The fixed connective-tissue cells and the endothelial cells pro- 
liferate to form the fibroblasts or young connective-tissue cells. From 
the walls of the capillaries little protoplasmic offshoots or buds develop 
which unite with similar capillary buds of other vessels to become 
canalized as new capillaries and thus the organization or vasculari- 
zation of the newly formed granulation tissue is effected and the wound 
is well on the way to healing by primary union. Granulation tissue, 
at first red, later contracts down thereby compressing the newly 
formed capillaries and becoming hard and pale white. At a later date 
the epithelium grows from the skin margins to bridge the gap. 

Healing by "second intention," or granulation is always associated 
with more or less suppuration and results when the wound becomes 
infected and there is a loss of considerable tissue through sloughing. 
The edges of the wound may become separated and the wound defect 
fills up from the bottom by the formation of friable capillary tufts 
surrounded by newly formed fibroblasts. As new fibroblasts develop 
and jbecome vascularized the cavity is finally completely obliterated. 
The epithelium gradually grows inward by proliferation of the marginal 
cells and healing by granulation is complete. 






SURGICAL FEVER AND INFECTIONS. 



BY JOHN W. NUZTJM, B.S., M.D. 

General Nature of Fever. Fever is a reaction on the part of the body, 
under control of the nervous system, and specially of the vasomotor 
mechanism, which has to do with the heat regulation. Any elevation 
above the normal temperature of the body constitutes fever. The 
process is usually associated with or accompanies inflammations or 
infections of the body. It should be emphasized that fever is not a 
harmful process to be dispelled by antipyretics and the use of cold 
packs, as was formally believed, but rather represents a reaction on the 
part of the body, whereby certain substances are formed in the blood 
stream to neutralize the toxins and destroy the invading bacteria. 

Fever is associated with a definite derangement of the heat-regulating 
mechanism. Oxidation processes are increased and both carbohydrates 
and fats are burned up to supply heat energy. 

Fever as an Immunity Reaction. There is real experimental and clini- 
cal evidence to prove that fever is a defensive and protective process 
rather than a harmful one. It has been shown that animals placed in 
- thermostats at elevated temperatures developed specific antibodies in 
the blood stream, w r hich enabled them to neutralize and destroy lethal 
doses of bacteria. Moreover, a definite and marked increase in the 
agglutinins and bacteriolytic substances occurs in the blood of these 
animals as compared with the controls. 

The clinical evidence of the protective value of febrile reactions is 
well demonstrated in the striking results that follow intravenous 
injections of foreign proteins in acute painful arthritis. Patients with 
painful, swollen joints often experience a most rapid disappearance of 
pain after a severe febrile reaction which follows the injection. Careful 
investigations of this phenomenon have shown that in general the best 
results occur in those cases which suffer a severe reaction, viz., a severe 
chill followed by a temperature of 102 to even 105 C. 

The foreign protein calls forth a leukocytosis and both specific and 
non-specific antibodies are increased in the blood stream. 

On the other hand it is well-known that in certain disease processes, 
such as pneumonia in alcoholics, or the aged, general peritonitis, etc., 
when the patient runs a subnormal temperature with a low white count 
or perhaps a leukopenia, the outcome is frequently associated with a 
grave prognosis. Here again it would seem that fever may be an index 
of the body resistance to infection. 

(131) 



132 SURGICAL FEVER AND INFECTIONS 

ASEPTIC TRAUMATIC FEVER. 

Aside from elevation of temperature associated with infections the 
surgeon meets with a type of fever known as traumatic fever or 
" postoperation rise." This fever occurs after aseptic operations, 
sprains, fractures, wounds and contusions, and is characterized by the 
absence of microorganisms at the site of injury or in the operative 
wound. This mild type of fever commonly appears the evening of the 
day of operation and persists for twenty-four to forty-eight hours, 
reaching a maximum of 100 to 102. It is not accompanied by a chill, 
and aside from the slight elevation of temperature the patient feels 
well. The blood often shows a moderate leukocytosis. The wound 
looks entirely normal and is not painful, red or swollen. The fever is 
presumably due to the absorption of the products of cellular disin- 
tegration, fibrin ferment, serous exudate and extravasated tissue 
juices. If of mild duration, it has no prognostic significance and 
requires no special treatment. However, a fevrt 1 appearing three or four 
days after operation and persisting practically always means infection 
and demands immediate inspection of the operative incision, A painful 
wound with red swollen margins is usually grossly infected. The ten- 
sion sutures must be loosened, and where pus is present in the sub- 
cutaneous tissues the wound should be laid wide open and hot dressings 
applied to prevent burrowing or deep dissemination of the infection. 
At a later time secondary suture may be necessary. 

MALIGNANT SEPTIC INFECTIONS. 

Introduction. A consideration of surgical infections necessarily calls 
for a discussion of septicemia and pyemia. Infection may be defined 
as the condition produced by the entrance and multiplication of 
pathogenic microorganisms within the body. In local infection the 
growth of the bacteria is largely restricted to the portal of entry and 
the associated tissue changes result from the toxic substance elabo- 
rated by the bacteria. When these toxic substances pass into the 
general circulation, giving rise to mild or grave constitutional symp- 
toms, the condition is known as toxemia. Diphtheria furnishes an 
excellent example of a toxemia, since the growth of the bacilli is 
largely restrained to the exudate over the tonsils and soft palate while 
the complicating paralysis of the muscles of the soft palate is due to 
the effect of the toxins on the nerve supply to these tissues. Sapremia 
is an obsolete and vague term applied to those conditions in which the 
symptoms are due to the absorption of poisonous products of decom- 
position without the presence of microorganisms in the general blood 
stream. Sapremia is well illustrated by the symptoms arising during 
the puerperium from portions of placental tissue retained within the 
uterus and undergoing decomposition. 

When during the course of infection pathogenic microorganisms gain 
entrance through the lymphatics into the blood stream and multiply 



MALIGNANT SEPTIC INFECTIONS 133 

in the blood and tissues of the body the process is known as septicemia. 
Formerly, septicemia was considered as a surgical affection limited 
largely to the pyogenic bacteria, namely, the Streptococcus and Staphy- 
lococcus pyogenes aureus. More recent investigations have shown 
conclusively that many of the acute infectious diseases, such as pneu- 
monia, typhoid fever, epidemic cerebrospinal meningitis, rheumatic 
fever, etc., are all accompanied by an early general invasion of the 
blood stream by the causative bacteria, with later specific localization 
in the various tissues. Blood cultures taken early during the febrile 
period of the disease or at the time of a chill will often yield pure cul- 
tures of the causative microorganism, although the percentage of posi- 
tive cultures is largely dependent on the cultural media employed 
and the technic and experience of the bacteriologist. To this general 
blood-stream invasion the broader and more comprehensive term 
bacteremia has been applied. 

If during the course of a septicemia or bacteremia, the invading 
microorganisms give rise to the formation of multiple metastatic 
suppurative foci or abscesses in various organs of the body the con- 
dition is known as pyemia. It will thus be seen that these different 
infectious processes are closely linked together and may be said to 
represent various degrees of severity of infection, depending largely on 
the general defensive powers of the human body. Pyemia presupposes 
the existence of a septicemia or bacteremia and represents merely 
the end-picture of the disease. 

Etiology. The etiology of septicemia and pyemia will be considered 
together. Our information is entirely due to the careful, painstaking, 
bacteriological examinations of the blood during life, together with 
routine cultural examinations of the body tissues and fluids at necropsy. 
It is obvious that septicemia can result only from infection somewhere 
within the body, but the portal of entry of the bacteria is frequently 
difficult to determine. It may result from an attack of tonsillitis, from 
infected teeth, otitis media, sinusitis, prostatitis, chronic appendicitis, 
gall-bladder disease, pelvic infections or gastric ulcer. The septicemia 
often results from a trivial scratch which has been forgotten or from 
a superficial pin-prick of the finger. Finally a most careful search may 
fail to reveal the portal of entry of the infection and to this class the 
name cryptogenic septicemia is given. It should not be forgotten 
that the bacteremia following pneumonia is frequently due to the 
causative microorganisms, the pneumococcus, while in scarlet fever a 
septicemia often is due to the common secondary invader, the strep- 
tococcus. 

The organisms isolated from septicemias in relative order of impor- 
tance and frequency are as follows: the Streptococcus, Staphylococcus 
pyogenes aureus, Pneumococcus, Bacillus typhosus, Colon bacillus, 
Bacillus pyocyaneus, Bacillus mucosus capsulatus, Meningococcus and 
some few others. 

Terminal Infections. Patients suffering from chronic diseases of the 
heart, kidneys, liver and lungs frequently succumb as a result of 



134 SURGICAL FEVER AND INFECTIONS 

secondary or terminal infections. Osier is authority for the statement 
that "the majority of cases of advanced arteriosclerosis and of Bright's 
disease succumb to these intercurrent infections." 

Flexner in a large series of 793 autopsies found 255 cases of chronic 
heart and kidney disease, in 213 either a local or general infection was 
present and in 52 there was a general infection of the body. He found 
the following organisms in order of frequency: Streptococcus pyogenes, 
Micrococcus lanceolatus, Staphylococcus pyogenes aureus, Bacillus 
welchii, Bacillus coli, Micrococcus gonorrhcese, Bacillus anthracis and 
Bacillus proteus. 

Technic and Value of Blood Cultures. It is obvious that bacterio- 
logical examinations of the blood during life yields information of 
great scientific, diagnostic, therapeutic and prognostic value. More- 
over, the rational employment of both sera and vaccines absolutely 
demands an accurate knowledge of the pathogenic microorganisms 
responsible for the disease. The persistence of large numbers of colo- 
nies of pneumococci in the blood stream during pneumonia gives a 
distinctly bad prognosis. The differential diagnosis between miliary 
tuberculosis and typhoid fever is immediately established by positive 
cultures of Bacillus typhosus when the clinical symptoms and physical 
findings are indefinite. It must be remembered that in septicopyemia, 
osteomyelitis or suppuration, bacteria may only be present in the blood 
at intervals, and especially is this liable to be true during the chill. 

The method of obtaining cultures from the blood may be briefly 
outlined as follows: The skin is carefully cleansed with alcohol or 
ether and may be painted with iodin. A constrictor is placed on the 
arm and the blood is withdrawn by venipuncture into a sterile glass 
syringe attached to a sharp needle. The median basilic or cephalic 
vein at the elbow is conveniently selected. Before clotting the fluid 
blood is inoculated in small amounts, viz., 5 c.c. blood into 50 or 100 
c.c. flasks of dextrose ascitic broth. Great care must be exercised to 
avoid aerial contamination. By using small amounts of blood the 
natural bactericidal properties of the blood may be largely overcome. 
Anaerobic cultures and inoculations of blood-agar plates should also 
be made. Staphylococci are frequently contaminations from the skin 
puncture. The inoculated cultural media is placed in the thermostat 
at 35 C., and allowed to incubate for twelve days. Daily examinations 
are made for evidence of bacterial growth, viz., turbidity and the 
organism is identified by morphological study of stained smears, cul- 
tural reactions and serological determinations. Certain of the less 
common pathogenic bacteria require special media for isolation. 

Morbid Anatomy. The bodies of patients dead from septicemia 
present little or no postmortem rigidity. Decomposition begins very 
early after death. The blood shows little tendency to clot and post- 
mortem hemolytic staining of the lining of the aorta and of the serous 
surfaces of the pleura and endocardium are often marked. Dissemi- 
nated petechial hemorrhages are present beneath the skin, and especially 
in the pleura, pericardium and epicardium. Occasionally these minute 



MALIGNANT SEPTIC INFECTIONS 135 

hemorrhages predominate throughout the body in so-called cases of 
hemorrhagic septicemia. The spleen is generally enlarged. The 
capsule may be soft and wrinkled and the splenic pulp is frequently 
soft and mushy. The heart, liver and kidneys present the common 
picture of cloudy swelling and fatty changes. An old otitis media, 
prostatic abscess or diseased appendix at autopsy may represent the 
hidden portal of entry of the infection. 

Pathology of Pyemia. In discussing the pathology of pyemia we 
must assume the presence of pyogenic organisms in the blood stream, 
but the essential characteristic is the development of multiple sup- 
purative foci in various organs and tissues of the body. In the majority 
of local suppurative processes leading to pyemia the walls of the veins 
adjacent to the area undergo an inflammatory process leading to the 
production of a thrombophlebitis. Small portions of these infected 
thrombi are swept into the blood stream and lodge usually in the lungs 
in the small capillaries or terminal vessels. Since these are infected 
emboli they produce widely disseminated minute metastatic abscesses, 
with a central zone of clumped microorganisms surrounded by a small 
area of necrosis and beyond this an area of leukocytic infiltration 
encapsulated by newly formed connective tissue. It has been 
demonstrated experimentally that anything which causes clumping 
or agglutination of the bacteria favors the development of abscess 
formation in the tissues. Moreover, bacteria in the blood stream show 
a special tendency to localize at the site of injured tissues. Indeed, 
it has been found possible to produce osteomyelitis in animals by 
fracturing a bone and then introducing microorganisms intravenously 
as they tend to be arrested at the site of the fracture and set up an 
acute suppurative process. In a similar manner appendicitis can be 
produced by crushing or ligaturing the appendix prior to intravenous 
inoculation. Endocarditis in animals is readily induced by intravenous 
injection of pyogenic bacteria, provided that the valve is the site of a 
previous mechanical injury. There can be no doubt that this factor 
of lowered resistance or tissue injury (locus minoris resistentise) is a 
very important element in the production of pyemia as well as in the 
causation of other acute disease processes. 

Thrombophlebitis in the neighborhood of pulmonary abscesses may 
give rise to showers of minute metastatic abscesses in the kidneys, 
spleen, myocardium, brain or muscles. 

An unusual form of pyemia is that resulting from infections of the 
gall-bladder, stomach, bowel or most frequently in the appendix lead- 
ing to the production of a septic thrombosis of the portal vein, with 
multiple abscesses of the liver, a condition always fatal and known as 
suppurative pylephlebitis. 

Symptomatology. Septicemia frequently complicates the puerperium, 
due to errors in technic at the time of labor, i. e., the so-called puerperal 
sepsis. A common and severe type of septicemia follows infections in 
the postmortem room. A slight abrasion of the finger or hand within 
a few hours may present the red streaks of lymphangitis running up 



136 SURGICAL FEVER AND INFECTIONS 

the patient's arm. The epitrochlear and axillary glands become 
swollen and painful. There are frequent chilly sensations or actual 
rigors followed by fever, usually moderate, but often high. The patient 
is prostrated and takes to bed. The fever often shows morning remis- 
sions and evening exacerbations. As the case progresses the tem- 
perature may fluctuate greatly. The pulse is rapid and weak. The 
tongue is dry and furred. The urine is scanty in amount and of high 
color. Sweating may be profuse. Vomiting and diarrhea are often 
prominent symptoms. Prostration dominates the general picture. 
The spleen may be palpable. There is a progressive and severe secon- 
dary anemia. Leukocytosis is usually marked except in those cases 
which succumb before the body has an opportunity to react. Repeated 
blood cultures taken during a chill will often yield pure cultures of the 
microorganisms responsible for the condition. A negative culture has 
no value while a positive result often gives information of prognostic 
and therapeutic value. Toward the end the patient may present the 
so-called facies Hippocratica, i. e., pinched ^nose, hollow temples, 
sunken eyes, etc. Low muttering delirium gradually is replaced by 
stupor and death. In the more protracted cases bronchopneumonia, 
lung abscesses, endocarditis, meningitis, peritonitis, arthritis or even 
osteomyelitis may appear as complicating sequelae. 

The symptoms of pyemia are quite similar to septicemia. The 
disease is ushered in by a severe chill or a series of chills. The tem- 
perature rises rapidly and fluctuates widely. With each successive 
shower of septic emboli there occurs a severe chill followed by drench- 
ing sweats. The temperature is subject to the greatest variations and 
may even drop to normal, only to shoot up again when new foci of 
suppuration develop in distant organs. The general symptoms of 
great prostration and weakness, vomiting, petechial hemorrhages in 
the skin, etc., are similar to those of septicemia. Acute pyemia may 
end fatally within a week while chronic cases may drag along for 
several months. The complications have been considered above. 

Diagnosis. A patient presenting in general the symptoms tabulated 
in the above paragraphs in association with a suppurating wound, an 
old osteomyelitis, chronic otitis media or a compound infected fracture 
must at once suggest the possibility of a septicemia or pyemia. When 
the symptoms develop rapidly after childbirth or subsequent to an 
autopsy infection the diagnosis is easy. Positive blood cultures render 
the diagnosis absolutely certain. 

It is extremely important to determine the portal of entry, as many 
chronic septicemias due to absorption of the microorganisms from 
infected tonsils, carious teeth, sinus disease, chronic appendicitis or 
gall-bladder infection clear up quickly after appropriate surgical 
treatment. In those forms of septicemia and pyemia due to hidden 
foci of infection such as prostatic abscesses, posterior urethritis or 
intestinal tract disease, the diagnosis is often difficult and is frequently 
misinterpreted as malaria, typhoid fever or miliary tuberculosis. 
Pyemia is to be suggested from the character of the fever and the local- 



MALIGNANT SEPTIC INFECTIONS 137 

izing symptoms of complicating abscesses when present in the lungs, 
kidneys, etc. 

Prognosis. The prognosis naturally varies with the age of the patient, 
duration of the disease, type of infecting microorganisms and the defen- 
sive power of the body. In general it may be stated that streptococcal 
septicemia offers the worst prognosis. In surgical septicemia, puer- 
peral sepsis, etc., complicated by meningitis, peritonitis or endo- 
carditis, the death-rate is very high. Suppurative pylephlebitis is 
always fatal. In the chronic types of pyemia with mild joint involve- 
ment recovery often follows. 

Treatment. The treatment naturally falls into three general 
divisions, viz., local, general and specific. 

Local Treatment. Local treatment demands the eradication of all 
foci of suppuration. Abscesses must be drained, carious teeth extracted, 
middle-ear disease treated in fact a most thorough search should 
be instituted for hidden foci of infection which may be feeding bacteria 
into the general blood stream. The tonsils, prostate and genito- 
urinary tract must not be overlooked. 

General Treatment. Absolute rest in bed is imperative. Fresh air 
can only do good. A liquid diet of high caloric value and given at 
frequent intervals is essential. Rectal feedings may be necessary. 
Copious consumption of large quantities of water is always beneficial, 
as it promotes elimination through the kidneys, bowels and skin. 
Hydrotherapy may be employed. Saline hypodermoclysis is often of 
value. Digitalis should be administered for a weak heart. Repeated 
blood transfusions are of benefit in those chronic cases with marked 
secondary anemia and low bactericidal properties in their blood. 

Specific Treatment. This method of therapy demands a careful 
bacteriological study of the patient's blood. If the septicemia is due 
to the streptococcus, large doses of antistreptococcal serum (polyv- 
alent) may be given intravenously, and as early in the course of 
the disease as possible. Investigations have shown that the strepto- 
cocci fall into several distinct classes. Each type possesses different 
cultural and serological characteristics and the questionable results of 
streptococcal serum therapy may be due to previous inadequate dosage 
or actual impotency of the serum. The serum when properly given is 
harmless, and in addition to its high opsonin content it stimulates the 
production of both specific and non-specific antibodies in the blood 
stream of the patient. 

In general it may be said that our knowledge of the streptococci as 
a group is as yet very incomplete and the disappointing results of 
streptococcal serum therapy in the past may be directly attributed to 
this fact. Recent epidemics of a peculiar, highly fatal type of broncho- 
pneumonia developing among soldiers convalescing from measles has 
been definitely shown to be due to the hemolytic streptococci. The 
antigenic properties of these hemolytic streptococci and the thera- 
peutic value of specific serum therapy are problems for future 
bacteriological study to solve. 



POSTOPERATIVE TREATMENT. 



BY JOHN H. GIBBON, M.D. 

IN no department of surgery will be found the exhibition of so great 
a display of individuality as in the after-treatment. Many surgeons 
are inclined to attribute their good results to their peculiar plan of 
postoperative care and yet, others, carrying out a postoperative treat- 
ment which is the exact opposite, claim equally good results. In 
recent years, however, there has been more unanimity of opinion, less 
stoutness in adhering to fixed rules, and more consideration shown to 
the individual patient. The change which has come about has been 
distinctly toward simplicity and a postoperative treatment directed 
especially toward the patient's comfort. These changes speak for 
reason and common sense. It is foolish to attempt to lay down for 
instance an iron-clad rule that every patient must have a bowel move- 
ment on a certain day following operation and equally absurd to say 
that every patient, after an operation, must have water withheld from 
the stomach for a definite number of hours. Common sense must 
guide us to a large extent, for in one case it may be imperative to have 
the bowels open the day after operation and in another no necessity 
for a movement for several days; one patient may be able to take 
water within a few hours after operation without nausea or ill effect 
where another may have his postoperative discomfort and nausea 
greatly increased. It should be understood therefore that what follows 
must not be taken as an inflexible guide never to be departed from 
unless it is so stated. 

Paradoxical as it may sound, postoperative treatment really begins 
before the operation in the preparation of the patient for the operation 
and extends throughout the operation itself because prevention is the 
most important part of treatment and much can be done before and 
during the operation to accomplish it. No discussion of postoperative 
treatment would be complete without mention of some of the factors 
which produce postoperative discomfort and complications and these 
should receive the first consideration. 

Correct Diagnosis. It may not be amiss in considering the post- 
operative comfort and safety of the patients to say that a correct 
diagnosisjjbefore the operation adds greatly to both. The failure to 
study carefully our patients, or to call to our aid the various laboratory 
methods of diagnosis, the tendency to look upon conditions as emer- 
gencies which are not emergencies at all and to do exploratory oper- 
ations upon patients where an approximate diagnosis can, with a little 

(139) 



140 POSTOPERATIVE TREATMENT 

care and effort, be made beforehand, result too often in a multiplication 
of incisions, a repetition of the operation and occasionally in the 
unnecessary death of the patient. Haste to operate in a case of appendi- 
citis complicated by some acute infection of the respiratory mucous 
membrane, "just an ordinary cold," is sure to result in a serious lung 
infection after the operation and serves to illustrate one of the points 
I would make. Hasty operations done for supposed acute abdominal 
crises, when the real condition is a pneumonia or a pleurisy, is another 
illustration. And still others are the hurried operations which have 
been done in cases of typhoid fever under the impression that the 
patients were suffering from appendicitis and where a simple leukocyte- 
count would have resulted in the avoidance of these catastrophes. 

It is these mistakes which we have made in the past that cause me to 
suggest that a correct diagnosis before operation has a remarkable 
bearing on the result and that hasty operations and those not preceded 
by a careful study of the patient and the employment of all those 
measures which aid diagnosis and tend to indicate the risk of operation 
and the patient's ability to withstand them, not only bring discomfort, 
danger, and often disaster to the patient, but are a distinct discredit 
to the surgeon and to surgery. 

Choice of Anesthetic. Probably in certain cases nothing contributes 
more to the patient's postoperative safety than a proper choice of 
anesthetic. Every experienced surgeon has a very marked preference 
for a certain anesthetic and is prepared to defend it on all occasions, 
and it is not my idea to attempt to change the opinion of any one in 
regard to his favorite anesthetic agent, but rather to urge that no one 
agent is always the best. There is no " safest anesthetic" for all cases. 
Ether, generally speaking, is probably the least dangerous of anes- 
thetics, but its irritating properties centra-indicate its use in the presence 
of acute infections of the respiratory tract, where nitrous oxide, chloride 
of ethyl, regional anesthesia or infiltration anesthesia can be used with 
comparative safety. In nephritis too, ether, instead of being a safe 
anesthetic, becomes a dangerous one. In disease of the heart valves 
and muscle, nitrous oxid, chloride of ethyl and chloroform are far more 
dangerous than ether. The use of some one of the various forms of 
regional or local anesthesia often places a particular operation in the 
category of safety, whereas a general anesthetic might make it unjusti- 
fiable. The use of intratracheal anesthesia and of spinal anesthesia in 
certain operations is plainly indicated and much safer than the ordinary 
means of bringing about the anesthetic state. What we need is a 
broader experience in the use of all anesthetics and the ability to exercise 
a wise choice in the selection of the particular anesthetic or method of 
administration in the individual case. There can be no doubt that 
such broader experience and choice of anesthetic will influence favorably 
the early recovery and convalescence of our patients. I cannot leave 
this subject without stating as a firm conviction that the adminis- 
tration of morphin and atropin by hypodermic one-half hour before 
the operation, not only results in a better and more complete anes- 



FIELD OF OPERATION 141 

thesia, but that it also helps to reduce the amount of the anesthetic 
to be used during the operation, tends to prevent shock and adds 
enormously to the patient's comfort and safety during the few hours 
immediately following the operation. 

Alimentary Tract. The former method of administering a purgative 
the night before operation has been given up by most surgeons and 
wisely because, in abdominal operations especially, the patients suffer 
in the postoperative period from gas and harmful peristalsis; more- 
over, the sleep and rest which they should have on the night preceding 
operation is disturbed. It is far better to give the laxative two, or 
even three, nights before the operation. Neither the same laxative 
nor the same dose should be given to every patient but the individual 
intestinal habit taken into consideration. Many a patient has been 
made uncomfortable and the intestinal tract greatly irritated by too 
free purgation or by the excessive or improper use of enemata just 
before being subjected to a surgical operation. My own custom is to 
find out what laxative the patient has been in the habit of taking and 
how it acts and then to give him, two nights before his operation, a 
sufficient dose of this laxative to produce two or three good bowel 
movements. After most operations the patient needs plenty of liquid 
and it is a mistake to deplete a patient before operation by producing 
a number of watery bowel movements. 

Too much attention, as a rule, is given to the bowels and too little 
to the condition of the mouth and nasopharynx. Even a slight acute 
inflammation of the upper respiratory tract is too often the cause of 
postoperative bronchitis or pneumonia. A cold in the head should be 
looked upon as an absolute contra-indication to the administration of 
any general anesthetic excepting in cases of the greatest urgency. The 
failure to properly cleanse the teeth and mouth before operation is a 
mistake in any operation which involves the mouth, pharynx, esophagus 
and upper gastro-intestinal tract, as wound infection can often be traced 
to a foul condition of the mouth. 

Nourishment. After the administering of the laxative, simple 
easily digested food with plenty of water should be given. Water alone 
can be given up to within two or three hours of the operation. The 
free administration of water supplies an element which is badly needed 
after the operation and tends to prevent the distressing thirst which 
follows the administration of an anesthetic and the loss of even a 
moderate amount of blood. 

Field of Operation. Most surgeons have discontinued the use of 
moist antiseptic dressings over the field of operation. This method 
certainly renders the patient uncomfortable and disturbs the rest which 
he should have prior to the operation. Antiseptics applied in this way 
also tend to produce irritation of the skin which adds to the patient's 
postoperative pain and discomfort. lodin, if improperly employed, 
especially upon delicate skin, may cause blistering and even wound 
infection. In order to prevent these complications, the iodin should 
be largely removed from the skin with alcohol at the conclusion of the 



142 POSTOPERATIVE TREATMENT 

operation. Too vigorous use of strong antiseptics on the skin cannot 
be too forcibly condemned. 

The Urinary Tract. Much of the postoperative trouble and dis- 
comfort arising from retention of urine can be avoided by a little investi- 
gation and care before the operation. The time to discover that a 
patient has a stricture, an obstructing hypertrophy of the prostate, or 
a specific urethritis is before and not after the operation. If such con- 
ditions are relieved before the patient is subjected to operation, a much 
smoother convalescence can be expected. While believing that the 
routine use of the catheter immediately before operation both unneces- 
sary and foolish, I think that when the patient can, he should void 
urine just before the operation and, if he is unable to do so, the bladder 
should be emptied by catheter at the conclusion of the operation. If 
this precaution is taken, it prevents the patient's bladder from becoming 
distended within the first eight or ten hours after operation. It also 
enables us to estimate the amount of urine secreted during the first 
forty-eight hours after operation with some decree of accuracy. 

Patient's Clothing and Position on Operating Table. There can be 
no question that insufficient clothing and exposure of the patient before 
and during the operation contribute not only to postoperative discom- 
fort but increase shock, lower resistance, and consequently render 
postoperative complications more likely. The too prevalent habit 
of removing warm woolen underclothes, in which the patient may 
have been in the habit of sleeping, and dressing him in a thin cot- 
ton shirt open down the back, is wrong and where it is followed we 
should not be surprised to find our patients on the day of operation 
with acute colds in the head. Exposure on the operating table and 
extensive and careless use of solutions over the patient's body should 
also be avoided. These solutions may be warm when they are applied 
but they soon cool and the patient lies covered with cold wet garments. 
It is too often the custom in abdominal operations to keep only the 
legs of the patient wrapped in a blanket, allowing the chest to be abso- 
lutely exposed to air and fluids which too soon become cool. A light 
blanket or woolen shirt should always encase the chest. The blanket 
which is over the lower extremities should come up 'as high as pos- 
sible without interfering with the field of operation. In other words, 
only so much of the patient should be exposed on the operating table 
as is positively necessary. Various methods of keeping the patient 
warm on the operating table have been devised, such as a rubber 
mattress containing hot water or an electrically heated table. Person- 
ally, I believe that if the patient is properly prepared beforehand, and 
if the surgeon and his assistants are careful not to allow the clothing 
to become saturated with fluids, there will be no necessity for any of 
these specially devised tables. If, on the contrary, it is the surgeon's 
custom to use large quantities of fluids, then some such method of 
heating the table is valuable. 

An unnatural position on the table with stretching of muscles and 
joints or with pressure on superficial nerve trunks may be the cause 



CONDUCT OF THE OPERATION 143 

of a great deal of postoperative suffering. Some of the unnatural 
positions into which the body is placed are necessary but they should 
not be maintained longer than absolutely needed. Much of the 
backache which the patient complains of after operation is due to the 
position occupied on the hard operating table. The perfectly flat 
position is very trying, especially to very stout patients, and it will be 
found that a slight elevation of the head and shoulders and a moderate 
flexion at the knees will render the respiratory act much easier and the 
postoperative backache less. The patient's arms should never be 
allowed to hang over the edge of the table as such a position is liable to 
result in a musculospiral palsy which will far outlast the normal post- 
operative convalescence. A further care should be taken to avoid 
blistering of the patient's skin by such agents as benzine, ether, etc. 
If these agents are applied in excess, they collect under the patient and, 
if the pad on the operating table is covered with rubber, as it usually is, 
quite severe blistering may occur. 

Conduct of the Operation. Undue haste in the performance of an 
operation is as bad as unnecessary prolongation of it, the one may 
lead to injury of organs requiring additional operative procedures 
or to some catastrophe during convalescence, and the other has to be 
avoided as it means the use of much more of the anesthetic with the 
greater likelihood of the postoperative complications which result from 
anesthetics. 

Rough handling of tissues during the performance of an operation re- 
sults in the injury of organs, reduces their resistance to infection, causes 
hemorrhage, increases shock, and interferes with healing. I have often 
thought that we would be better surgeons, would possess more manual 
dexterity and skill and show greater respect for the tissues we handle 
if we had to do all our early work with the aid of local anesthesia only. 

If a certain care is used in the application 'of ligatures, much post- 
operative discomfort and in abdominal work occasionally a serious 
postoperative complication may be obviated. The ligation of large 
masses of tissue should be avoided. I believe also that as a rule it is 
better to use small gut in ligating small vessels. Suture ligatures are 
much less apt to become displaced than the ordinary ligature. The two 
great objections to the ligation of large amounts of tissue in the abdo- 
men are that such ligatures are very apt to slip during the subsequent 
manipulation of the tissues or after the operation and that it is more 
difficult to cover the raw area to which the intestine is apt to become 
adherent with a resulting obstruction. When large masses of tissue are 
included in ligatures passed on the pedicle needle, there is also a risk of 
including within the ligature some important structure, such as the 
ureter. The ligation of the individual vessels in the broad ligaments, in 
the mesocolon and elsewhere is a far better plan than the older method 
of including a large amount of these structures in a single ligature and is 
followed by much less likelihood of subsequent adhesion and obstruc- 
tion. Too much stress cannot be put on the importance of avoiding the 
ligation of large masses of omentum, as such are sure to become adher- 



144 POSTOPERATIVE TREATMENT 

ent to the intestine or to the abdominal wall, whereas, if a number of 
ligatures are placed the omentum can be restored to the abdomen 
and spread out in a fashion somewhat like the normal. 

A common fault in technic is the too tight constriction of tissues with 
sutures. This not only applies to the skin, but to deeper structures. 
It should be borne in mind that all that is required is a comfortable 
approximation. Sutures too tightly placed interfere with circulation, 
produce necrosis, and lower resistance to infection. If the suture 
material is silk or linen thread, the too tight constriction of the tissues 
results in cutting and the primary object of the suture is thwarted. 
Many accidental wounds, such as lacerations of the scalp, are made to 
suppurate by the too close and the too tight introduction of sutures. 
In the accident wards of our hospitals it would be much better to pro- 
vide the interne with horse hair alone as a skin suture, as it is so delicate 
that too tight tying is impossible. 

The care and position of the drainage which may be necessary in 
an operation has an important postoperative bearing, especially in 
abdominal work. Personally I am inclined to believe that it is only in 
exceptional cases that rigid, inflexible drainage tubes should be used, 
since by pressure they may cause ulceration, especially when introduced 
into a mucous-lined cavity and often are responsible for persistent reflex 
vomiting. Such tubes also may be the cause of intestinal obstruction. 
Whenever a drainage tube is introduced into a mucous-lined cavity, 
care should be taken to see that the end of the tube does not make 
pressure on the wall of the cavity; to drain such organs as the gall- 
bladder it is only necessary to have the tube extend into the cavity for a 
short distance. Tubes should always be fixed by suture or some other 
means so that they cannot slip either in or out. This applies not alone 
to abdominal drains, but to all, and particularly to those of the chest 
wall. Uncovered gauze drains possess very serious disadvantages, the 
greatest of which is the disposition of the tissue to become firmly 
attached to them, thus interfering with drainage to some extent and 
rendering their removal difficult and very painful. Unless there is 
sufficient discharge from the wound to keep the drain moist, it is sure 
to become adherent at its exit from the wound and acts then more as a 
plug than a drain. Large unprotected gauze drains in the abdominal 
cavity also produce adhesions which often result in subsequent obstruc- 
tion. Because of the capillary quality of the gauze drain when placed 
against a closed organ, such as the intestine, common duct, renal 
pelvis, ureter, etc., it invites leakage. When covered with gutta-percha 
or thin rubber dam in such a way as to leave the gauze exposed only at 
the extremity of the drain or through small openings on the side, the 
drain at once possesses all the advantages of the tube and gauze drains 
and many of their disadvantages are obviated. It is true that these 
drains tend to slip about and may not remain in just the situation that 
the surgeon would like and therefore they should always be fixed with 
a light catgut suture in the desired position. As a general rule it is 
well to let the drain, of whatever character employed, pass out through 



DRESSINGS 145 

that part of the wound where it naturally falls instead of carrying it to 
one or the other extremity of the wound ; this is particularly important 
where it is known that the re-introduction of a drain will be necessary 
later. 

All drains should be fixed at their exit through the skin by a suture, 
safety-pin or some other device which will prevent any shifting of the 
drain. 

Dressings. In regard to the material used in dressing wounds and 
the method of holding them in position, there will probably never be 
any fixed rule, but it is not out of place in this connection to speak in a 
general way of both. 

In all clean wounds the dressing should be dry and gauze is the 
material commonly used* Zinc oxide adhesive strips are generally 
employed for the fixation of the dressing, but care should be taken not 
to apply these strips to skin covered by hair or to skin recently painted 
with iodin, unless the iodin has been thoroughly removed with 
alcohol, neither should the strips be applied so tightly as to interfere 
with normal movement of the underlying muscles, unless such inter- 
ference is desired. The adhesive strips should not, as a rule, overlap 
one another but an area of uncovered skin should be left between them. 
Wrinkling or pinching of the skin should also be avoided. We often 
make the mistake in applying the dressings after an operation of plac- 
ing the parts in abnormal positions, which is only occasionally neces- 
sary and which results in a great deal of postoperative discomfort. The 
old method of fixing the arm to the chest wall after a breast amputation 
with a tight binder or bandage is as good an illustration as I could give 
of the point I would make, since the position is unnecessary and gives 
rise to the greatest pain and discomfort, especially at the elbow. Very 
often in the use of splints and casts the bony prominences and nerves 
are not sufficiently protected from pressure and the patient conse- 
quently suffers an unnecessary amount of pain and he may suffer for 
weeks after the healing of the wound or injury from pressure ulcerations 
or from palsies; it is only necessary to refer to pressure ulcerations 
over the internal condyle of the humerus, over the heel and to Volk- 
man's contracture and to paralysis of the perineal nerve due to pressure 
below the knee. We have often seen patients spend days and nights with 
pain and discomfort due to a too tightly applied spica of the hip. This 
bandage is frequently applied improperly by an orderly while the 
patient is still anesthetized and, the only position which will relieve the 
tension, that of flexing the thighs on the abdomen, is denied the patient 
by a too careful nurse. A complaint on the part of a patient on recovery 
from an anesthetic of pain, especially at a distance from the wound, and 
of tightness or constriction of the bandage, or of a burning tingling pain 
at the site of a bony prominence requires inspection of the dressing and 
often the entire removal and re-application of the bandage, the splint, 
or the cast. 



VOL. I. 10 



146 POSTOPERATIVE TREATMENT 

IMMEDIATE CARE AFTER OPERATION. 

As far as possible the postoperative care should consist largely in 
making the patient comfortable and seeing that he does nothing which 
will disturb the normal healing of his wound and in aiding where 
necessary the reestablishment of normal functions. 

Immediately after operation, that is from the time the patient leaves 
the operating table until he has entirely regained consciousness, he 
should be constantly watched by a nurse or physician who is capable of 
preventing or dealing with any of the simpler difficulties which may 
arise in a patient recovering from an anesthetic and of recognizing 
early the symptoms of hemorrhage, suffocation or collapse. Even 
after the simplest operation a competent surgical assistant or the 
surgeon himself should be within easy call in case of emergency. 

Restraint and Position. The patient should be allowed such 
freedom of movement or position as will not disturb the wound or 
dressing. Too often patients are restrained fr^pm the simplest move- 
ment and made to lie absolutely quiet on the back when such restraint 
is not in the least necessary and only adds to their discomfort and 
makes them either rebellious or needlessly apprehensive. One often 
sees a patient who habitually sleeps with two or three pillows made 
absolutely miserable by being compelled to lie flat on his back with no 
pillow at all. In the early days of abdominal surgery this restraint 
was rigidly carried out, the patient not even being allowed to move a 
leg and the after-treatment was a torture. It is often better to allow 
the patient to try an attitude, which you know will be painful or uncom- 
fortable and let him discover for himself that it is not advisable, for 
in this way he is resigned to the necessary limitation of movement. In 
many cases a change of position such as the legs flexed on a pillow, 
slight elevation or lowering of the head, a hand on top of, instead of 
under, the bed clothes, or turning on the side produces a degree of 
comfort and satisfaction which only morphin can produce. Whenever 
a patient wishes to assume his accustomed attitude of rest in bed, he 
should be allowed to do so unless the character of the wound or oper- 
ation forbids it. 

Patients are always restless after an anesthetic unless morphin has 
been given and at times may be difficult to control. Forcible restraint 
of a patient, is a mistake as a rule and should be avoided if possible. 
Often a patient will quiet down if his attention can be diverted and 
he realizes his surroundings. As soon as a patient recovers from an 
anesthetic he should be assured that everything is all right and that he 
is in good condition. Such assurances will usually satisfy him and 
if it is not given in response to his inquiries, his anxiety is naturally 
increased. An intelligent and sympathetic nurse at this time is far 
more valuable than the patient's friends and relatives who are too apt 
to misinterpret his restlessness and reveal to the patient himself their 
own anxiety. 

The Fowler position is so generally understood at the present that 



NAUSEA AND VOMITING 147 

no description of it or illustration seems necessary. It should be under- 
stood, however, that this position cannot be comfortably maintained 
without one of the variously constructed supports which are placed 
either under or on top of the mattress. A few surgeons of wide experi- 
ence do not look with favor on this posture, but it is used in cases of 
peritonitis in a large majority of clinics. 

Artificial Heat. Artificial heat in the form of hot-water bags and 
hot- water tins can I think be overdone and of course if not properly 
employed can give rise to the most distressing burns. What a patient 
requires after an anesthetic of any length is warmth and protection 
from draughts while perspiration is active. Too much heat either in 
the shape of hot-water bags or blankets, I am convinced frequently is 
the cause of continued sweating. As far as possible the skin of the 
patient should be kept dry and warm. A cold clammy skin, especially 
when accompanied by restlessness, anxiety, and a rapid small pulse, is 
of course significant of hemorrhage and presents a very different picture 
from that of the ether delirium and profuse sweat seen immediately 
after an operation. 

Nausea and Vomiting. Nausea and vomiting is a more or less 
constant sequel of operation, especially of abdominal operations. We 
are prone to boast that with our individual method of inducing anes- 
thesia and of conducting our operations that the patient has " prac- 
tically no nausea," but this is an indefinite and often untrue statement. 
Although the anesthesia is responsible to a large extent for the nausea, 
it is not altogether so for we sometimes see distressing nausea after an 
abdominal operation performed under infiltration anesthesia. Internes 
and internist are far too prone to give drugs or drinks for the purpose of 
arresting nausea and vomiting and the patient and his friends beg for 
something to "settle the stomach;" drugs in this early stage are much 
more apt to aggravate it. A far better plan is to give nothing or else 
a full glass of water, which is usually promptly vomited with some 
relief. 

Care should be taken, especially after those emergency operations 
where there has been no opportunity to prepare the patient for an 
anesthetic, to see that none of the vomited material obstructs the 
pharynx or is inspired. My experience in using morphin and atropin 
in abdominal cases has shown vomiting to be so much less than in other 
operations in which it was not employed that I now use it in every 
operation of magnitude or long duration or those which I expect to be 
followed by much pain. It is seldom necessary to give a second dose, 
and this I try particularly to avoid, for it is better not to let the patient 
learn the comfort of morphin. Repeated small doses after operation 
do not appeal to me, because the patient is apt to become dependent 
upon it. When the single full dose is given before the anesthetic, the 
patient will often sleep for from one to three hours and remain quiet 
Jx>r a much longer period. 

Pain developing some hours after an operation is not to be treated by 
the immediate administration of an anodyne, but its cause should be 



148 POSTOPERATIVE TREATMENT 

carefully sought and removed. A careful and considerate nurse can do 
much to relieve such pain. Oftentimes the simple change of posture, the 
cutting of a tight bandage, the relief of pressure on some bony promi- 
nence, straightening out the clothing, or some such little attention will 
give relief. I have seen a patient kept awake all night by pressure on the 
heel after a fracture of the leg, and by pressure on the internal condyle by 
an internal angular splint. Pain under such circumstances is absolutely 
unnecessary, and its possible cause should always be considered. I 
have known a safety-pin to be passed through the patient's skin in 
fixing a bandage and to remain in this position for days. Therefore, 
instead of attributing the patient's complaint of pain to nervousness 
or to want of pluck, we should always make sure that there is not some 
actual cause for the complaint. 

Thirst. After all operations, but particularly after abdominal 
operations, thirst is an early complaint and one which I believe 
should be satisfied by giving water by the mouth, unless it is contra- 
indicated and in such cases by the rectum. 4f the patient is vom- 
iting, he may be given a glass of hot water w r hich as mentioned 
before will result in a fair gastric lavage. It is only \vhere vomiting is 
persistent, in certain operations on the stomach itself, and in cases of 
peritonitis that water by the mouth should be forbidden. Unless given 
with the idea of washing out the stomach, I think that cold water is 
preferred by most patients and I usually allow the patient the choice. 
If an operator does not believe in giving the patient water to drink, he 
certainly should give large quantities slowly by the rectum. 

Diet. The very old and the very young patients require earlier 
feeding after an operation than others and it seems to do them no 
harm. As a general rule a desire for food should precede its adminis- 
tration. It is a mistake to urge food upon any healthy patient soon 
after an operation, unless he really wants it. Water in good quantities 
is all the patient needs in the majority of instances during the first day 
or two, or albumen water with orange juice or orange juice alone may 
be given. 

In regard to the liquid feeding, the patient's choice and habit should 
be considered, as for instance, a patient who is accustomed to drinking 
tea should have tea and not be forced to drink milk. 

The return to a full liberal diet should be gradually brought about 
by following the liquid nourishment with cup custards, ice-cream, soft 
boiled eggs, etc. Spinach is a vegetable which is particularly useful 
after operation because it tends to produce movement of the bowels. 
Only easily digested and no rich food should be given to the patient 
the first week or two following operation and thorough mastica- 
tion should be insisted upon. Smoking, if habitual with a patient, 
should be allowed as soon after operation as desired, as it produces 
a sense of comfort. The first request of a French soldier during 
the late war after operation was for a cigarette and it was always, 
allowed him. 

Rectal feeding must often be depended upon after operation and 



BLADDER 149 

I believe that little else than peptonized or malted milk with eggs 
should be given. Alcohol in any form, if long continued, produces an 
irritation of the rectum and an intolerance for the nutrient enema. 

Bowels. One of the mistakes of the past and still too often made 
is that of the excessive and too early administration of laxatives after 
operation. If the patient has been properly prepared for operation 
and has taken only liquid food, the administration of any laxative 
within the first few days after an abdominal operation accomplishes 
very little good and adds enormously to the patient's discomfort and 
loss of sleep. The "gas pains" which patients complain of after oper- 
ation are not really due to gas, but to peristalsis and to increase this 
perstalsis with a laxative, when the intestinal tract is comparatively 
empty, does more harm than good. A small enema or the introduction 
of the rectal tube will accomplish more good and give rise to little dis- 
comfort. When it does become necessary to give a laxative, it should 
be of a mild character. For some years I have found that one of the 
preparations of mineral oil is very satisfactory. Milk of magnesia is 
another useful mild laxative in these cases. Of course occasionally 
when a patient has not been prepared for operation, a thorough opening 
of the bowels is a good thing, but to routinely administer a laxative on 
the second day after an operation as was formerly the custom, is a 
great mistake. 

Bladder. Many patients have difficulty in voiding urine, especially 
after abdominal operations and those done on the perineum and rectum. 
Excepting those cases where contamination of the wound is feared, 
every effort and means should be employed to make the patient pass his 
own urine and to avoid the use of the catheter. The patient should 
even be allowed to stand on his feet beside the bed in order to void, 
unless such a position is apt to interfere with the integrity of the wound 
closure and female patients should always be allowed to sit up on a 
bed-pan rather than be catheterized. Too frequently the catheter is 
passed when the patient has had no discomfort and there is no evidence 
of distention of the bladder and it is done simply because the patient 
has not voided within eight or ten hours after operation. It should be 
borne in mind that patients often secrete very little urine during the 
first few hours after operation and, when once the catheter has been 
used, there is a great likelihood of it having to be used again. If a 
patient voids once, he should be able to void afterward and the catheter 
should not be used unless absolutely necessary because of distention. 
The administration of an enema very frequently enables the patient to 
void and in rectal cases inability to do so is due to too tight packing of 
the wound or to the presence of a tube or tampon in the rectum and 
their removal will bring about a normal micturition. 

If a patient has urethritis, the passage of the catheter is strongly 
contra-indicated as it is sure to result in an extension of the infection. 
One of the strong arguments against the use of the catheter is the danger 
of infection and an irritation of the urethra from continued catheteri- 
zation. When catheterization is absolutely necessary, it should not be 



150 POSTOPERATIVE TREATMENT 

done I believe at regular intervals, but when the patient becomes 
uncomfortable because of a full bladder. We have all seen patients 
suffer great torture because the stipulated number of hours between 
catheterizations had not yet expired. Nothing is more uncomfortable 
to a patient who has been operated upon than a distended bladder 
and no one can predict in any given case the number of hours required 
to bring about an uncomfortable distention. As a rule a patient is 
more apt to pass urine before the bladder becomes greatly distended 
and it is at this time that he or she should be encouraged to do so. The 
character of the urine* and the amount passed should be as carefully 
determined after the operation as before it. 

Pulse, Temperature and Respiration.^In determining the value of 
these after an operation, it is important to have a record of them a day 
or two previous to operation. Nurses should be instructed always to 
feel and count both radial pulses, as often one of these vessels is much 
larger than the other. 

The significance of the pulse, temperature and respirations in shock 
and hemorrhage are dealt with so completely in the chapters dealing 
with these subjects that it is unnecessary to mention it here. Axillary 
temperature after an operation is not very reliable and where there is an 
unexplained difference in the mouth and axillary temperature, it should 
be confirmed by a rectal thermometer. An increased respiratory rate 
is not given the consideration in surgical cases that it deserves and 
when it is not in proportion to pulse and temperature or is not explained 
by the character of the operation, it usually means some inflammatory 
condition in the lung or pleura or it may indicate an acidosis. 

Time in Bed. No definite rule can be laid down as to the number 
of days a patient should stay in bed after an operation. In the early 
days of abdominal surgery, too much restraint was put on a patient in 
this way and every other way, and a few years ago there was a move- 
ment which went too far in the other direction and resulted in 
wound infection and other complications. 

The question is not how soon the patient can get out of bed, but how 
soon should he do so. Generally speaking he should remain in bed until 
his wound is healed, if it should be an abdominal wound, and if it is a 
large abdominal wound he should remain in bed at least a week after 
it has healed. 

CARE AFTER RECOVERY FROM OPERATION. 

Many of our finest surgical results are spoiled by a lack of care after 
the patient has left the hospital and simply because he has not been 
told what he should and should not do or has not received the late 
postoperative treatment which he requires. 

What would be the results in our cases of exophthalmic goiter if no 
attention were paid the patients after operation? 

I should say the two conditions most neglected after the operation 
were tuberculosis and syphilis. The results of surgical interference in 



COMPLICATIONS AFTER OPERATIONS 151 

localized tuberculosis are remarkably good and the patients usually 
make complete recoveries, if they carry out the proper hygienic, 
dietetic and medicinal treatment after operation. If these measures 
are not enforced, there is a fair chance of recurrence of the trouble or its 
development somewhere else. Syphilitic patients are too frequently 
operated upon and no instruction given them as to their subsequent 
treatment. The same applies to operations for malignant disease; the 
use of the z-rays after operations for cancer, and the use of the oxrays or 
radium with Coley's toxins after operations for sarcoma have resulted in 
many cures that would have never been obtained through operation only. 
Most surgeons are too busy to carry out these postoperative treatments, 
but the responsibility of seeing that the treatment is carried out is theirs. 
Another important thing after operation and one generally neglected 
by surgeons is some plan of following up the patient in order to record 
the result obtained. Such a plan does more to destroy self-satisfaction 
on the part of the surgeon and stimulate him to better efforts than 
anything else. 

COMPLICATIONS AFTER OPERATIONS. 

Hemorrhage and Shock. Hemorrhage and shock, two serious but 
fortunately not common sequels of operation have been considered in 
other sections of this work and it is needless to speak of them again. 
(Pages 117-124.) 

Abdominal Distention. Abdominal distention of some degree is 
common after abdominal operations but may occur after any operation 
or after an injury, such as a broken leg or the laceration of a kidney. 

The postoperative distention may be due to a simple accumulation 
of gas in the intestinal tract, the result of fermentation or the swallow- 
ing of air, to a paralytic ileus, to an obstruction of the bowels (mechani- 
cal or septic) or to acute dilatation of the stomach. The simple type 
of moderate distention is, as a rule, easily relieved by the use of the 
rectal tube, change of position, the administration of a carminative or 
the use of an enema and as the employment of these agents has been 
dealt with, it is needless to consider them again, but the distention 
resulting from the other causes mentioned deserves more serious 
consideration. 

Paralytic Distention. Paralytic distention is not always due to a 
peritonitis as some would have us believe but should be distinguished 
from that form of intestinal obstruction due to peritonitis. We see 
the paralysis of peristalsis after operations on the kidney where the 
peritoneum has been subjected to only the slightest traumatism and 
after injuries, especially in strong muscular individuals and in the aged, 
when rest in the recumbent position is necessary, and in many other 
conditions. Although in the majority of cases the distention can be 
relieved in the beginning by simple means if it lasts for any length of 
time it becomes very distressing and possibly serious. In the post- 
operative cases it comes on early and is accompanied by vomiting. Its 



152 POSTOPERATIVE TREATMENT 

distinctive feature is an absence or marked lessening of peristalsis. 
There is often great difficulty in differentiating this condition from an 
ileus due to peritonitis but the patient does not show the other symp- 
toms of peritonitis and the distention of a peritonitis is a late, not an 
early symptom, after operation, unless the peritonitis was present at 
the time of the operation. 

Where there is a doubt as to the cause of the obstruction, that is, 
when a peritonitis or a mechanical obstruction is suspected, the 
treatment of these conditions, which is given later, should be followed, 
and not that to be outlined now. 

Where one can be sure then that a mechanical obstruction or a 
peritonitis is not present relief of the distention may be obtained by 
attempting to stir up peristalsis by the administration of drugs and by 
the use of enemata. Local applications such as turpentine stupes or 
flax-seed poultices often give comfort and cause the passage of flatus. 
Enemata of soap and water with turpentine, given high, in good 
quantity are indicated. An asafetida enema A am sure I have seen 
give relief although its efficacy is doubted by many. The rectal tube 
or nozzle left in position for several hours, especially with the patient 
on his left side, when this position is not contra-indicated, is of the 
greatest service. 

Among the drugs employed in this condition are strychnin, eserin 
and pituitrin. The ordinary purgatives often only increase the con- 
tents of the intestine by causing secretion from the mucous membrane 
and do little to produce peristalsis. I have used eserin but confess that 
I have not been impressed with its power. Pituitrin will certainly 
increase peristalsis and I have seen it cause a rapid subsidence of a 
distended abdomen following a nephrotomy. I should not use either 
of the two latter drugs for a distention coming on after forty-eight 
hours after an abdominal operation for fear of aggravating a peri- 
tonitis or an obstruction due to a mechanical cause. Too much stress 
cannot be laid on the importance of eliminating these two conditions 
before resorting to any measure which will increase peristalsis. C. L. 
Gibson 1 strongly recommends pituitrin. He urges a fresh preparation 
and advises "an ampoule (1 c.c.) of the preparation and repeat every 
hour up to three doses; subsequent doses two hours apart." 

The old method of attempting to relieve paralytic distention by 
puncturing the bowel through the abdominal wall is certainly always 
dangerous and practically never efficacious. Even the opening of the 
abdomen and establishment of an artificial anus will as a rule only 
relieve the distention of two or three feet of intestine, although this is 
a far safer plan than puncturing the bowel through the abdominal 
wall, which is no longer a justifiable procedure. 

Postoperative Intestinal Obstruction. This distressing complica- 
tion is not as frequent as formerly, due to the development of a more 
careful technic and the observance of those precautions to prevent it 

1 Ann. Surgery, April, 1916. 



COMPLICATIONS AFTER OPERATIONS 153 

which have already been repeatedly referred to, particularly the 
avoidance of rough handling of tissues and the covering over of raw 
areas with peritoneum and omentum, because it is adhesions which con- 
stitute the chief cause of postoperative obstruction. Of course the 
cause of the obstruction may have existed before operation, such as a 
septic peritonitis, or may be unavoidable during the operation owing 
to a necessarily extensive procedure, such as the removal of a large 
portion of the colon or a large adherent tumor. 

Mechanical Obstruction. In this type there is definite mechanical 
pressure exerted upon the intestine which first prevents the passage 
of the intestinal contents and later produces either gangrene of 
the intestine or peritonitis or both. Adhesions certainly cause the 
majority of the mechanical postoperative obstructions and the most 
potent type is the adhesion of the small intestine to some fixed point, 
such as the abdominal or pelvic wall, the raw surface of a broad liga- 
ment, the uterine stump and the mesentery. One constantly sees 
numerous coils of small intestine bound together by the densest 
adhesions and yet no obstruction results. The degree of mobility of 
the structure to which the intestine is adherent then strongly deter- 
mines the development of obstruction. It may be said in this con- 
nection that the surgeon is frequently surprised on opening an abdomen 
a second time to find that nature has done away with many adhesions 
which were present at the first operation and if this were not true, the 
number of obstructions would be greatly increased. It is also a com- 
mon observation that a severe and extensive infection of short duration 
gives rise to fewer permanent and obstructing adhesions than a more 
localized or milder infection requiring prolonged drainage. Drainage 
itself in the absence of infection is a frequent cause of obstructing 
adhesions. This was seen frequently in the early days of abdominal 
surgery when drainage was employed after all operations. 

Symptoms. The symptoms of the mechanical obstruction are often 
insidious and rarely appear before the fifth or sixth day after operation 
and often not until much later. The first complaint is usually of 
paroxysmal pain and difficulty in satisfactorily emptying the bowels; 
this is followed by vomiting if the obstruction is high or distention if it 
is low. Vomiting develops later regardless of the situation of the 
obstruction, but distention may not be marked if the obstruction is 
high up in the small intestine. Visible peristalsis with distention is 
absolutely indicative of mechanical obstruction. It is quite evident 
too that the sharp paroxysmal pain is caused by peristalsis. 

The patient may be relieved in the early stages by a move- 
ment of the bowels or the passage of a large quantity of gas but the 
symptoms are apt to recur and if they do, it is another indication 
of some mechanical obstruction, but it may not be so easily relieved 
as in the first instance. After the onset of the symptoms it is not at all 
infrequent to have a copious movement follow an enema or consider- 
able gas escape through a rectal tube, but if this does not relieve the 
pain, diminish the distention and arrest the vomiting, it is evident that 



154 POSTOPERATIVE TREATMENT 

the fecal matter and gas have come from the bowel beyond the point 
of obstruction. One then must not be misled by the mere fact that a 
movement or the expulsion of gas has followed the employment of an 
enema or the introduction of the tube. 

Septic Obstruction. In this type of intestinal obstruction the cause 
is a septic infection of the peritoneum and the obstruction is paralytic 
or adynamic. It comes on early after operation, usually those done for 
a septic condition of one of the abdominal viscera or a diffuse peritonitis, 
or it may have existed before operation. It is characterized by per- 
sistent vomiting, restlessness, pain, apprehension, anxious expression, 
abdominal distention, absent peristalsis, no passage of fecal matter or 
flatus and later by a complete absence of pain, but unfortunately by a 
realization of danger on the part of the patient. The facial expression 
is that typical of peritonitis and near the termination the patient is apt 
to show a peculiarly happy form of delirium in which he may convince 
the inexperienced that he is much better. 

Diagnosis. It is not always easy to differentiate this type from the 
mechanical and the difficulty often arises because we have present both 
a peritonitis and a mechanical obstruction. The typical cases, however, 
are very different and we should always endeavor to distinguish them, 
for the treatment of the two differs greatly. 

Treatment. In the mechanical type, unless the use of an enema or the 
continuous use of a mild remedy such as mineral oil brings complete 
relief, operation is plainly indicated and should not be delayed. Much 
valuable time is lost and the patient's suffering greatly prolonged and 
increased by the use of purgatives and the employment of drugs to 
increase peristalsis. When there is evidence of a definite obstruction 
one should operate just as promptly as in a strangulated hernia. 
Delay means gangrene or peritonitis and an operation which may be 
only palliative or preliminary, whereas prompt action gives extremely 
good results when there is no infection. Before re-opening the 
abdomen the possibility of a strangulated hernia, particularly of a 
partial enterocele, should be eliminated. 

The choice of the anesthetic in these cases is of great importance and, 
if the patient has been vomiting persistently, gastric lavage should 
precede the anesthetic. Whenever the patient is very ill the abdomen 
should be opened under infiltration anesthesia and if possible the entire 
operation conducted without the use of a general anesthetic. As a 
rule the previous incision can be re-opened, but if this is so placed as to 
give poor access to the region where the obstruction is suspected or is 
badly placed for a general examination of the abdominal cavity, a new 
incision should be made. These patients can usually indicate approxi- 
mately fairly well by the location of the pain and tenderness the region 
in which the obstruction will be found , After the abdomen has been 
opened it is important to prevent the extensive protrusion of the coils 
of distended small intestine. Evisceration for the purpose of locating 
the point of obstruction is not only unnecessary but contra-indicated 
because it produces shock, increases risk of infection and subjects the 



COMPLICATIONS AFTER OPERATIONS 155 

distended and infected bowel to unnecessary traumatism. The site 
of the obstruction can usually be detected by tracing the distended 
bowel until the collapsed portion is encountered, or preferably by 
tracing the collapsed bowel up to the point of distention. By pursuing 
the latter plan injury to the distended intestine is less likely. One 
should not feel that all the adhesions encountered should be separated, 
but wherever the small intestine is adherent to a fixed point, such as the 
mesentery or the abdominal wall, it should be liberated. If the patient's 
condition is very bad, it may be a better plan to do an enterostomy, 
particularly if difficulty is encountered in finding the point of obstruc- 
tion. This rule should certainly be followed in the case of the large 
intestine as it is a well-established rule that resections of the large 
intestine in the presence of acute obstruction are contra-indicated. 
Resections of the small intestine can be done in the presence of acute 
obstruction if the patient is not very ill and the proximal portion of the 
bowel is in good condition. The short-circuiting of the small intestine 
by anastomosing a coil of intestine above and below the obstruction is 
a feasible procedure and in certain instances where the separation of 
the adhesions may mean perforation of the bowel, a wise one. 

The treatment of paralytic ileus due to peritonitis is the same as that 
of peritonitis, which has been fully dealt with elsewhere. The majority 
of surgeons do not as a rule recommend operative interference in these 
cases as the mortality is very high and as it is believed that practically 
as many cases recover without as with operation. Where one is unable, 
however, to eliminate the question of mechanical obstruction, the 
abdomen should be re-opened. 

I believe that in these cases the best results will be obtained by 
following Ochsner's method of treatment in general peritonitis. C. L. 
Gibson in his paper already referred to in the section dealing with 
paralytic distention expresses great confidence in the use of pituitrin. 
In the septic cases I have had but little experience with it and am not 
in a position to recommend or decry its use. 

Acute Dilatation of the Stomach. Acute gastric dilatation or gastro- 
jnesenteric ileus may occur after any operation but is most frequently 
seen after abdominal operations, especially those involving the bile 
passages. The condition is also seen in pneumonia and other diseases 
which are in no sense surgical. The explanations of the condition are 
so numerous and diverse that it may be safely presumed that there are 
many causes or that the true cause is unknown. It corresponds in many 
ways to the paralytic distention of the small intestine already described. 
Surgical writers have laid so much stress upon pressure by the mesen- 
teric vessels upon the duodenum as a cause that the term gastro- 
mesenteric ileus has become synonymous with acute dilatation of the 
stomach. The dilatation has, however, in too many cases stopped 
short of the mesentery and its vessels for this term to be considered 
generally applicable. 

In septic cases the condition is often associated with general dis- 
tention of the small intestine and the paresis of the stomach like that 



156 POSTOPERATIVE TREATMENT 

of the intestine is due to infection but it is seen too frequently in clean 
cases and where no operation has been done to explain all cases on 
this basis. The following paragraph from Crandon's Surgical After- 
treatment gives a good idea of the variety of supposed causes: "It is 
said to be common in thin, weakly individuals, especially those with 
general enteroptosis. Abdominal trauma, errors of diet, the accumula- 
tion of gas due to fermentation of retained foods, drinking large quan- 
tity of fluids, especially carbonated waters, and tight abdominal 
binders have all been blamed as the source of this complication. Con- 
nor makes the statement that obstruction of the duodenum by the 
overlying mesentery must be regarded as a factor in the development of 
one-third to one-half of all cases of acute gastrectasis, and Polak states 
there can be no doubt but that the Fowler posture favors constriction of 
the lower end of the duodenum between the root of the mesentery and 
the vertebral column. Peritonitis may be a factor in certain cases." 

Bloodgood 1 discusses the subject at length and considers mesenteric 
pressure at the juncture of duodenum and fejunum the commonest 
cause and reports several cases. 

Chloroform anesthesia and pyloric spasm are two other causes which 
have been suggested. 

The whole subject has been exhaustively dealt with by Lewis A. 
Connor 2 of New York, and later by Laffer 3 who has collected 217 cases 
and gives an extensive bibliography. 

Vomiting is the most common and pronounced symptom although it 
has been absent in a few cases. The profuseness of the vomiting is 
distinctive and has usually been persistent, although intermittence 
has been noted and the vomiting is apt to cease some hours before 
death. The fluid vomited is bile-stained and has a sweetish odor. It 
is never fecal. 

The distention is characteristic in the typical case, it is first noticed 
in the epigastrium and extends then to the left side. In the early stages 
the lower abdomen remains flat or even scaphoid, though the stomach 
has in one or two instances been so dilated as to fill the entire abdomen. 
The succussion splash can usually be detected. Pain or a sense of 
great discomfort in the epigastrium is a more or less constant symptom. 
The facial expression denotes distress and anxiety and hiccough is often 
present. Constipation is the rule but in a few cases there has been a 
marked diarrhea. A visible peristaltic wave has been noted by Blood- 
good and others but it has not been a common sign. The pulse-rate 
increases with the distention but the temperature remains normal or 
subnormal. Respiration is rapid and embarrassed and dyspnea may 
develop. Nearly all observers have referred to the complaint of great 
thirst. Collapse may supervene in twenty-four or forty-eight hours 
after the onset of dilatation, but many cases have extended over a 
number of days and relapses are reported even after an apparent com- 
plete recovery. 

1 Ann. Surg., 1907, xlvi, 736. 

2 Am. Jour. Med. Sc., 1907, cxxxiii, 345. 3 Loc. cit. 



COMPLICATIONS AFTER OPERATIONS 157 

Prognosis. The prognosis is very grave in this condition. Laffer 
gives the mortality in his collection of 217 cases as 63.5 per cent. A 
study of the reported cases goes to show that the mortality is influenced 
very largely by the promptness with which the condition is recognized 
and the persistence with which the stomach tube is employed. 

Treatment. As might be expected from a consideration of the many 
causes of the condition, the treatment is more or less unsettled. The 
repeated employment of gastric lavage regardless of the seriousness 
of the patient's condition and continuous enteroclysis constitute the 
most valuable means we have of relieving the condition. Great stress 
has been laid by a number of writers upon the importance of keeping 
the patient either in the prone position or on his right side and many 
recoveries have been attributed to the avoidance of the dorsal position. 
It seems hardly necessary to state that nothing whatever in the way 
of food, drugs or drinks should be given by the mouth. Although 
various operative procedures have been undertaken for the relief of 
acute dilatation, gastro-enterostomy is the only one which would 
seem feasible but even after its performance the repeated use of the 
stomach tube may be necessary as the new stoma does not always 
drain the stomach. In fact one case has been reported where fatal 
dilatation followed gastrojejunostomy and at the autopsy the new 
opening as well as the pylorus showed no obstruction. 

I am inclined to believe that a successful treatment of these cases 
depends upon the early recognition of the condition and the prompt 
and repeated use of the stomach tube. 

Hiccough. Hiccough often becomes a distressing postoperative 
complication but it cannot in any sense be attributed to the operation 
in most cases. This spasm of the diaphragm is reflex and is due to 
irritation of the pneumogastric or phrenic nerves. It is seen usually 
where there is an inflammation in the structures supplied by the nerves, 
but it often occurs where no such condition can be demonstrated during 
life or at autopsy, for occasionally it alone is responsible for death. 
The surgeon sees it usually in cases of peritonitis and after operations 
on the upper abdomen. I have seen persistent hiccough follow two 
cases of gunshot wound involving the diaphragm; both patients 
recovered. 

Treatment. No reliable method of treatment can be given. It is 
well first to eliminate any discernible cause of irritation in the gastro- 
intestinal and respiratory tracts which may possibly cause the con- 
dition. Such simple means as holding the breath and drinking water 
or semifluids, which are efficacious when hiccough occurs in health, 
may be employed first and later compression of the lower thorax and 
abdomen by a tight bandage or the hands. Antispasmodic medicines 
may also be employed and I think it is important to see that the patient 
gets either by the mouth or rectum large quantities of water. 

Acidosis. This question has become one of practical importance 
to the surgeon in estimating the risks of operation and in the pre- and 
postoperative treatment. 



158 POSTOPERATIVE TREATMENT 

Acidosis, acetonuria or acidemia first engaged surgical attention 
when it was shown to follow the administration of a general anesthetic, 
especially chloroform and particularly in children. The "late chloro- 
form poisoning" which has long been recognized and variously explained 
is acidosis. Ten years ago the surgical literature teemed with reports 
of postanesthetic deaths due to acetonuria and postoperative diabetic 
coma. An enormous advance has been made in our knowledge of this 
important subject by the work done in the laboratories of physiological 
chemistry and experimental surgery. Crile has probably done more 
than anyone else in this country to put this matter before the surgical 
profession and his laboratory and experimental work has the advantage 
of being supported by a large clinical experience. 

It is probably safe to say that a certain degree of acidosis exists for 
a limited period of time after any surgical operation which necessitates 
a general anesthetic (of whatever kind), produces pain, or occupies 
any length of time, and is manifested by rapid respiration, sweating, 
late or persistent vomiting, the odor of acetone on the breath, increase 
in pulse-rate, great thirst, and the presence of acetone and acid bodies 
in the urine. In the more marked cases which we designate as toxemia, 
the symptoms are persistent, very much increased and the patient is 
apt to pass into a coma and die. 

Anesthetics and surgical operations are not the only causes of 
decreased alkalinity of the blood, for Crile and others have shown that 
exertion, emotion, injury, infection, auto-intoxication, Graves' disease, 
etc., may cause it. He 1 says of his studies of this subject that "they 
determine that the brain, the adrenals, the liver, the thyroid, and the 
muscles together play important parts in energy transformation, and 
that at least three of these organs, the brain, the adrenals, and the 
liver, are especially concerned also in the neutralization of the acids 
resulting from energy transformation," and again "if in a certain case 
there is shown a continuous increase of acid by-products for the 
neutralization of which an unusual amount of alkali is required, then 
we may presume the liver, the adrenals, and the brain are undergoing 
abnormal changes; and that unless the acid condition be altered, these 
structural changes in the brain, the adrenals, and the liver will become 
permanent and certain of the chronic diseases will result." 

That all general anesthetics produce acidosis is also testified to by 
Crile who says that "nitrous oxid, ether and chloroform during their 
administration all produce increased acidity of the blood. In our 
experiments we have found out recently the additional fact that the 
acidity of the urine is increased markedly under ether and chloroform 
and less under nitrous oxid. This finding has a most important signifi- 
cance for the surgeon, as it explains why the administration of the 
anesthetic to a starved patient with gastric or duodenal ulcer, for 
example, may cause death by precipitating the impending acidosis." 
I might add that chloride of ethyl which I have used extensively during 
the past fifteen years is no exception to the rule. 

1 Tr. Am. Surg. Assn., 1915. 






COMPLICATIONS AFTER OPERATIONS 159 

With these evidences of the cause or causes of this common post- 
operative condition, we should pay some attention to the subject in 
preparing our cases for operation and in endeavoring to prevent or 
limit the postoperative acidosis. 

First we should do everything to eliminate fear, avoid starvation, 
give plenty of water, traumatize tissue as little as possible, make our 
anesthesias as short as possible consistent with thorough surgery, and 
exercise a choice of anesthetics. 

The treatment of acidosis can be expressed in two words: water and 
alkalis; the one hastening elimination of the acids and the other 
neutralizing them. Soda bicarbonate is the simplest and best alkali 
and can be given by the mouth when vomiting is not marked and the 
symptoms not severe. Twenty or thirty grains should be given every 
hour or two. Subcutaneous administration may produce irritation 
and abscesses. In most cases the rectum is the best avenue for this 
medication which should be given by the continuous "Murphy drip" 
method. Three or four hundred grains a day is not too much. Carbo- 
hydrates are also indicated in the postoperative treatment of this 
condition. 

In all cases after a prolonged anesthesia, in severe shock after the 
loss of considerable blood and whenever an acidosis might naturally 
be expected, bicarbonate of soda and large quantities of water should 
be given by continuous enteroclysis. 

Thrombophlebitis Pulmonary Embolism. Thrombophlebitis is a 
fairly common postoperative complication, especially after operations 
upon the female pelvic viscera and rectum. It is also seen occasionally 
after operations for hernia and appendicitis. Anemia particularly 
favors this complication and consequently it is seen more frequently 
after operations for fibroid tumors which have caused profuse bleeding. 
General debility of the patient also predisposes to the condition. 

As a rule thrombophlebitis does not occur until about ten days have 
elapsed after the operation and often not until the patient gets out of 
bed. 

The veins most frequently involved are the pelvic tributaries of the 
iliac, the long saphenous, especially the left, and the femoral. The con- 
dition is not in itself serious and recovery as a rule is complete but there 
is always the possibility of the detachment of an embolus with its sub- 
sequent lodgment in the pulmonary circulation. A less serious and more 
frequent result of thrombophlebitis is varicose veins. The frequency 
of the condition in the pelvic veins is indicated by the casual finding of 
phleboliths in x-ray plates of the pelvis. These phleboliths represent 
the calcification of a thrombus. Although permanent occlusion of the 
vein by the clot and conversion into a fibrous cord is a common result 
of thrombophlebitis, in many cases complete blocking of the vein does 
not occur and the normal caliber is reestablished through absorption 
and repair. 

The cause of thrombophlebitis has been a matter of much discussion. 
Most authors, however, agree that infection is the most common 



160 POSTOPERATIVE TREATMENT 

factor. Da Costa 1 says " In the formation of thrombi four conditions 
are to be considered, viz., chemical alterations in the blood, a bacterial 
attack on the intima, tissue changes in the inner coat of the vessel, and 
slowing of the circulation. . . . The essential cause of all intra- 
vascular thrombi is damage to the endothelial coat and in most 
instances the damage is effected by bacteria, hence most cases of 
thrombosis seen by the surgeon are infectious." 

It cannot be denied, however, that thrombosis frequently occurs 
in patients who show no evidence whatever of any septic process. 

Of the symptoms pain, tenderness and edema are the most con- 
spicuous. When the leg is involved the patient usually complains of 
pain in the calf and over the long saphenous and pressure in these 
regions reveals great tenderness and in a short time the leg becomes 
edematous. There is a moderate rise in temperature and a consider- 
able increase in the pulse-rate. In the septic cases the symptoms are 
often preceded by a slight chill or chilly sensations. 

In the case of the pelvic veins, vaginal or rental examination reveals 
tenderness and edema and if the iliac or femoral veins become Subse- 
quently involved edema of the extremity occurs. Extension of the 
process from one extremity to the other is by no means infrequent, 
there usually being an interval of several days between the two involve- 
ments. With complete thrombosis of the superficial veins one is able 
to palpate them easily and the tributary veins are often markedly 
distended. 

Under proper treatment the acute symptoms subside in a few days 
but the swelling may not disappear for two or three weeks. If the 
patient is allowed to get out of bed before the condition has entirely 
subsided there is a rapid recurrence of the edema. 

The treatment consists in absolute rest in bed with moderate 
elevation of the part and the application of an ice-bag. Many surgeons 
prefer to apply heat but I have certainly had more satisfaction in the 
use of the ice-bag. An absorbent ointment of belladonna and ichthyol 
seems also to give comfort, especially where the superficial veins are 
acutely inflamed, as indicated by a redness of the overlying skin. The 
patient should not be allowed to become constipated but the bowels 
should be kept open by either mild laxatives or the use of enemata. 
Massage of even the lightest character, which the patient often asks 
for, should never be permitted because of the likelihood of detaching a 
portion of the clot. The patient should be kept in bed for at least ten 
days after the subsidance of all symptoms. Many cases of fatal pul- 
monary embolism have occurred on the day the patient first gets out 
of bed. 

It has been suggested by many surgeons that ligation or ligation and 
extirpation of thrombosed veins should be done in order to prevent 
the serious complication of pulmonary embolism. Although such pro- 
cedures might prevent a catastrophe in rare instances, its use in all 
cases would certainly seem to be unjustifiable. 

1 Modern Surgery, 7th edition, p. 185. 



COMPLICATIONS AFTER OPERATIONS 161 

Pulmonary Embolism. Pulmonary embolism is caused by the dis- 
lodgment of a clot or portion of a clot which is blocking one of the 
veins and which finally lodges in one of the bifurcations of the pul- 
monary artery. If the clot is a small one it may not lodge until it 
reaches the smaller branches of the pulmonary and, if no large clot 
forms behind it, the portion of the lung supplied by the branch becomes 
ischemic and an infarct develops. If such a small clot is septic, a septic 
pneumonia results. If the larger branches of the pulmonary artery are 
blocked by the embolus a rapid clot forms behind it and the patient 
will die within a few minutes or within a few hours. Lodgment of small 
emboli in the pulmonary circulation is probably more frequent than 
is generally supposed and often is not recognized, although the physical 
signs are usually distinct after a day or two. The serious type of pul- 
monary embolism is by no means rare and is a common cause of sudden 
death after operation. Such a catastrophe may take place a day or two 
after the operation or may not occur for several weeks as it usually 
follows a recognized thrombophlebitis. It frequently occurs after 
abdominal operations, however, where there has been no evidence of 
thrombophlebitis. It is probably the most rapidly fatal and most 
distressing postoperative complication. 

Symptoms. The symptoms are unmistakable, the patient being 
suddenly seized with a sense of suffocation or pain in the chest with 
rapidly failing circulation and marked dyspnea. Anxiety, apprehen- 
sion and restlessness together with a sense of impending death are 
present. In practically all cases these symptoms are rapidly followed 
by dilatation of the pupils, cold sweat and unconsciousness. The 
patient may die in less than a minute or may survive for several hours. 

Treatment. The treatment is most unsatisfactory and consists in 
the administration by hypodermic of cardiac and respiratory stimu- 
lants, particularly camphor and ether, in the employment of artificial 
respiration, and in the use of morphin and atropin. 

Wherever a thrombophlebitis is present one cannot be too careful 
in seeing that the patient avoids any strenuous movement or straining 
and that he does not get out of bed for ten days or two weeks after all 
symptoms have subsided. This care will be appreciated when it is 
remembered that the catastrophe has occurred in many patients when 
they have first sat up in bed or on their first day out of bed. 

The operative treatment of this condition remains sub judice. 
Trendelenburg was the first to suggest and practice the removal of the 
clot from the puhnonary artery and has performed the operation 
several times. In none of the cases has it been successful although two 
of the patients have survived the operation. The pulmonary artery 
is exposed by resecting the second rib and opening the pleura and peri- 
cardium; it is then incised, the clot extracted and the wound closed. 
In order to successfully accomplish the operation it should be carried 
out with the greatest promptness and celerity. I know of no complete 
recovery following this operation and the only warrant for its per- 
formance is the universally fatal result which follows the occlusion of 
the pulmonary artery by a clot. 
VOL. i. 11 



VACCINES. 

BY A. F. JONAS, M.D. 

GENERAL STATEMENT. 

WE must guard against the optimism of certain enthusiasts in 
vaccine therapy who look upon every recovery from an infection, as 
being brought about by vaccine which they may have administered. 
The experienced practitioner who had become familiar with infections 
long before the advent of vaccines, has been among the first to note 
that the majority of infections are self-limited and end in recovery 
quite as promptly as those cases in which the vaccine therapy has 
been used. Therefore, many of the claims made for the advanced 
therapy are not borne out by every-day experience. But to dis- 
credit the entire method, as is done by some, is not warranted. That the 
underlying principles appear to be well founded, but there is something 
wrong with the method, is well expressed by Hektoen. He states: 
"The simple fact is that we have no reliable evidence to show that 
vaccines, as used commonly, have the uniformly prompt and specific 
curative effects proclaimed by optimistic enthusiasts, and especially 
by certain vaccine makers who, manifestly, have not been safe guides 
to the principles of successful and rational therapeutics." 

We know from everyday experience that if we carefully search 
for the source of the infection and relieve the primary focus by local 
treatment, as for example, a thorough disinfection at the port of 
entry, the free evacuation of localized infectious material in the form 
of pus or any foreign substance facilitating free drainage, the absorp- 
tion of toxins will cease and bacterial propagation will come to an 
end without further systemic treatment. The normal immunization 
mechanism will rapidly eliminate and bring to an end bacterial 
propagation and their products. 

Wright made a determined effort to place vaccine therapy on an 
exact basis. His discovery of opsonins and the use of the opsonic 
index as a guide to the administration of vaccines was an encourag- 
ing move in the right direction and was at first generally accepted by 
the profession. The painstaking and exact microscopic training and 
laboratory equipment that the method required was found to be 
impractical for the general practitioner, and it soon fell into disfavor. 
Further, laboratory experts questioned the accuracy of the method 
and it was not regarded as essential by many practical workers. 
Very soon stock vaccines came into general use. Their effects 
appeared doubtful and the whole method became discredited. How- 

(163) 



164 VACCINES 

ever, enough of the principles of their action was known to be well 
founded in that certain investigators pointed to the fact that a vac- 
cine should be made from microorganisms taken from the individual 
suffering from the disease, and they insisted on autovaccines. The 
preparation of autovaccines, however, must ever be regarded in the 
majority of infections as the only exact and scientific method in the 
use of vaccines. When we pursue the reports of Rosenau wherein 
he shows the frequent and almost constant change in the strains of 
bacterial growth, we are impressed with the necessity, if vaccines 
are at all useful, of making vaccines from the blood or pathogenic 
products of each individual who is being treated. No two individuals 
are affected by or react to a given bacterial toxin in precisely the 
same way. 

It is clear that each individual harbors microorganisms that are 
specific to himself, and must differ from those of every other indi- 
vidual. Therefore, to obtain the best possible results, each individual 
must furnish his own vaccines. But to do* this is clearly beyond 
the general practitioner and most hospital attendants. When this 
fact was realized, especially in our country, it was not long before 
there was an unrestrained and indiscriminate exploitation of vaccines 
by certain makers. The profession was easily persuaded to employ 
the many products put out by commercial firms. Autovaccines 
rapidly gave way to stock vaccines. The commendable efforts to 
secure exactness soon were displaced by routine and guesswork. 
Commercial concerns became the educators in yaccine therapy. 
The fundamental principle that vaccines must contain bacteria that 
are exactly or nearly identical with the strains causing the infection 
was forgotten. It is clear that with vaccines made in large quantities, 
this condition cannot be maintained. "The changes in virulence and 
affinities which take place in bacteria under artificial cultivation 
cannot be avoided." (Hektoen.) It cannot be expected that the 
specific element on which the desired antigenic effect depends is still 
existent. 

The wholesale producer of vaccine soon evolved a shotgun vaccine 
which he termed a polyvalent vaccine, which contained all manner 
of strains of nearly the whole group of pathogenic bacteria. But, after 
all, like the shotgun prescription of old containing many drugs, this 
is a poor substitute for a specific autogenous vaccine. The use of an 
autovaccine means a careful study of the case under treatment. It 
means an exact diagnosis. If it is true that every microorganism 
produces its own antibody, an etiological diagnosis is imperative. 
It is owing to this last essential that the autovaccine therapy has 
been robbed of its practicability. Because physicians are either not 
equipped or not trained and also lack the time to make an etiological 
diagnosis, the mixed unstandardizable vaccines phylacogens have 
enjoyed more or less popularity. These preparations have no anti- 
genic value and are, at best, only poor uncontrollable makeshifts. 
The tendency of the medical attendant is to become more superficial 



GENERAL STATEMENT 165 

in the examination of his patient and subsequently his diagnosis is 
more inexact. 

The tendency to the employment of vaccines in all forms of infec- 
tions, both acute and chronic, the vast majority of which are self- 
limited, is to be deplored. This practice has given rise to undeserved 
praise of many vaccines that really are inert and ineffective and leads 
to erroneous conclusions. Its tendency is to discredit the entire 
vaccine therapy in the minds of many observers. 

While we have met with many disappointments, we must ascribe 
the failures to the methods of their employment. Vaccine therapy is 
of undoubted value as has been shown by its employment in 
typhoid by Fraenkel, Ichikawa and in pneumonia by Rosenow and 
others. And more recently as prophylactic in tetanus, especially in 
the late European war. The method is of undoubted value and 
has found a permanent place in our armamentarium in the treatment 
of certain infections. At present, the main facts are obscured by a 
mass of uncertain and ill-considered theories and faulty application. 
But we are in possession of sufficient facts that will enable us to 
make intelligent use of vaccines in certain well-selected cases. While 
we may accept the teaching that all vaccines should be made from the 
microoorganism causing the disease in each individual, which is 
especially true in acute cases, we cannot condemn all stock vaccines. 
Occasionally the use of the latter has been followed by prompt results. 
In the absence of time and a proper equipment for the production of 
autovaccines, stock vaccines may be resorted to providing an exact 
diagnosis, either clinical or bacteriological or both, can be made. 

We must not lose sight of the fact that within the human organism, 
there exists a self -immunizing power that is responsible for spontaneous 
recovery from bacterial disease. There is a cellular mechanism that 
exerts a destructive effect on bacteria. 

The human organism is constantly exposed to the inroads of bacteria 
of various kinds. As long as the immunizing or protective mechanism 
can cope successfully with the invading organism so long we have 
health; if the protective mechanism fails and the microorganisms are 
not inhibited, we have disease. 

Artificial stimuli may so affect the immunizing processes that 
individuals may become immune to a certain disease by inoculation 
with specific antitoxins. Persons may be made immune to smallpox, 
typhoid, rabies, diphtheria and other diseases by the use of artificially 
prepared vaccines and serums that contain antibodies which are 
specifically antagonistic to organisms found in each disease. 

The animal organism adapts itself to various noxious conditions 
by a gradual process of elaborating bodies antagonistic to them. 

While studying the process of immunization and particularly the 
ways of increasing the power of the immunizing mechanism, we must 
not forget that there are several processes, besides vaccines, that 
play an important role. The removal of foreign bodies, elimination 
of infectious material by drainage, germicides or antiseptics, cellular 



166 VACCINES 

infiltration and the flow of blood to the seat of infection known as 
active and passive hyperemia which may be increased by massage 
suction, antitoxins, vaccines and bacteriotropic chemicals, all of 
these may be aided by hygienic measures. 

Animal experiments have proved that gradually increasing doses of 
a given poisonous substance, by a process of adaptation of the immun- 
izing mechanism, will enable the animal finally to tolerate amounts 
that would have proved fatal if given as an initial dose. 

When recovery from an infection takes place, we assume that 
the immunizing mechanism is producing an antitoxin of sufficient 
power to neutralize the toxin that circulates in the body fluids. If we 
inject an artificial antitoxin, we add to the already existing anti- 
toxins and in that way relieve the excessive strain put on the body 
cells. 

There are other substances aside from toxins that protect the body. 
There are a number of substances classed under the head of antitropin 
that play their role in the protective process. JVe find that they exert 
their power against microorganisms, each in its own way. We find 
that such organisms, as found in typhoid and other diseases, when 
killed and then injected into the body already infected with the same 
organism, have acquired the power of agglutinating and liquifying these 
organisms and destroying them. We speak of these substances as 
agglutinins, bactericidins and bacteriolysins. The role of these anti- 
bacterial bodies is an important one in the control of many infectious 
diseases. 

There is another factor aside from antibacterial substances known 
as opsonins that seem to bear a close relation to leukocytes and phago- 
cytic cells. The opsonins seem to prepare the bacteria so that they 
are more easily taken up by the phagocytes and destroyed. There- 
fore, we find that the antitropin, the opsonins and the phagocytes 
have a destructive effect on all forms of pathogenic bacteria. 

In the light of our present knowledge, we may assume that phago- 
cytosis and opsonins are the chief factors in establishing the line of 
first defense against invading bacteria. 

According to Wright, opsonins probably develop from the con- 
nective-tissue cells, and are produced by a stimulation of specific 
poisons forming protective substances. These protective substances 
may be regarded as free receptors which destroy bacteria. Opsonins 
and other antibacterial substances are formed by an inoculation of 
killed cultures of vaccines. New substances are formed which play 
their role in the disintegration of bacteria; these new substances are 
known as antibodies, bactericidins, agglutinins and opsonins, they 
are taken up in the blood stream and find their way to all parts of the 
body and to the foci of infection and unite with the bacteria causing 
their destruction. 

When bacteria enter the subcutaneous or submucous connective 
tissues they encounter the first active defenses in the form of opsonins 
and phagocytic cells. The fact that general systemic infections 



GENERAL STATEMENT 167 

must be frequent, suggest that the body possesses defenses greater 
than can be furnished by the usual opsonins and phygocytic cells at 
the point of infection. We find that the usual defenses are enhanced 
by an active hyperemia, a reaction known as inflammation. The 
increased blood flow carries an increased amount of antibacterial 
bodies and fresh leukocytes. This process is prompt and efficient in 
the innumerable instances where bacteria penetrate the connective 
tissue. Should this united phenomenon of active hyperemia fail, 
the first defenses would yield, then infectious diseases would develop. 
If the virulence of the invading bacteria is of such a great degree or 
their numbers are greater than the active hyperemia is capable of 
controlling, the defenses are defective. All observations tend to con- 
firm the accepted facts that the reaction developing immediately after 
the entrance of an infection known as inflammation, is essentially a 
protective process in all its phases. 

Of recent years, a method of prophylaxis and the treatment of 
certain diseases with vaccines has become popular and has been 
practised with more or less success. This method consists of the use 
of certain agents that have become known as vaccines. The term 
vaccine is derived from the Latin word vacca (a cow) and refers to the 
"cow disease" or cowpox and has been called vaccinia. Jenner 
described his discovery as a protective inoculation against smallpox 
with cowpox virus and termed the method vaccination. The terms 
vaccine and vaccination do not accurately describe the material used 
in treatment of all infectious diseases. Jenner, being acquainted with 
only one form of disease and its treatment, naturally applied the term 
suitable to his epoch-making method. Perhaps out of respect for 
the great Englishman, later investigators, chief among whom was 
Pasteur, adhered to it and applied the term vaccine to emulsions of 
dead and attenuated bacteria. While the term vaccine is not accurate, 
in a modern sense, it has crept into the nomenclature that deals with 
agents which are made up of bacterial suspensions used for the purpose 
of creating immunization. 

In connection with the study of vaccines, we must, first of all, 
make clear to ourselves, that they operate by effecting a condition 
known as immunization. The study of immunity occupies a place 
of first importance in the consideration in the well-being of the animal 
economy. We cannot overrate the immunity that is natural or 
physiological. It not only gives the protection against bacterial 
invasions that are constant, but it protects against the occasional 
inroads of special forms if not too numerous or too virulent. Natural 
immunity is relative but not absolute. There is a constant conflict 
between body cells and bacterial invaders but, under ordinary con- 
ditions, the body cells contend with success. This is known as natural 
resistance or physiological immunity. But if the organism becomes 
weakened from any cause and its natural defenses become defective, 
the bacterial hordes are overwhelming, we have disease. 

We may establish a lasting immunity by a process of adaptation. 



168 VACCINES 

If our body cells are vigorous and active, we may establish an active 
immunity. This may be done when certain cells produce certain 
antibodies that neutralize special bacteria or pathogenic agents. It is 
well known that a permanent degree of immunity is usually established 
after a recovery from certain acute affections; among these we may 
name measles, scarlet fever, smallpox, typhoid and typhus fevers. These 
are among those infections where the immunity is considered per- 
manent. Among other infections are created an uncertain immunity 
if it exists at all which may be of short duration and, in some instances, 
appears to have created a state of hypersusceptibility. 

The severity of the disease does not always give us a clue to the 
probable degree of lasting immunity. A mild form of the disease 
may produce a permanent immunity and, in some instances, a severe 
attack of a disease does not confer a lasting freedom. It is, however, 
a well-established fact that in general an active immunity is estab- 
lished with the use of a modified antigen that will produce specific 
antibodies without affecting the general health? of the subject. 

History. Our present-day vaccine therapy began with the vac- 
cination against smallpox by Jenner. Prior to the discovery of 
vaccination, and since it was the custom in many European countries 
to expose children to mild cases of smallpox so that a mild form of 
the disease might be acquired, usually insuring a permanent immun- 
ity. This practice was not without its dangers, for it was not uncom- 
mon that a mild form of the infection became severe. It had become 
well known that milk-maids and others milking cows, whose hands 
had become infected through small abrasions with cowpox were 
immune to smallpox. 

In 1796, Edward Jenner announced that when a human being was 
inoculated with a very small amount of cowpox virus, it produced a 
mild form of the disease and that this was followed by absolute immun- 
ity for long periods. It was shown that when smallpox virus was 
passed through a cow, it became so attenuated that it would not 
produce the typical disease, but that it had the power to produce a 
substance which insured freedom from the disease. 

Jenner had made the practical observation that smallpox could be 
prevented, but he did not know how the immunity was brought about. 

It was Pasteur, in 1879, who showed us by his experimental work 
that the virulence of microorganisms could be modified by exposing 
them to light, high and low temperatures and, further, that prolonged 
cultivation could so modify their virulence, that they could be injected 
into an animal without ill effects and at the same time bring about an 
immunity by stimulating the protective mechanism of the host. 

Pasteur was aided by an accidental discovery while working with 
chicken cholera. He was obliged to interrupt his work by an absence 
from home. On his return he discovered that his cultures had lost 
their virulence, that hens were not greatly affected by the introduction 
of a quantity that had formerly been a fatal dose. The discovery 
that a prolonged cultivation of microorganisms would attenuate 



VACCINES 169 

them was very great. It occurred to him that in this way a mild form 
of the disease could be produced and that fowls might be given a 
quantity to prevent a severe attack of the disease. His future work 
proved the correctness of his conjectures. He found that by attenuat- 
ing the virulence of bacteria and their products, the body cells could 
be so stimulated that they produced antibodies that would protect 
the organism without producing the actual disease. All the later 
work of bacterial therapy and prophylactic immunization, rests to a 
large degree on these discoveries. 

Side Chain Theory (Ehrlich). In 1896 Fode demonstrated that rab- 
bits' blood in a test tube free of cells and phagocytes, will destroy 
anthrax bacilli. This led Buchner to the belief that the bactericidal 
action of blood serum was due to a special body that he called Alexin. 

Fresh support was given to this theory by the discovery of anti- 
toxin by von Behring, chiefly in diphtheria. 

Pfeiffer in 1894 added support to the humoral theory by showing 
that cholera vibrios when introduced into the peritoneal cavity of a 
guinea-pig, previously immunized against cholera, became liquefied 
apparently without the aid of cells (bacteriolysis). Bordet found a 
"sensitizing substance" which exists in immune serum and acts on 
the bacteria against which the animal has been immunized. A second 
body was shown to exist in nearly al animals which he called Alexin, 
which Ehrlich later designated as complement. 

Then followed the attractive "side chain theory." Ehrlich attached 
two functions to a cell. First certain cells, like a nerve cell conducts; a 
gland cell secretes, this he called the physiologic function. Second, each 
cell has the function of nutrition, waste and repair. The latter has to 
do with immunity. He believed that molecules of food were seized 
from the surrounding tissues by a " selective action or chemical affinity 
between food atoms and the portion of a cell or side chain for which it 
has a chemical affinity." By this theory Ehrlich sought to explain 
the action of toxins and the production of antitoxins. He assumed 
that numerous side-arms receptors belong to every cell molecule. 
Special cells anchored special toxins. When combined with side arms 
or receptors in sufficient quantity, the toxins may destroy the cell, 
and if a sufficient number of cells are killed, the death of the host may 
ensue. The cells produce receptors in large quantities and are thrown 
off in the blood stream. Each thrown off receptor retains the same 
function of the original receptor, they become free receptors, and they 
combine chemically with their specific antigen neutralizing it and 
rendering it harmless. The antitoxin consists of cast off receptors, or 
antibodies. The antigen must possess sufficient toxic power to stimu- 
late the cells in order that sufficient antibodies may be produced. 

Following these epoch-making discoveries, an endless amount of 
work was done. While many modifications and amplifications have 
followed, the fundamentals have remained unchanged. It was shown 
that disease might be prevented by so cultivating a strain of patho- 
genic bacteria and modifying and attenuating it that it might be 



170 VACCINES 

injected and produced in an extremely mild form of the disease 
without producing harm, by establishing an immunity by the produc- 
tion of antibodies. 

All earlier work in immunity was done on animals and all experi- 
mental work of a similar character was done in the same way before 
being tried on the human being. Pasteur prepared a vaccine of 
anthrax bacteria by attenuation and exposure to elevated temperatures 
for varying periods of time. The same researcher soon published his 
discovery of modifying sections of the spinal cord of infected rabbits 
who had been infected with hydrophobia, by a process of drying. 
Out of this method was developed a prophylactic that immunized 
against the disease. Other vaccines were first produced in his labora- 
tory which seemed to accord with the principles that he had laid down. 



SERUMS. 

Definition. We must not confuse serum witlf vaccine therapy. By 
serum therapy is understood a process of passive immunization for 
the purpose of inducing a protective or curative condition. A serum 
is obtained from an animal that has been immunized by the injection 
of bacterial toxins or the microorganisms themselves. The blood of 
the immunized animal is withdrawn and blood serum only is injected 
into the subject that is to be immunized. 



VACCINES. 

Definition. Vaccines or bacterins used for therapeutic purposes are 
made by the injection directly into the patient of pathogenic bacteria, 
modified by certain processes. The difference between serums and 
vaccines must not be lost sight of and we must not forget that a serum, 
as used here, is an actively immunized filtered blood-serum free from 
bacteria. A vaccine is composed of an emulsion of attenuated or dead 
bacteria. Therefore vaccines and serums are not synonymous terms. 

General Principles in the Preparation of Vaccines. Most observers 
are now agreed that the special microoorganisms contained in a 
vaccine should receive the least possible modification or just enough 
to deprive them of their disease-producing power. Any given vaccine 
should be prepared by suspending a given strain of microorganisms in 
a salt solution or other vehicle and then expose them to a degree of 
heat that will so change them that they will proliferate no longer. 
Great care must be exercised during the heating process for it has 
been shown that when too much heat has been applied the vaccine 
loses its immunization qualities. 

There are several ways that immunization may be produced both 
for prophylactic and active purposes. 

I. Living organisms may be introduced into the human organism. 
This method has not been generally adopted, for the reason, that the 



LIPOVACCINES 171 

technic for their safe use is not fully established. The results are 
not uniform and there is still much experimental work necessary 
before a standard will be worked out so that the method may be used 
safely by the profession. 

II. Modified or attenuated microorganisms are now more generally 
in use. They are prepared by one of the following methods : 

1. The microorganisms are passed through lower animals by inject- 
ing them into the general circulation. 

2. The most frequent method of preparing vaccine is by suspension 
of microorganisms that are exposed to heat after being grown on 
culture media, and then are modified by heat to a point at or just short 
of producing their deaths. Long exposure to cold may attenuate the 
organisms in the same way. Whichever method is used, exposure to 
heat or cold, great care must be exercised to avoid actual microorganic 
death because a suspension of dead organisms under some conditions 
may have no. more effect than the salt solution in which they are 
suspended. 

3. Microorganisms are attenuated when exposed to light and air 
(chicken cholera). 

4. Microorganisms are attenuated when they are dessicated or dried. 
The longer they are dried the greater the attenuation (rabies). 

5. Some .vaccines are prepared by exposing microorganisms to ele- 
vated temperatures for varying periods of time (anthrax). 

6. Chemical germicides are employed to modify certain micro- 
organisms (anthrax Roux) (diphtheria Behring). 

III. Bacterial constituents, the soluble toxins and products of bac- 
terial autolysis as used by Koch in the preparation of tuberculin, etc. 

LIPOVACCINES. 

The success of prophylactic vaccines in a number of infectious 
diseases is acknowledged by all well-informed practitioners of medicine 
and surgery. One of the drawbacks has been the more or less severe 
local and general reactions in some cases after the initial dose, so that 
many cases refused to return for subsequent inoculations. The pro- 
fession knows that in 1885, Ferran in Spain, vaccinated many thousands 
against cholera; in India, Haffkine successfully dealt with plague and 
Shiga in Japan with excellent results inoculated against dysentery. 
The epoch-making results obtained in our Army with typhoid and 
paratyphoid vaccines are well known. The severe reactions sometimes 
observed have created much prejudice in the popular mind. 

Various expedients have been employed to solve the problem among 
them Le Moignie and Piony substituted oils for physiologic sodium 
chlorid solution commonly employed in making vaccines. The term 
lipo vaccines has come into general use. The lipoid oil menstruum carry- 
ing the vaccine seems to delay the absorption so that the system is not 
so suddenly overwhelmed. Le Moignie and Piony demonstrated that 
three and four of the usual doses of lipovaccine, could be injected 



172 VACCINES 

without marked reaction producing an immunity equal to that of 
repeated injections of the usual saline vaccines. Further, it was shown 
that vaccines made with oil, do not deteriorate and have the further 
advantage of enabling the safe use of mass injections when so desired. 
Several lipovaccines have been produced. There is no doubt that 
vaccines in oil will answer some of the objections that have been urged 
against the vaccine treatment of several infectious diseases. 

OPSONINS. 

While our early ideas of immunization were so closely linked with 
Metchnikoff's idea of phagocytosis, we were very soon obliged to 
modify these views because it was shown that substances in the body 
fluids increased the phagocytic process. It was observed that when 
leukocytes were deprived of their fluids they became powerless to 
take up and destroy the pathogenic microorganisms. . If they were 
placed in fresh serum, their phagocytic power ^as restored. Metch- 
nikoff believed this power to be due to a body that he termed " stimu- 
lins" and believed they changed leukocytes to phagocytes. This 
view was given up for a later observation which seemed to show that 
the phagocytes were not facilitated to increase their powers to take up 
bacteria but that the microorganisms were prepared so that they could 
more easily be taken up. Denys and Leclef, 1895, suggested that 
these bodies in the serum neutralized the exotoxins and endotoxins of 
bacteria that caused a negative chemotactic influence, in that way 
deprived them of two resisting powers exposing them to increased 
phagocytosis. 

In 1903 Wright and Douglas again demonstrated that phagocytosis 
was increased when bacteria were subjected to the action of serum. 
They first determined that phagocytosis depended on some specific 
substance in the blood and further that the bacteria themselves 
were acted upon, so that they could more easily be devoured by the 
leukocytes. This substance they named opsonin. This body is a 
constituent of normal serum. Neufeld and Rimpan obtained similar 
results in working with immune serums, they named this substance 
bacteriotropin. 

Definition. Opsonins are substances in normal and immune serums 
which act upon bacteria and other cells in such a manner as to prepare 
them for more ready ingestion by the phagocytes (Kolmer). Opson- 
ins are found in varying amounts and of different varieties for different 
bacteria in normal serum. Apparently opsonins are more or less 
specific for different bacteria. All bacteria are not equally prone to 
opsonification. The profession generally recognizes the importance 
of opsonins in their relation to phagocytosis in the process of immuni- 
zation. 

Wright and Douglas, who have greatly illumined this chapter by 
their researches, have perfected a technic for detecting the presence 
of opsonins and their quantity in the body fluid and, further, a method 



OPSONINS 173 

for increasing the opsonins and thereby the phagocytic process which 
they have designated by the opsonic index. 

Opsonic Index. According to George P. Sanborn, Wright's method 
of determining the opsonic index is as follows : " Into a capillary pipet, 
with a rubber teat affixed, are drawn equal volumes of the blood serum 
of a normal individual, of blood corpuscles which have been washed 
free from serum, and of an emulsion of bacteria against which it is 
desired to determine the opsonic power of the patient's serum. Each 
of these three volumes is drawn into the pipet separated by an air 
bubble, and then expressed upon a slide, mixed thoroughly, drawn into 
the pipet again. The pipet is sealed in a flame and incubated for 
fifteen minutes at 37.5 C. 

A similar procedure is carried out, using the same corpuscles and 
the same emulsion of bacteria, but the patient's serum instead of the 
normal, and incubation is carried out for the same length of time. 
These pipets are removed at the end of the incubation period, the 
small end broken off and the contents expressed upon a clean slide, 
mixed thoroughly and a small drop of this mixture placed upon a clean 
slide and a smear made. Each of the mixtures is treated in this way. 
If the smears are then stained and the leukocytes scrutinized, it will 
be found that they have ingested numbers of bacteria in each of the 
specimens. All bacteria contained in 100 leukocytes in the case of 
each slide are counted and the average number ingested by each 
leukocyte is calculated. This number is termed the phagocytic index. 
The opsonic index is determined by dividing the average number of 
bacteria per leukocyte, which have been ingested in the experiment 
with the patient's serum, by the average number ingested when the 
normal blood stream is used. The resulting figure representing the 
ratio between the phagocytic power of the patient's and the normal 
serum, the normal serum being considered as the unit. An opsonic 
index, therefore, of 1.5 indicates that the effective phagocytic power 
or opsonic power of the patient's blood is one and a half times that 
of a normal individual. If the result of the division is 0.5, it shows 
that the effective phagocytic or opsonic power of the patient's serum 
is just half that of the normal individual. In order to obtain an 
average normal serum, it is the custom to mix the blood serum of 
several individuals who are known not to be infected with the particu- 
lar organism in question." 

Wright states that when the opsonic power is elevated above the 
normal, it is indicative of a favorable response of the immunizing 
mechanism. 

We may conclude that the organism can adapt itself to poisonous 
influences of different kinds, according to their chemical nature. We 
find that particular cells or groups of cells harbor this mechanism 
of adaptation. Such cells have the ability, when stimulated by 
poisonous stimuli, to produce bodies that are carried by the blood 
stream, enabling them to destroy such stimuli if they are of a bacterial 
nature. 



174 VACCINES 

Method for Preparing Bacterial Vaccines. When preparing vac- 
cines, infected' material must be procured from suitable subjects. 
Pure cultures must be made of the bacteria that are producing the 
disease. The cultures must be suspended in a saline solution or oil 
and a preservative is added before placing the prepared vaccine in 
suitable containers. 

In procuring infected material contamination must be avoided. 
Every care must be exercised to procure material that is apparently 
causing the disease. When possible material for making vaccines 
should be obtained from closed cavities. If pus from an abscess 
cavity is to be used, touching the surrounding skin must be avoided, 
the material should be only from pus contained in the abscess and 
not from the surrounding skin and other structures. We wish to 
obtain only the bacteria that are responsible for the suppuration. 
We wish to secure the Staphylococcus aureus or citreus and not the 
Staphylococcus epidermidis albus. Therefore, we should prepare the 
surrounding skin as for any other operation wifch Harrington solution 
or tincture of iodine. If the material is to be secured from the nose, 
the nasal cavities should be carefully prepared as if for an operation. 
The secretions to be used for the vaccine may be procured by rubbing 
a sterile cotton swab on the undersurface of the turbinated bones and 
septum. If from the ear, the auditory canal should be free of all 
excess secretions, the pus from which the culture is to be made should 
be taken with a sterile cotton swab from the infected areas. If we 
wish to secure cultures from infected lung tissues where there is no 
sputum or where it is clear that the sputum has no direct connection 
with the diseased areas, a sterilized glass syringe with a long needle 
may be used to obtain the desired substance. The skin, over the 
infected area, is carefully disinfected as for any surgical procedure. 
A puncture with the needle is made into the infected pulmonary tissue. 
Some authors recommend that the syringe should contain peptone 
broth, and after the needle has reached a desired depth, 1 c.c. of the 
broth should be injected into the lung structures and after a lapse of 
a few seconds, it should be drawn back into the syringe. This aspi- 
rated material is then to be used to make the vaccine. The usual 
method of collecting sputum does not always lead to satisfactory results. 
The ordinary expectorations are mixed with microorganisms from the 
buccal cavity, teeth, tonsils and postnasal spaces. To obtain the 
best results, the teeth should be brushed with a sterile brush, the 
mouth and throat washed with sterile water several times. Water 
shoulcl be swallowed to clean the pharynx. Then the sputum is to 
be expectorated into a wide-mouthed sterile bottle. 

When collecting urine, the most satisfactory results are obtained 
by catheterization with a sterile catheter after the meatus has been 
carefully cleansed. 

Blood is best obtained from a conspicuous vein at the bend of the 
elbow. After the skin has been carefully sterilized, a quantity may 
be withdrawn with a sterile syringe. 



OPSONINS 175 

Making Pure Cultures. By this is meant a technic that will enable 
one to secure the one or more varieties of organisms that cause a cer- 
tain process. To separate the chief offenders from other microorgan- 
isms is often a most difficult task but, if we desire a certain effect, it 
is necessary, that the specific organisms be procured that will produce 
the desired antibodies. No one method can be followed for all varie- 
ties of bacteria. Briefly, the following methods have proved to be 
practical. 

The nature of the infection may sometimes be found in stained 
smears of the secretions of the disease. Often an isolation of the 
specific germ may be effected by making plate cultures on solid 
media. Primary cultures may be developed. The pus from newly 
incised abscesses, or microorganisms in the urine or urethral discharges 
or secretions from the throat in influenza or sputum in pneumonia, 
may exhibit the characteristic microorganisms. The best culture 
media are those that contain blood serum. 
Solid media are best suited for the preparation of vaccines. 
Slant agar tubes are frequently used in making bacterial vaccines. 
Two tubes may be used for rapidly growing bacteria and six or more 
are used for more slowly growing organisms such as pneumococci and 
streptococci. 

Shorter or longer periods are necessary to grow cultures; the time 
depends on the special organism. Usually twenty-four hours in an 
oven at a temperature at 37 C. and less time for those that grow 
more rapidly. 

When cultures have been developed in the incubator, specimens 
from each colony are stained and examined in order to find the organ- 
ism that causes the infection. 

It has been the practice to employ an attenuated culture where the 
original organism is virulent. A second strain has been found to be 
safe in cases of certain streptococci and of pneumococci, etc. 

When the cultures have become fully developed, the next step is 
to make an emulsion. This must be done with aseptic care. Take a 
test-tube of sterile normal salt solution and pour it on the surface of 
the slant tube containing the culture, then shake the tube so as to 
cause the microorganisms to become suspended. If the culture 
adheres to the medium, it may be separated with the aid of a platinum 
loop. The loop must be used with care so as to remove only the 
bacteria from the medium. The emulsion thus formed is poured on 
the surface of the second culture causing the latter to be suspended 
and add more salt solution if indicated. The entire series of cultures 
are suspended in the same way. The last suspension is then poured 
into a heavy flask containing glass beads. This flask is then shaken 
by hand or a mechanical shaker until the bacterial contents have been 
disintegrated and the emulsion has become thoroughly homogeneous. 
In order to be certain that the emulsion contains no large particles, 
it should be centrifugalized or filtered through a sterile filter. Culture 
media that contain peptone may develop toxic bodies that sometimes 



176 VACCINES 

produce anaphylaxis. "In addition, when, in the preparation of a 
vaccine, bacteria grown on a serum medium are washed off with 
normal salt solution, a portion of the serum may be removed and in 
this way be capable of producing disagreeable local and general reac- 
tions. For these reasons it is advisable to wash all suspensions by 
repeated centrifugalizations until the supernatant fluid reacts nega- 
tively to the biuret or ninhydrin reaction." (Willard Stone, Kolmer.) 

Standardization and counting of bacteria in suspension in a given 
quantity of fluid is done by several methods and while it might be of 
interest to describe several procedures, it will suffice for our purpose 
to detail only one, viz., that of Wright as described by Kolmer. 

"Method of Wright. Prepare a simple capillary pipette, making a 
mark on its stem about one inch from its tip, and fit a rubber teat to 
its barrel. Cleanse and prick the finger, press out a drop of blood, 
take up the pipette and draw up into it first one volume of sodium 
citrate solution, one of blood and then one volume of bacterial sus- 
pension or two or more volumes, if it appears on inspection to contain 
much fewer than 500,000,000 of bacteria to the cubic centimeter. 
To guard against crimping of the corpuscles in drying the film, Wright 
advocates aspirating one or two volumes of distilled water after the 
blood and bacterial suspension. 

Now expel from the pipette first only the distilled water and the 
bacterial emulsion, and mix these, so that there may be no danger of 
the red corpuscles becoming hemolized and then proceed to mix 
together the whole contents of the pipette, aspirating and re-expelling 
these a dozen times. Then make two or three microscopic films 
from the mixture spreading these out on slides that have been rough- 
ened with emery. 

The films are dried in the air, fixed by immersing them for two 
minutes in a saturated solution of corrosive sublimate, washed thor- 
oughly and stained for a minute with carbolfuchsin diluted 1 : 10 or 
carbolthionin for two to five minutes and then washed and dried. 

The films are now given a preliminary examination. If red corpus- 
cles and bacteria are found in approximately the same numbers and 
the suspension is free from bacterial aggregates, the count may be 
made. If either of the bacteria or the corpuscles are largely in excess, 
new mixtures and new films must be made. In case the bacteria are 
gathered in clumps, the suspension should be shaken again and new 
film prepared. 

When satisfactory films have been obtained, the actual counting 
may be done. This is carried out with an oil-immersion lens, and in 
order to secure accuracy, it is necessary to restrict or divide the field 
by a small square diaphragm made of paper or cardboard, or by 
inscribing lines on a small clean cover-glass and dropping them on a 
diaphragm of the eye-piece. 

The field is now chosen at random, and the corpuscles and bacteria 
are counted, the results being jotted down on a sheet of paper. Pro- 
ceed at random from field to field, traversing every part of the slide. 



OPSONINS 177 

Establish a rule for counting corpuscles that transgress or touch the 
edge of the field. Eliminate from consideration any parts of the 
film in which the preparation is unsatisfactory as regards staining or 
with respect to the integrity of the red corpuscles. The examination 
is continued until at least 500 corpuscles have been counted, half of 
the count being made from the second slide. The number of micro- 
organisms is now totalled, and the approximate number per cubic 
centimeter estimated. Let us assume, for example, that 600 red 
cells and 1200 bacteria have been counted. A cubic millimeter of blood 
contains 5,500,000 red corpuscles, and equal volumes of blood and 
emulsion were taken. A cubic millimeter of the emulsion, therefore, 

. . , 5,500,000 X 1200 . , . .... 

contained - ' - = 11,000,000 organisms per cubic milli- 

meter or 11,000,000,000 per cubic centimeter." 

Vaccines are sterilized and their sterility tested after the prelimi- 
nary examination. Heat is the usual agent employed, germicides are 
likewise used. When the films for counting are satisfactory, the 
vaccine is transferred to a test-tube. The latter is sealed and placed 
in a water-bath, care being taken that the whole tube is immersed. 
In the process of sterilization, pains must be taken to employ the 
lowest possible temperature and the shortest possible time to produce 
sterility. The usual temperature is between 50 and 60 C., if no 
more than an hour to complete the process. 

Cultures should then be made of the vaccine to ascertain its sterile 
condition. A dozen or more loopfuls are then placed on slant culture 
mediums of blood serum or blood agar. The tubes are then placed 
in a culture oven for twenty-four or more hours, the time depending 
on whether the organisms are rapid or slow-growing ones. If the 
following examination indicates sterility, the vaccine is finished. If 
not sterile, more heat must be applied or a new one is made. 

If the vaccine is found to be satisfactory, it must be diluted with a 
sterile saline solution so that each centimeter contains a definite 
number of organisms. A portion of the prepared vaccine is diluted 
and the remainder is saved in case the dose is to be modified in the 
subsequent treatment of the cases. If a vaccine of Staphylococcus 
aureus contains 1,500,000,000 organisms per cubic centimeter and the 
dose decided upon is 500,000,000 per cubic centimeter, sufficient vac- 
cine for thirty doses is prepared by withdrawing 10 c.c. of vaccine 
in a sterile container and adding 20 c.c. of sterile salt solution. The 
mixture is agitated to insure thorough mixing, and 0.1 c.c. of a 1 : 100 
dilution of phenol is added to each cubic centimeter of vaccine as a 
preservative. (Kolmer.) The vaccine should be kept in a sterile 
bottle, closed with a rubber cap. When a dose is to be given, the 
rubber cap is painted with tincture of iodine. The needle is thrust 
through the rubber and the desired amount is drawn out with an 
aseptic syringe. Flexible collodion is applied over the needle punc- 
ture. Frequently vaccines are placed in ampoules, each one containing 
a single dose. These ampoules must be sealed by heat. 

VOL. I 12 



178 VACCINES 

Sensitized Bacterial Vaccines. Sensitized bacterial vaccines are pre- 
pared by first immunizing a rabbit with subcutaneous injections of 
microorganisms which have been killed by heat. Increasing doses 
are given until the animal withstands living organisms intravenously. 
The animal is then bled and the serum is mixed equal parts with 
emulsions of bacteria. After being thoroughly mixed and centrifugal- 
ized, washed and tested for sterility, counted and suspended in normal 
salt solution, the sensitized vaccine is ready for use. 

Method of Administration. An all-glass sterile syringe is used to 
administer bacterial vaccines. The syringe should have a sharp 
platinum-iridium needle. Vaccines are best given in the early part of 
the day because they are often followed by depression and ill feeling. 
These symptoms pass away in a few hours and will have disappeared 
by night so that the patient will have a better night's rest. Injections 
are best given in loose areolar tissues and at such points where there 
is a minimum amount of muscular movement and where the clothing 
causes the least discomfort. * 

The points of election are below the clavicle, upper margin of the 
buttocks, along the McBurney line. The skin is first disinfected with 
soap and water or tincture of iodine. The skin, at the point of injec- 
tion, is raised between the thumb and finger and the needle is then 
thrust into the subcutaneous tissues between the raised layers of skin. 

In the greater number of cases, there is a local irritation of the skin 
at the point of injection. 

The site of the injections sometimes shows a decided reaction after 
an inoculation, this is known as a focal effect. Such a reaction, as 
shown by increased redness, may serve as a guide for further dosage. 
A decided reaction indicates decreased dosage. The general systemic 
effects vary greatly in different subjects. An indicated dose usually 
produces more or less exhaustion, fever, headache and accelerated 
pulse-rate. 

We are still undecided in reference to frequency and exact dosage. 
Each case must be judged by itself. Since the opsonic index has been 
found impracticable in general practice, we must depend on the reac- 
tion of the patient to each dose and the general condition for which he 
is treated. It can be easily understood that in very acute infections, 
particularly when occurring in weakened persons, a small and safe 
dose is indicated. All therapeutic vaccines should be used, in their 
initial dose, in minimum amounts. Begin with a safe dose and, if 
there is no reaction in forty-eight hours, a larger one may be given. 
Should local or general symptoms follow the first inoculation, a second 
one of the same size may be administered in four to six days. It must 
be borne in mind that fresh infections by other organisms may occur, 
and if it does, new vaccines should be made, in order that the anti- 
bodies for the new invaders may be included. 

Sometimes there is a decided and severe reaction after the initial 
dose which would indicate that a negative phase had been induced 
which is a period of lowered opsonic power, of lowered resistance, in 



SEPTICEMIA 179 

fact, the use of too large doses of vaccines, is manifested at once by 
local changes, which show that the process is increasing. On the 
other hand, if there is an amelioration of the general symptoms, we 
have a period of increased resistance, of elevated opsonic power, known 
as the positive phase. 

It is often difficult to decide the intervals between the inoculations. 
The tendency is to repeat them with too great frequency. The better 
plan is to underdo than overdo. 

The dose of the vaccine varies somewhat in the kind of organisms 
involved in the infection and also whether the process is acute or 
chronic. In acute cases the dose is smaller and given oftener and 
in chronic cases it is large and in longer intervals. The age and 
weight of the patient are also determining factors. When in doubt 
begin with small doses and increase or diminish according to the 
local and general reaction. Repetition of doses depend upon the 
reaction and the results obtained. 

The following list is offered as a suggestion as to dosage for vaccines. 

Staphylococcus aureus 100,000,000 to 1,000,000,000 

Staphylococcus albus and citreus .... 200,000,000 to 1,000,000,000 

Streptococcus pyogenes ....... 25,000,000 to 200,000,000 

Gonococcus 25,000,000 to 200,000,000 

Typhoid bacillus 250,000,000 to 1,000,000,000 

Colon bacillus 100,000,000 to 1,000,000,000 

Under the following heads several infectious conditions usually 
known as surgical infections have been briefly considered, and their 
treatment with bacterial vaccines have been indicated. 

The vaccine treatment of tuberculosis has been omitted for the 
reason that the effects of heliotherapy and an atmosphere compara- 
tively free from pathogenic microorganisms, general hygienic sur- 
roundings, and diet have shown increasingly brilliant results, both in 
surgical as well as in pulmonary tuberculosis. Vaccines, both bacterial 
and non-bacterial, have not fulfilled our optimistic expectations, espe- 
cially in tuberculous affections. In the light of our present knowledge 
of their effects they can only play a subsidiary role. 

SEPTICEMIA. 

In septicemia we give vaccines subcutaneously to produce a reaction 
followed by an increased immunity. But before proceeding with the 
use of vaccines we must determine whether we have to do with 
bacteria that originate in an active focus of infection, such as a deep- 
seated abscess or that form in which the bacteria appear to be growing 
in the blood stream. If the infection originates in a definite focus, 
there is a constant addition of bacteria to the blood stream, and we 
may speak of continuous auto-inoculation. We must place under 
this head acute fulminating infections and also carbuncle, phlegmon, 
erysipelas and others. The other class comprises infections whose 
source is clinically not demonstrable and where the point of infection 



180 VACCINES 

cannot be removed or drained. These are the true septicemias. It is 
clear that before the treatment of septicemia is begun, the locus of 
infection when found must be attacked and eradicated or drained or 
both. We cannot hope for success if this is not done. 

Diagnosis. It is important to make a bacteriological diagnosis when 
possible. It is desirable to determine whether our septicemia is due to 
a streptococcus, staphylococcus or other organisms. Having found 
the pathogenic micrococci the usual technic well known to all labora- 
tory workers must be employed with the view of preparing an autog- 
enous vaccine. Agar, as a medium, for blood cultures of a pneu- 
mococcus, the most common factor in septicemia, has been successfully 
used by Rosenow. Both solid and liquid media have given satisfactory 
results. The methods for their preparations have been indicated in the 
preceding pages. 

Prognosis. That the prognosis is different in these two types of 
septicemia is evident. When we can eliminate by early operation the 
source of auto-inoculation, the chances for recovery are good. In 
the true septicemias the point of auto-inoculation is beyond our control. 
The blood current appears to be a favorable medium for bacterial 
growth. The prognosis is correspondingly grave. 

Dose. When possible be guided by the opsonic index, but septi- 
cemia may be successfully treated by taking into account the clinical 
manifestations. We must guard against overdosage on account of the 
danger of overstimulation which may be inimical to the protective 
mechanism. Therefore, prudence would dictate that the initial dose 
be small. In streptococcic septicemia, the primary dose should not be 
over 1,000,000 to 2,000,000 and be repeated in twelve to twenty-four 
hours if no unpleasant symptoms develop. The increase in dosage 
depends on the resulting reaction. If no untoward conditions appear, 
the dose may be increased from day to day until the maximum of 
25,000,000 daily has been reached. As improvement takes place, it 
may be well to repeat the dose every second day and even longer. We 
must not always be guided by the number of bacteria contained in a 
given dose but rather by the effect that each dose produces. A good 
rule to follow is, the more ill the patient, the smaller the initial dose. 
If, in the course of the treatment, there is a sudden aggravation of 
toxic symptoms as is shown by a rise in temperature and increased 
prostration, the next dose must be smaller and the interval between 
the doses should be increased. 

SUPPURATIVE ARTHRITIS. 

In these conditions the microorganisms found are the staphylococcus, 
streptococcus and pneumococcus. As soon as the condition is recog- 
nized, we must attack the local condition either by the injections 
of solution of formaldehyde according to Murphy, or by the establish- 
ment of thorough drainage. If this is not done promptly, the function 
of the joint is endangered no matter how carefully the vaccine therapy 



ARTHRITIS 181 

has been employed. The details of the surgical management need 
not be discussed here but it is of first importance. 

If, in spite of thorough surgical measures, the infection does not 
subside, and we can find no other locus of infection or if the septicemia 
becomes chronic, an appropriate autogenous or stock vaccine may be 
employed. The dose should be small and their size and frequency 
regulated according to the effects on the local and general conditions. 

GONORRHEAL ARTHRITIS. 

The majority of the cases of this type of infection when acute subside 
by immobilization and rest in bed. In the initial stage of this infec- 
tion, we have a more or less auto-inoculation but it soon becomes 
localized. Vaccines are usually not indicated in the acute stage, but 
they have been used with success. When the case becomes chronic, 
a vaccine may become a stimulus and incite the protective mechanism. 
Many observers testify to the efficiency of gonococcus vaccines 
and speak highly of their use. Hartwell 1 tabulated 31 cases. He 
treated these cases for periods varying from one month to one year. 
He described 27 cases as having completely functionating joints. 
The others had ankylosed joint of varying degrees when the treatment 
began. He gave doses as high as 600,000,000 at intervals of five days 
to a week. In 21 cases he employed autovaccines which he believed 
more effective than stock vaccines. He states that the pain was 
diminished in 20 acute cases and hastened recovery. In some of his 
acute cases other joints became affected which is not uncommon in the 
ordinary course of the disease. He gave doses of from 25,000,000 to 
100,000,000 in from two to four days. 

Hartwell believes gonococcal vaccine is useful in gonorrheal arthritis 
in all stages except in cases of ankylosis. It does not prevent metas- 
tases to other joints. 

The consensus of opinion by the majority of observers is that gonor- 
rheal vaccines are more effective in chronic than acute cases. 

RHEUMATIC ARTHRITIS. 

Many cases of chronic articular rheumatism have recently been 
regarded as being of bacterial origin, although no specific organism 
has been found. These joint affections present local inflammatory 
symptoms. They sometimes follow the development of pyorrhea, 
rhinitis and especially tonsillitis. They appear after scarlet fever. 
Undoubtedly bacteria, that have found their way into the blood 
stream, localize themselves in the joints. Streptococci are often 
obtained from the blood by means of cultures. We know that we 
have postscarlatinal kidney infections showing streptococci. Like- 
wise can the same organism be demonstrated in scarlatinal arthritis. 
The same form of bacteria can be cultured from secretions found in all 

1 Ann. Surg., November, 1909. 



182 VACCINES 

joints that come to suppuration. Streptococci once having gained 
access to the blood current find points of predilection, such as occur 
in a retarded circulation, and almost stagnant lymph fluid near joints. 
The blood seems to have been greatly deprived of its germicide power, 
the bacteria find favorable conditions for their propagation in their new 
locus. The opsonic index, at these points of infection, is subnormal. 
When these arthritic infections become chronic, the opsonic proper- 
ties of the blood stream becomes low. The circulation is more or less 
retarded and almost stagnant, consequently the diminished amount 
of opsonins coming in contact with the microorganisms is not sufficient 
to insure their destruction. It would seem that this theory is con- 
firmed by the relief afforded after the use of the constricting band 
used in Bier's method where we find that fresh blood with normal or 
increased amount of opsonins as well as fresh leukocytes are driven 
into the infected area, and later driven into the general circulation 
and lymph channels. The stagnant blood and lymph has been 
replaced by fresh blood and lymph including new antibodies. 

Bier's method has recorded many clinical successes and deserves 
a more extended trial than it has generally received. It has the 
advantage that a bacterial diagnosis is not necessary. 

Diagnosis. A local bacteriological diagnosis is often very difficult 
and, in most instances, impossible. We must bear in mind that 
many cases of " rheumatic" and other forms of arthritis have been 
preceded, and seem to have had their origin in an attack of tonsillitis, 
laryngitis, pharyngitis or rhinitis and pyorrhea. It has, therefore, 
been advised that cultures be made from the nasopharynx or nasal 
cavities and the pus from the alveolar margins and, if, for instance, a 
culture of pneumococcus be obtained from the tonsil, an autogenous 
vaccine be made and administered. 

Before giving vaccines local infections must be attended to. Tonsils 
and teeth should first be removed if they appear to be infected. 

Dosage. If there is an increased temperature, the dose would be 
from 5,000,000 to 25,000,000. In non-febrile cases small doses at 
intervals of one to two days are given according to the reaction. In 
chronic cases large doses may be used at intervals from three days 
to a week. 

If vaccines are of any value, it would seem that an increasing experi- 
ence, theoretically at least, would promise encouraging result in 
chronic non-suppurative or peri-arthritis, providing our technic of 
making a bacteriological diagnosis can be perfected. There is danger 
of overdosage. 

FURUNCLE. 

In'a case where the infection begins in a hair follicle as indicated by 
a tender, red, painful induration, its treatment depends on the stage 
and location in which it is found. If a pustule, it should be opened 
by a puncture and disinfected and dressed with a hot moist anti- 
septic dressing. If there is no evidence of suppuration, one dose of 



FURUNCLE 



183 



Staphylococcus pyogenes aureus of stock vaccine may abort it. A 
repetition once or twice at intervals of two or three days may be 
necessary. In two or three days the infected area will begin to slough. 

Furunculosis is a condition where there is a repetition of furuncles. 
In some cases there is a tendency to furuncle formation. We some- 
times find individuals with an oily pale skin that frequently develop 
many furuncles over a long period of time. They seem to have a 
predilection to harbor pyogenic cocci. In some cases the individual 
may inoculate himself in new localities by scratching often during 
his sleeping hours. He scratches the primary furuncles, infectious 
material is caught under the finger nails and transplanted to other 
parts of the body. One furuncle is incised when others develop. 
In one of the author's cases a full year passed before the furuncular 
process came to an end. More than one hundred furuncles were 
incised. A urinalysis must not be neglected, especially in reference 
to the existence of glycosuria. It is in this field that many excellent 
results have been reported. It is here where an accurate bacterio- 
logical diagnosis can be made. The pus can be easily obtained and 
cultured and should be used when practicable. In these cases stock 
vaccines seem to have been useful. The vaccines are composed of 
three or four virulent strains of Staphylococcus aureus. However, 
when possible, autovaccines should replace stock vaccines as soon 
as they can be made. The initial dose should be 100,000,000 to 
150,000,000 and should be repeated every third day. The dose may 
be gradually increased to 300,000,000. 

If in twenty-four hours the furuncle appears larger and more pain- 
ful and if one or two new ones develop, the dose should be smaller 
because we have to deal with a negative phase. If in one or two days 
there is improvement and the general symptoms are improved, the 
correct dose has been found and we have a positive phase. New 
furuncles may continue to develop for a time but they are less severe 
and the intervals become longer and they disappear more quickly. 

If the case is chronic, and especially if there are present many 
comedones and the pustules are on the back and neck, the treatment 
may require two or three months of time. 

Recurrences are not uncommon and must be guarded against by 
advising the patient to return for fresh inoculations as soon as the 
first evidence of return is manifest. The final outcome is favorable 
if the treatment is persisted in. Since the opsonic index has been 
found impractical we are obliged to regulate dose and interval by 
clinical observations. 

In the treatment of these cases, we may feel uncertain as to the 
interval between doses and their exact size, therefore we must be 
guided by the manner in which the patient responds. Many writers 
of large experience, advise intervals of three days. We should try to 
measure the dose so as to insure a short period of negative phase 
with its lowered resistance so as to produce as long a period of posi- 
tive phase a period of increased resistance. Each patient is a law 



184 VACCINES 

unto himself. A safe rule is to employ a small dose which insures a 
short duration of the negative phase, which makes a short positive 
phase. But as we learn the tolerance of the cases, the dose can be 
increased and repeated in from one to six days. 

CARBUNCLE. 

There are those who have grown enthusiastic over the use of vac- 
cines in the treatment of carbuncle. They feel certain that in almost 
every case the process is modified so that surgical intervention becomes 
simplified and can very often be avoided. Our experience has taught 
us that radical interference, that is, total extirpation of the carbuncle, 
is usually efficient and leads to prompt recovery. We have found no 
reason why prompt operation is still not the best method. It cannot 
be denied that bacteria and their products have found their way 
into the blood stream. There is a constant auto-inoculation. In a 
furuncle the pus and necrotic material is usually confined to a single 
pocket which may be evacuated by a single puncture or incision. In 
carbuncle there is an extensive infiltration of the connective tissues 
with pus. In carbuncle there is apparently an absence of a line of 
demarcation, owing to the virulence of the pathogenic organisms 
and to the liquefying power of the pus which dissolves the fat 
and connective tissues as it extends. The circulation is everywhere 
cut off, so that the invading organisms are unaffected by the anti- 
bodies carried in the blood stream. The coagulated lymph and 
exudation prevent an access of blood. The process is essentially 
an infiltrating one, particularly when located on the back of the neck. 
The columnse adipose separate the subcutaneous connective tissues 
into numerous cells composed of connective-tissue walls. In cases like 
this it would be unreasonable to do anything but radical surgical inter- 
ference and this is true of all carbuncles wherever located. After 
free excision, a culture should be made of the pus to prepare an autog- 
enous vaccine for the purpose of antagonizing the infectious sub- 
stance floating in the circulation. The operative procedure often 
causes an exacerbation of the temperature due to auto-inoculation. 
A moist antiseptic dressing, frequently changed, must be applied. A 
free discharge from the wound takes place owing to an increased blood 
supply to the wound. After the effects following the surgical inter- 
vention have subsided, the injection of the vaccine may be done. A 
small dose of vaccine not exceeding 100,000,000 may be employed 
which may be repeated two days later and then every three to four 
days if the temperature continues to fall. Should there still be an 
elevated temperature after the third day, especially if there is no 
drop, a smaller dose of 50,000,000 should be used and repeated daily 
until we have a normal temperature and then 100,000,000 every 
second day, and at longer intervals until recovery is complete. The 
wound must be dressed daily. 

The urine must always be examined especially for sugar. If the 



ERYSIPELAS 185 

latter is present, the opsonic index is always lowered. The usual 
dietetic restrictions for glycosuria must be observed. 

When the carbuncle is on the face the excision should be short 
with due regard to the resulting scar. Only the necrotic tissue should 
be excised. Since carbuncles in this region are usually not large and 
the auto-intoxication relatively less, the initial inoculation need not 
exceed 25,000,000 Staphylococcus aureus and increased as conditions 
seem to indicate. Any new pustules are to be punctured and any 
necrotic margins are to be excised with scissors. In five to six days 
the wound is usually clear and granulating. 

EMPYEMA. 

This condition is usually due to the pneumococcus and strepto- 
coccus. Usually a free opening and efficient tubular drainage is quite 
sufficient for recovery without the aid of other immunizing agents. 
There are a few cases where, in spite of thorough drainage, an elevated 
temperature persists which may be due to defective immunizing power; 
bacterial vaccines are indicated. In such cases doses of pneumococcus 
of from 10,000,000 to 100,000,000 may be given. The more profound 
the intoxication, the smaller the dose. The dose is to be repeated 
every twenty-four hours if it is small and at longer intervals if it is 
larger. 

OSTEOMYELITIS. 

The administration of vaccines should always be preceded by 
operative interference and complete and free evacuation of the patho- 
logical products. Free drainage is of prime importance. In some 
cases an infection of the soft parts continues as is indicated by a 
persistence of local and systemic manifestation such as swelling pain 
and increased temperature. Vaccines may be indicated in these 
cases, in doses ranging from 100,000,000 to 300,000,000 every three to 
five days. Usually, however, all systemic manifestations disappear 
when the infectious material has a free exit and when the improve- 
ment is prompt, as it usually is, vaccines are superfluous. 

ERYSIPELAS. 

The most common seat of erysipelas as met with in general practice, 
is in the face. These attacks are usually self-limited and are of such 
short duration that vaccines are not indicated. It is only in the 
spreading type in which we may expect some assistance from vaccines. 
Autogenous vaccines should be used when they can be obtained, but 
the more common practice has been the use of stock vaccines. During 
the active stage small doses are indicated. We must regulate our 
dosage as in septicemia. The initial dose should not be over 1,000,000 
once daily and increased slowly not to exceed 25,000,000. The 
usual local treatment must not be neglected. Observations thus far 



186 VACCINES 

have not enabled us to speak with certainty as to the actual benefits 
derived from the use of vaccines in erysipelas, but their use must not 
be entirely ignored. 

VARICOSE ULCERS. 

Staphylococci are often found in these ulcers. It has been claimed 
that autogenous vaccines of these organisms are useful in leg ulcers. 
It is asserted that the use of stock vaccines has cleared up the ulcer 
in a few days. The wound was dressed daily with Wright solution 
consisting of 0.5 per cent, of citrate sodium and 2 per cent, of sodium 
chloride. However, vaccines must be looked upon as only an adjunct 
to other measures which are indicated. We must take into account 
and treat the venous varicosities which exist in most cases, nor must 
we neglect antiseptic and aseptic precautions so essential in the 
treatment of all wounds. 



BLOOD TRANSFUSION. 



NELSON MORTIMER PERCY, M.D., F.A.C.S. 

WHILE the transfusion of blood as a practical procedure is a com- 
paratively new acquisition in the field of surgery, the idea of using 
blood as a therapeutic measure dates back to the fifteenth century. 
In 1660, Lower 1 in his experiments made successful transfusions in 
various animals. Following this, the blood of animals, usually from 
sheep, was given to humans with apparent benefit in an occasional 
instance. It soon became evident that the introduction of the blood 
of lower animals into man was an unsatisfactory and dangerous pro- 
cedure and the practice fell into disuse. It is probable that many of 
the deaths were due to hemolysis or anaphylaxis. 

Animal transfusion was then abandoned for human transfusion, and 
during the past century many experiments were made on the direct 
transfusion of blood from one person to another. Transfusion of human 
blood, as practised during this period, was so unsatisfactory and 
dangerous that this procedure also fell into great disfavor. 

The failure of these early transfusions was probably due to two 
main factors: that the attempt was made before the days of aseptic 
technic; and because of the lack of knowledge of the incompatibility 
of various bloods with each other. In 1870, Landois 2 opened the way 
for the safe transfusion of blood when he discovered that the blood of 
one individual was not always compatible with that of another. While 
he did not explain this phenomenon, nor offer any method of deter- 
mining the incompatibilities of various bloods, he showed that the 
serum of one animal might dissolve the red corpuscles of another. 

It remained for Moss 3 to publish in 1910 his studies of iso-agglutinins 
and isohemolysins. He showed that the blood from two individuals 
may not mix well because of the fact that the red corpuscles of one or 
of each may be agglutinated by the serum of the other, and that^the 
corpuscles agglutinated in this way may be hemolyzed as well. He 
further showed that all individuals soon after birth may be grouped 
into four distinct classes, depending upon the ability of their serum to 
agglutinate the red corpuscles of members of the other groups, and on 
the susceptibility of their corpuscles being agglutinated by the serum 
of members of other groups. The principles established by Moss really 
opened the way to the practical work of using blood as a therapeutic 
measure in patients suffering from various conditions. 

1 Philosophical Transactions and Collections of Medical and Philological Papers, 
John Lawthrop, 1731. 

2 Die Transfusion des Blutes, 1875. 

3 Bull. Johns Hopkins Hosp., March, 1910. 

(187) 



188 BLOOD TRANSFUSION 

Recently, because of the increased interest in the possibilities of 
transfusion, many methods of transfusing the blood have been devised, 
making transfusion practical. With the development of these various 
methods, the various factors responsible for the untoward symptoms 
following transfusion have been eliminated, and as a result, transfusion 
of blood in the hands of an experienced operator can be done with 
very little or no danger to either the donor or recipient of the blood. 

Indications for Blood Transfusion. Blood transfusion is used as a 
surgical therapeutic measure whenever all or part of the elements of 
blood tissue are needed and cannot be obtained in sufficient amounts 
from the hematopoietic organs of the individual. These elements 
may be required: (a) To replace loss of whole blood, (6) to increase 
coagulability, and (c) to stimulate resistance to infection and various 
other toxic processes. 

It is a well-known fact that the administration of normal salt solution 
or the various modifications of Ringer's solution, either intravenously 
or subcutaneously, has a marked beneficial effect in certain conditions 
where more fluid is needed that cannot be ingested by any other means. 
By this form of treatment, then, one can hope only to give an increased 
amount of body fluid. On the other hand, by the transfusion of whole 
blood, one injects a living tissue which has functions inherent on its 
own constituents, and which thereby serves an entirely different 
purpose. 

When this treatment was first exploited it was used, as is usually the 
case, in many conditions in which it had no effect, or even did harm. 
At present, however, we know that in many instances the addition of 
fresh, living, whole blood to a patient from another individual may save 
a life, cure the pathological condition present, or at least, greatly 
improve the patient. 

The indications which, from our experience, are those best suited 
to this form of treatment will now be given in more detail. 

Hemorrhage. Severe hemorrhage is, of course, a specific indication 
for blood transfusion, and it is in these cases that the most brilliant 
results have been experienced. In postoperative, postpartum, and 
gastric ulcer bleeding this method has been advocated and used with 
success for a number of years. However, one should bear in mind the 
fact that Nature attempts to control the hemorrhage in two ways: 
(a) by producing a fall in blood-pressure and, (6) by attempting to 
cause a clot at the end of the bleeding vessel. If additional blood be 
added in sufficient quantity to increase the blood-pressure momen- 
tarily a clot may in this way be dislodged and the hemorrhage increased. 
Where it is possible to check the hemorrhage by mechanical means, 
such as by open operation in gastric ulcer or in ectopic gestation, or by 
packing in postpartum bleeding, blood transfusion, both before and 
after such procedure, tides the patient over an otherwise frequently 
fatal period. It is in the severe hemorrhages that large amounts, from 
600 c.c. to 1500 c.c., are given. The transfusion of amounts less than 
600 c.c. has not, in our experience, been sufficient to control such cases. 






OBSCURE HEMORRHAGES 189 

We have also noted that amounts greater than 900 or 1000 c.c. do not 
produce more satisfactory effects than the giving of 600 to 800 c.c., 
and repeating one or more times. This amount seems to be best 
suited both to replace the lost blood and to favor clotting at the 
bleeding point. 

Obscure Hemorrhages. Occasionally one encounters a patient in 
whom, following a surgical operation, without any apparent cause 
a secondary hemorrhage occurs from the wound after a period of from 
one to three weeks, and will keep recurring in spite of all the ordinary 
medicinal and surgical means at one's command. Many of these cases 
in the past have terminated fatally. These cases usually do not give a 
history of hemophilia, and, so far as I know, no reasonable explaniation 
as to the cause has ever been given. 

Illustrative Case. A woman, aged forty-eight years, in apparent 
good health, except for usual symptoms from a lacerated perineum. 
The patient was taken to the hospital and a perineorrhaphy performed. 
A good immediate recovery followed and the patient returned home at 
the end of two weeks. A few days later, which was eighteen days after 
the operation, a severe hemorrhage occurred from the perineum. The 
hemorrhage was finally controlled by enlarging the opening in the 
perineum from which the blood was coming and packing the area with 
gauze. Three days later, when the packing was removed, a lively 
hemorrhage followed immediately. Packing was replaced and as soon 
as could be arranged the perineum was reopened and sutured. At this 
time the patient was given some coagulose. One week later the 
hemorrhage recurred. The perineum was again partially opened and 
packed with gauze. During the following two weeks the packing was 
changed every three or four days and each time active hemorrhage 
occurred. During this period coagulose was used and also several 
doses of horse serum. Calcium chloride was also given and the patient 
placed on a gelatin, white of egg and milk diet. I saw the patient seven 
weeks after the operation, at which time she had a pulse of 140, was 
extremely weak; had no appetite; temperature subnormal; hemo- 
globin 20 per cent.; red count 1,200,000; white count 8000. A donor 
was immediately selected and the patient was taken to the operating 
room . Upon removing the perineal packing a marked bleeding occurred, 
the blood being very watery like. The principal part of the bleeding 
was controlled by suturing the perineum, but in spite of the fact that 
round, non-cutting needles were used, slight bleeding came from around 
each suture and it was impossible to control the oozing. As soon as the 
perineal wound was rendered as dry as possible a transfusion of 900 
c.c. of blood was given. Within ten minutes from this time the perineal 
wound was perfectly dry and the pulse had dropped from 150 to 110. 
Five days later a second transfusion of 700 c.c. was given. There was 
absolutely no bleeding from the time of the first transfusion, the wound 
healed primarily, the patient made a rapid convalescence and left the 
hospital at the end of three weeks, with a red count of over 4,000,000, 
and has remained in good health. No doubt this case would have 



190 BLOOD TRANSFUSION 

terminated fatally, in spite of anything that could have been done, had 
not the blood transfusion been given. 

Hemorrhages Complicating Infectious Diseases. Troublesome hemor- 
rhanges occurring as a complication of one of the infectious diseases 
can usually be relieved by blood transfusion. 

Illustrative Ca#e. A boy, aged seven years, with apparent good 
health, developed rather typical signs and symptoms of measles, 
except that the accompanying rash disappeared in about twenty-four 
hours. One week later he began to bleed from mouth, stomach and 
bowels. Blood was also present in the urine. The bleeding persisted 
and at the end of the second week numerous purpuric areas appeared on 
the skin. At this time his condition was grave; pulse, 160 per minute, 
weak; hemoglobin, 15 per cent.; red count, 1,200,000; hemorrhages 
persisting. Transfusion of 600 c.c. of blood gave instant relief. The 
hemorrhage ceased within five minutes and the patient made a rapid 
and complete recovery. 

Typhoid Fever Early in transfusion work, hemorrhage complicating 
typhoid fever was not considered as a condition in which blood trans- 
fusion was indicated. Recently, however, a number of typhoid cases 
complicated with hemorrhage have been transfused, in which the 
hemorrhage stopped immediately after transfusion of whole blood, 
following which the patients went on to complete recovery. 

Icterus. Patients with obstruction of the common duct with long- 
standing jaundice are extremely hazardous surgical risks. These 
patients usually do well for a couple of days following an operation, 
then have some hemorrhage from the wound, not severe, however, 
and then gradually weaken and just slip away without any special 
symptoms and without any apparent cause. Blood transfusion is indi- 
cated in these cases if a surgical operation is performed and will often 
tide the patient over an otherwise hopeless period. During the past 
two years the author has systematically transfused all cases of marked 
persistent icterus at the time of the operation, none of which has died 
from cholemia, while from past experience it is evident some of these 
cases would have terminated fatally without the transfusion. 

Anemia Complicating Pregnancy. Occasionally one encounters a rare 
type of anemia occurring as a complication of gestation, which simulate 
very much a pernicious anemia. In most instances the anemia improves 
immediately following delivery without any special treatment. Occas- 
ionally the anemia continues to progress after delivery. In such 
instances blood transfusion is indicated and is followed by brilliant 
results. 

Secondary Anemia. In cases of persistent oozing of blood in small 
amounts from any part of the body, with a consequent secondary drop 
in the blood picture or in which there is a constant destruction of cir- 
culatory elements from an infective or toxic process, blood transfusion 
has been found of great value. Amounts of 500 to 700 c.c., repeated 
at every six to ten days, do as much good as when larger amounts are 
used. The transfusions should be repeated until the bood picture has 



ACUTE SURGICAL SHOCK 191 

permanently improved. Conditions included in this class are: intes- 
tinal bleeding, epistaxis, pulmonary hemorrhage, hemorrhoids, and 
hematuria from various causes. 

Hemophilia. In this condition there is a greatly delayed coagulation 
time, so that small abrasions may allow of severe and persistent 
hemorrhage. Frequently, the blood of these patients will fail to clot 
in an hour or more. Here, blood transfusion may be employed during 
the active stage of bleeding, because enough prothrombin will in this 
way be supplied to produce the necessary clotting. At the same time 
the lost blood is being replaced by new blood elements. For this 
reason whole blood is a better medium than blood serum alone. Even 
after the bleeding has stopped, it is advisable to give occasional 
prophylactic transfusions of 500 to 700 c.c. of whole blood in order to 
supply the demand for prothrombin. 

Hemorrhagic Diseases of the Newborn. In these conditions the 
treatment by blood transfusion has been successful in a large number of 
instances and the lives of many infants have been saved. There is, of 
course, great difficulty in using the veins of infants, and for this 
reason, Helmholz has recently carried out a method which has been 
used in many cases. He punctures the anterior fontanelle in the mid- 
line and so enters the superior longitudinal sinus, which is a relatively 
large vessel in infants. 

Toxemia. In toxemia from any cause, or where there is a condition 
of general debility due to disease or metabolic derangement, blood 
transfusion has proved of marked benefit. 

Septicemia. We have seen several cases of severe septicemia fol- 
lowing pelvic cellulitis, postpartum infection and peritonitis in which 
the process had gone on to a practically hopeless stage and in which 
blood transfusion was resorted to as a last measure. Several of these 
cases were definitely improved and a few of them recovered. It would 
seem that in such instances the resistance of the patient was just 
insufficient to combat the disease. By the administration of whole 
blood, new antibodies and fresh red cells were furnished which became 
the added stimulus necessary to give the resisting process the upper 
hand. We therefore believe septicemia, bacteremia and toxemia to be 
favorable indications for blood transfusion. 

Banti's Disease and Hemolytic Icterus. These conditions are essen- 
tially surgical and blood transfusion is not indicated where the blood 
picture is not materially lowered. When, however, the red cell count 
is lower than 2,500,000 or there are persistent hemorrhages, blood trans- 
fusion should be resorted to as a preliminary treatment to splenectomy. 
The latter procedure offers the only hope of a permanent abatement, 
but the previous administration of new blood usually allows of a 
better surgical risk. In fact, blood transfusion has been shown by 
many different workers to be of benefit, at least temporarily, in 
practically every blood disease. 

Acute Surgical Shock. In cases in which it is known that a severe 
operation is necessary, such as in carcinoma of the intestine and in which 



192 BLOOD TRANSFUSION 

there is a marked cachexia and general weakness, these cases can often 
be improved in a general way to such an extent that the danger of 
surgical shock is markedly decreased. One, two or three blood trans- 
fusions of 500 to 700 c.c., given a week apart before the operation, will 
sometimes make an otherwise hopeless condition a fairly good surgical 
risk. Likewise, after a long, tedious, severe operation, the adminis- 
tration of a .pint of whole blood just after the operation is finished and 
while the last stitches are being applied will make a change that is often 
quite remarkable. A marked improvement of the general condition of 
the patient is evidenced by a better surface color, a strengthening of 
the heart action and a drop in the pulse rate of 30 to 50 beats per 
minute. 

Illuminating Gas Poisoning. In illuminating gas poisoning there is a 
permanent destruction of the hemoglobin in the red cells so far as the 
oxygen-carbondioxide carrying capacity is concerned. In such cases 
the transfusion of whole blood, thus adding enormous numbers of red 
cells and fresh hemoglobin, has in several instances saved the lives of 
individuals that would otherwise probably have gone on to a fatal 
termination. 

Pernicious Anemia. The transfusion of blood in pernicious anemia 
has recently received a great deal of attention and has been advocated 
by some as the sole means of treating this form of anemia. 

In view of the fact that pernicious anemia is, in all probability, a 
disease of infectious origin and that the spleen has abnormal hemolytic 
action on the blood elements with a late bone-marrow exhaustion, the 
writer is convinced that, the rational treatment consists of three main 
factors, viz.: (a) massive stepladder transfusions of whole blood, (6) 
splenectomy and (c) removal of all possible sources of infection. 

Each of these steps plays an important part in the treatment. The 
repeated blood transfusions nourish and stimulate the bone-marrow 
to action and help to restore the secondary changes in the various 
organs; the splenectomy unquestionaby reduces the amount of blood 
destruction, and the removal of the various foci of infection will 
relieve the patient of a chronic toxemia and possibly of an etiological 
factor of the disease. 

The employment of blood transfusion will result in marked tempo- 
rary improvement in the vast majority of cases. Our experience has 
been that while the blood pictures will improve immediately in prac- 
tically every case, and that in some early cases a prompt and marked 
remission will take place and may persist for a period of several months, 
on the other hand, in the late cases, the improvement in the blood 
picture from transfusion alone is very transitory, as the blood will 
begin to decline within a period of two or three weeks unless trans- 
fusion is repeated. 

In all of our cases except two that have come to operation * trans- 
fusion has been used as a preliminary measure before operation. It 
has also been employed in several extreme cases simply as a measure of 
prolonging life for a short time. From our experience it would seem 



PERNICIOUS ANEMIA 193 

that practically every case of pernicious anemia, even those in an 
extreme condition, can be temporarily improved. Ottenberg and 
Liberman, 1 however, found that in 25 cases of pernicious anemia 
treated by blood transfusion only 14 showed, for a time, progressive 
improvement. Tn 11 cases transfusion was of no avail. From this they 
conclude that blood transfusion induces' a remission in about one-half 
of the patients, and that if improvement does not follow the first 
transfusion, another donor should be selected and transfusion repeated. 

During the past five years the reader has transfused ninety 
patients suffering from pernicious anemia, including sixty-six that 
have come to operation, and a marked improvement, both in the blood 
picture and clinical condition of the patient, has resulted in all but one 
case. This patient was brought to the hospital in a comatose condition, 
received one blood transfusion, with practically no change in condition, 
and death resulted ten days later. 

The immediate effects of transfusion are usually quite striking. The 
red blood count is increased (often doubling immediately when the 
count is very low), the hemoglobin percentage rises and the number of 
platelets is increased. The blast cells usually become more numerous, 
and occasionally Howell's particles will appear in the blood, thus indi- 
cating a stimulation of the bone-marrow. 

Robertson 2 studied 4 cases of primary pernicious anemia treated by 
blood transfusion, with a view of determining the effect of the treat- 
ment in the excessive output of urobilin. Three of the four patients 
gave evidence of a resulting bone-marrow stimulation and at the same 
time showed a temporary increase of urobilin excretion. In one 
instance there was no change in the output of urobilin. 

After transfusion the patients immediately, as a rule, volunteer the 
information that they feel stimulated and much "stronger than they 
felt before." A few hours later they become ravenously hungry, while 
previously food often had to be forced upon them. This hunger and 
relish of their food persists even after the red blood count begins to 
fall, which usually takes place about ten days or two weeks later. 
With the improvement in appetite the mental symptoms grow better, 
the insomnia is relieved and the glossitis clears up. There is no doubt 
that the transfusion of large masses of whole blood accomplishes more 
than the mere mechanical addition of so much blood. It seems that it 
actually exerts either a curbing influence on the hyperactive spleen or 
a stimulating action on the bone-marrow, since the blood picture 
continues to improve for several days after transfusion. This may be 
due to the fact that the blood-forming organs are not only overworked, 
but are also undernourished. Furthermore, multiple blood transfusions 
supply protective antibodies and assist the patient in getting rid of the 
secondary changes which have taken place in the various organs. 
During the period when the individual is being prepared for operation 
by multiple blood transfusions, he should be treated to eradicate any 

1 Jour. Am. Med. Assn., 1915, Ixiv, 2163. 

2 Arch. Int. Med., 1915, xvi. 429. 

VOL. I 13 



194 BLOOD TRANSFUSION 

self-evident infection, such as infected teeth or tonsils, pyorrhea 
alveolaris, etc. 

The patients begin to improve immediately after the first trans- 
fusion and continue to improve with each subsequent transfusion until 
they are good surgical risks, and splenectomy can be done without 
greater Shock than would be produced in any other patient by an oper- 
ation of the same magnitude. At the time of operation a transfusion 
of from 600 to 1000 c.c. of blood should be given immediately at the 
close of the operation. 

By combining the blood transfusions with splenectomy and eradi- 
cation of all foci of infection our results in pernicious anemia have been 
very encouraging. 

Preliminary Examination. The most important part of transfusion 
is the selection of a healthy donor, and the making of hemolytic and 
agglutination tests between the two bloods. In addition to this, it is 
well to determine as nearly as possible the exact condition of the blood 
before transfusion in both the donor and the recipient . This exami- 
nation should consist of a red and white cell count, hemoglobin per- 
centage, coagulation time, a differential count, also noting the character 
of the various types of corpuscles. 

Donor. In selecting a donor it is important, in addition to making 
hemolytic and agglutination tests, that a careful history be obtained 
from the donor, and a complete physical examination made, including 
a Wassermann test. Donors should not be chosen from persons giving 
a history of recent attacks of typhoid fever, pneumonia, diphtheria, 
tonsillitis, malaria or influenza, or from persons suffering from tuber- 
culosis, chronic arthritis, rheumatism or where there is a history of 
hemophilia. 

Hemolytic and Agglutination Tests. A hemolytic or agglutination 
test of each blood upon the other should always be made before trans- 
fusion, because it has been found that in a considerable percentage of 
cases there is a tendency of the serum of one blood to cause a disinte- 
gration of the red cells of another even when the latter be a near 
relative. While the bloods from members of the same family are more 
liable to be compatible with each other than aliens' blood, still it is never 
safe to use even a close relative as a donor without making a hemolytic 
test between the bloods to be mixed. 

Hemolysis Test. Ten cubic centimeters of blood are collected from a 
vein of the donor (D.), 5 c.c. of which is placed in a dry centrifuge tube 
and allowed to clot and the remaining 5 c.c. mixed thoroughly with 
10 c.c. of a 0.5 per cent, sodium citrate in normal salt solution. The 
latter solution preserves the red cells and prevents clotting. Both 
tubes are now rapidly centrifuged. In one tube the clotted blood will 
separate, leaving a clear serum as an upper layer; 1 c.c. of this serum 
is then added to 9 c.c. of normal salt solution in a test-tube and labelled 
10 per cent, solution of D.'s serum. The other centrifuge tube now 
contains a compact layer of red cells in the bottom and an upper clear 
layer of mixed serum and salt solution. This upper layer is carefully 



AGGLUTINATION TEST 195 

poured off and the same amount of fresh normal salt solution is added, 
with a pipette, so as to thoroughly mix the cells. The tube is again 
centrifuged. This procedure is repeated ten or twelve times in order 
to thoroughly wash the red corpuscles free of serum. Finally, 1 c.c. 
of the corpuscles is mixed with 9 c.c. of normal salt solution in a test 
tube and labelled 10 per cent, suspension of D.'s corpuscles. Ten cubic 
centimeters of blood are collected in the same way from the recipient 
(R.) and a 10 per cent, solution of serum and a 10 per cent, suspension 
of cells are prepared as above and placed in separate test-tubes. These 
four 10 per cent, solutions and suspensions are used in setting up the 
test. 

In a clean test-tube 1 c.c. of D.'s serum is mixed with 1 c.c. of D.'s 
corpuscles. In a second tube 1 c.c. of R.'s serum is mixed with 1 c.c. of 
R.'s corpuscles. These two tubes are used as controls. In a third tube 
1 c.c. of R.'s serum is mixed with 1 c.c. of D.'s corpuscles and in another 
tube! c.c. of R.'s corpuscles is mixed with 1 c.c. of D.'s serum. These 
four tubes are placed in the incubator at 37.5 C. for two hours, during 
which interval the tubes are shaken several times. They are then 
placed in the icebox for twelve hours and shaken occasionally to ensure 
mixing. If the blood cells remain as a layer in the bottom of the text- 
tubes and there is a clear, nearly colorless fluid above, or if the tube, 
when shaken, be quite cloudy and not transparent there has been no 
hemolysis. If there are no red cells present as a layer, or if the shaken 
tube is clear and wine-colored, there has been hemolysis of the red cells. 
The two control tubes should show no hemolysis. If they do, there has 
been an error in technic. 

Agglutination Test. During the past year the writer has been deter- 
mining the hemolytic action of the blood by the Moss method, the 
technic of which has been modified by Brem. 1 This method is based on 
the principle that before the serum of one blood will cause a hemolysis 
of the corpuscles of another it will first, or simultaneously, cause an 
agglutination of the corpuscles. The reverse, that all cases that show 
agglutination will also show hemolysis, is not necessarily true, only 
occurring in about 20 per cent, of cases. Adopting this principle, all 
bloods are classified according to the agglutinative properties of their 
elements into one of four groups. In selecting a donor it is always 
advisable to have a donor whose blood belongs to the same group as 
that of the patient. If this is impossible the donor's blood should 
belong to a group whose corpuscles are not agglutinated by the serum 
of the patient. The bloods of Group IV answer this requirement for 
all the other groups, as its corpuscles are not agglutinated by the serum 
of any group. Fortunately, group IV is the most common group, Moss 
having found that 43 per cent, of all individuals belong to this group. 

Moss found that all bloods, whether normal or pathological, could be 
classified into four groups by agglutination tests of the serums against 
the corpuscles. He found the groups to be as follows: 

1 Jour. Am. Med. Assn., July 15, 1916. 



196 



BLOOD TRANSFUSION 



Group I. 10 per cent. Serum does not agglutinate corpus 3les of 
any group. Corpuscles are agglutinated by serum of II, III and IV. 

Group II. 40 per cent. Serum agglutinates corpuscles of groups 
I and III, not IV. Corpuscles agglutinated by serum of III and IV, 
not I. 

Group III. 7 per cent. Serum agglutinates corpuscles of groups I 
and II, not IV. Corpuscles agglutinated by serum of II and IV, not I. 

Group IV. 43 per cent. Serum agglutinates corpuscles of groups 
I, II and III. Corpuscles are not agglutinated by any serum. 

The serum of one group will not agglutinate the corpuscles of blood 
belonging to the same group. 

Corpuscles 



Group 

I 


Group 
II 


Group 
III 


Group 
IV 


















Group 

I 





- + 





+ 





Group 
II 


1 


+ 


+ 








Group 
III 




+ 


+ 


+ 





Group 
IV 





Moss chart, showing the reaction of the various groups against each other. 

In grouping, the unknown blood should be tested with a blood whose 
group is known. This " standard" blood must belong to either group 
II or III in order to be of any value in grouping other bloods. The 
group to which a blood belongs becomes fixed by the third year of life, 
and remains constant. It is not influenced by age, disease or trans- 
fusion of blood belonging to another group. 

It will be seen from the above table that the serums and corpuscles 
of the same groups do not in any way interact. It will also be noted 
that there is a wide, undetermining variety of reactions possible in the 
cases of group I and IV. The reactions in the two remaining groups are 
more limited and definite, and for that reason, groups II or III only may 
be used as the standards in the Moss test. 

The basis of the blood examination for transfusion is the aggluti- 
nation reaction. Agglutination is considered as an early stage of 
hemolysis and is always present, hemolysis never occurring without a 
primary agglutination of the blood cells, while, on the other hand, 
agglutination may occur, and does occur without hemolysis. It is 
from this agglutination that we arrive at our conclusions. The serum 
of a given blood contains a protective agent (antihemolysin) for its own 



AGGLUTINATION TEST 197 

corpuscles, this serum having a tendency to prevent hemolysis. The 
serum does not contain a corresponding antiagglutinin, so hemolysis 
may be prevented without in any way hindering the agglutination 
reaction. In the original method of Moss, two platinum loopfuls of 
the agglutinating serum were added to one loopful of corpuscles from 
the blood to be tested. By this method oftentimes the stage of aggluti- 
nation was so transient that its presence was not recognized, and the 
agglutination went on to complete hemolysis. The correct interpre- 
tation of the test was therefore impossible, as the observer failed to 
recognize the determining factor: agglutination. To remedy this, 
Brem, besides the two loopfuls of agglutinating serum and one loopful 
of the corpuscles of the blood to be tested, added one loopful of the 
protecting serum, that is, serum of the same blood from whence the 
corpuscles were derived. This protective serum, as we stated above, 
contains antihemolysins but no agglutinins. In this way the aggluti- 
nation is not in any way affected, but the hemolysis of the blood cells 
is retarded or prevented, so giving a relatively slow, definite, easily 
recognizable stage of agglutination. The technic, based upon these 
considerations, is as follows: 

Ten to twenty drops of blood are collected in a small test-tube from 
the lobe of the ear. This is allowed to clot and then the tube is centri- 
f uged so as to obtain a clear serum above. This is the protective serum 
when used with its own corpuscles, but when it is used with the cor- 
puscles of another blood it is called the agglutinating serum. In another 
small test-tube are collected 2 drops of blood in about 1 c.c. of solution 
composed of 1.5 gm. sodium citrate, 0.9 gm. sodium chloride in 100 c.c. 
of distilled water. This gives approximately a 5 per cent, suspension of 
the corpuscles. This tube requires no further preparation. 

Upon cell slides rimmed with petrolatum to prevent evaporation are 
made ordinary hanging drops. 

On one slide is placed: 

Two loopfuls of standard serum (agglutinating serum), plus 

One loopful of the suspension of corpuscles of the blood to be tested, 
plus 

One loopful of the protecting serum; that is, the serum from the 
same blood as the corpuscles. 

On the other slide: 

Two loopfuls of the unknown serum (of the blood to be tested), plus 

One loopful of the suspension of corpuscles from the standard or 
known blood, plus 

One loopful of its protective serum. 

It will be seen from the above table that one slide contains the 
standard or known serum, while the other the standard or known 
corpuscles. Deductions are made, using the standard serum and cor- 
puscles as a basis (group II or III used as the standard groups) after 
the agglutination is recognized. 

For instance, if using group II as a standard we get agglutination in 
the slide containing the standard serum and none in the slide containing 



198 BLOOD TRANSFUSION 

the standard corpuscles the undetermined blood is of group I. From 
the above table we will find that the serum of the standard blood (group 

II in this case) agglutinates the corpuscles of groups I and III and not 
of groups II or IV, and that the corpuscles of this standard group II 
are agglutinated by the serums of groups III and IV and not by groups 
I or II. Then, since there is agglutination in the slide containing the 
serum of the standard group II the undetermined or unknown blood 
must be either of group I or III. In the other slide containing the cor- 
puscles of the standard group II there is no agglutination, so the 
undetermined or unknown blood must be either of group I or III. 
Since group I satisfies the agglutinating reaction in both instances the 
unknown blood must belong to that group. 

If agglutination occurred in both slides prepared as stated above, by 
similar deductions we find the undetermined blood would belong to 
group III, as the standard serum agglutinates the corpuscles of groups 
I and III and not of groups II or IV, while the standard corpuscles are 
agglutinated by the serums of groups III and fV and not by groups I 
or II. As the serum and corpuscles of group III satisfy the agglutinating 
reaction in both instances the blood being tested belongs to that group. 

Taking the third possible reaction, if no agglutination occurred in 
the slide containing the serum of the standard blood, and agglutination 
was present in the slide containing the standard corpuscles, the undeter- 
mined blood would be of group IV, since, from the table given above, 
we see that the standard blood (group II) agglutinates the corpuscles 
of groups I and III, and not of II or IV. The standard corpuscles of 
group II (the standard blood used in this instance), are agglutinated 
by the serums of groups III and IV, and not by I or II. Therefore the 
serum and corpuscles of group IV satisfy the agglutinating reaction of 
group II, the standard; consequently, the blood tested belongs to 
group IV. 

Lastly, if there occurs no agglutination in either slide, the unknown 
blood is of the same group as the standard blood used, as bloods of the 
same group do not in any way interact. 

These are the four possibilities in using group II as a standard. The 
method of deduction is identical to that given above when using group 

III as the standard. 

An endeavor should always be made to have the donor and the 
recipient of the same group, so reducing to a minimum the possibilities 
of reactions. If, in an emergency, blood must be given immediately, 
or if the recipient be a member of group I or III, the rarer groups, 
certain deviations, may be practised in which bloods of unlike groups 
can be used. Under such conditions, the serum of the recipient must 
never agglutinate the corpuscles of the donor, while the serum of the 
latter may agglutinate the corpuscles of the patient. The serum of the 
donor, as it enters the blood stream of the recipient, is diluted to such an 
extent as to be practically inactive. The lack of agglutination of the 
patient's corpuscles is in part prevented by the fact that the recipient's 
corpuscles are protected by his own serum: i. e., the protective serum. 



AGGLUTINATION TEST 199 

Vincent's Method of Determining the Moss Grouping of Blood. 
Because of the technical difficulties of grouping bloods in a private 
home without any laboratory facilities, Vincent worked out a method 
by which a patient's blood group can be determined in from three to 
five minutes, requiring no laboratory facilities. 

In making the test one must have on hand a stock serum from an 
individual whose blood belongs to group II and from one in group III. 
These stock serums are obtained by drawing blood from an individual 
in group II and from one in group III. The serum is separated from 
the blood by centrifuging or allowing the blood to clot, the serum from 
which is placed in a sterile bottle. The serum is preserved by adding to 
it enough sodium citrate to make a 1.5 per cent, solution and chloro- 
form is added to the extent of .3 per cent. These serums, when sterile, 
can be kept indefinitely. 

Technic of Grouping the Blood. One drop of group II serum is placed 
on a glass slide near one end, and one drop of group III serum on the 
same slide, near the other end. A drop of blood from the person to be 
grouped is mixed with each of the serums on the slide and the reaction 
noted. Clumping of the corpuscles, if it takes place, will occur in from 
one to three minutes, and can be readily seen with the naked eye, 
appearing as a brick red deposit. The various groups will be noted 
by the following reactions: 

1. If agglutination of the corpuscles takes place in the group II 
serum and not in the group III serum, the blood being grouped belongs 
to group III. 

2. If agglutination is noted in the group III serum and not in the 
group II serum, the blood being grouped belongs to group II. 

3. If agglutination is noted in both group II and group III serums, 
the blood being grouped belongs to group I. 

4. If agglutination does not occur in either serum, the blood being 
grouped belongs to group IV. 

When noting the reaction, if, by simply looking at the slide with the 
naked eye there be any doubt as to whether or not agglutination has 
taken place, this can be definitely determined by placing the slide 
under the microscope. From the above it may be noted that if one has 
on hand a stock serum belonging to group II and to group III, the 
technic of grouping blood is very simple and can be done in a few 
minutes, even without laboratory facilities. The simplicity and rapid- 
ity with which it can be done is the only advantage it has over Brem's 
technic as previously described. 

The determination of the hemolytic reactions of blood by the Moss 
method in the selection of donors, has proved very satisfactory in our 
hands . Since adopting this method, three hundred and fifty transfusions 
have been made without encountering a single case of hemolysis. The 
milder reactions have been rare. These have been manifested by a 
chill in 5 per cent, of the cases and by a rise in temperature occurring 
on the same or following day in 10 per cent, of the cases. 

Except in extreme emergency, one is never justified in making a 



200 BLOOD TRANSFUSION 

blood transfusion without first having made a hemolytic test between 
the two bloods to be mixed. Even between near relatives, such as 
sister to sister or parent to child, etc., severe fatal hemolysis may occur 
from mixing the two bloods. In case of a large family in which the 
father and mother are not in the same blood group, usually some of the 
children will be in the same group as the mother and some in the 
father's group, and occasionally, some in still another group. Thus it 
is plain that a brother might be a suitable donor for one brother but 
not for another; also, he might be a suitable donor for one parent and 
not for the other, thus making it a dangerous procedure to transfuse 
one member of a family from another member without first determining 
the hemolytic action of one blood with the other. 
Methods of Transfusion. 1. Direct method by means of: 

(a) Suture of vessel to vessel as practised by Carrel, Murphy and 
others. 

(b) By use of a paraffin-coated cannula interpolated in the blood 
stream as devised by Brewer 1 and the two-piec* tube of Bernheim. 2 

(c) By use of one cannula, bringing intima to intima as represented 
by the Crile method. 

2. The indirect methods: 

(a) Needle and syringe method of Lindeman 3 and Crotti. 4 
(6) The direct and indirect valve and syringe method of Miller, 5 
Unger 6 and others. 

(c) The indirect paraffin tube methods of Kimpton and Brown, 7 
David and Curtis 8 and Percy. 9 

(d) By drawing blood into a receptacle containing anticoagulants, 
such as the citrate methods of Weil 10 and Lewisohn, 11 and the use of 
Herudin by Satterlee and Hooker. 

(e) The method of drawing blood into a receptacle, defribinating, 
then injecting the defibrinated blood into the vein through a 
needle. 

The direct method of transfusion by bringing intima to intima would 
be the ideal method were it not for the fact that it requires expert 
surgeons to perform the operation and that there is no way of deter- 
mining with any degree of accuracy the quantity of blood transfused. 
On account of the technical difficulties -of the operation the direct 
methods of transfusion have been almost entirely replaced by the 
various indirect methods. 

Percy's Method of Transfusion. The method is an indirect, closed 
method and consists of drawing blood into a specially designed glass 
tube and then injecting it into the vein of the recipient. The tube is 
coated inside with solid grocers' paraffin and liquid paraffin is floated 

1 Jour. Am. Med. Assn., January 30, 1909. 2 Ibid., October 9, 1915. 

a Am. Jour. Dis. of Child., 1913, vi, 28. 

4 Surg., Gynec. and Obstet., 1914, xviii, 236. 

6 Medical Record, September 11, 1915. Ibid. 

7 Jour. Am. Med. Assn., July 12, 1913. 8 Ibid., Ixii, 775. 
9 Surg., Gynec. and Obst., September, 1915. 

10 Jour. Am. Med. Assn., January 20, 1915. Am. Jour. Med. Sc., 1915, cl, 886. 



TECHNIC OF TRANSFUSING THE BLOOD 201 

on top of the blood, preventing the blood from coming in contact with 
the air. 

Description of Tube. The tube to be described is a modification of 
the Brown tube, which was changed with the object of making a 
venous transfusion tube and also a tube more easily constructed. It 
consists of a glass cylinder, 5 cm. in diameter, with a cannula leading 
from one end, the other end being drawn out into a tube about 1 cm. 
in diameter, to which a Y-connection containing a two-way valve is 
made. To one arm of the Y a rubber tube is attached for suction to aid 
in filling the tube and to the other arm a rubber bulb is connected to aid 
in injecting the blood. The tube differs from the Brown tube in that 
there is no side tube coming off from the cylinder, and the upper end 
of the cylinder, instead of being closed with a large cork, is drawn out 
into a tube for the Y connections, as described above. The cannula 
part of the tube is so constructed that it can be inserted directly into 
the vein of the donor and then into the recipient. An open dissection 
of the vein of both donor and recipient is made for two reasons: (1) 
If the operation were done subcutaneously, it would be necessary to 
use a needle with a rubber connection to the cannula, which connection 
would make a roughened area which would favor clotting, whereas 
with the smooth, paraffin-coated cannula there is no such tendency. 
(2) After the tube is filled with blood, the cannula can be inserted into 
a vein of the recipient without delay, an essential feature because of the 
tendency to clot after blood has been withdrawn. 

Preparation of Tube. The tube should be cleansed by washing with 
water, alcohol and then with ether, and, after it is perfectly dry, 2 
ounces of melted grocers' paraffin are poured into the tube through the 
upper end. It is then wrapped in a towel and placed in a steam auto- 
clave for fifteen minutes under fifteen pounds' pressure, after which, 
with sterile rubber gloves over the hands, the tube is rolled around while 
cooling so that every part of the inside is covered with melted paraffin 
and any excess allowed to run out of the large end. Care should be 
taken not to allow the cannula to become plugged with paraffin. If 
it does the tip is warmed over a flame and the paraffin allowed to run 
back into the tube. Sterilizing the rubber tubing, Y-valve and mouth- 
piece is done by placing them in a towel and autoclaving in the same 
way and at the same time as the transfusion tube or boiling them for 
twenty minutes. The atomizer bulb is thoroughly washed with 
alcohol to sterilize it. When ready to use the connections are all made 
and 2 ounces of sterile liquid paraffin aspirated into the tube through 
the cannula by means of suction at the mouth-piece. A simpler method 
of sterilizing the tube consists of first pouring the melted paraffin into 
the tube, then carefully heating the tube over a gas-burner until the 
paraffin in the tube begins to smoke. The excess paraffin is allowed to 
run out of the tube and the tube is carefully rolled with the hands 
while the paraffin is cooling, thus evenly coating the entire tube. 

Technic of Transfusing the Blood. The arms of both the donor and 
the recipient are prepared as for a surgical operation. Proper constric- 



202 



BLOOD TRANSFUSION 




FIG. 2. 1, 2, preparation of the arms of donor and recipient for blood transfusion; 
la, 2a, dissection of the veins of donor and recipient shown in detail. (Surgical 
Clinics of Chicago.) 



TECH NIC OF TRANSFUSING THE BLOOD 



203 




FIG. 3 8, method of obtaining blood from donor. Note layer of liquid paraffin 
floating on blood. Insert shows detail of the two-way valve. The operator and his 
assistant hold the vein over the cannula by means of traction on the mosquito clamps. 
Gentle suction is made by a second assistant. 4, the cannula of the transfusion tube 
inserted in the vein of the recipient. The edges of the vein are held in the same way. 
Gentle air pressure is applied above the blood chamber by means of a rubber atomizer 
bulb. (Surgical Clinics of Chicago.) 



204 BLOOD TRANSFUSION 

tion of the donor's arm is essential if one wishes to draw off a large 
quantity of venous blood rapidly. Constriction by means of a rubber 
tube is not satisfactory because the amount of pressure is not known, 
nor can the pressure be varied as desired. An ordinary blood-pressure 
apparatus placed about the arm and pumped up to 50 to 80 mm. of 
mercury, depending upon the rapidity with which the blood flows, 
makes an excellent constrictor. By this means the venous circulation 
is impeded but not the arterial, thus making the entire arm a blood 
reservoir, and so increasing the pressure in the vein elected. 

It is imperative to use a separate set of instruments on different tables 
for donor and patient in order not to transmit infections from patient 
to donor. Under local anesthesia, using 0.5 per cent, novocain solution 
intradermally, an incision is made over the cephalic vein just above the 
elbow on both the donor and the recipient, and a ligature placed about the 
vein on its proximal portion in the donor and on its distal portion in the 
recipient. Small Carrel clamps are placed on that portion of the vein 
away from the ligature in each patient and* a longitudinal incision 
3 mm. long made through all coats of each vein midway between 
clamp and ligature. Small mosquito retention clamps are placed 
on the two edges of the incision in each vein in order to hold them 
open. 

Just before the tube is inserted into the donor's vein about 25 c.c. 
of sterile liquid paraffin are aspirated into the tube. The cannula is 
placed, pointing distally, into the vein of the donor, and the Carrel 
clamp released from the vein. Slight suction will facilitate filling of 
the tube with blood. The blood is well protected from the sides of the 
glass by the paraffin coat. As the tube fills the liquid paraffin floats 
over the blood, thus preventing the blood from coming in contact with 
air. As soon as the tube is filled, which in our experience averages about 
three and one-half minutes to withdraw 600 c.c. of blood, the Y-valve 
is closed, the cannula removed from the vein and the small clamp 
reapplied to the donor's vein. 

The cannula is now quickly transferred to the lumen of the vein of the 
recipient and the Carrel clamp released. The blood will now flow into 
the vein of the recipient toward the heart, the velocity of which flow 
may be controlled by careful pumping of the rubber atomizer bulb. 
As soon "as it is evident that the blood is flowing properly an assistant 
may release the constrictor from the donor and ligate the vein distally 
to the opening from which the blood has been taken. Not more than 
five minutes should be utilized in obtaining the blood. The tube can 
be emptied in about a minute and a half, but greater deliberation is 
advisable, so that possible hemolytic phenomena may be noticed, acute 
dilatation of the heart avoided and that aeration of this venous blood 
may be more ready. Inhalation of oxygen in very weak patients is 
advisable during the injection of large amounts of venous blood. The 
length of time required to fill the tube with blood varies with different 
donors. It is well to have two tubes ready, so that if it is found that 
the first tube fills slowly, taking more than five minutes to get the 



REACTIONS FOLLOWING TRANSFUSION 205 

required amount, the process may be repeated with the second tube, 
aspirating only the remainder of the required amount of blood. 

Factors of Safety. The chief points to be borne in mind in blood 
transfusion are the avoidance of hemolysis, air ambolism, clot embolism 
and acute dilatation of the heart. 

The greatest risk from the operation is that from hemolysis. This 
danger can be avoided in the vast majority of cases if careful hemolytic 
and agglutination tests are always made preliminary to transfusion. 
While laboratory methods have their limitations and are not infallible, 
still, if the tests are always carefully made, the danger from hemolysis 
is slight. 

The danger from air embolus and clot embolus can always be avoided 
if proper care is exercised in carrying out the technic of the operation. 

The danger of acute dilatation of the heart is probably not as great 
as is generally supposed. So far the author has not encountered a 
case in which there was any evidence of the heart having been embar- 
rassed by the transfusion. It is well, however, not to inject the blood 
too rapidly in very weak and anemic patients, especially if it be the 
first transfusion. 

Advantages of the above method of transfusion are: 

1. Known quantities of blood may be administered. 

2. As much as 600 to 700 c.c. of blood can be given in from five to 
eight minutes. 

3. Venous blood is utilized, so that arteries, such as the radial, are 
not destroyed. 

4. Transfusion can be made without danger of contaminating the 
donor with the blood of the recipient. 

5. The blood does not come in contact with the air during the entire 
operation. 

6. There is direct communication between the vein and the chamber 
by a simple paraffin-lined glass cannula. There are no metal, rubber 
or other connections which might cause resistance to the flow of blood 
and thus favor the formation of a clot. 

7. Plain, whole blood is administered in its normal state. The blood 
is not diluted with any foreign substance and not traumatized by 
beating, as in the citrate method; nor is it traumatized by passing 
through a series of valves and connections, as it might be in some of the 
other indirect methods of transfusion. 

Reactions following Transfusion. The majority of our patients have 
experienced no noticeable reaction whatsoever. In about 5 per cent, 
of cases a slight chill has occurred, followed by temperature, and in an 
additional 5 per cent, a mild temperature developed the same evening 
or day following the transfusion. This applies to transfusions in which 
the patient and donor were in the same blood group, as classified by 
Moss. Whenever we deviated from this and used a donor from a 
different blood group than that of the recipient, as was occasionally 
necessary, the transfusion was usually followed by a marked chill and 
temperature. A donor from a different group than that of the recipient 



206 BLOOD TRANSFUSION 

was never used except when the patient was in one of the rarer groups 
and it was difficult to find a donor belonging to the same group. In 
these instances a donor was chosen from group IV, a group whose 
corpuscles would not be agglutinated by the serum of the recipient. 

A number of operators using the citrate method have noted a com- 
paratively high percentage of reaction following transfusion. This is 
probably due to two causes: (1) the introduction of the sodium 
citrate into the circulation, which may be slightly toxic to some 
individuals; (2) the whipping of the blood and exposure to the air in 
mixing it with the citrate solution may cause some change in the blood 
which, when injected into the circulation, may help to account for the 
chills and temperature. 

The clinical effect of transfusions apparently is not impaired by these 
slight reactions, which not infrequently do occur. Novy's 1 experiments 
in the toxicity of normal blood serum are interesting. He believes that 
normal serum is always toxic and that the effects produced by the 
injection of serum vary with the method of pieparing the serum. A 
serum made by defibrinating with glass beads was found to be more 
toxic than one prepared by simply whipping with a glass rod. He also 
found that with whole blood some change takes place in the blood by 
being out of the body a few minutes, rendering the blood toxic. This 
is illustrated by the following experiment: When 10 c.c. of blood 
were drawn from a rabbit and injected intravenously into a guinea-pig 
with the least possible delay it caused very little or no reaction. On 
the other hand, when such blood was kept in the syringe for three 
minutes before it was injected the blood became toxic, 2 c.c. of which 
was sufficient to kill the animal. 

The symptoms of hemolysis or " anaphylactoid" phenomena, as 
spoken of by Brem, which follow transfusion when one blood is incom- 
patible with the other are quite typical, and, as a rule, occur within a 
few seconds from the time the transfused blood first enters the circu- 
lation. Before using the Moss group method of selecting donors the 
author met with three of these severe reactions, two of which resulted 
fatally, one living twenty days and the other twenty-one days after 
transfusion. The symptoms were practically the same in all 3 cases; 
the 2 which resulted fatally ran practically the same course. 

The following report illustrates the symptoms and course of a case 
of hemolysis from transfusion. The case transfused was a tuberculous 
patient, suffering from Pott's disease with psoas abscess, also tuber- 
culosis of the ribs. On making a hemolytic test a marked hemolytic 
reaction existed between her blood and her husband's, but a test with 
the sister's blood was negative, so she was chosen as the donor. Five 
hundred cubic centimeters of blood were taken from the donor and 
after about 250 c.c. had been given to the recipient, she suddenly com- 
plained of a peculiar feeling over her entire body and of severe pain low 
down in the spine radiating along both sciatic nerves. The transfusion 

1 Jour. Am. Med. Assn., July 15, 1916, p. 193. 



REACTIONS FOLLOWING TRANSFUSION 207 

was stopped immediately without giving the remaining 250 c.c. of 
blood in the tube. Chills and vomiting began at once. A peculiar 
biuret-pink blush flushed the woman's face and body, being strikingly 
intense on the palms. Sweating, so profuse that droplets formed on the 
fingers and the palms, was noted immediately. Great respiratory 
distress accompanied these signs, persisting somewhat longer than the 
characteristic blush which quickly changed to a transient cyanosis, as 
though the capillaries had been suddenly gorged to their full capacity 
and then had suddenly contracted to their utmost. This entire chain 
of symptoms occurred within three minutes of the beginning of trans- 
fusion. The vomiting and chills persisted in their full intensity for 
about one hour, when the temperature mounted to 101, returning 
to normal within twenty-four hours. The vomiting continued, regard- 
less of food (bile and mucus), at intervals of from a half to a few hours. 
Two hours after the transfusion bleeding began from the uterus and the 
small cutaneous wound in the arm, and it was uncontrollable except by 
tight compression of the entire arm and heavy sealing of the wound 
with collodion. Bleeding subsided within twelve hours. 

Six hours after transfusion a peculiar yellow color, different from yet 
suggesting jaundice, made its appearance over the entire body, includ- 
ing the sclerse. This color disappeared in thirty-six hours. Within two 
hours after transfusion blood appeared in the urine. This was followed 
by a complete suppression of urine, persisting for thirty-six hours, 
when 2 ounces were passed in the next twenty-four hours. The quan- 
tity of urine increased about 2 ounces daily to 10 or 12 ounces. 

One week after transfusion an urticaria appeared over the entire 
body, persisting for about a week, and being followed by a peeling 
resembling the scaling of a scarlet-fever rash. Constant nausea and 
vomiting persisted without abatement. The patient gradually lost 
strength and died at the end of three weeks without evidence of any 
terminal infection. 

It may be noted that the donor in this case was the patient's sister. 

SUMMARY. 1. Transfusion of blood is the most efficient means at 
our command for treating hemorrhage and the majority of hemorrhagic 
diseases, as well as many of the wasting diseases. 

2. The proper selection of donors by adequate preliminary tests for 
compatibility is essential. 

3. Amounts of from 500 to 800 c.c. of whole blood, repeated at 
intervals of seven to fifteen days, are most desirable. 

4. A simple, rapid method of transfusing should be used. This 
should preferably be one in which plain, whole blood is administered, 
without mixing with any foreign substance; furthermore, the blood 
should not be unduly exposed to the air, and the interval that it is out 
of the circulation should be reduced to a minimum. An indirect, 
closed method by means of a prepared container seems to best answer 
these'requirements. 



EFFICIENCY OF KADIUM IN MALIGNANT 

DISEASE. 

BY ROBERT ABBE, M.D. 

IN considering the subject of this title, we must ask ourselves two 
questions: 

1. What can we regard as definite knowledge of the action of radium 
as a physical force? 

2. What effect is seen by its use, on vital growth in health and 
disease? 

Without an intelligent appreciation of this first step we are not 
prepared to ask the question 

"What is its effect on malignant disease?" 

Under the latter head we must also ask ourselves: "What constitute 
the essential characteristics of malignant tumors?" 

No observer of the action of radium can fail to be impressed with its 
terrific penetrating force, which no material substances, even metals, 
are capable of resisting. The severe test, with an inch thickness of 
lead, shows that this is a barrier to its penetration only for a time. 
One thinks he is immune from its action when he carries radium in a 
lead box of a quarter inch thickness, but soon discovers his fingers 
becoming tender from it. 

The many streams of penetrating particles emanate in unceasing 
flow from the eternal disintegration of this material. They travel in 
undeviating lines in all directions, and barriers of varying resistance 
retard them only for a time. They enter space, but are never lost in it. 

The nature of this matter is now sufficiently understood to define 
it as a discharge of infinitely small particles mostly bearing an electric 
current, some positive and some negative, called "electrons." The 
eternal breaking up of radium particles is not unlike the change and 
decay that characterize all matter, and differs only in being so much 
faster than anything heretofore known, that it can be seen, measured, 
and applied. All other metals are undergoing this forcible change, 
but with them it is so many million times slower, that it cannot be 
identified, studied or used, though it can be computed. 

The force we are dealing with, then, is a stream of electrons which 
we spray upon a diseased part and study the effect which follows. 
Whether we use a nearly pure salt of radium, like the pure radium bro- 
mide, or an impure radium-barium sulphate, chloride or carbonate, 
of one-third or one-tenth strength, we are applying the same force and 
obtain the same effect if we give a proportionate exposure. 

VOL. ii4 ( 209 ) 



210 



EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 



It will be essential to intelligent understanding of the action and 
value of radium to know a little of the detailed physics of electrons. A 
few words comprehend the whole. 

There are three kinds of particles issuing from the disintegrating 
atom: 

One slow moving and heavier than the others, each particle carrying 
a charge of positive electricity ("if, indeed, it be not electricity itself," 




FIG. 4. Schematic representation of alpha, beta and gamma rays from a surface of 
radium on a metal block. 

as Clifford suggested). This alpha series travels in straight lines, but 
has a small radius of action. 

The second, and most important, the beta series, much faster and 
lighter, each particle carrying negative electricity. 

The third, the gamma, practically a neutral electron, travelling 
nearly with the rapidity of light and almost undeviated by the mag- 
netic current. 




FIG. 5. Alpha, beta and gamma rays in a strong magnetic field. 

The stream of rays issuing from radium moves in straight lines in all 
directions (Fig. 4) . When, however, it is placed in the magnetic field, 
between two poles of a strong battery, only the gamma rays continue 
to go straight while the beta and alphas go swirling around the poles, 
one in one direction and the other in the opposite, obeying the law of 
metallic particles in the magnetic field (Fig. 5). Taking advantage 
of this it has become possible to study the effects of the differentiated 
groups. Two simple experiments put the reader in the way of under- 



EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 211 

standing the full value of each group. Their effect on vital growth can 
be demonstrated: 

First experiment. Let radium be spread on a small block of lead, 
an inch square, placed at right angles to a photographic plate, on which 
are standing small lead pillars, in front of and behind the block (Fig. 
6). In a few moments the developed photograph shows shadows 
of all columns radiating away from the radium (Fig. 7) . At the foot 
of each column is an intensification of the illumination of the plate, 
due to a series of secondary rays resulting from the impact of all these 
groups, straight-travelling, and striking the little lead post, set up on 
the plate. 




FIG. 6 

Second experiment. Repeat the above arrangement of lead block, 
radium, and lead posts on a fresh plate and place this in the field of a 
powerful magnet. On developing this plate an entirely different picture 
is shown (Fig. 8). The posts in front of the radium again show 
radiating shadows, but another set now appear on one side and behind 
the lead block, resulting from the beta rays, torn from the straight 
course they were travelling hand-in-hand with the gammas, and made 
to swirl round the magnetic pole, in obedience with laws of electrically 
charged bodies, and casting curved shadows. These also have intensi- 
fied illumination at the foot of each post, from secondary rays, gener- 
ated always where any obstruction is met. This experiment can now 
be used to demonstrate the effort of isolated beta rays (negative elec- 
trons) on living cells. (Fig. 9). The device shown provides a shelf 
on which are showered beta and gamma rays separated. The only 
scientist competent to give aid in perfect demonstration at this stage 



212 



EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 




Fia. 7 




FIG. 8 



I believed to be Dr. Alexis Carrel, who had been growing living cells of 
chicken tissue for three years by cultivation, in vitro, in a warm chamber 
under strictest guard of all circumstances. The process seemed as 






EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 



213 



perfect as culture of bacteria in a test-tube. Every other day an 
atomic bit of new-grown cells had been cut from the margin of two days' 
growth, and placed in a cell or a microscopic slide, sealed hermetically 
in modified chicken serum. Thus, generation after generation, up to 
nearly three hundred, had established normal growth for each day, 
under identical conditions. It thus became possible to take a corre- 
sponding group of new cells day after day, repeat the old experiment 
and add the new ones, of an identical bit of tissue subjected to isolated 
beta rays and another to isolated gamma rays for a half hour, and culti- 
vated altogether side by side for two days' growth. 




FIG. 9 

This experiment Dr. Carrel eagerly took up day after day, appre- 
ciating its significance, and pursuing it for many months with the 
following striking demonstrations: 

1. The beta ray uniformly produced great retardation of the cell 
growth. The gamma gave no effect. 

2. This stunting of the cells was persistent, so that all attempts to 
make them grow like the unradiumized, failed, and through eight 
generations the dwarfed cells continued as dwarfs. 

(Further work was prevented by Dr. Carrel's call to the service of his 
country). 

The two illustrations of normal and stunted growth here shown are 
from studies in other research work by this master, but, at his request, 
I use them as exact illustrations of beta ray effects. 

Before this beautiful demonstration was made the effects of radium 
on animal and plant life had been confined to the effects of mixed rays. 
Although from the first Bequerel had showed the deviation of small 
pencils of the rays in a magnetic field, no proof of the separate ray 
effects had been known. On seeds the stunting of growth by mixed rays 
of radium was demonstrated by Danlos to whom Madame Curie gave 



214 



EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 



her first radium for study. Thousands of experiments on every kind 
of bulb flower and seed, by those of us who have had enough to make 





FIG. 10. Two days' growth of living cells of chicken tissue (300th generation) dwarfed 
by thirty minutes' beta rays, unaffected by gamma rays. 




FIG. 11. Growth of oats, exposed to naked radium at distances from J to 4 inches. 
Twenty rows. Two rows for comparison, without radium. Exposure six days. Growth 
after planting, one month. Nearest two rows killed. Fourth, fifth, sixth, seventh, stim- 
ulated. Beyond seventh (1J inches) all retarded. The nineteenth most stunted of all. 



1-1J inch. 



2 inch. 



3 inch. 



No 

radium. 



Row 


1 


2 


3 


4 


5 


G 


7 


S 


9 


10 


11 


12 


13 


14 


15 


16 


17 


IS 


19 


20 


N 


N 


Weight, grains 




^ , 





14 


70 


87 


77 


79 


03 


61 


49 


62 


58 


50 


59 


63 


60 


64 


62 


45 


61 


74 


95 



Killed. 



Stimulated. 



Stunted. 






EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 215 

tests, all show the same. Let us illustrate by one only (Fig. 11). If 
oats be exposed to mixed radium rays for varying hours and planted 
simultaneously the longest exposed will be killed; shorter exposed will 
germinate and die; still shorter will grow stunted, but continue to 
grow or flower, dwarfed; still less exposed will grow less than normal; 
while some with a very small radiumizing will be stimulated and grow 
above the normal. 

The effect on animal and vegetable life is the same. There has never 
been any known difference between the vital force actuating a cell of 
.animal or vegetable structure. It is fair to say that science is about 
ready to admit that electricity is the basic force actuating animal life, 
energizing nerves and muscles, tactile sense and cerebration. The 
recent study of cardiography by electrical conduction, whereby dis- 
orders of rhythm and function of the heart can be studied a half mile 
from the bedside, stand sponsor, if any were needed, for placing the 
responsibility on correct electric charges for normal action of our bodies 
and on disordered electric action for their variations. 

Having grasped this idea, we easily take the next step and note the 
pathological changes in the cells of our complicated bodies, indicated 
by stimulation, repression, decay and death. 

It is reasonable to offer a working hypothesis at this stage of our 
study, based upon grounds consistent with our limited knowledge. 

It seems reasonable to think that the orderly growth and life of a 
cell is due to a balance of its electric charges, positive and negative 
existing in each cell. When we find a small tumor composed of an over- 
growth of cells normal to the part, we must admit that some force has 
gone out of or entered into its life which has caused the disordered 
growth. Its balance has been disturbed. If, at this stage, we supply it 
with electrons, of one or another kind, and see a rapid return to normal 
growth, there can be but one logical conclusion, namely, we have 
supplied the needed force which was lost. Just at this point we face the 
discovery that a shower of negative electrons freshly liberated from 
radium will cause a stunting of cell growth. Facts which will be demon- 
strated and illustrated further on are these: Growth composed of 
overgrown masses of cells, return to orderly growth permanently, 
when given the exact dosage of negative electrons are shot into them. 
Growths to which too much is supplied, undergo atrophy, and, if exces- 
sively oversupplied, undergo death. We may assume, therefore, 
that the dosage must correspond with the loss. We are thus coming 
closer and closer to the unfolding of one of the puzzling problems of 
life, viz.: What is inherent in the nucleus of every cell that causes its 
stability? In the cosmos we turn to students of geology, zoology and 
biology to learn what new thoughts have been evolved to elucidate a 
better understanding of the origin of life on the earth. Definite propo- 
sitions, based on fact, have been recently set forth by Prof. H. F. 
Osborne in an address before the National Academy of Science. The 
ripe thought of scientists turns to chemistry to provide the substance 
and framework to explain this earliest protoplasmic development after 



216 EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 

the earth crust had cooled, and water and rock disintegration, with 
nitrogen, carbon and oxygen, gave material to form corporate material 
for electric stimulation to vitalize. These electrons originated perhaps 
from friction of elements, from atmospheric discharges, or, who can 
say, radium latent in the earth, or electrons shot through space. 

It is a little surprising to see the trend of scientific thought toward 
electricity in recognizing the probable vitalizing life force. It lends 
much weight to the growing recognition of the latent force residing 
in radium or issuing from the roentgen tube which is counted only in 
terms of electrons. 

It is no flight of fancy to regard the force in radium as incorporated 
life or the electrons as imprisoned life released. The pathologist then 
must take his cue from the scientist and accept the view that proto- 
plasmic matter is endowed with one vitalizing actuating force, viz.: 
electricity. After its initiation, matter thus endowed proceeds on its 
career of more and more complicated development and combinations 
until infinitely complex beings like the human body are developed. 
In such complex machinery, however, there remains the solitary force 
behind the life of every component cell. 

In disordered states this has been shown by the elaborate study of 
Lazarus Barlow, who demonstrated a measurable amount of radio- 
activity in the structure of cancer of the gall-bladder with gall-stones. 
This is not to say that radium is present, but a liberation of negative 
electrons due to cellular activity and disordered growth. 

We may now turn to the first questions in this paper, and consider 
what constitute the essential characteristics of malignant disease. The 
grouping of enormous myriads of cells that form a complex human 
body, requires a harmonious interaction which staggers the imagin- 
ation, but appeals to reason as essential. It is the lack of harmonious 
action that shows in the development of any and every curious growth, 
to which we give the name of tumor, whether it be a papilloma or horny 
excrescence of the skin or epithelioma, sarcoma, cancer, fibroma or 
myomatous tumor. They are one and all, altered cell growths, exag- 
gerating their normal activity, and representing a disorderly unbal- 
anced action, out of harmony with the rest of the system. It is as if 
a patch of grass on an even lawn began to grow luxuriantly and out of 
keeping with the rest of the lawn, but it is still healthy grass. It is 
a literary error to speak of "diseased" tissue when we speak of tumor 
structure. While this word may be rightly applied to tissues attacked 
by parasitic infective destructive agents, calling the structures "dis- 
eased" as we would a tree attacked by "blight," it is quite an error to 
apply the word to tumors, even though they may be in the end destruc- 
tive. More properly we should look upon the mass of overgrown 
cells which from habit we call tumors, as aggregations of cells which 
are enjoying the excessive freedom of growth, an ecstasy of joy and 
growth, such as comes to an imprisoned city scholar set free in vacation 
spirit. The riotous overgrowth of cells normal to the site of their 
growth, constitutes a tumor or colony of healthy cells, which have lost 



EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 217 

their balance or equilibrium in their relations to their neighbors. In the 
ultimate outcome of this disorderly growth, the result is what may be 
called a diseased condition as compared with orderly, systematic com- 
munity growth in the complex system of the body. That word " dis- 
ease " applied to them only refers to the incidental suicidal action of the 




FIG. 12. Extensive warty growth on vocal cords before cure by one radium treatment. 

cell life, because it depends on nutrition supplied by the whole living 
organism, which its very overgrowth crowds out, so that death follows 
in that colony group and mars the health of the whole. 




FIG. 13. Perfect restoration of vocal cords. Return of fine singing voice continuing 

eight years afterward. 

Malignant cells have no characteristics to distinguish them from 
non-malignant tumor cells, either microscopically, physically, chemic- 
ally, or in responding to radiant energy. It is fair to say that certain 
groupings of cells are found in advanced malignancy, and that proto- 
plasmic nuclei show more active mitoses indicating rapid growth, but 



218 



EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 



in no particular do individual cells show anomalous character, or 
refuse to respond to agents like electrons of radium and roentgen ray. 
It is true that their successful application is full of difficulty, still to be 
overcome, but their efficiency in even so slight a degree encourages the 
belief in ultimate advancement. 

Enough basis for understanding of the action of electrons on all 
cell tumors is found in the simpler forms, illustrated by papilloma and 
myeloids to choose only two out of many varieties. A wart, or massive 
overgrowth of cells of either the papillary layer of the skin or of the 
delicate layer of mucous membrane of the vocal cords, is identically 
the same type of tumor. If it is played upon by rays of radium for a 
few minutes it slowly disappears and leaves no traces of its existence. 
The same electrons have played upon the healthy cells about it but 
only the weak overgrown structure has changed. 




FIG. 14. A, destructive myeloid sarcoma. B, condition of jaw fourteen years 
after radium cure. Jaw-bone restored to normal form and great strength, teeth, solidly 
embedded. 

If an excessive treatment has been given even the healthy growing 
cells are altered and a slight scar results. Otherwise nothing is dam- 
aged. To illustrate, I will cite the case of a young girl with beautiful 
singing voice, which first became husky, then was lost and finally left 
her with serious obstruction to breathing' from growth of warts over 
two-thirds of her vocal cords (Fig. 12). Radium was applied for 
thirty minutes. Three months later, the warts were entirely gone and 
her voice restored. Her singing power returned later and was even 
sweeter than ever. Five years later this perfect condition continued 
(Fig. 13). Thus exact dosage corrected erroneous growth, without 
damage to normal cells. As a second illustration, I will cite a case of 
myeloid tumor of the lower jaw, cured by radium and followed by 
complete restoration of the bone, a result never previously obtained by 



EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 219 

surgery. A lad of seventeen years, had a soft tumor on the left side of 
his lower jaw, absorbing the entire bone except a thin strip on one edge. 
The swelling was several times the natural thickness of the bone, and 
three teeth were loosely held in it ready to drop out (Figs. 14 and 15). 
The tumor was treated by radium only. In a few weeks it became 
gritty throughout with newly regenerated bone. The tumor shrank 
rapidly. New bone reformed. The teeth became solid in their beds 
and every trace of tumor disappeared. The jaw-bone took on the 
identical shape of its original contour, and today, after thirteen years, 
it is as solid and perfect as a normal jaw-bone. 




FIG. 15. Thirteen years after treatment. 

What answer can be made to the claim that here we see the alterative 
action of electrons reversing the disordered growth of marrow cells, of 
the bone, which in their riotous action were in line of destruction of the 
jaw and of the life of the man, if unchecked. Whether pathologists 
choose to class myeloid tumors as "malignant" matters little, for in 
their progress they were destructive to human life, and in that intent 
malignant. The same type of tumor in every part of the body yields 
in similar fashion. A dozen patients with pure myeloid growths have 
shown identical curative action of radium. Tumors in the lower and 
upper jaws, in the humerus, in the sternum, in the sacrum, m the tibia. 
The same alterative and curative action has been demonstrated to 
follow judicious use of the roentgen tube electrons by Dr. Pfahler, of 
Philadelphia. 



220 



EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 



The cure of epithelial tumors by radium, notably the disfiguring 
and destructive type of so-called skin cancers of the face, is universally 
admitted. 




It is no small testimony to its usefulness in surgery, but it is a 
greater testimony to its unique action as a therapeutic agent. Hereto- 
fore surgeons have not been able to cure this disease. They have cut 
it out or destroyed it by caustic acids or by cautery. Thereby they 



EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 221 

have cured the patient, but they have not cured the disease. They 
have only removed it. This new agent supplies the tumor with a force 
which works within itself and causes it to remove itself, if we may so 




FIG. 17. Same patient as represented in Fig. 16, showing permanence of cure by 
radium after thirteen years. 

speak. Not only that, but^if the correct dosage of electrons has been 
supplied, the growth never comes back. Witness the case of destruc- 







FIGS. 18 and 19. Epithelial cancer, had been burned out by caustic pastes and 
acids for several years and recurred. Received one radium treatment only. "Fig. 18 
before treatment, Fig. 19 after nine years, soft scar. 

tive epithelioma of the face, cured by radium, in five weeks after many 
years' growth. The small, smooth scar remains without return of 
trouble after thirteen years_[(Figs. 16, 17, 18 and 19) or, the case 



222 



EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 



of epithelial cancer behind the ear, cured in six weeks and remaining 
absolutely perfect nine years later. Or, the case of epithelial tumor of 
the lower eyelid, cured in eight weeks and remaining cured nine years 






o 

a 

0) 

I 

13 J3 

sj 



11 



H Q. 

2 I 



t 



later. Serious consideration must be given to one phase of this case, 
illustrating clearly what may be claimed as a "specific" action of 
radium, that is, of a kind unlike that of any other agent. Here the 



EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 223 

lower eyelid was entirely lost, in a tumor covering more than half its 
length. The structures of the lid were engulfed in the growth beyond 
identification. The tumor was heaped up on the skin, it mounted up 
above the edge of the lid and grew inside the lid as upon the outside. 
After brief radium treatment, shrinkage rapidly ensued, the lid was 
evolved out of the conglomerate mass of cells and in eight weeks a 
normal shaped eyelid was self-restored, to speak exactly. Even the 
skin took on normal appearance. The edges of the lid were sharp, the 
mucous membrane was smooth, the eyelashes grew in again (Fig. 20) . 
Out of the enormous mass of overgrown cells of the tumor, the original 
ones which constituted the eyelid and skin were reassembled and for 
nine years after, no one could tell on which eyelid the tumor had been. 




FIG. 21. Round-cell sarcoma of the FIG. 22. Same case as in Fig. 21. 
skull. Complete absorption of bone out- Cured by radium, 

lined by iodine. 

One must evolve some theory to account for this extraordinary over- 
growth of cells, which retreated, or melted away, like fog before the sun, 
under radium rays. Were they the product of growth of a micro- 
scopically invisible network of intercellular cells so to speak, which 
overwhelmed the native ones, forming the lid, and when in retreat 
left the original ones unharmed by the electrons which affected the new 
growth? Or, were they simply a hypertrophic development from 
excited growth of lifelong cells of the part, throwing off a generation 
of tender new cells of their own kind, which could not withstand the 
bombardment of radium electrons. In either case such types point 
the way to a better appreciation that we have to reckon with a new 
force in therapeutics from which more may be expected. 
There are hundreds, yes, thousands, of cases similar to these already 



224 EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 

credited to the alterative action of electrons, and it may rightly be 
called a specific and unique action. Regardless of futile discussions 
as to what types may or may not be styled malignant, there are others 
that must be credited with specific cure by electrons which no other 
surgical method can touch (Figs. 21 and 22). 

As an example, a round-celled sarcoma of the skull of a man of 
forty-five years had eaten through the parietal bone to an area of 4 x 3 
inches. This soft vascular growth rested on the dura and elevated the 
skin, comprising a depth of 2 inches of tumor tissue. Enough was 
removed for microscopic examination and radium tubes inserted 
throughout the mass, lying parallel to the dura. The tumor soon 
disappeared and after four years has never returned. The patient has 
maintained perfect health and working power. Photographs before 
and after show clearly. The type of round-cell sarcoma is not the most 
common, but seems to yield with peculiar facility, while the spindle 




FIG. 23 

cell is intensely resistant. Feriosteal tumors, mostly of spindle cell 
with some myeloid cells scattered throughout are not yet amenable to 
cure by radium; nor are the gliomas, especially of the nervous tissue. 
A few attempts have been, as yet, wholly ineffectual. There are certain 
structures which we are still compelled to excise, inasmuch as either 
we do not know how to use the electrons for them or they must be 
corrected by some yet unknown remedy (Fig. 23). 

Among these are the squamous-celled epitheliomas of the skin, which 
usually, though not always, present a character clinically different 
from the basal-cell type. If one can discern one from the other, the 
squamous-cell type must be eradicated by caustics, cautery or the 
knife. This is not wholly true, however, of the cancer most commonly 
known as malignant. One must study the effect of radium electrons on 
relatively small areas of recurrence, after removal of typical scirrhus 
cancer, such as seen in mammary cases, to know definitely that the 
same specific action can easily be demonstrated there as in simple 



EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 225 

epitheliomas. It is futile, to assert that radium is ineffectual because 
one is called upon to excise a large, or long-standing mass of cancer. 
If a small beginning of one, or a part of a recurrent cuirasse carcinoma 
yields definite cure, its removal is quite as triumphant if radium or 
the scalpel brings it about. 

It has long been proved, that in the early recurrences of the skin 
after mammary removal for cancer, radium can cause a complete 




FIG. 24 



melting away of moderate invasions. It only needed the greater 
efficiency of the Coolidge oxray tube, in demonstrating the rapid 
destruction of larger cancer masses, to endorse the work of radium 
in similar lines. Technically one is more difficult than the other, but 
the principle of action by electronic discharge is the same. As an 



Tumor 




Jugular vein 



'Clavicle 
FIG. 25 



illustration of radium action alone in combating the disease, let me cite 
the case of a lady of seventy-five years, seriously weakened and poisoned 
by absorption from an ulcerative and bleeding cancer of the breast. 
Six short, painless applications of radium caused a rapid healing and 
shrinking of the masses, until a small group of inert fibrous remnants 
about the smooth scar remained unchanged for two years. The patient 
died suddenly of acute nephritis, entirely unrelated to the disease. 

VOL. I 15 



226 EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 

One of the principles best illustrating the efficient use of radium in 
typical cases of clinical cancer was enumerated by Wickham in the 
early years of his work, by which he demonstrated that if the surgeon 
removed all possible cancer from a mass and left only a thin shell, this 
remnant could be efficiently controlled, for a time at least, by radium, 
but that it was useless and hazardous to treat masses by exerting the 
destructive agency of radium. This I have demonstrated by such cases 
as the following: 

A lady whose breast showed a small typical scirrhous nodule, the 
size of a prune stone, permitted excision only under cocain. It was not 
at all wide of the disease from a surgical point of view and recurrence 
would have been speedy had I not given a good radium insertion 
embedded in the operative field. Three years have elapsed and no 
trace of hardness shows in the soft scar. 




FIG. 26. Perfect health eight years later. Small flat remnant left at operation now 

dormant. 

Again, a lady of forty years presented a hard growth above the left 
clavicle near the^sternoclavicular tendon (Fig. 24). 

It was close beneath the skin and not very moveable. At operation a 
dense cancer mass was removed with great difficulty (Figs. 24 to 26) . 
It lay between the jugular and carotid at their points of origin. The 
former was carefully dissected off but the growth adhered so tightly 
to the common carotid artery for an inch away from the innominate 
that a thin layer of tumor was necessarily left attached to it. The 
wound was closed except a sinus where a strong tube of radium was 
left resting against the shell of the cancer. After a few hours this was 
removed and the wound healed. Nine years have gone by and no trace 
of trouble has shown. Examination of the tumor showed it to be 
cancer. Its size was that of a half egg. 

Again, on two occasions I have excised carcinomatous masses of the 
lower parotid gland and implanted radium tubes in the bed of the 
excised mass, knowing that speedy recurrence was inevitable without 
that sequel. In both cases more than four years have gone by and no 



EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 227 

trace of trouble can be felt in the soft cicatrix. In other cases of parotid 
tumors the more common mixed sarcomas, the arrest of growth has 
been commensurate with the amount of radium used, but slowly the 
recurrences have come, yet each time one feels that a heavier dosage 
will make an end of the local residue which the surgeon cannot see but 
only suspect. In all radium work diseases involving the gland struc- 
tures, cutaneous, lymphatic or salivary, seem to yield better than those 
entering areolar or muscular structures. 

Great discouragement necessarily follows all pioneer work in new 
fields, because, attempts must be made to test apparently hopeless 
trails which must be abandoned temporarily, only to be taken up again 
and again as new methods prevail. In this line of pursuit, hundreds 




FIG. 27. Cancer of tongue. 

of advanced cases of cancer have been submitted to test, sometimes 
mild, sometimes heroic. Discredit and abuse have been undeservedly 
received. Out of all, however, it is fair to say that in grave cases much 
that has been helpful has resulted, and in the early cancer cases, appar- 
ent cure results. More cannot be said to the credit of surgery by 
cutting methods. 

Let me speak in order of types of cancer in places difficult of treat- 
ment; in the alimentary tract; cancer of the tongue; mouth; pharynx; 
esophagus; stomach; intestines; rectum. Every surgeon knows that 
leukoplakia, a hypertrophic white growth of the mouth and tongue, 
cannot be cured by any method except radium, and that, only by most 
judicious use. Also, he knows that when it has become ulcerated it 
becomes cancerous and must be cut out extensively. It now seems that 
such early growths yield to radium and stay cured, at least for such 
time as radium has been available. Again, every surgeon knows that 



228 EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 

excision of a half tongue for typical cancer with lymphatic extirpation 
is almost sure to be followed by recurrence (Fig. 27). Some recent 
work by such surgery supplemented by radiumization of the edges 
without recurrence up to more than four years, suggests a happier 
issue than plain surgery has to offer. 

Cancer of the tonsil and pharynx in advanced conditions, has little 
to hope from surgery alone, and but little more from radium. This is 
due partly to the difficulty of exact application, where salivation, 
choking, pain and deglutition add to the discouragement of patient 
and surgeon, partly to the high vascular and lymphatic supply of the 
part. Few good effects of radium are seen. In the nasopharynx an 
occasional control of the disease can be accomplished, owing to the 
facility of continued application of radium applications. In massive 
cancers of the tongue itself with foul ulceration, one sometimes can 
cause rapid reduction of the mass and get the sore almost healed, but 
sooner or later the growth takes on its wontecj activity. The field is 
not a hopeless one, for further study of radio-active agents. The lip 
cancers are not yet legitimate material for cure by radium, though 
some superficial types have been cured. It is far better for the patient 
to have wide excision which usually insures future immunity. 

In the esophagus, a cancer usually takes the form of a cylindrical 
development, with thickening on one side or the other, to a mass of 
half an inch or more. This is not as yet amenable to control by radium, 
although one would think the opportunity for exact central application 
of a radium tube would permit efficient action, which is true as far as 
radiumizing the mass goes. There are factors of peculiar seriousness 
in the central mediastinum which baffle the operator. One must aim 
at the destruction of the massive cylinder. This means ulceration, 
absorption, toxemia and peril to an already weak subject. The efficient 
dosage also implies severe radiant effect on the cardiac nervous system, 
and finally if the erosion and destruction of the cancer mass takes place, 
one must expect hemorrhage, pain, perforation and abscess from acts 
of deglutition, which are an unwarranted jeopardy. On the whole, 
therefore, the use of radium in esophageal cancer, mostly tried in 
advanced cases thus far, has nothing to recommend it. 

The same may be said of cancer of the stomach and pylorus. Never- 
theless, while one does not look for a cure, in these cases, it is possible 
in a few selected types to control growth and repress hemorrhage if 
one can have access to the disease through a gastrostomy sinus. This 
means technically that an internal and external use of radium in 
quantity sufficient to filter out the soft rays with lead, and "cross fire" 
the mass if accessible enough. It is fair to say, however, that here one 
uses mostly gamma radiation, which may probably be more penetrat- 
ingly and efficiently obtained from an x-ray tube, or, that without, 
and radium within. 

In malignant disease of the rectum we have several varieties known 
to every surgeon, and many stages of each variety. It is a fairly good 
field for study of radium. Let us first premise that the best surgical 



EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 229 

treatment stands today as (1) preliminary colostomy; (2) where 
feasible, a well considered surgical extirpation of part or of the whole 
rectum with the disease. The surgeon who wishes to do his full duty 
to his patient then has to consider whether radium offers any additional 
help. My judgment is that it does, if used discreetly, which means 
that our first duty is to advise colostomy as early as possible. It will 
have to come some time. It removes the incessant irritation of the 
growth and arrests its rapid progress. If its removal is not possible 
then we use radium, varying the amount and method according to 
conditions. The immediate effect is usually to check hemorrhage by 
vascular occlusion of the surface of the growth, and incidentally 
usually to relieve severe pain. More constant even than these results 
there is almost uniformly a speedy gain in color, a loss of the cachexia, 
whether it be anemic or toxemic, and a diminished foul secretion, from 
the absorption of which some of the toxemia may have resulted. 

When one reviews a large surgical experience of forty years in this 
field and makes due allowance for the natural improvement follow- 
ing the simple, highly valued, colostomy, he still finds prolongation of 
life and relative relief from pain and hemorrhage with continual 
increase in color, to the credit of radium. The expected prolongation 
of life may be therefore estimated about double, that is to say, if when 
seen first, two years may be rated as the patient's hope, it may be four 
years if radium be used. 

Experience shows that the best method of using radium, here as 
elsewhere, is to give as much as the part will stand at one or two 
seances, and then dismiss the patient for two months at least. In this 
way only can one estimate the gain. Usually there ensues stenosis of 
the lumen of the bowel as atrophy of the mass takes place. One must 
not deceive himself by occlusion from progress of the growth in some 
cases. 

In uterine cancer much the same record prevails today as in rectal, 
except that the general trend is better. Both types are helped by 
radium when there is a marked adenocarcinoma, and in its early stage 
when the cervix uteri has erosion and cellular ingrowth into the sub- 
mucous layer, this can be destroyed by radium. One such case only in 
my experience has endured with no return of disease twelve years. In 
other cases where intense radiumization has been tried out the destruc- 
tion of malignant cells has gone out into the extra-uterine tissue and 
made inoperable cases operable. In the face of universal acknowledg- 
ment that such cases invariably return with bad recurrences (usually 
early), the hope of cure of early uterine cancer lies in the use of radium, 
or some powerful destructive agent (caustic or cautery), with subse- 
quent operation. 

When inoperable recurrences occur in the vaginal scar, usually in the 
vault, and spreading into the broad ligaments, the liberal use of filtered 
radium will at times cause a striking retrograde of the recurrence. In 
one case, sent to me with extensive and inoperable recurrence, after 
complete hysterectomy for cancer, by Dr. Robert T. Morris, followed 



230 EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 

by a second apparently thorough operation for proved secondary cancer, 
I was able to induce so perfect a disappearance of all the typical mass 
spread through the scar and broad ligaments, that for two years nothing 
could be felt and the patient maintained perfect health. During the 
third year a nodule again appeared and slowly extended. Again the 
radium retarded its growth, but slow extension exhausted the patient 
after four years. In most such cases the utmost I have been able to 
accomplish (having due regard to uncomfortable vaginal burns) has 
been to retard growth, check hemorrhage, reduce the distressing foul 
discharge and improve color. 

The cervix occasionally shows fungating cancer protruding massively 
into the vagina. This type is especially amenable to curetting away, 
until a hard base is left, which is given a heavy radiumization. One 
such case in my hands lived many years and died from other causes with 
no recurrence. Knowledge of its full value in these cases must await 
some years more of study by those who have enough experience with 
surgery as with radium, to speak with authority. It would be useless 
to pursue the theme further to speak of the multiple and efficient uses 
of radium in other parts. 

The subject is by no means ready for encyclopedic conclusions. The 
field is open for progress in both efficient and wider usefulness, and for 
technical improvement in its applications. It seems, at present, that 
its greatest benefit comes from using, at will, the Beta rays, mixed with 
gamma as given off from applicators and tubes, or, in suitable cases, by 
enveloping it with metal of varying thickness to utilize the penetrating 
gamma rays alone with no risk of burning the skin or mucous mem- 
brane. In both cases, a cross-fire attack upon the disease by an 
opposing radium applicator as correctly credited to Wickman, is 
without question the surest way to promote its good work. 

It seems to the author that malignant cells are not inherently differ- 
ent in their nature from other living cells. They have a different 
coefficient of resistance, so have spindle cells, and others, but that they 
do respond to radium has been proved, and can be demonstrated in 
recurrent nodes under the skin in breast cancer cases. 

Fig. 28, made for me by Dr. F. C. Wood, demonstrates clearly the 
sphere of influence, though it be small, which a tube of radium has 
when laid on the skin over such a nodule. Technical methods remain 
undeveloped, but the efficiency of radium as a new force must be 
reckoned with in the future of surgery. 

Technical Application. No good result can be expected from the 
use of radium without earnest study on the part of the operator. It 
has long been the expressed opinion of the author that no one who 
ventures to use it in practice should do so without first testing his 
particular specimen or specimens upon his own skin. While there is 
probably very slight difference in idiosyncrasy of patients to its action, 
there is the greatest difference in the working efficiency of each specimen. 
This is due to the fact that any ten milligrammes may differ in purity, 
or in its container, that is, it may be sealed in a thin or a thick glass 



TECHNICAL APPLICATION 



231 



tube, or in a tube of metal, or spread on a metal plate (plaque) em- 
bedded in varnish or enamel. To speak therefore of the number of 
milligramme-hours that may serve to produce a certain efficiency is 
quite uncertain. It is evident that ten milligrammes confined in a very 
small tube affects a local area close to it, while, when spread on the 
surface of a metal plaque, the size of a quarter dollar, its effective 
radiumization of the same area covered by the tube would take longer. 
The author has long held that no physician can so well work with 
his own specimens, or understand so well the working of radium, as 
he can when he has first tried it on himself. He may best choose per- 
haps the inner side of the calf of his leg for this test. Let the appli- 
cation be placed on the skin, at three nearby spots, for different periods 
say, five, ten, and fifteen minutes for very strong specimens, or twice 



SKI 




-><i:v>% : 



FIG. 28. Showing sphere of influence with dead cancer nests. Recurrent subcutaneous 
nodule degenerating under one radium application. 



that time for weaker ones. The effect should begin to show in ten days 
as a dermatitis; itching, burning and perhaps blistering in the following 
ten days; subsiding and forming a dry crust during the third ten days. 
On the thirtieth day the crust falls from a smooth skin. This is about 
the usual effect desired to restore a simple keratosis, mild epithelioma 
or a wart. 

Having once experienced the very definite results of using his 
specimens he never loses the mental picture of its action, or rarely 
misjudges the requisite time of application to each patient. For the 
greater number of mild epithelial lesions, the author prefers one or 
two exposures near together, and then gives the patient a written 
statement of what to expect during the month following. If, however, 
more intensive treatment is necessary, then cumulative or successive 
attacks are better, and an interval of one or two weeks between treat- 
ment works out a better result. Thus, successive blows fall upon the 



232 EFFICIENCY OF RADIUM IN MALIGNANT DISEASE 

disease, sustaining a long corrective action, rather than an intense and 
destructive one. 

Any epithelioma less than one centimeter in thickness can be treated 
by radium which is not shielded by lead. The container or applicator 
should be covered by thin rubber sheeting (dental dam) and by several 
layers of gauze. If a recurrent cancer node or a lymph gland lies under 
healthy skin, then a lead shield must be interposed to prevent burning 
the skin, while penetrating rays are efficient below it. For ordinary 
purposes thin sheet lead, T V millimeter thick (thickness of thick 
writing paper) is adequate. This permits an hour exposure, with a 
specimen which without lead would give sharp dermatitis in one-third 
that time. A two-hour exposure with T 2 ^ more lead will be more 
efficient in deeper growths. In pelvic recurrent cancer in the upper 
vaginal scar, the best results I have seen were from one hundred milli- 
grammes or more in tubes, surrounded by ^ millimeters thickness of 
lead for two hours. The same amount in a brass container, 2 mm. 
thick is equally efficient applied ten to twelve^hours. 

The best surface applicator now devised is one in which radium is 
mingled with the least possible amount of pulverized glass and fused 
at a very high temperature into an enamel on a metal button. By this 
way the maximum concentration is obtained and a surface of the 
diameter of a ten-cent piece can be enamelled with 25 mg. of radium, 
which would require a disk the diameter of a silver half dollar if made 
with the usual varnish, which is much more perishable. Such a con- 
centration in a small disk has very great advantages. It permits a 
short application of ten minutes which justifies the physician in devot- 
ing that amount of time to concentrated thought in applying it with 
extreme care exactly as he wishes, instead of strapping it upon the 
patient, and finding in half an hour that it had slipped from its place, 
or been displaced by the patient. By its size, also, it permits exact 
application about the tongue and inside the mouth and other cavities. 
This is most essential in its difficult but effective use in leukoplakias. 
This small 25 mg. enamel button I regard as the finest working model 
for radium therapy. It is readily enveloped in rubber, thin lead and 
gauze, clamped by its small knob at the back of the button in the bite 
of a long clamp, and thrust into a narrow thin rubber bag which permits 
it to be pushed against the tonsils or far up in the vault of the vagina 
against a diseased cervix or cancerous scar, and there held with unrival- 
led precision during the needed exposure. Being carefully protected 
it is never soiled, but if it does become so, it can be safely washed 
without dissolving the radium from the enamel. In practice it is 
found that ten minutes' use of this concentrated enamel plaque equals 
thirty minutes of the same amount in a varnish plaque which must be 
of four or five times larger area. It has the added advantage also of 
being moved back and forth over irregular surfaces, as in nevus, or 
skin lesions, and evenly affecting the disease with no scarring or spotty 
results. The method of concentrating radium emanation into capil- 
lary glass tubes which can be inserted in thin metal needles and thrust 



TECHNICAL APPLICATION 



233 



into tumors for penetrating and cross-fire result, finds many uses and 
some advantage. Nevertheless, tubes of stiff thin celluloid have been 
successfully used by the author for twelve years, to contain two to 
five glass tubes of radium, each holding 25 mg., which he has pushed 
into stab wounds in tumors to cross-fire them in every direction. These 
superseded long experimentation with purified goosequills, which offer 
no resistance to the radium penetration. The celluloid tubes are very 
inexpensive, four inches long, smaller than a lead pencil, and are never 
used twice. 

It will be evident to the reader that it is impossible for an amateur 
with only 10 mg. of radium to do effective work. He will only disap- 
point himself and his patient and bring disrepute on this important new 
field of surgical endeavor. It is fair to say also that no one without a 
previous varied and large surgical experience can do justice to com- 
parisons between the efficiency of radium and of other well established 
destructive remedies. The use of this wonderworking agent should be 
left to those who have enough to study its effect and whose clinical 
opportunities enable them to select suitable cases for its use. 



DEEP ROENTGENTHERAPY. 



BY HENRY SCHMITZ, A.M., M.D., F.A.C.S. 

ROENTGENTHERAPY of today differs from that of yesterday as 
fundamentally as surgery of today differs from that of the era before 
Lister, Pasteur and Koch. 

The introduction of the Coolidge tube, the development of the 
modern interrupterless transformer, as first devised by Snook, of Phila- 
delphia, and lastly the replacement of the rheostatic control with the 
magnetic autotransformer control, have contributed immeasurably to 
the development, efficiency and efficacy of deep roentgentherapy. 

The Coolidge tube possesses simplicity in operation, accuracy in 
penetration and duplication of results. The modern interrupterless 
step-up transformer with the autotransformer control gives us a con- 
stantly maintained voltage when tube current is increased. 

The roentgentherapist should understand the principles involved 
in the physics of roentgenology. He should be well informed in general 
medicine; should understand the pathology of the disease that he is 
called upon to treat and should be familiar with the technical knowledge 
that is approved by the best authorities in the treatment of each par- 
ticular disease. He should be familiar with the effects of the roentgen 
rays on the living cell. We can see at a glance that the mastery of 
these requirements is no child's play but means hard and continuous 
work, and should be associated with a deep sense of responsibility. 1 

THE COOLIDGE TUBE. 

The great difficulty in the operation of the ordinary gas tube lies in 
the irregular supply of electrons and the impossibility of their accurate 
development. In therapy these obstacles are continuously a source of 
worry. For as the vacuum of the gas tube through the heating of the 
anticathode becomes lower and lower on account of the requirements of 
prolonged use, the rays given off proportionately decrease in their 
penetrating power. It could only partly be corrected by water- 
cooling devices, a frequent exchange of tubes and reducing the load of 
milliamperage which necessitated a proportional prolongation of the 
time of application. 

Wehnelt and Richardson had found that electrons also were emitted 
by hot metals. This led to a series of developments of the roentgen 
tube, beginning with Lilienfeld, in December, 1911, continuing with 

1 Pf abler, G. E.: Am. Jour, of Roentgenology, August, 1916, iii, 404. 

(235) 



236 DEEP ROENTGENTHERAPY 

Fiirstenau, in April, 1912, and culminating with Coolidge, in December, 
1913. This particular development of the roentgen tube has given to us 
the electron type of tube, as first presented in Germany by the Lilien- 
feld tube, and finally in this country by the Coolidge tube. These 
developments have been epoch-making, demonstrating as they did, 
for the first time,, the possibility of transferring electricity through 
space without the interposition of ponderable matter. This may be 
said to be one of the most striking facts of modern science (see Fig. 29). 




FIG. 29. Coolidge tube. 

For the proper operation of the Coolidge hot filament tube the 
highest possible vacuum must be attained, so there might be no source 
of electrons except from the hot filament. Thus the operator has per- 
fect control of the number of available electrons by simply changing 
the auxiliary current heating the filament, an increase of this current 
raising the number of electrons, and vice versa, a decrease in the current 
lowering the number. The filament current in the tube cannot get 
increased after the supply of electrons is entirely utilized, no matter 




B 

FIG. 30. The anticathode or target of a Coolidge tube. 

how much the voltage is raised. This maximum current is known as 
the saturation current. The Coolidge tube will give us accuracy of 
adjustment, stability of hardness, possibility of exact duplication of 
results, unlimited life, great range of flexibility, absence of inverse 
radiation and extremely large output. 

The Coolidge tube consists of a tube exhausted to a pressure of not 
more than a few hundredths of a micron (a micron is 0.001 mm.), in 



THE COOLIDGE TUBE 



237 



which is supported the cathode so arranged that it may be heated 
electrically; an electrically conducted cylinder or ring connected to 
the heated cathode and so located with reference to it as to focus the 
cathode rays on the target and the anticathode or target, which func- 
tions as an anode. 




FIG. 31. The filament of a Coolidge tube. 

The filament (see A, Fig. 30) which forms the cathode consists of a 
flat, closely wound spiral of tungsten wire. By means of a rheostat 
the heating current may be varied from three to five amperes, giving 
a potential drop through the filament of from 4.2 to 10 volts, with a 
corresponding temperature variation of from 1700 to 2350 C. 




FIG. 32. The filament current transformer. 



The focussing device consists of a cylindrical tube of molybdenum 
(see B, Fig. 30), mounted concentric with the tungsten filament and with 
its inner end projecting about 0.5 mm. beyond the plane of the latter. 
Besides acting as a focussing device it also presents any electron dis- 
charge from the back of the cathode. 

The anticathode or target (Fig. 31), which also serves as an anode, 



238 DEEP ROENTGENTHERAPY 

consists of a single piece of wrought tungsten (C) attached to a 
molybdenum rod (D) and supported by a split iron tube (E). 

The important characteristics of the Coolidge tube are: (1) No dis- 
charge current through the tube unless the filament is heated; (2) 
the amount of discharge current is determined primarily by the amount 
of current passed through the filament; (3) the penetrating power of 
the roentgen ray is determined by the voltage across the tube terminals ; 
(4) the starting and running voltages are the same; (5) the allowable 
energy imput is determined by the size of the focal spot; (6) contin- 
uous operation is possible without change of characteristics; (7) the 
focal spot is fixed in position. 

To simplify and render more accurate the operating of the Coolidge 
tube, some source of filament current is needed which gives a perfectly 
constant potential. A specially designed step-up transformer has been 
devised for this purpose (see Fig. 4), which is connected with the usual 
filament current controller. It is the function of the former to make it 




FIG. 33. The filament current transformer control. 

possible to deliver to the filament constant current, even though the 
line voltage may fluctuate greatly and suddenly. The filament current 
transformer is retained merely to provide the necessary insulation 
between the filament circuit and the supply mains. The special 
constant potential transformer has no moving parts and no time lag. 
It allows the filament current to fluctuate less than 1 per cent., when 
the supply voltage varies 25 per cent. This means that it completely 
takes care of the ordinary fluctuations in the supply voltage, due to 
causes external to the roentgen-ray installations and of the sudden 
drop caused by the closing of the roentgen-ray switch as well. 

Changes in the filament temperature may be effected by means of a 
dial switch (see Fig. 33), which controls a resistance connected in series 
with the primary of the filament current transformer. Each point of 
the dial, with the same tube, always means the same temperature, and 
hence the same milliamperage. The higher the filament current the 
greater the milliamperage. The higher the voltage backed up by the 
tube the higher the penetration. 



THE TRANSFORMER 



239 



THE TRANSFORMER. 

The rapid development of modern roentgenology made it necessary 
to increase the capacity of the x-ray apparatus in order to meet the 
requirements of therapeutic irradiation as well as of radiographic 
and fluoroscopic practice. 

These demands were met by the interrupterless step-up transformer. 
It was first introduced and made in 1907 by H. Clyde Snook, of 
Philadelphia (see Fig. 34.) 







FIG. 34. A modern interrupterless transformer. 

The machine consists essentially of three parts : the motor, the high- 
tension transformer and the high-tension rectifier or commutator. 

The interrupterless transformer makes use of the alternating cur- 
rent, which is the current furnished American cities by most of the 
commercial power plants. A rotating pole-changing switch rectifies 
the high potential alternating current from the secondary of the trans- 
former. To secure perfect synchronism, which is essential for recti- 
fication, the motor is mounted on the same shaft as the rectifier and 
runs about 1500 revolutions per minute. The motor must be very 



240 DEEP ROENTGENTHERAPY 

carefully designed and constructed, otherwise it will cause trouble if 
there is any possibility of its running not absolutely in step or in 
synchronism with the current. The transformer is capable of an 
enormous output and easy control; there is no inverse current and no 
interrupter is needed. 

The rectifying switch in the Snook apparatus is of the cross-arm 
type while other makes usually use the disk type. 

The transformer changes voltage approximately in the ratio of the 
number of turns in the primary to the number of turns in the secondary, 
and changes current in the inverse ratio. Thus a particular roentgen- 
ray transformer might be wound with 500 turns in the secondary for 
each turn of primary, and it would be said to have a step-up ratio of 
500. The secondary voltage would be 500 times the voltage in the 
primary and the secondary current -%^-Q of that in the primary. 

Approximate spark gap, 
Primary applied voltage. Resultant high tension voltage. inches. 

80- 40 3 

90 45 3* 

100 50 4 

110 55 4J 

120 60 5 

130 65 5i 

140 70 6 

150 75 6* 

160 80 7 

170 85 7i 

180 90 8 

190 95 8J 

200 100 9 

210 105 9J 

220 110 10 

A table of voltages that must be supplied and maintained at the 
primary terminals to give various high-tension voltages can easily be 
made in this case. 

Such primary voltages can be secured from a line supply of 220 volts 
by proper controllers, either the rheostat or the autotransformer 
control (see Fig. 35) . The former is an adjustable resistance used to 
consume a part of the line voltage and leave the proper voltage to be 
applied at the transformer. 

The autotransformer control consists of a continuous coil of wire 
wound around an iron core with taps taken out to control buttons at 
proper intervals. If an alternating current be applied to the complete 
winding of such a coil there will be a voltage induced in any part of 
the winding, bearing the same relation to the applied voltage that 
the number of turns of this part of the winding bears to the number 
of turns in the whole coil. The ratio between the number of turns in 
the primary and secondary circuits is changed by setting the control 
lever on the various buttons. The autotransformer is used as a con- 
trol device to reduce the line voltage to that which is applied to the 
interrupterless transformer primary. Therefore it is a step-down 
transformer and has fewer turns in the secondary circuit than in the 



THE TRANSFORMER 



241 



primary. As the control handle is moved to higher readings more 
turns are cut into the secondary circuit and higher voltage is applied 
to the primary of the interrupterless transformer. 

The use of a rheostat to control tube voltage has the disadvantage 
that slight variations in tube current result in serious changes in volt- 
age. The voltage "regulation" under various loads of a rheostat con- 
trolled transformer is poor. Softening of a gas tube during exposure or 
fluctuation in the filament temperature of a Coolidge tube will lower 
the voltage 10 kv., or about an inch of spark gap. Hence there is a loss 
in penetration. Also, if there were a break in the Coolidge filament line 




FIG. 35. The control table with autotransformer and rheostat controls. 



or polarity were wrong, so that no current flowed in the secondary 
circuit, the primary voltage would rise to that of the line, with con- 
siderable likelihood of sparking to the patient or causing damage to 
the apparatus. 

The autotransformer control is of special value with the Coolidge 
tube, as in this tube the voltage and filament current are independently 
controlled; the voltage by the autotransformer and the high-tension 
current through the tube by adjustment of the temperature of the 
cathode filament. If the filament current is not entirely steady with a 
rheostat control the radiation would be reduced in quantity and be less 
penetrating, while with the autotransformer control the same change 

VOL. I 16 



242 



DEEP ROENTGENTHERAPY 



would result in an increase in quantity and also in penetration. Hence 
the cathode filament current controller and the autotransformer 
control are two instruments of precision which give us almost absolute 
control of penetration. It is simple and accurate and can be duplicated 
day after day. 




FIG. 36. Tube stand. 



It is important to note that in using the autotransformer control 
it is advisable to also throw in the rheostat control. If anything should 
go wrong with the former the latter will immediately take care of the 
changed current condition, so sparking of the patient, puncturing the 
tube or other accidents are effectually prevented. The patient also 
should be grounded. A wire screen netting is placed over the patient, 



THE TRANSFORMER 



243 



for instance the lower extremities. It is weighted down by suspending 
a heavy object from either side. The wire is grounded to a water or 
waste pipe. Should a full spark strike the patient it is thus imme- 
diately dispersed down the grounded wire and the patient thus remains 
protected. 

To recapitulate: Modern deep roentgentherapy requires for the 
source of the z-ray current an interrupterless transformer, an auto- 
transformer control, a Coolidge tube with a medium focus and a 
transformer control for the cathode filament current. 

Accessories. A great variety of accessories also are necessary such 
as a tube stand, a treatment table, markers and so forth. 

A very simple and practical tube stand is shown in Fig. 36. It is 
arranged so that the tube lies parallel to the axis of the carrier, though 




FIG. 37. A simple but practical treatment table. 

it may be moved in any direction. The former position is necessary in 
suprapubic and neck treatments, especially when crossfiring must be 
used. It is advisable to ground the stand to a water pipe to prevent 
sparking of the patient. 

The treatment table should be a wooden one, the top must be very 
carefully padded, so the patient can lie on it for any length of time. A 
common examining room table, as reproduced in Fig. 37, has been 
found very practical and gives great satisfaction. 

The patient can be arranged in any position desired, as prone position, 
lithotomy position, extended neck position and left lateral. 

The roentgen treatment room should be large and well ventilated. 
The transformer is preferably located in a separate room, so as to deaden 
its noise as much as possible. The switchboards are located in a small 
booth The partition toward the patient should be lined with lead- 



244 DEEP ROENTGENTHERAPY 

sheeting of 0.3 mm. thickness. A window of leaded glass must be in- 
stalled, so the patient may be continuously observed by the operators. 

The patient must be protected by leaded rubber sheeting. An opening 
3 inches square is cut in about the center which exposes the part of the 
patient to be treated. To obviate any error in applying the rays, it is 
necessary to map out the area to be treated into squares, usually of 
1J inches. This is best done by using a skin ink composed as follows: 
1$ Acidi pyrogallici 1.0, acetone 10.0, liq. ferri perchlor. fort. 2.0, 
sp. vini menth. ad 20.0; m. et s.: skin ink. The areas are crossed off 
with the same ink after a treatment, so errors are impossible. A 
standard to mark the squares should be used. The one for more super- 
ficial work should have 16 squares of 2 inches, and the one for very deep 
work 12 squares of 1J inches each. The smaller squares are needed to 
cut out the greatly dispersed peripheral rays in treating deeply located 
tumors. This precaution must be observed to avoid stimulation of the 
tissues by the weak peripheral rays. 

The compression tube must be built so tCat it tapers down to a 
square of 1 J inches or it may be of the ordinary cylinder type. Then a 
lead plate having the same diameter as the tube and a square of 1J 
inches in the center is placed on a given square. In this manner no 
portion of the body surface receives any rays except the area to be 
treated (see Fig. 44). 

We also must employ means for determining the erythem dose for 
each Coolidge tube under exactly like conditions of application. This 
will be discussed in another paragraph. 

Technic. The radiation given off from a roentgen tube, i. e., one 
backing up a 9-inch spark or activated by 100 kv., is nearly always of a 
heterogeneous character. It not only emits highly penetrating rays, 
but simultaneously a varying proportion of medium hard and soft 
rays. Half of the medium hard rays are absorbed within the upper 
2 cm. of tissue beneath the skin, while one-half of the soft rays do not 
penetrate deeper than abour 7 or 8 mm. In deep roentgen-ray therapy 
it seems to be desirable to only use rays which are absorbed at the 
depth of the diseased organs or regions. Rays absorbed without this 
area would strike healthy tissue which is not desirable. If we could 
filter out these rays we would gain a distinct advantage. This can be 
attained by the interposition of a filter, usually made of aluminum . The 
questions arise: What has been done to a beam of x-rays on inter- 
posing a filter in its path? In what ways have its intensity and char- 
acter been altered? The quantitative estimation of the absorption 
suffered by a beam of x-rays in its passage through a substance may be 
made by measuring the ionization caused by the beam initially and to 
trace the gradual diminution in this ionization as successive layers of 
the material in question are interposed between the beam and the 
ionization measure. The results would differ according to whether a 
soft, a medium or a hard tube is used. 

With regard to the penetration of animal tissue by roentgen rays an 
extensive series of measurements were made in 1905 by Perthes, who 



THE TRANSFORMER 



245 



found that the absorption by most of the tissues was extremely near 
that of water. He also determined the thickness of tissue required to 
reduce the intensity of roentgen rays by a certain amount as measured 
by a fluorescent screen and also the thickness of aluminum which pro- 
duced the same reduction. From the values given in his monograph 
it appears that aluminum is from seven to ten times as effective an 
absorber of roentgen rays as tissues of about the same density as water. 
This is nearly three or four times as much as its density would suggest. 
Guilleminot has made an elaborate study of the absorption of x-rays 
by determining the intensity of the rays after passing through various 
thicknesses of tissue; this was done for screened as well as unscreened 
rays. 



Quality of rays. 


Surface. 


0.5 cm. 


1 cm. 


2cm. 


3 cm. 


4 cm. 


5 cm. 6 cm. 


7cm. 


8cm. 


4 Benoist 


Dose transmitted 100 


65.0 


43.0 


22.0 


13.0 


8.0 


5.2 3.8 


2.6 


1.8 


5 Benoist 


100 


72.0 


53.0 


32.5 


21.9 


15.5 


11.6 8.8 


7.0 


5.5 


6 Benoist 


100 


78.0 


63.044.0 


33.0 


26.0 


21.0 17.2114.4 


12.0 


7 Benoist 


100 


81.0 


68.050.0 


39.0 


32.0 


26.5:22.8 


19.717.2 


8 Benoist 


" 100 


83.2 


69.9 52.7 


42.0 


34 8 


29.525.522.3 ! 19.6 


8 Benoist filter 1 mm. Al. 


100 


86.5 


76.261.1 


50.6 


43.037.332.628.5 


25.4 


8 Benoist 2 mm. Al. 


" 100 


89.2 80.4|67.0 


57.1 


49. 4 43. 3 38. 2i33. 8 30.1 


8 Benoist 3 mm. Al. 


100 


91.0 


83.571.8 


61.8 


54.548.042.537.834.8 


8 Benoist 4 mm. Al. 


" 100 


92.8 


86.0 


74.5 


65.4 


57.851.345.7 


41.037.0 


8 Benoist 5 mm. Al. 


100 


95.0 


87.0 


76.1 


67.2 


60.0:53.848.5 


44.0 


40.2 














1 1 







A variety of substances may be used when it is desired to screen a 
beam of roentgen rays that is to say, to cut off its softer components. 
Salmond has made a comparison of the efficacy of different screens 
commonly used. 



Alumimum. 
mm. 

0.5 
1.0 
2.0 
3.0 



Pure paper. Tanned leather. Chamois leather. Felt, 

mm. mm. mm. mm. 

3 3 10 13 

7 7 18 30 

13 13 35 67 

17 16 59 97 



Porter and Christen have shown that in order to apply a maximum 
intensity of rays at a depth d, that particular radiation should be chosen 
which is diminished to one-half of its intensity by this thickness of 
tissue. 

Thus the interposition of a proper filter arrests all the rays that 
would otherwise become absorbed in the skin and healthy structures 
lying in the path of the rays between the growth to be treated and the 
source of the rays. However the erythem dose of filtered rays is of a 
different intensity than that of unfiltered rays. If a pastille placed 
above the filter and at a half distance from the focus to the skin surface 
shows an intensity of 6 E. within ten minutes by a given current, the 
same pastille will record only one E., if placed on the skin beneath a 
filter of 3 mm. if the focal distance is 11 inches. Therefore the time 
period of the application of a filtered roentgen ray may be safely 
extended without any corresponding injury to the skin. 

These considerations enable us to select that particular radiation 



246 



DEEP ROENTGENTHERAPY 



necessary in the treatment of deep-seated lesions. For instance let us 
assume we were treating a carcinoma of the left ovary. The organ lies 
on an average 8 cm. beneath the skin surface. Hence we must select 




FIG. 38. Wehnelt radiometer. 



a ray which becomes absorbed by one-half at a depth of 4 cm. Refer- 
ring to the table of Guilleminot, we see at a glance that a tube must be 
used of a hardness of 8 Benoist and an aluminum filter of 3 mm. 
Again we intend to treat a breast cancer confined entirely to the organ . 







FIG. 39. Heinz Bauer Qualimeter. 

The radiation is applied as a prophylactic measure. Anteriorly the 
ray should penetrate the chest wall, which is about 4 cm. Over the 
sternum we wish to penetrate the mediastinum, which is 10 cm.; 



THE TRANSFORMER 



247 



posteriorly we propose to treat the lymphatic structure, including the 
chest wall, which measures on an average 3 or 4 cm. The problem 
would be solved as follows: Anterior chest wall tube 7 Benoist, 2 mm. 
aluminum filter; sternum tube 8 Benoist, 4 mm. aluminum filter; 
laterally and posteriorly tube 8 Benoist, 2 mm. aluminum filter. 

The multiple small fields and cross-fire method described has a 
great many disadvantages: the penetration of the rays is low, and 
the quality heterogeneous. The higher the voltage of the current the 
shorter the wave length of the electrons will be and the more penetrat- 
ing or harder the rays must be. The quantity of the hard rays is also 
much larger than those obtained from a current of lower voltage. We 
are conducting experiments with a coil that furnishes current up to 
180,000 volts. The tube is charged with 3 to 5 milliamperes. The 
arms of the tubes as at present built must be lengthened to about 
20 inches to reduce the danger of puncturing. Provision, also, must 
be made to cool the tubes either by water or oil. The focal distance 
has been increased to 24 inches. The metal filters consist of aluminum 
18 mm. thick or pure copper 1 mm. thick. The compression tube has 
a diameter of 9 inches at the base. One field 9 inches in diameter over 
the pubic region is exposed to the rays for one consecutive hour and 
another field of the same diameter over the sacrum and buttocks for 
thirty to forty-five minutes. The difference in intensity of the rays 
between the skin surface and the depth is very small and almost 
negligible, proving the homogeneous quality of the rays. 

The next question to decide is: How do we determine the pene- 
trability of the radiation? Various methods are in use : The radiom- 
eters of Walter, Benoist, Wehnelt and Bauer. I have used the 
Wehnelt and Bauer which are reproduced in Figs. 38 and 39. 

The Wehnelt radiometer is provided with a wedge-shaped aluminum 
strip, and along this a flat silver strip, both of which can be moved by 
means of a ratchet over a brass plate provided with a thin slit. The 
apparatus is adjusted until both strips show the same brightness on a 
fluorescent screen. A scale denotes the permeability of the activated 
tube. 

The Bauer qualimeter is connected by a wire to the negative terminal 
of the coil or cathode of the tube. It is a static electrometer and con- 
denser which indicates automatically the potential of the cathode, and 
hence the quality of the radiation. We may say that each division 
represents the energy of ten kilowatts. Hence if the Heinz Bauer 
instrument indicates at 9, we assume that the tube is charged with 
90 to 100 kilovolts. 

The comparative value of the instruments most frequently used 
is as follows: 



Usual termination. 


Very soft. 


Soft. 


Medium. 


Hard. 


Very hard. 


Bauer 


102 3 


4 


567 


8 


9 10 


Wehnelt 


153 45 


6 


759 10 5 


12 


13 5 15 


Walter .... 


1 1-2 2-3 


3-4 


4-5 5-6 6-7 


7-8 




Benoist 


123 


4 


567 


8 


9 10 















248 



DEEP ROENTGENTHERAPY 



The method of estimation of dosage depends on the determination of 
the erythem dose. An erythem dose, i. e., one E, is one which causes 
a slight erythema and loss of hair to appear on the skin fourteen days 
following the application. It is apparent that the application to a 
given area should not be repeated before this time-period has passed. 

The estimation of an erythem dose depends on the change the 
a>rays produce on a disk of barium platinum cyanide, the green color 
changing to a brown. By experiment the exact tint was found which 




FIG. 40. Holzknecht quantimeter. 

the pastilles assumed after exposure to an erythem dose. Holzknecht 
has devised a color scale. The pastille is compared with an unexposed 
pastille of the same material arranged under a celluloid film of red- 
brown color, increasing gradually in intensity. By moving the exposed 
pastille along this film, the discoloration can be measured, 5H equal 
10 x or an erythem dose. Another instrument based on the same 
principle as Holzknecht's radiometer and frequently employed is the 
quantimeter of Hampson, shown in Fig. 41. 

The methods of measuring quality and quantity of rays as enumer- 
ated are not very exacting and rather liable to errors, because they are 
dependent on color determination. This is liable to cause subjective 
errors on account of individual differences in judging color changes, 



THE TRANSFORMER 



249 



varying light conditions and differences arising in the tint of the 
tablets if exposed to radiation, and sunlight. 

The only correct and scientific method must be based on the ioniza- 
tion power of the rays. Such instruments are known as ionization 
meters. They consist of an electrometer to which an ionization 
chamber is attached. The apparatus enables one to determine the 
exact amount of electrostatic units emanating from an activated 
roentgen tube within a known time period. The ionization chamber is 
constructed so it may be inserted into the vagina or the rectum. The 
exact number of electrostatic units of roentgen rays can thus be deter- 
mined that reach the posterior pelvic wall in the treatment of pelvic 
carcinomata, while the exact surface dosage is obtained by placing 
the ionization chamber upon the exposed skin surface. Kroenig and 




FIG. 41. Hampson's quantimeter. 

Friedrich have gauged the skin dose as 170 e, the cancer dose as 150 e 
and the ovarian dose as 33 e. The skin dose causes an erythema of the 
first degree. The carcinoma dose results in a visible and palpable 
decrease of the growth. The ovarian dose brings about amenorrhea, 
due to a degeneration of the ova and follicles by the rays. 

The quantity of roentgen rays received by a given object depends 
on (1) the quantity of x-rays generated; (2) the quality of the tube 
radiation; (3) the distance between the focus and the object; (4) 
the time of exposure; (5) the sensitiveness of the object. 

The quantity of the radiation is determined by the filament current, 
the voltage and the amperage, which also give us the quality. Both are 
subjected to the determination of the erythem dosage, which gives us 
the time duration. The latter varies according to the distance of the 



250 DEEP ROENTGENTHERAPY 

focus from the skin. Distance has a great influence, because the inten- 
sity of roentgen rays diminishes inversely as the square of the distance 
increases. If the focal spot is 40 cm. from the skin surface it requires 
four times as many minutes to obtain an erythem dose as a tube ex- 
posed at a focal distance of 20 cm. 

The Biological Action of the Rays. A study of the biological reaction 
of tissues to radiation enables us to correctly interpret the thera- 
peutic value of the latter and assists us in the choice of the quality 
and quantity of rays to be employed. Since the effect of the action 
of rays, whether the source is radium or a roentgen tube, is not only 
local but also general, i. e., systemic, a correct interpretation of the 
systemic reaction to the rays is very necessary. The latter enables 
us to formulate ?xact indications and centra-indications for the 
remedial use of radiations. Not only that; they also will materially 
aid us in the prognosis of radiation treatment. 

Some of the earliest observations of the changes occurring in malig- 
nant tumor by roentgen-ray applications were reported by Clunet in 
1910, who divided the changes seen in squamous-cell cancer treated 
with roentgen rays into five successive phases: (1) The latent phase; 
(2) development of giant cells; (3) keratinization ; (4) disintegration 
and phagocytosis; (5) formation of connective tissue. The latent 
phase varies from six to fifteen days. During this time no changes in 
the cells are seen. In the second phase we see the formation of giant 
cells characterized by an enlargement of all parts of the cells, which 
may be increased in diameter as much as two or three times. Atypical 
mitoses are increased in number. The nuclei appear much enlarged 
and chromophile. During the third phase irregular forms of a pseudo- 
parasitic character appear within the cells. Keratinization is seen in 
the protoplasm as well as the nuclei. Ihe protoplasm becomes gran- 
ular, often exhibiting vacuolation. The granules gradually are fused 
together into one mass of keratin. The nucleus may show karyor- 
rhexis, diffusion into the protoplasm and granulation. At this time also 
a round-cell infiltration and active proliferation of fibroblasts in the 
stroma become very marked. Macrophages and microphages appear, 
evidently to devour the degenerated cells and cell debris. In the final 
phase regeneration is completed by a connective-tissue formation. All 
these changes are identical with those occurring in tissues irradiated 
with radium rays (see Fig. 42). 

If, after some time, a portion of the scar be examined microscopically, 
epithelial cells may be seen, some representing giant cells, others 
degeneration of the protoplasm and still others abnormal stages of 
nuclei. They are probably dormant or in a kind of lethargic con- 
dition. If the treatment is not continued they may give rise to recur- 
rences. 

Sarcoma cells exhibit a somewhat similar transition; however, the 
latent phase is very much shorter, being only one or two days. 

The changes occurring in cells by roentgenization are identical with 
those seen after applications of radium rays. The response to radiation 



THE TRANSFORMER 



251 



by the cells may be best expressed by the law of Bergonie and Tri- 
bondeau, which has equal importance for both radiations: "Immature 
cells, and cells in an active state of division are more sensitive to rays 
than are cells which have already acquired their fixed adult morpholo- 
gical or physiological characters. " Very rapidly growing cells are the 
most affected of any by radiations. However, different rays give rise 
to quite different effects upon one and the same cell. They have a 
"differential" action. Thus the action on tissues of soft, medium and 
hard roentgen rays differs as does also that of the Alpha, Beta and 
Gamma rays of radio-active substances. A careful distinction should 



<** 








FIG. 42. Effect of roentgen rays on cancer tissue. Mr. M., Augustana Hospital, 
No. 42283. Carcinoma of neck involving muscles. Tissue removed March 30, 1915. 
Low power magnification, a, carcinoma cells; 6, leukocytic cells; c, connective-tissue 
fibrils; d, lymphocytic infiltration. 

be made between the "differential" action which different rays have 
upon the same variety of cell, and the "selective" action which the 
same kind of radiation has upon the many different varieties of cells. 
The degree of selective absorption of rays by Hying cells depends on 
the particular phase of its life cycle, their species, as well as the age of 
the host whom the cells inhabit. Cell elements which are embryonal 
or undifferentiated are destroyed by a radiation which would only 
cause a slight reaction in the surrounding mature or highly differen- 
tiated cells. The basal cells of the epidermis and hair follicles, lymphoid 
cells, sex cells, as ova and spermatozoa, are readily killed by a quantity 



252 DEEP ROENTGENTHERAPY 

of rays which would leave intact the surrounding and neighboring 
mature cells. 

Selective absorption also depends on the elementary variety or 
species of the cell, whether epithelial, connective tissue or endothelial, 
and on the different varieties within each species. Normal connective- 
tissue cells are less receptive than normal epithelial cells. Epithelial 
cells of the basal layer of the skin are less sensitive than those of the 
papillae of the hair follicles. They are different kinds of the same 
species. Lastly the tissues of a child are much more easily altered by 
radiation than corresponding tissue elements in the adult. 

The observations made on normal cells apply with equal force to 
abnormal cells and tissues, neoplastic as well as inflammatory. 

Remarkable examples of radiosensitive tumors are ectodermal and 
basal-celled epitheliomata derived from the basal-celled layers of the 
epidermis, lymphadenomata originating from embryonal lymph cells, 
sarcomata derived from embryonal connective-tissue cells, and in 
which the connective-tissue fibrillse, cartilagenous and osseous tissues, 
have undergone resorption, fibromata in which fibroblasts are present 
in large numbers and do not develop into highly differentiated adult 
cells and connective-tissue fibers. 

On the other hand, squamous-celled epitheliomata, fibrosarcomata, 
chondrosarcomata, osteosarcomata and fibromata in which atrophic 
fibroblasts and abundant fibrous tissue have been retained are very 
refractory to radiation. 

The action of roentgen rays on neoplastic cells is of an impeding, 
destructive and evolutional character. The radiation arrests the 
growth of the tumors before it destroys them or renders them harmless 
by an evolutional process or metaplasia. Arrest of growth results 
from a cessation of the function of mytosis or genoceptor. Destruction 
of tumor cells is either a direct or an indirect process. In the direct 
form the tumor cells undergo necrobiosis. The cytoplasm and nucleus 
disintegrate, the cells are absorbed by phagocytosis. In the indirect 
destruction a metamorphosis of the tumor cells precedes absorption. 
This consists in a hypertrophy of the cells, enlargement of the nucleus, 
nucleolus and even centrosomes, so they appear like pseudoparasites 
and achromatism, vacuolation and granulation of protoplasm. 

The evolutional influence of roentgen rays on tumor cells is evidenced 
by a retrogression or stimulation of the embryonic tumor cells so they 
develop to maturity. To understand this process we must have a clear 
conception of the formation, growth and function of a cancer cell. 
Tumor formation deprives the cells of their normal functions. They 
become "strangers" to themselves and to the mature normal cells 
from whence they originate. The growth of tumor cells is not only the 
result of a proliferation of a single embryonal cell group but also 
depends on a retrogression or metamorphosis of normal mature cells 
to an embryonal phase after they have become included into the cancer 
tumor. By a process of evolution the embryonic abnormal cell is 
stimulated to grow and developed into a mature, highly differentiated 
normal cell, thus becoming benign. 



THE TRANSFORMER 253 

The action of roentgen rays on inflammatory tissues depends upon 
two phenomena: (1) The destruction by the rays of the anatomical 
elements, modified by inflammation; (2) the absorption of the degener- 
ated tissue by phagocytes and its replacement by scar tissue. 

This statement would presuppose that inflammatory products are 
more readily acted upon by the rays than normal tissues. This, indeed, 
is borne out by clinical observation. However, the reaction to radia- 
tions of inflammatory tissues differs, depending upon the underlying 
bacterial cause. Thus, simple inflammatory glands are quickly in- 
fluenced by a few exposures however, suppurating glands are not 
amenable to radiation treatment. Lymphadenomatous glands are 
less quickly acted upon, but they invariably diminish in size after a 
thorough exposure. Tuberculous glands are less readily affected. It 
requires a large number of exposures to induce retrogressive changes, 
but ultimately they also slowly respond to radiation treatment. 

The employment of radiations in any form leads to a constitutional 
reaction which varies in the tune of onset according to dosage and 
character of rays, the type and location of the tumor or tissue and the 
systemic condition of the patient. The constitutional reaction results 
from the changes occurring in the blood by the action of the radiation 
and from the degeneration set up in the growth by the rays which leads 
to an absorption of protein ferments into the circulation of the patient. 

Some patients possess a marked idiosyncrasy in the sense that the 
same dose of radiation will provoke a reaction, the degree of which 
varies with the individual. Dosage is a complex quantity and includes 
the quantity and quality of radiation, the distance of the focus of the 
tube from the body surface, the area over which the rays are spread, 
the nature of the rays selected, the filter used, and the kind of tissue to 
which they are applied. In describing and comparing results obtained 
we should always state the size of tube, the hardness, the milliamperage, 
the focal distance, the filter, the size and number of each field or portals 
of entrance and the time duration of the treatment. We also must 
give an exact statement of the type and size of growth, its extent and 
the formation of glandular and distant metastases. Finally, all general 
constitutional signs must be stated as pulse-rate, temperature, general 
nutrition of the patient, whether the disease has rendered the patient 
quite ill and moribund, a correct urinalysis and a complete examina- 
tion of the blood, including a differential white count, and pulse and 
blood-pressure. These observations should be made and recorded 
before treatment is begun. They should be repeated at daily intervals 
until such a time that they have returned to normal or that their 
permanent existence is unquestionable. The patient must again be 
subjected to the same routine examinations at each subsequent course. 
It is only in this way that we are able to correctly interpret the con- 
stitutional reaction and the efficacy of the treatment as regards the 
local diseased conditions and the general state of health of the patient. 
The pulse-rate gives us valuable information about the influence of the 
disease on the general condition of the patient. A rapid pulse is usually 



254 DEEP ROENTGENTHERAPY 

associated with an advanced cachexia or complicating infection. A 
rise in temperature indicates either a complicating infection or exten- 
sive destruction, necrosis and absorption of tumor debris. Abnormal 
constituents in the urine may mean organic kidney disease or secondary 
disturbances in the kidney set up by the influence of the tumor on the 
general constitution. Increase in the total nitrogen and purin base 
output is a direct result of radiation. Low percentage of hemoglobin, 
decrease in the number of erythrocytes and leukocytosis, with an 
increase of neutrophiles, may indicate a secondary anemia due to 
hemorrhage or cachexia, an active infectious process, and so forth. 
If all of these signs are absent the general condition of the patient must 
be termed good. If one or all are present they either indicate compli- 
cations of the underlying disease or constitutional reaction from the 
radiation treatment. It is clear that we could not determine the 
presence of the latter if a painstaking examination did not precede each 
course of treatment. 

Attention to the changes occurring in the bfood by the action of 
radiation was first directed by Senn in 1903 in cases of leukemia. This 
observation led to numerous investigations, the outstanding feature of 
which was that a diminution in the total number of white cells results 
from the general effect of prolonged exposure to x-rays. The lympho- 
cytes appear to be the most sensitive of the white cells, the number of 
which gradually decreases, while there seems to be an initial increase 
in the polymorphonuclear leukocytes. Chronic exposure of roentgenol- 
ogists to the ray almost invariably leads to a decrease in the number 
of erythrocytes, without apparently affecting their general health. 
(Aubertin.) 

Stevens in an extensive study on the blood in cancer under roentgen- 
therapy derives the following conclusions: Roentgen rays, applied 
in repeated large doses, with deep penetration, profoundly affect the 
erythrocytes of human beings. For the first few days the lymphocytes 
are suppressed or destroyed by large doses of roentgen rays in the 
treatment of cancer. In favorable cases this is followed by a reaction 
with lymphocytosis between the third to the seventh days, which may 
continue almost uninterruptedly till the fourteenth day, or it may stop 
shortly after the seventh day and reappear more strongly and per- 
sistently on or about the fourteenth day. There is a strong resem- 
blance between the curves of these lymphocytic reactions and those 
which constitute the opsonic index. The treatment should probably 
not be repeated until the reaction is over. The repetition of the dose 
should probably by governed by the reactions in the blood as well as in 
the skin, the former being much more sensitive than the latter. In 
some cases of cancer the roentgen rays tend to stimulate a general 
immunity if lymphocytosis is an indication of immunity. The action 
of roentgen rays in cancer, therefore, would appear to be twofold: 
local by its destruction of disease cells and general by stimulating lym- 
phocytosis, and, consequently, resistance. 

The clinical symptoms of the systemic reaction resemble an acute 



TREATMENT 255 

intoxication. They include extreme prostration, together with such 
gastro-intestinal symptoms as vomiting, diarrhea and anorexia, an 
increase in the pulse-rate and a rise in temperature. At the same time 
there is observed an increase in the excretion of uric acid, the total 
nitrogen and purin bases in the urine and also a marked increase in the 
non-protein nitrogen in the blood. All observers agree that the 
intoxication results from the destruction of tissue cells by the ray, 
particularly tumor cells, on account of the much increased selective 
absorption the latter possess in comparison to normal mature cells. 
The liberated protein ferments are absorbed into the circulation, 
causing a temporary hyperleukocytosis. The decrease in the number 
of lymphocytes is the result of a directly destructive process of the rays. 
As the blood circulates through the area under treatment the highly 
selective absorption of rays by the lymphocytes causes their destruc- 
tion. The tissue injury may be so great and tissue catabolism so 
increased that the intoxication may become so severe as to cause death/ 

The nausea and vomiting so often observed in patients during the 
time of treatment result from the effects of the rays on the vasomotor 
system and the inhalation of gases, especially ozone, liberated by the 
high-tension currents in the treatment room. They are transitory and 
immediately subside after the treatment. 

It is clear that an organism not weakened by the tumor disease is 
much more able to resist the toxic action of rays and much more capable 
to respond to the sudden demand on the organism for the complete 
disintegration and excretion of a large amount of the products of tissue 
breakdown. It is also a fact that treatments should not be repeated 
until the organism is entirely freed from the intoxication. 

TREATMENT. 

Having discussed the source of the ray, the technic of the thera- 
peutic application, the degenerative changes brought about in normal 
and abnormal tissue and the effect of the radiation on the constitution 
of the patient, it now behooves us to discuss the employment of 
roentgen rays in surgical diseases. The latter may be divided into 
several divisions: 

1. Malignant growths. 

2. Benign growths. 

3. Inflammatory diseases. 

4. Blood diseases. 

1. Malignant Growths. Success in cancer therapy can only be 
attained by the total eradication or degeneration of all cancer cells in 
the host attacked by the disease. Whether the means employed are 
surgical or radiological does not matter. The danger in the treatment 
of cancer with surgery consists in the fact that we frequently cannot 
totally remove all of the cancer tumor and the latter now begins to 
grow with an increased rapidity due to a rapid autotransplantation of 
tumor cells caused by an incomplete procedure. The danger in the 



256 DEEP ROENTGENTHERAPY 

treatment of cancer with radioactive substances consists in the fact 
that we cannot rapidly destroy all the pathologic cells. We stimulate 
proliferation. An accelerated proliferation increases the danger of the 
formation of metastases. 

Complete surgical eradication of a neoplasm is the best available 
means to prolong the life of the patient. But to be effective it must be 
early. An anatomical cure can be obtained only if absolutely all 
cancer cells have been removed from the body of the bearer. It is only 
rarely that such an ideal result is obtained. Otherwise recurrence 
could not be the rule as statistics and clinical observations clearly 
prove. Surgical eradication is in most cases defective: (1) Because the 
whole growth is not removed and the roots or seeds are left behind; 
(2) because these vestiges develop with an increased rapidity when the 
primary tumor is removed; (3) because operation favors the formation 
of distant embolism, sources of incurable metastases. Surgery removes 
but cannot modify cancer cells or render them harmless. However, 
as we have shown above, roentgen rays can Annihilate that power of 
boundless cellular activity which constitutes the secret, the malignancy 
of cancer. It is necessary to concentrate a sufficient quantity of 
penetrating rays into the depth of the body to kill the cancer cells 
without seriously impairing the skin and the overlying and surrounding 
normal organs and tissues. Deep roentgentherapy correctly applied 
enables one to do so. It is clear that results and statistics in cancer 
therapy would be very much improved by a combination of surgery 
and radiation treatment. It also follows that results of surgical 
trauma of cancer cells would be rendered negligible if the cells were 
rendered harmless before the patient is subjected to operation. Indeed 
the method of treatment of cancer tumor at our clinic during the past 
three years has been carried out along this line. Namely, we first 
irradiate the growth, the neighboring regions and the regional lymph 
gland groups, next we operate early and radically remove all that is 
visible and palpable, and lastly we again irradiate the former seat of 
the tumor, the neighboring tissues and the regional lymph gland groups. 
Wherever it is possible we combine radium with roentgen therapy 
either inserting the radium tubes through the natural channels into 
the organs or carrying radium needles through small openings in 
the skin into the invaded tissues and tumor by specially constructed 
trochars. 

Success in roentgen-ray therapy can only be attained by adhering 
most rigidly and minutely to a systematic technic. This includes the 
correct determination of the degree of penetration of the ray, the 
amount necessary to degenerate the cancer cells and the proper dis- 
tribution of the fields to be radiated. Figs. 43 to 46 show at a glance 
the methods to be followed. 

The degree of penetration is determined by referring to the table 
of Guilleminot given on page 245. The amount of roentgen rays 
necessary to degenerate a cancer in the depth of the abdominal cavity 
has been accurately determined by Bumm who found that from 3 to 5 E 



TREATMENT 



257 



of massive, filtered roentgen rays are necessary to destroy a carcinoma 
within 2 cm. from the body surface. However, it takes from 30 to 50 E 
to obtain the same result in the depth of the pelvis, which is about 10 
cm. beneath the compression cylinder if the latter is pressed down onto 
the abdominal organs. The tube must always be directed toward the 
cervix, so that the application of 3 E through each one of the fields 




FIG. 43. Arrangement of fields in treating cancer of the oral cavity, throat and neck. 

1 to 7 and 16 to 20 in Figs. 17 and 18 would give an amount of twelve 
times 3 E, i. e., 36 E or 360 X. Thus by "cross-firing" the desired 
result would be attained. Four such courses are repeated every two 
or three weeks to make doubly sure that the disease has been arrested. 
If surgical removal is advisable it is instituted soon after the reaction 
following the first course subsides, i. e., within two or three days. 




FIG. 44. Arrangement of fields on anterior chest wall in cancer of chest. 

The method of treatment just described and the schematic drawings 
of the fields of entrance of the various regions of the body will enable 
anyone to pursue the plan of treatment instituted in our clinic. 

The local result of successful ray treatment is arrest and gradual dis- 
appearance of the growth, the healing and epithelialization of necrotic 
ulcers and cessation of discharge and bleeding and in favorable instances 

VOL. I 17 



258 



DEEP ROENTGENTHERAPY 



subsidence of pain. Constitutional symptoms improve proportionately 
Thus appetite, sleep, weight and strength return; pulse and tempera- 
ture become normal, so that subjectively the patient appears to be 
normal. 




l" 8 [9] lolll 
I I"- +--4 
| 4 | 5 ! 6 | 7 

T 




FIG. 45. Arrangement of fields in suprapubic regions in cancer of the pelvic organs. 

How long should the radiation be continued? If an improvement in 
the local and constitutional condition does not ensue within six to 
eight weeks the treatment should be discontinued as useless. On the 
other hand, should the local and constitutional signs show amelioration 
or cessation the patient must be instructed to return every four weeks 




FIG. 46. Fields over perineum and buttocks in cancer of pelvic organs. Patient in 

knee-chest position. 



for examination. On the slightest sign of a recurrence, either locally or 
symptomatically, another course of radiation must be instituted. If 
after a time period of two years the patient has remained apparently 
well after most painstaking examinations the interval between ree'x- 
aminations may be extended to three months. The patient should be 



TREATMENT 259 

instructed to return sooner if any disturbance appears. After five 
years, during which time the patient has remained free of any recur- 
rence, the patient can be discharged as well, although careful reexami- 
nations made every six months should be insisted upon for some time. 

In conclusion, we must always realize that success in cancer treat- 
ment can only be attained by the total eradication or degeneration of 
all cancer cells present in the body of a victim of the disease. This 
principle must be observed if we are to expect results whether the means 
chosen are surgical or radiological. The danger in the treatment of 
cancer with surgery consists in the fact that we cannot always remove 
all tumor tissue. The vestiges left now grow with an increased rapidity 
and by autotransplantation cause secondary growths in different parts 
of the body. The danger in the treatment of cancer with radio-active 
substances consists in the fact that proliferation is enormously stimu- 
lated if we cannot rapidly destroy all the pathological cells. An 
accelerated proliferation increases the danger of the formation of 
metastases. 

Sarcoma. The treatment of sarcomata with the roentgen ray 
depends chiefly on the histological structure of the growth. A spindle- 
celled sarcoma is very refractory to the action of any ray while a round- 
celled growth responds very readily. " It melts away like snow in the 
sun" is a very apt comparison for the reaction. Sarcomata containing 
a large amount of adult connective tissue, cartilage, osseous tissue, 
muscle or nerve structure, do not react nearly as readily as a growth 
composed chiefly of embryonic structures. 

We invariably combine roentgentherapy with the administration of 
Coley's vaccine. 

The principles of the application of the massive and intensive 
roentgen ray are the same in this class of growths as those observed 
for carcinoma. However the prognosis is different. If a patient suffer- 
ing with a malignant connective-tissue tumor has remained well for 
one year, he may be considered cured. 

2. Benign Growths. The object of radiation treatment in benign 
growths is to render them symptomless. This may necessitate either 
the arrest of some abnormal function caused in the organ invaded by 
the tumor or the reduction in size of the growth if the latter causes an 
obstruction. 

Benign growths of the following organs have been successfully 
subjected to roentgen-ray treatment : Diseases and enlargements of the 
thyroid gland complicated with hyperthyroidism, enlargement of the 
thymus, hypertrophy and benign tumors of the prostatic gland in the 
male accompanied with residual urine, and myomata uteri causing 
profuse uterine hemorrhages. 

The region above the thyroid and thymus glands is divided into four 
squares of 2 inch each, or if the gland is very large six such fields are 
marked off. To each field 3 E of filtered rays are applied, the technic 
not differing from that employed in cancer. At the end of two weeks 
a comparison in the triad of symptoms and the circumference of the 



260 DEEP ROENTGENTHERAPY 

neck is made with that existing at the beginning of the treatment. The 
usual general treatment must be observed, i. e., rest, diet and inter- 
nal medication. Such radiation treatment is indicated whenever the 
patient suffering from hyperthyroidism is a poor surgical risk or refuses 
surgical treatment. Radiations should be continued until the patient 
is rendered symptomless. The treatment of enlarged thymus glands 
is conducted according to the one recommended for the thyroid gland. 

Enlargements of the prostatic gland, that cannot safely be subjected 
to surgical enucleation, are treated by applying the roentgen rays 
through the perineum and the suprapubic route, the same method as 
in treating cancer of the uterus in the female. If radium is available 
it should be used in conjunction with the roentgen ray. It is best to 
insert radium needles into each lobe of the prostate. If relief is not 
immediate it is deemed advisable to perform a suprapubic cystotomy 
under local anesthesia. It is of course understood that surgery must 
be resorted to unless urgent contra-indications forbid it. 

The success of roentgen-ray treatment of myomata uteri depends 
on an arrest of ovulation. The following indications must be observed : 
The tumor must not cause pressure symptoms. It must not be compli- 
cated by another pathological condition in the pelvis. It should not be 
larger than a newborn infant's head. It must not be located in the 
cervix or be pedunculated or subserous or submucous. The patient 
should be thirty-five years or older. However, if the patient is a poor 
surgical risk she should be subjected to radiation treatment even in 
the presence of one or all of these conditions. 

The rays are applied to seven portals of entrance in the suprapubic 
region as advised for treatment of carcinoma uteri. A course must be 
given soon after the cessation of a menstrual period and should be 
repeated every four weeks until amenorrhea is permanent. 

At times menstruation recurs. If it is normal it need not cause alarm. 
If the bleeding becomes profuse another course of radiation treatment is 
given. Such recurrences result from a reestablishment of ovulation. 
The younger the subject is the more probable the likelihood that 
menstruation reappears. 

Reduction in the size of the tumor takes place with the progressive 
senile atrophy of the genital organs. Such tumors may gradually and 
completely disappear. Should the myoma contain a marked admixture 
of highly differentiated connective tissue and connective-tissue fibers 
a reduction in size or total disappearance of the growth is unlikely. 
A symptomless myoma uteri does not necessitate treatment. There- 
fore, persistence of the growth is not an indication for any further 
treatment. 

3. Inflammatory Diseases. Inflammatory hypertrophies have been 
successfully treated by roentgen rays. It is not necessary to describe 
the technic. The fields of entrance are outlined exactly the same as 
employed in the treatment of cancer. Though the treatment is 
individualized for each patient yet the fields are always outlined in the 
same manner. Thus neglect or inaccuracy are impossible. 



TREATMENT 261 

Inflammatory diseases thus treated are chronic infections and 
hypertrophy of glands, tuberculous adenitis, tuberculous diseases of 
the breast, the skin, the peritoneum, the abdominal and pelvic organs, 
fibrosis uteri accompanied by menorrhagia, hemorrhagic myopathies, 
pseudoleukemia, although the latter is probably a lymphosarcoma and 
so forth. 

The tuberculous process must be free of cheesy degeneration. Other- 
wise the latter should be aspirated before radiation treatment is begun. 
Therapeutic results obtained in such tuberculous diseases are better 
than those of surgery. 

Radiation treatment in tuberculous and chronic inflammatory dis- 
ease is repeated every two or three weeks until a subsidence of all 
local signs of the disease is attained. Should the process not yield to 
the treatment within six to eight weeks further treatment is inadvisable. 
Recurrences are again subjected to another course or courses of 
roentgen-ray treatment. 

The contra-indications of roentgen therapy in bleeding uteri are 
the same as for bleeding myomata uteri. However, it is imperative 
that malignancy must be ruled out. In doubt hysterectomy is the 
only correct procedure. It must, however, be preceded and followed by 
irradiation treatment. 

The event of amenorrhea means successful treatment. Recurrences 
of profuse menses necessitate additional courses of roentgen-ray 
treatment, though success is certain if indications are strictly adhered 
to. Failure in arresting hemorrhage means existence of complications 
which escaped our examination findings. 

Roentgen treatment of Hodgkin's disease constitutes the best 
palliative method we possess. It surpasses in efficacy any other thera- 
peutic procedure. The treatment to be successful must be extended 
over all of the glandular organs, and especially the mediastinum and 
spleen. Disappearance of the enlarged lymph nodes indicates success 
of therapy and the treatments should then be interrupted. Reappear- 
ance of swellings necessitates further treatment. 

We also must mention the rather frequent occurrence of keloid 
formation in scar tissue which is very troublesome in some and objec- 
tionable from a cosmetic standpoint in others. Radiation pushed to 
the extent of causing a superficial burn will be followed by a dis- 
appearance of the keloid. 

In chronic malaria roentgen rays applied to the enlarged liver and 
spleen will cause a diminution in size. However, the improvement 
is a symptomatic one only as the schizomycetes remain undisturbed. 

4. Blood Diseases. Diseases of the blood offer a thankful field for 
roentgen-ray therapy. Results obtained are equally as good if not 
better than those following the usual methods of treatment. The 
diseases to be considered are polycythemia, lymphatic and spleno- 
myelogenic leukemia. The rays must be applied in either instance 
over all the long bones and the spleen. * 

In polycythemia a reduction in the red corpuscles is readily attained. 



262 DEEP ROENTGEN THERAPY 

Horwitz and Falconer report a case of polycythemia vera. On May 18, 
1915, a blood examination showed a hemoglobin percentage of 105, 
12,400,000 red blood corpuscles and 9000 white blood corpuscles. The 
spleen could be palpated about a hand-breadth below the costal 
border; the edge was rounded, smooth and slightly tender. October 
9, 1916, benzene was administered, about 5 gm. per day, until 33 gm. 
had been taken. November 10 another course of benzene therapy 
was given until 8.5 gm. had been taken. November 23 to 28, three 
additional grams of benzene were given. The drug had to be stopped 
permanently on account of nausea, gastric discomfort and headaches. 
During the period of September to January seven roentgen-ray 
exposures over the spleen were made of about 30 ma. minutes each. 
January, 1917, the blood picture showed a complete return to normal, 
the red count being 5,200,000, the white count 9200. and hemoglobin 
percentage 98. The spleen also had completely receded. When last 
seen, February, 1918, the patient was continuing well. 

In lymphatic leukemia the glands must be rayed in addition to the 
bone-marrow and spleen. A combined treatment of radium and 
roentgen ray in leukemias is preferable. The radium should be applied 
to the splenic area and the z-rays to the bone-marrow. The white 
blood count returns to normal and the red blood corpuscles increase 
rapidly within two or three weeks; the spleen is often reduced to an 
almost normal size. At the slightest recurrence another course of 
treatment must be given. Since it appears that the number of the white 
blood corpuscles increases with a simultaneous enlargement of the 
spleen we advise splenectomy in every case as soon as the white blood 
count returns to normal. Splenectomy apparently retards a recurrence. 
However, when it takes place radiation must be again resorted to, the 
former splenic area being also irradiated. It is interesting to note 
that irradiation of the spleen area in splenectomized patients is often 
followed by a remission. The latter is probably caused by the selective 
action the leukocyte and myelocyte have to the rays. 



INJURIES AND DISEASES OF THE SKULL 
AND ITS COVERINGS. 

BY CHARLES E. KAHLKE, M.D. 
COVERINGS OF THE SKULL. 

ANATOMY. 

THE several layers of the soft tissues covering the vault of the skull 
are so constructed and so arranged with relation to each other as to 
form a most suitable covering for the skull. The first three layers, 
viz., the skin, the subcutaneous fibro-fatty layer and the occipitofrontalis 
muscle with its aponeurosis (galea), are so intimately bound together 
that they form a pad by themselves constituting what is usually spoken 
of as the scalp. The latter is freely movable over the skull and its 
closely-fitting adherent pericranium because of the laxity of the sub- 
aponeurotic connective tissue. This latter tissue is of such a nature as 
to admit of the easy accumulation of fluids, even throughout its entire 
extent, from brow to occiput and from ear to ear, and hence is often 
incorrectly referred to as a space. In infancy the scalp is very thin and 
velvety and is very loosely attached. In subsequent years, when pos- 
sessed of a good growth of hair, it forms a thick, dense, resistant cover- 
ing. When the hair falls out, or in advanced age, it again becomes thin, 
but less movable. 

The skin of the scalp is exceedingly thick and, under normal con- 
ditions, heavily beset with hair follicles and sebaceous glands. The 
subcutaneous layer of fibro-fatty tissue is very much like the corre- 
sponding layer in the palm of the hand, and its connective tissue is so 
firm as to prevent any appreciable increase in the amount of fat such as 
occurs in the body in obesity or locally in the form of a fatty tumor. 
The pericranium is not firmly adherent to the bone except at the suture 
lines and foramina for vessels. While it serves as a protection to the 
bone, it has but slight boneforming power in adults, as is very evident 
after the destruction of the cranial bones from injury or disease. 

Blood Supply. The blood supply of the scalp is very rich and is 
peculiar in that the vessels are found almost entirely in the skin itself, 
thus allowing the scalp to be floated upon a large subaponeurotic 
accumulation of fluid, or even torn away from the skull as a large 
pedicled flap, without losing its nourishment. The subaponeurotic 
area contains very few vessels. The chief arteries of supply are the 
frontal, the supraorbital, temporal, posterior auricular and occipital. 
In a general way the large veins accompany the large arteries. An 

(263) 



264 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

important point in the arrangement of the venous system of the scalp 
is the communication of the superficial veins with those of the diploe 
and the intracranial sinuses, notably along the sagittal suture, the 
inner angle of the eye, the mastoid region and along the base generally. 



CORRUGATOR SUPERCILI 



DILATATOR NARI8 ANTERIOR 

DILATATOR NARI8 POSTERIOR. 

COMPRESSOR NARIUM MINOR 

DEPRESSOR ALAE NA8I. 



LEVATOR MENTI. 




FIG. 47. Muscles'of the head, face and neck. (Gray.) 

Lymphatics. The lymphatic vessels form a very rich plexus over 
the vault and drain into the necklace of glands around the base of the 



INJURIES OF THE COVERING OF THE SKULL 265 

head; those of the forehead passing partly through the lymphatics of 
the face into the submaxillary glands, and partly to the parotid glands; 
those from the temporal and anterior parietal regions to the parotid 
glands; and those from the posterior parietal and occipital regions to 
the mastoid and suboccipital glands. 

Nerves. Of the nerves supplying the scalp, those of special interest 
to the surgeon are sensory, with the exception of one of the temporal 
subdivisions of the facial nerve supplying the frontalis. 

INJURIES OF THE COVERING OF THE SKULL. 

Wounds, open or closed, involving the scalp, demand an immediate 
anatomical diagnosis, as complete as possible. In many contusions 
we must consider the possibility of an underlying fracture or intra- 
cranial injury. If we are dealing with a punctured wound, we must 
determine whether the subaponeurotic area, the so-called dangerous 
area of the scalp, has been entered, or whether the skull has been 
penetrated. Though many of these wounds, from the standpoint of 
trauma, are insignificant, yet, from their nature and location, they call 
forth many questions as to hemorrhage or infection in the near future, 
and as to epilepsy, insanity and various mental states in the remote 
future. The fate of many a case depends upon the diagnosis and treat- 
ment instituted by the physician first called to the case. 

Contusions. In the case of contusion the findings will depend 
largely upon the force and direction of the blow, and partly upon the 
size and character of the contusing surface. Thus a direct blow, 
striking the head squarely, may produce a contusion resulting merely 
in a hematoma of the subcutaneous or subaponeurotic area, or it may 
split the scalp in such a way as to resemble an incised wound. If the 
blow, on the other hand, falls obliquely, it may loosen the aponeurosis 
from the pericranium or even the pericranium from the bone, resulting 
in a more extensive extravasation of blood; it may even tear up a flap 
of the soft parts. 

Hematoma. We recognize as a subcutaneous hematoma, a swelling 
of the scalp which has appeared directly after an injury to these parts, 
and which has the following characteristics: It is painful, tender, 
tense and moves with the scalp. Discoloration is more or less marked. 
Fluctuation is usually not present unless it is over the brow where the 
skin is more easily separated from the aponeurosis. 

Deep hematomata have the same history of trauma and prompt 
appearance of the tumor, but with these differences: The swelling 
is usually more gradual in onset and tends to increase in size; is more 
extensive, and consequently flatter; it does not move with the scalp 
and usually fluctuates; even pulsation may be noticed where a large 
vessel has been ruptured, or if there is a coincident skull fracture with 
gaping. Discoloration is not so marked right after the injury, but may 
appear later. These deep hemorrhages may lie under the galea or 
beneath the pericranium. In the latter case they are known as cephal- 



266 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

hematomata. If the hemorrhage is under the galea and extensive, its 
location would be easily recognized; if under the pericranium, it would 
be limited in outline by the attachment of the pericranium to the suture 




FIG. 48. Large hemotoma under the galea. 

lines of the bone; but a hematoma under the aponeurosis, of limited 
size, and situated over one cranial bone might be difficult to recognize 
from a collection under the pericranium. Cephalhematoma is rare in 
adults. It occurs chiefly in infants and is due to injury during labor, 




FIG. 49. Bony wall of subpericranial hematoma. 

the hemorrhage coming from the vessels between the pericranium and 
skull. It appears usually on the second or third day after delivery and 
tends to increase in size for a time. These deep hemorrhages are alike 



INJURIES OF THE COVERING OF THE SKULL 267 

in that they usually have a firm ring of reactionary edema at the border 
of the hemorrhagic infiltration of the tissues. This ring is elevated and 
so hard in contrast to the rather soft fluctuating center of the hema- 
toma, and so gradual in its rise from the surrounding normal tissues, 
that it feels much like the edge of a depressed skull fracture and is 
occasionally mistaken for such. Firm and continuous pressure on any 
point of the ring will cause the ridge to disappear at the point of pres- 
sure. In case of reasonable doubt as to fracture it is best to make an 
incision and examine the skull. 

All of the hematomata, both superficial and deep, tend to disappear 
spontaneously by absorption. Occasionally a large vessel may require 
ligation. Only rarely will the blood remain long enough under the peri- 
cranium to become encysted, thus constituting a blood cyst. 




FIG. 50. Suppurating cephalhematoma in an infant of five Weeks. Incised. Death 
in four days. Children's Hospital. (Ashhurst.) 

Diagnosis. The diagnosis in case of a blood cyst is to be based upon 
the history of injury, the location and non-inflammatory nature of the 
swelling, the fluctuation, the absence of pulsation and the non-reduci- 
bility.of the tumor. There may be a thin bony shell rising up from the 
borders toward the dome, representing the bone-forming power of the 
pericranium. The exploring needle would reveal reddish or yellowish 
fluid. It would be differentiated from meningocele spuria or hernia 
cerebri by its non-reducibility on pressure, its failure to increase in 
size or tension with increased intracranial tension, and by the absence 
of pulsation. Cephalocele would have the characteristics of meningo- 
cele spuria, but it would be situated in the median line and would be 
congenital. 

Treatment. In case a hematoma does not disappear spontaneously 
in the course of ten days or two weeks, it should be aspirated with a 
large needle or incised. The cavity should be emptied by gentle 
pressure and a light compression bandage applied. Any thin bony shell 



268 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

should be broken down. Special care should be observed to avoid 
infection. In case infection should occur it should be recognized early 
and free drainage established. 

Contusion with open wounds should be carefully cleansed by first 
packing sterile or mildly antiseptic gauze into the wound, shaving the 
surrounding area and disinfecting in the usual way. Dry shaving, 
followed by the application of tincture of iodin, is the usual emergency 
preparation. Benzine may be used instead of iodin, or one part of 
iodin in 1000 parts of benzine may be used, especially if grease is 
present in the wound. Benzine is inflammable, and is furthermore very 
irritating to the skin if allowed to lake or collect in creases or pockets, 
hence it must be handled with great care. Then the wound should be 
cleansed with a mild antiseptic, preferably a 1 per cent, or 3^ per cent, 
iodin solution; all dirt and cinders ground into the tissues should be 
removed with scissors and forceps. If the edges of the flaps are badly 
contused or very dirty on the raw edge they sjiould be trimmed off. 
The skull should be carefully inspected. If no fracture is present the 
wound should be closed, leaving plenty of room for free drainage. 
The galea, if cut or torn, as it usually is in a flap wound, should be 
included in the suture. Where the wound is large it is preferable to 
shave the entire scalp. This is the best course to follow, too, if the scalp 
is very dirty. No scalp wound should be explored until every detail of 
surgical cleanliness has been carried out. 

Reasonably clean incised wounds are to be cleansed the same as the 
above, except that it is not necessary, in the smaller wounds, to shave 
the skin over such a wide area, not at all in some cases. The wound in 
many cases can be sutured without drainage. If the aponeurosis has 
been divided, as is evidenced by the gaping of the wound, drainage 
should be provided. Stitches through the galea should be removed in 
forty-eight hours (Gushing). It is well to paint the suture lines with 
3J per cent, iodin solution before applying the dressing. In case a 
moderate-sized flap is entirely cut away an attempt should be made to 
suture it in place. I recently had an interesting case of a young woman 
whose head had been forced through the glass wind-shield of an auto- 
mobile. The glass shaved a thick Thiersch graft, f by 4 inches, from 
her forehead. At one end of the graft was the long hair of the scalp, at 
the other the hair of the eyebrow. The graft, which I discovered in the 
matted hair at the back of the head, was cleansed in sterile water and 
replaced on the wound which had been cleansed with a weak lysol 
solution. A light dry compression dressing, fixed with adhesive plaster, 
resulted in a perfect healing, without loss of the hair on the graft. The 
dressing was not disturbed for ten days. 

Punctured Wounds. Punctured wounds, if deep, should be laid 
open freely enough for disinfection, hemostasis and drainage. Pockets 
should be cared for by a counter drain if necessary. If not deep, and if 
the wound of entrance is small and caused by a reasonably clean object 
swab the wound with 3J per cent, iodin solution and dress without 
suture or drain. 



INJURIES OF THE COVERING OF THE SKULL 269 

Every case of marked contusion should be carefully watched for 
intracranial complications and every scalp wound for infection. Deep 
stitches should be removed in forty-eight hours, superficial ones in five 
days at the latest. 

The prophylactic administration of 1500 units of antitetanic serum 
may be called for on the same grounds as in other soiled wounds, 
especially of the punctured variety. 

Complications. The chief complication, barring skull and intra- 
cranial injuries, that may arise is infection. If this is circumscribed, 
whether superficial or deep, removal of a sufficient number of stitches 
to allow very free drainage from the bottom of the wound, followed by 
the local application of tincture of iodin, is usually sufficient. Wet 
boric acid dressings are indicated in the more serious cases. 




FIG. 51. Lacerated wound of the scalp, with subaponeurotic cellulitis; the result of 
sealing the wound with a cotton and collodion dressing. Forty-eight hours after injury 
the cellular infiltrate had gravitated into the temporal region where it was arrested by 
the attachment of the temporal fascia to the zygoma. Episcopal Hospital. (Ashhurst.) 

If the infection takes the form of a diffuse cellulitis under the aponeu- 
rosis we will have the constitutional symptoms of sepsis plus a diffuse 
swelling and edema of the scalp. In a case of this kind the entire head 
should be shaved, the stitches removed, the wound opened and counter- 
drains placed in the lowermost portions of the subaponeurotic area 
around the head. Wet boric acid dressings are of service here. All 
infected wounds must heal by granulation, but skin grafting in suitable 
cases with loss of tissue will hasten the recovery. Extension of the 
infection to the bones and intracranial regions will be considered under 
their proper headings! 

When any scalp wound becomes even mildly infected the possi- 
bilities of the spread of the infection to the skull or intracranial struc- 
tures is so great that it is not wise to offer a favorable prognosis. To 
emphasize this point I will cite the following case: A laborer in a 



270 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

factory was hit on the head with a belt which had slipped off its wheel. 
There resulted a small wound over the left parietal region which did 
not open the subaponeurotic space, nor were there apparently any 
evidences of other deeper injuries. A fellow-laborer washed and dressed 
the wound and the patient continued with his work. When he con- 
sulted his physician a week later because of headache, there was found 
a healthy looking granulating wound, though the patient stated that 
there had been "some matter" in the wound a few days previously. 
He grew slowly but progressively worse, with all the classical signs of 
increasing intracranial tension, plus right-sided convulsions. Oper- 
ation disclosed an intact skull and dura, but a superficial brain abscess. 




FIG. 52. Lines for incisions for subaponeurotic suppuration. 

Subpericranial suppuration, like cephalhematoma, is limited, at least 
for some time, by the boundaries of a single bone. This infection may 
arise secondarily to an osteomyelitis caused by an air sinus infection, 
or it may develop in a hematoma as the result of operative interference 
or through hematogenous infection. The diagnosis is to be based 
upon the history of sinus disease, such as mastoiditis, with the subse- 
quent appearance of a deep fluctuating swelling located over the bone 
involved. Other cases may give the history of cephalhematoma, with 
or without operative interference. All of the cases are progressive and 
are accompanied by the constitutional symptoms of sepsis. The treat- 
ment consists of free drainage, and careful watching for complications. 

Avulsion of the Scalp. The entire scalp may be torn completely 
from the head, or it may retain attachment by more or less of a pedicle. 
In the latter case the scalp should be sutured in its proper position, with 



INJURIES OF THE COVERING OF THE SKULL 271 

provision for free drainage. Davis, 1 reviewing the literature up to 191 1 , 
reports 92 cases of complete and 30 of incomplete scalping. Of the 
former the scalp was replaced 21 times,, but that of Malherbe 2 is the 
only one which has resulted in even partial success and even this is 
doubtful, as Lejars in Urgent Surgery, vol. 1, 1910, p. 87, speaking of 
the case says: "The scalp died, but turned into a parchment-like 
covering which remained adherent to the cranium, and under which 
healing took place without complications. In such a case the reappli- 
cation is practically only a dressing with the skin." Both clinical and 
experimental evidence shows that it is useless to replace the scalp in 
toto and expect it to heal, but strips of the scalp may be successfully 
applied to the periosteum along the wound edges, as immediate, whole- 
thickness grafts. 

Perimoff 3 cites a successful case of free transplant of a flap of hairy 
scalp from the head of a Tartar to the head of a Russian officer, who had 
a disfiguring scar on the temporal region. The transplant not only 
lived, but the hair did not fall out afterward. He attributed Lauen- 
stein's failure in a similar case to the use of iodobenzine. Perimoff used 
only soap and water as cleansing agents. 

In complete avulsion early skin grafting by the Thiersch method 
should be performed. Gushing believes that extensive wounds healing 
by granulation may lead to delicate scars and possibly epithelioma. 

Charles H. Mayo 4 describes a practical method of "hastening the 
healing of denuded surfaces of bone." He drills holes about one fourth 
inch apart through the outer table of the skull into the vascular diploe. 
"Through these perforations granulations are rapidly thrown out and 
soon merge together on the surface, allowing an abundant blood supply 
for the skin grafts." 

Grafts of skin from the patient give better results than those taken 
from other individuals. In the latter case they tend to disappear, even 
though they may "take" in the early stages. 

Gunshot Wounds. As gunshot wounds of the scalp are usually 
only minor features of serious head injuries the treatment is usually 
given under the head of skull injuries. In case a spent ball becomes 
lodged under the scalp without injury to the bone it Is good surgery to 
remove it, as this can be safely done, and thus avoid any irritation and 
secondary infection. Small shot, from a shotgun, need not be removed 
if they have entered as a scattering shot from a distance. These shot 
wounds are to be regarded as clean wounds. Merely painting the 
wound of entrance with tincture of iodin is all that is necessary. 

Cases have been mentioned in the literature of bullets traversing the 
subaponeurotic area nearly half way around the head without entering 
the skull. I once saw a case in which a similar thing happened about 
the chest. In a shot wound of this sort the absence of the usual brain* 
symptoms would be a striking feature, and in all probability the track 

1 Johns Hopkins Hosp. Rep., 1911, xvi, 257. 

2 Bull. med., 1898, No. 97, p. 1121. Zentralbl. f. Chir., 1913, p. 1443. 
4 Ann. Surg., September, 1914, p. 371. 



272 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

of the bullet would manifest itself a day or two later by a streak of 
discoloration and tenderness. A skiagraph would show no bullet hole 
in the skull. 

That an absence of brain symptoms does not always exclude pene- 
tration of the skull is evidenced by a case of mine hi which a 22 caliber 
bullet entered through the eyebrow. A drop of blood at the latter 
site was wiped away and the incident forgotten, as neither the patient 
(a boy of twelve) nor his friends knew he was shot. He remained in 
a normal condition until three weeks later when symptoms of a severe 
meningo-encephalitis suddenly developed, resulting in death two days 
later. At the autopsy the bullet was found in the right lateral ventricle. 

Powder stains on those portions of the scalp not covered by hair are 
usually so disfiguring as to demand treatment. In recent cases the 
little grains of powder may be picked out with a needle or sharp- 
pointed knife, or they may be treated by the hydrogen-dioxide method. 
Crile, 1 Rhoads 2 and Clark 3 report satisfactory and rapid results. The 
site of the stain should be kept moist, preferabty by wet dressings of 
the hydrogen dioxide, unless the latter is too irritating. Crile states 
that after a white zone has appeared around and under the grains the 
latter can be easily picked out with a pointed instrument. Clark 
applied a wet dressing of one part of glycerin and three parts of hydro- 
gen peroxide, if not too irritating, and the stains disappeared. 

Stelwagon 4 speaks very highly of the method of removal of the grains 
by a cutaneous trephine of small caliber, as originally suggested by 
Watson. 5 The small punch is pressed firmly, but not too deeply over 
the speck, using a rotary motion. The little disk of skin which pro- 
trudes through the opening is snipped off, and the cavity filled with 
powdered subsulphate of iron or with a paste of the tincture of benzoin 
and boric acid, or with the compound powder of boric acid or ace- 
tanilid. He also mentions the method of tattooing in glycerol of appoid 
or caroid. Brault tattoos the stained area with a needle and solution of 
30 parts of zinc chloride to 40 parts of water, then paints this area 
lightly with the same solution after tattooing. This method may pro- 
duce a deep eschar if not skilfully carried out. 

Many authors advise the use of the electrolytic needle. If the grains 
are thickly set the superficial layer of the skin may be shaved off and 
skin grafts applied. 

DISEASES OF THE SOFT COVERINGS OF THE SKULL. 

Erysipelas. Erysipelas, though it occurs oftenest about the head, 
is not common as a primary scalp infection. When it involves the scalp 
by migration from the face the diagnosis is easy, but when it starts 
in the hairy scalp the condition may be unrecognized until it reaches 

1 Cleveland Med. Gaz., 1896-1897, xii, 183. 2 Am. Med., 1901, i, 16. 

3 Ibid., 1901, p. 384. 

4 Treatise on Diseases of the Skin, 7th ed., Philadelphia, 1914. 
6 Med. Rec., 1878, xiv, 78. 



DISEASES OF THE SOFT COVERINGS OF THE SKULL 273 

the free surface outside of the hair line, where it takes on all the local 
characteristics of the disease. This is because of the fact that in ery- 
sipelas of the hairy scalp there is no marked redness or elevation of the 
skin and hence no sharp cut line of demarcation. There is, however, 
some edema and tenderness on pressure over the involved area, and 
enlargement and tenderness of the nearest lymphatic glands. Always 
however, there are the usual constitutional symptoms which accompany 
erysipelas, viz.; a sudden rise of temperature, often to 103 to 104, 
initiated in most cases by a chill. Headache, vomiting and a rapid 
pulse are common. The scalp cases often have a stormy course from 
the beginning, with delirium and even unconsciousness as prominent 
symptoms. The disease is usually of the nine-day type. These cases 
sometimes arise after the drainage of deep abscesses, as in cases of 
mastoiditis. For this reason some have advised that the opening of 
these abscesses be made with a cautery for the sake of sealing up the 
lymphatics. This latter treatment, however, does not seem indicated, 
and is seldom used. 

Prognosis. The prognosis is not bad if the patient is a healthy adult. 
Complications, such as phlegmon or intracranial infection, are rare 
except in infants or debilitated people, or where there has been deep 
contusion with hematomata or fracture or in cases of meddlesome 
treatment. The prognosis is bad in alcoholics. 

Treatment. Nutritious liquid diet, good elimination of the toxins 
through the use of laxatives and the free administration of water by 
mouth or proctoclysis, combined with the local use of mildly anti- 
septic cooling lotions, such as equal parts of alcohol and saturated boric 
acid solutions, are all that have as yet proved of value in the line of 
treatment. While the mild lotions may relieve pain they sometimes 
cause eczema and so may occasionally do harm. Antiseptic ointments 
may be necessary to relieve intense itching. The solution of equal 
parts of alcohol and saturated aqueous solution of boric acid is used as 
a wet dressing, being covered with gutta-percha tissue. If the face 
also is involved the dressings are cut in the form of a mask. Sera have 
thus far not proved efficient. Scarification and circumscribing incisions 
are to be reckoned as meddlesome. Clipping of the hair will permit 
more efficient cleansing of the scalp. An ice-cap may control the 
delirium. Abscesses are to be drained, and a failing heart is to be 
stimulated. 

Carbuncle. Local suppurations, such as pustules, boils or carbuncles 
of the hairy scalp are uncommon, except at the hair line in the occipital 
region. The carbuncle usually starts on the back of the neck and invades 
the hairy scalp secondarily, though I had one case starting in the hairy 
scalp just above the base of the mastoid process. The carbuncle begins 
like a boil on the surface of the skin, but soon spreads into the deeper 
tissues, usually to the fascia covering the muscles, giving rise to a firm, 
brawny induration rising up somewhat like a truncated cone. It is 
painful and tender, and the skin soon undergoes the characteristic 
color changes of inflammation from a red to a reddish purple. In this 

VOL. I 18 



274 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

dense mass of subcutaneous necrosis are multiple small pockets of 
pus which break through the discolored surface at numerous points, 
giving rise to the so-called pepper-box openings. In spite of these spon- 
taneous openings the process tends to spread progressively and in some 
cases may become as large as a small dinner plate. The temperature 
may not be marked. 

Prognosis. While the prognosis is good in healthy young adults, it 
is bad in the aged, the debilitated, and in those suffering from diabetes, 
in whom it is so common. In any case the prognosis is distinctly more 
favorable if the condition is recognized early and the focus promptly 
excised. Simple incisions are not very satisfactory, and curettement 
is dangerous, because it may disseminate the infection. 

Operation.- The operation which is probably as satisfactory as any 
other is one in which two skin flaps are raised, through an H-shaped 
incision. After the excision of the necrotic mass and painting the deep 
wound with tincture of iodin the flaps are suiured, but free drainage 
instituted. The operation should be done under gas and oxygen 
anesthesia. 

Syphilis of the Scalp. Syphilis of the scalp is of interest to the surgeon 
in its tertiary stage only. It offers little difficulty as a rule in diagnosis, 
especially when accompanied, as it usually is, by other manifestations 
of the disease. Even if a gumma exists as a solitary lesion it possesses 
characteristics which stamp it as luetic. On the scalp the favorite 
seat is the forehead, occasionally the parietal region. It may start as 
small, flat, reddish-brown nodules in the skin or as a subcutaneous 
node. In the former case they are multiple, are usually arranged in 
groups and tend to ulcerate in the center while they proliferate at the 
periphery of the group. The ulceration is in turn usually followed by 
healing. The solitary subcutaneous nodule develops as a slow inflam- 
matory process which may become arrested and absorbed, or which 
may break down and ulcerate. The skin, which is at first movable over 
the nodule, later becomes fixed, discolored, and breaks down. Their 
favorite seat is on the brow, back of the neck, back or shin. 

The characteristics of the syphilitic ulceration are the sharply 
punched-out appearance of the edges, the dirty sloughing grayish base, 
and the tendency to heal with the formation of radiating scars. Where 
there are multiple coalescing skin lesions the general shape of the ulcer 
is spoken of as serpiginous. In the latter case the most of the forehead 
and parietal regions may be covered with these irregular ulcers and 
scars. When the solitary ulcer heals it usually leaves a round depressed 
scar. 

Diagnosis. The diagnosis in most cases can be made upon the 
appearance of the local lesion. However, concomitant lesions in other 
parts of the body and the presence of a positive Wassermann reaction, 
or the finding of the spirochetes, clinches the diagnosis. The history 
of the primary and secondary manifestations, when it can be obtained, 
also has much weight. The spirochetes are only occasionally found in 
tertiary lesions. They seem to be very few in number and are found only 



DISEASES OF THE SOFT COVERINGS OF THE SKULL 275 




FIG. 53. Syphilis of the scalp. (Hertzler.) 




FIG. 54. Syphilis. Nodular gummatous type. (Knowles.) 



276 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

after diligent search. That they are sometimes present in even late 
tertiaries is evidenced by.the occasional, but unquestioned, infectivity 
of these lesions in man and, experimentally, in monkeys. 

In the differential diagnosis we must exclude lupus, sarcoma and 
carcinoma. Lupus occurs most frequently upon the face, near the nose, 
rarely upon the forehead. It is of slower growth, has not the serpig- 
inous outlines, and has the pale flabby granulations so characteristic 
of tuberculosis. The edges of the ulcer are irregular, flat and under- 
mined. In the vast majority of cases the nearest lymph glands are 
involved, as are also other tissues and organs in the body. Most cases 
will give a positive tuberculin reaction. Sarcoma, like gumma, may 




FIG. 55. Destruction from syphilitic gumma. (Knowles.) 

spring as a solitary nodule from the pericranium or subcutaneous tissue. 
Like gumma it may be bluish-red and softened in the center as it reaches 
the skin, but it does not present the bogginess so often seen in gumma, 
as for some time it is more or less encapsulated, due to its growing by 
expansion into the surrounding tissues rather than as an inflammatory 
infiltration. When a sarcoma leads to necrosis of the skin the resulting 
ulcer presents more of a hemorrhagic or yellow gelatinous degeneration, 
whereas a gumma, on opening, reveals a sticky, gummy, cheese-like mass 
in the center. Sarcoma is of more rapid growth than gumma. Further- 
more, those not of bony origin usually arise in the skin rather than in 
the subcutaneous structures and belong to the class known as melano- 
sarcoma. This is the most frequent variety found in the skin, and it 



DISEASES OF THE SOFT COVERINGS OF THE SKULL 277 

starts as a rule from a pigmented mole or nevus. It is exceedingly 
malignant and grows rapidly. Carcinoma may appear as a deep growth 
but is then secondary. The superficial epithelioma is ordinarily easily 
recognized by its irregular, indurated, elevated margins and a base 
which bleeds on the slightest irritation. It almost always has its 
starting point in a wart, an old scar, or in the edge of an old unhealed 
lupus. The glands are involved late. It is seen mostly on the brow or 
temporal region below the hair line. 

Non-neoplastic Swellings. Swellings containing air may occur as 
solitary air chambers beneath the pericranium or as an emphysema. 
The former condition is known as pneumatocele capitis and arises from 
an open communication between the subpericranial area and the out- 
side air through some air-containing cavity like a sinus (frontal or 
mastoid). It may be bilateral in the frontal and occipital regions. The 
communication may be congenital, or it may be acquired through 
injury (fracture), or disease resulting in erosion of the bone. 




FIG. 56. Pneumatocele of cranium. 

Diagnosis. The diagnosis is to be based upon the presence of a 
swelling overlying the bone containing the sinus involved, the swel- 
ling presenting the following characteristics: It is non-inflammatory 
and painless; is tympanitic on percussion; reducible on pressure and 
refills promptly on forced expiratory efforts, sneezing, coughing, etc. 
In addition there is usually the history of injury or disease involving 
the sinus. The bone itself may feel rough at the periphery of the 
swelling, owing to the mild bone-forming powers of the pericranium. 

Emphysema presents itself as a more or less diffuse flat swelling which 
occurs right after a fracture involving one of the air-containing sinuses. 
It may involve the subaponeurotic or subcutaneous area and sometimes 
increases in area on forced expiratory efforts. Pressure on the swelling 
elicits a characteristic dry crackling under the skin. 

In the differential diagnosis of pneumatocele it may be said that the 
location and time of appearance would exclude meningocele, the latter 



278 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

being congenital and mesially located. As the air sinuses do not develop 
until puberty, pneumatocele would be rare before that time. Because 
of the not infrequent occurrence of tuberculosis of the mastoid it may be 
necessary to exclude cold abscess underneath the pericranium. In this 
case the swelling, while fluctuating, would not be reducible on pressure 
and would be dull on percussion. The abscess tends to work its way 
to the surface. The history of the disease and the presence of enlarge- 
ment of the nearest lymph glands would also point to cold abscess. 
Cephalhematoma (blood under the pericranium) is most frequently 
found over the parietal bone the second day after birth, but may occur 
at any age, after injury, and in the same location where pneumatoceles 
occur. The swelling, however, is not reducible, and is dull on percus- 
sion. Ecchymosis will probably be present after the lapse of a few days. 
As in air tumor, there is apt to be a ridge of bone at the periphery if it 
lasts more than two weeks. The exploring needle would settle the 
diagnosis. ^ 

A pericranial sinus, though infrequent, should be thought of. It 
consists of a "blood cyst" of traumatic origin, situated between the 
pericranium and the bone. The reported cases have been found over 
the brow or on top of the head near the median line, and none has been 
larger than a walnut. As they contain circulating blood and communi- 
cate with the superior longitudinal sinus it is evident that they are 
reducible on pressure, and develop tension on forced expiratory efforts 
or when in a dependent position. They are dull on percussion. A small 
exploring needle would settle the diagnosis. 

Treatment. The treatment of pneumatocele that offers the most 
certain results is the Konig-Miiller osteoplastic operation, though in a 
number of cases other methods, such as incision and packing, with 
compression, freshening the edges of the fracture, etc., have been 
successful. Puncture with the needle, or simple compression, iodin 
injection, etc., are not favorably considered. One would naturally 
suppose that in the case of the mastoid a puncture of the ear drum, or a 
drainage operation in case of the frontal sinus, would effect a cure by 
preventing air tension. Infection calls for drainage. 

Emphysema arising from an air-containing sinus calls for no treat- 
ment. 

The treatment of the pericranial sinuses, like that of spurious 
meningoceles, is to let them alone, unless the underlying cause can be 
relieved. Harvey Gushing described two cases in connection with 
brain tumors which disappeared after decompression. 

Meningocele Spuria (Traumatica) or Cephalohydrocele Traumatica. 
This, as its name implies, is a false meningocele of traumatic origin. 
It is found only in children and, while its existence implies both sub- 
cutaneous fracture and rupture of the dura, its persistence implies 
some alteration in the secretion or absorption of the cerebrospinal 
fluid which leads to a persistent increased intracranial tension. For 
this latter reason the skull opening does not close and we have what is 
known as the chronic form. The acute varieties without persistent 



DISEASES OF THE SOFT COVERINGS OF THE SKULL 279 

increased tension may close spontaneously, or after aspiration and 
compression dressing. 

Diagnosis. The diagnosis is to be based upon the history of injury 
during birth, or later as the result of a fall or other accident, followed 
immediately by the appearance of a circumscribed fluctuating tumor 
beneath the scalp. This tumor pulsates synchronously with respiration 
and the heart beats, and possesses a tension which varies with the 
intracranial tension, i. e., it is increased when the patient cries, coughs 
or sneezes, or when the head is in a dependent position, and diminishes 
when the child is quiet or when the head is elevated. Reduction by 
pressure may lead to symptoms of acute brain compression. As the 
condition follows fracture the tumor is not usually situated in the 
median line, as is true of meningocele. The use of the exploring needle 
may be necessary to settle the early diagnosis. 







FIG. 57. Meningocele spuria traumatica 



Fig. 57 is a photograph of a two and one-Jialf year old boy who, 
eighteen months previously, fell out of an upstairs barn door, striking 
on the back of his head. There was no evidence of serious trouble until 
several days later when the meningocele was noticed. Two months 
after the accident I found a fluctuating swelling the size of a grape- 
fruit. It had all the characteristics of a meningocele. On deep pressure 
the corners of the bones at the lambda could be felt curled outward. 
The child was otherwise normal and had no signs of choked disks. 

One month later the boy fell from his little wagon, striking on 
the tumor. Violent convulsions followed for several hours. These 
gradually subsided, leaving a left-sided paralysis which has gradually 



280 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

disappeared until at the present time he is about normal, except for 
the presence of the tumor. 

No operation was performed. 

Treatment. Though various operations have been devised, surgical 
treatment is useless, for it is a fact that under normal conditions the 
fracture will heal spontaneously, while with persistent increased tension 
an opening will be maintained in spite of operation. Furthermore the 
cerebrospinal fluid is apt to find its way through the scalp wound. To 
say the least, operation will not only fail in most cases, but a distinct 
danger of leakage and infection will have been added. 

TUMORS OF THE SCALP. 

Dermoid Cysts. Dermoid cysts, being congenital, are first noticeable 
at birth or any time up to puberty, and are found at special points 
of predilection where there has been an infolding of the skin, viz., 
at the outer border of the orbit, or deep in the orbit, in the region 
of the mastoid and squamous portions of the temporal bone, and in the 
median line of the skull, especially at the root of the nose and the region 
of the fontanelles. They are deeply situated above or beneath the peri- 
cranium, often resting in a saucer-shaped depression in the bone, or 
even hanging from the bone with a connective-tissue pedicle, especially 
in the occipital region. They may even rest on the dura and thus 
pulsate with the brain. In very rare cases they may be found in the 
bone itself, especially in the mastoid. Not being attached to the skin, 
inflammation is rare. 

Differential Diagnosis. The differential diagnosis is usually not 
difficult, especially if the dermoid is found in one of its favorite locations 
In the rare cases where it is resting on the dura in the median line it 
may be mistaken for cephalocele, which occurs usually at the glabella, 
or near a fontanelle. In the latter condition the variations of intra- 
cranial tension produce corresponding variations in the tension of the 
tumor. Furthermore, cephalocele is more or less reducible. The very 
rare cases of serous cysts found deep in the midline are probably brain 
cysts isolated from the intracranial space during closure of the sutures. 
Sebaceous cyst is attached to the skin, is entirely above the galea, occurs 
later in life, and is seldom found in any of the favorite seats of dermoid 
cysts. 

Treatment. The treatment consists in early excision, care being 
taken to avoid injury of the dura in the cases resting on the latter. 

Sebaceous Cysts. Sebaceous cysts commonly known as atheromat- 
om cysts, or wens, offer no difficulties in diagnosis. They are oval 
tumors situated partly in the skin and partly in the subcutaneous 
tissues, varying in size from a pea to a walnut. Occasionally they may 
be much larger. The small ones are hard, the larger ones soft. As the 
tumor grows the overlying skin becomes tense, thinned and devoid of 
hair. The skin at the summit is adherent and dotted with comedones. 
They occur mostly in adult life and are rare before puberty. They are 



TUMORS OF THE SCALP 



281 



often multiple in advanced life. They grow slowly and are painless 
unless inflamed. In very rare cases they have produced sufficient 
pressure to cause atrophy of the underlying bone. They may be 
pedunculated in the occipital region. 

Treatment. The treatment is excision under local anesthesia, the 
essential feature being the complete removal of the sac. The latter may 
be difficult in case a friable, thin-walled cyst should rupture during 
the operation, especially as the surrounding tissues are very vascular and 
bleed freely. An elliptical incision which allows the adherent skin to 
be removed with the sac facilitates removal without rupture of the sac. 




FIG. 58. Wens. 



Many years' duration; movable, non-sensitive, hard. 
(Martin.) 



Adenoma. Adenoma of the skin is a very rare tumor. It may 
arise from a sebaceous or sweat gland and may appear in the form of a 
warty growth or a subcutaneous tumor. In the case of the adenoma 
sebaceum one can often see the openings of the sebaceous glands. 
Some of the glands may develop into sebaceous cysts. 

Cutaneous Warts and Horns. Cutaneous warts and horns which 
occur in the hairy scalp are readily recognized. As they are not infre- 
quently the starting-point of malignant growths the treatment should be 
complete removal, the incision being deep enough to prevent recurrence. 

Hard Fibroma. Hard fibroma is a very rare tumor of the scalp. 
The case reported by Gushing from Halsted's clinic was a slow-growing 



282 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

hard tumor attached to the movable scalp. It had a mushroom shape 
and was covered with a thin epithelium devoid of hair. The soft 
fibromata found on the scalp are part of a generalized fibromatosis 
(Fibroma molluscum) and are easily recognized. The treatment is 
excision, chiefly for cosmetic reasons. 

Keloids. Keloids are quite common in the scalp and offer no diffi- 
culty in diagnosis. They are found chiefly in the negro race. Their 
starting-point is in the superficial scar of a wound or healed infection, 
and as they involve only the reticular layers of the cutis, they are mov- 
able with the skin. Their general appearance is that of a red, shining, 
hypertrophied scar, covered with epidermis, but free from hair. At 
times they take on the form of nodular new growths of considerable 
size. 

Differential Diagnosis. Hypertrophied scars rarely attain much size, 
and after a time tend to disappear spontaneously. They are seen 
chiefly in those with a personal or family history of tuberculosis. 

Treatment. As keloids usually recur after retnoval, operation is not 
indicated, especially while the growth is enlarging. As to remedies 
warranting some consideration the following may be mentioned: 
Thyroid extract, usually in conjunction with x-ray; thiosinamin or 
fibrolysin injected into the keloid. Static electricity in the form of 
sparks is also well spoken of by some observers. The x-ray is probably 
the best form of treatment. Ochsner states that he has had many 
keloids disappear and remain permanently well after intensive x-ray 
treatment. He gives a vigorous treatment daily for six days; then 
repeats this procedure in one month. 

Frank E. Simpson 1 describes the efficiency of radium rays in the treat- 
ment of keloids. Some experience is necessary in order that one may 
estimate the amount of raying necessary. The apparatus and technic 
employed vary somewhat with the type of lesion. "In practice the 
theoretic use of purely selective doses, which may cause the keloid to 
disappear, must often give way to the more rapid method of destructive 
doses. The general principle of using a sufficient dose to produce a 
slight but not an excessive reaction is the one I usually follow." He 
states that "In upward of a dozen keloids of various types which I 
have treated with radium, the results have been superior to those 
obtained by other methods." 

Lipoma. Lipoma is rare in the scalp When present it is most 
frequently found on the forehead, under the occipitofrontalis muscle 
or under the fascia of the temporal muscle. Being situated deeply it 
loses the characteristic lobulation of the subcutaneous variety, and 
there is of course no dimpling of the skin. It is immobile because it is 
usually attached to the pericranium. It is slow-growing and sessile, 
though the pedunculated variety has been seen. 

Differential Diagnosis. The favorite locations for dermoids are seldom 
the seat of lipoma. Dermoid is noticeable at birth or up to puberty, 

1 Jour. Am. Med. Assn., April 17, 1915, pp. 1300 and 1301. 



TUMORS OF THE SCALP 283 

lipoma usually later. Cold abscess gives a history of preceding tuber- 
culosis of a bony sinus (frontal or mastoid), and tends to perforate 
the skin. The course is not so chronic. While cephalocele is congenital 
and occurs in the median line, and presents all the characteristics 
mentioned under the diagnosis of this condition, still it must not be 
forgotten that lipoma sometimes overlies it. 

Diseases of the Nerves of the Scalp. Neurofibroma, Elephantiasis 
Nervorum, Plexiform Neuroma, von Recklinghausen's Disease. This 
is a rare disease of early life, involving the scalp nerves, and character- 
ized by a fibrous thickening of the peri- and endoneural connective 
tissue. It is situated entirely within the movable scalp and starts by 
predilection in the frontotemporal region, often from a wart or mole, 
and frequently after injury, and spreads out over the side of the head. 
In a well-developed case the side of the patient's head looks like a land- 
slide, dragging the ear and outer angle of the eye with it. The scalp 
may sag even to the shoulder as a pendulous mass. The skin presents 
the usual appearances of elephantiasis, thick, rough, ridgy and some- 
times fissured or ulcerated. There is no pain unless the case is compli- 
cated by secondary changes. 

Diagnosis* The only condition to be considered at all in differential 
diagnosis is multiple fibrosarcomatosis of the peripheral nervous system. 

Treatment. Operation is performed for cosmetic reasons and because 
of the possibility of the development of sarcoma. The dangers of the 
operation are hemorrhage and infection, for evident reasons. Because 
it is a superficial affection it is not necessary to go below the subcutan- 
eous tissue. 

The hyperesthesias, neuralgias and herpes zoster are considered in 
another chapter. 

Bloodvessels. Conditions Due to Injury. Blood cyst or sinus 
pericranii has already been described as often being due to a torn 
emissary vein near the median line of the skull. It contains circulating 
blood and communicates with the superior longitudinal sinus. 

Traumatic Aneurysm. Traumatic aneurysm, usually of the tem- 
poral artery because of its exposed situation, is easily recognized by the 
classical signs of such condition. Here we have a tumor appearing 
suddenly at the site of an injury, the tumor possessing an expansile 
pulsation, a thrill and a bruit synchronous with the heart beat. Pressure 
over the vessel on the proximal side of the tumor stops these symptoms 
and leads to a diminution in the size and tension of the tumor. Pres- 
sure on the distal side leads to increase in the size and tension of the 
tumor. 

Treatment. The treatment is proximal and distal ligation and extir- 
pation. 

Arteriovenous Aneurysm. Arteriovenous aneurysm has the same 
history as traumatic aneurysm. The pulsating tumor possesses a thrill 
and bruit, exaggerated during systole. In addition, the anstomosing 
venous trunk and its immediate tributaries are markedly dilated, and 
pulsate with the artery, owing to a reversal of their stream. 



284 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

Aneurysmal Varix. Aneurysmal varix is the same as the above 
except that there is no sac or tumor. It is sometimes quite difficult 
to differentiate clinically the arteries from the veins, and occasionally 
it may be difficult to differentiate this condition from a racemose 
aneurysm. 

Fig. 59 is a photograph of a case of aneurysmal varix due to a shot 
wound sustained fifteen years previously. The patient, in getting out of 
a boat, drew the gun, muzzle first, out after him, with the result that 
the gun was discharged, many duck shot being deeply embedded in 
the side of his face. The buzzing tumor was noticed immediately 
afterward. Though the venous enlargement was progressing very 
slowly an operation was demanded to relieve the buzzing. During 
the operation for ligation of the external carotid between the superior 




FIG. 59. Aneurysmal varix. 

thyroid and lingual arteries the veins in the neighborhood were found 
to be very much dilated. The facial was the size of my little finger, 
while the temporal was half again as large. The ligation stopped the 
buzzing completely. Excision was impossible as the anastomosis 
evidently occurred in the external carotid near its bifurcation in the 
parotid gland. 

Treatment. The treatment for these cases is extirpation or exclusion, 
if possible, of both arterial and venous trunks near the sac or anas- 
tomosis. This may be difficult owing to the distended thickened veins 
in the dense tissues of the scalp. Gushing advises the plan which 
Krause and Korte practice in cases of cirsoid aneurysm, viz., lifting a 
skin flap through a crescentic incision, and dissecting the vessels from 
underneath. The incision is to extend down to the galea. 



TUMORS OF THE SCALP 



285 



Cirsoid Aneurysm, Aneurysm by Anastomosis, Plexiform Angioma, 
Rankenangiom, Angioma Arteriale Racemosum. Of all the terms 
applied to this rare condition, the last one is the most descriptive, for 
it is really more of an arterial angioma than an aneurysm. It consists 
of a tumor-like aggregation of dilated, elongated and tortuous arteries, 
involving primarily some definite "arterial tree." This dilatation 
implicates even the fine capillaries and sometimes also the veins. It 
seems to progressively invade the apparently normal vessels at the 
periphery until at times even the entire scalp and face may be involved. 
The cause of this condition is not known, but the starting point is often 
a simple angioma or vascular scar. Trauma is sometimes a factor. 
It usually starts in the region of the temple or ear, though it may be 
found in any portion of the scalp or in other parts of the body. 




FIG. 60. Cirsoid aneurysm of the scalp. (Hertzler.) 



The tumor is rather flat and presents an irregularly undulating sur- 
face, only slightly raised above the surrounding surface. Through the 
thin overlying skin can usually be seen a bluish tint and the pulsating 
vessels. On picking up the skin and vessels between the fingers the 
plexus of pulsating arteries and veins feels like a bunch of earth worms. 
A distinct systolic thrill and bruit are present and they cannot be 
obliterated by pressure. Subjective symptoms of noises in the head, 
dizziness and faintness are common. There is always danger of fatal 
hemorrhage. 



286 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

Differential Diagnosis. Differential diagnosis may possibly call for 
consideration of arteriovenous aneurysm or aneurysmal varix. 

Treatment. The treatment consists in extirpation if possible. This 
should be attempted, if the risk is not too great, because of the danger 
of hemorrhage in the non-operated cases. When one stops to consider 
that sometimes the vessel changes extend through deep communicating 
vessels to the subaponeurotic area or even to the intracranial region, 
the possible difficulties are manifest. The most successful of the radical 
procedures is that consisting of the raising of a flap of scalp and vessels 
with dissection of the vessels from the undersurface of the flap. This 
is facilitated by first ligating the external carotid or, in suitable cases, 
by the application of a rubber constrictor about the head just above the 
ears. The next best treatment so far has been the multiple ligations 
at the borders at different sittings. Simple ligations of the main affer- 
ent trunks are of no service, while injections, cauterization, etc., carry 
with them real dangers rather than benefits. 

Wyeth reports a case involving one-half of the scalp cured by the 
injection of boiling water. Under ether he injected the water along the 
course of the chief arteries leading to the tumor, then through the tumor 
from side to side in various directions until pulsation ceased. The case 
remained well. The following is quoted from Wyeth's article: "The 
needle was entered along the course of the arteries leading injto the 
tumor, beginning about two inches from the mass, a quantity of boiling 
water sufficient to coagulate tjiese vessels being employed. It was then 
introduced through the tumor from side to side, injecting about a dram, 
withdrawing the needle for one-half of an inch and then repeating this 
procedure until the entire mass had ceased to pulsate. The quantity of 
boiling water so used was between five and six ounces. Temperature 
on the surface was noticed by touch, and when the heat became very 
perceptible to the hand and the skin began to bleach, the injections in 
that particular area were discontinued. The warty growths noticed on 
the surface of the scalp were touched with the Paquelin cautery. No 
reaction followed the operation. The patient complained of no pain, 
but there was a very considerable edema of the scalp, and this, begin- 
ning on the left (the side of operation), closed the left eye and spread 
over the face, closing the right eye within forty-eight hours. The 
swelling spread as far down as the neck and was so great that had I 
cause to repeat a similar operation I would use only about one-half 
the quantity of water, and would then repeat the operation after an 
interval of about a week." 

Neoplastic Vessel Tumors. Vascular Nevi. These are either con- 
genital or develop soon after birth, and are found in the vast majority 
of cases about the head. It is the prognosis and treatment, rather than 
the diagnosis, that is of the greatest interest to the surgeon, for the 
diagnosis is easy except in those deep cases occurring primarily in the 
bone or its covering. 

Angiomas. Some of the simple angiomas, or port-wine stains, dis- 
appear spontaneously. This is noticeable chiefly in the flat variety, 



PLATE I 




Multiple Nevi, Affecting Scalp, Forehead, Left Foot, etc., in a 
Baby Aged two and one-half Months. Episcopal Hospital. 
(Ashhurst.) 



TUMORS OF THE SCALP 287 

those producing no elevation or deformity of the skin surface, and 
particularly those of this type which occur on the brow. On the other 
hand those producing more or less elevation and irregularity of the skin 
surface, especially if they have a distinct arterial or gross venous char- 
acter, tend to either remain as they are, or more often to grow progres- 
sively worse. 

A simple port-wine stain may develop into a cavernous angioma or 
into a racemose angioma. 

The cavernous angioma differs from the simple variety in that it 
consists of larger veins, and is situated chiefly in the subcutaneous 
rather than in the cutaneous area. It always appears more like a 
tumor and does not tend to disappear spontaneously, but rather tends 
to increase in size, at times invading adjoining muscles, bones, etc. 
These angiomata are to be recognized by the bluish appearance of 
the veins, visible through the irregularly elevated skin surface, their 
peculiar spongy compressibility, and the variations in size and tension 
corresponding with the variations in intravenous pressure. Because of 
their peculiar bluish tint they have occasionally been mistaken for thin- 
walled cysts. With care this error should not occur. A cavernous or 
telangiectatic lipoma may offer serious difficulty in diagnosis, but this 
is an exceedingly rare condition. Under these circumstances it would 
be impossible to reduce by pressure the size of the tumor to the same 
extent as in the uncomplicated angioma. Blood cysts due to complete 
isolation of certain sections or spaces from the rest of the angioma are 
very rarely found in cases of cavernous angioma. 

Treatment. Early excision for all kinds of small angiomata is 
unquestionably the best treatment. The incision should be made 
outside of rather than through the tumor. It is particularly important 
to excise the cavernous varieties early as they constitute the most for- 
midable and aggressive group, often becoming inoperable. Those 
cases having a distinctly cavernous character and which are too exten- 
sive for operation, or which are so situated that operation would give 
a poor cosmetic result, should be treated by the injection of boiling 
water into the tumor as recommended and practiced by John A. 
Wyeth. His method of treatment of the cavernous angioma is the 
same as described under cirsoid aneurysm, except that he advises 
peripheral compression "to preclude as far as possible the danger of 
embolism." 

Another method for the cavernous angioma, probably not so good, is 
the multiple puncture with the cautery needle at numerous sittings. 
Cures have been reported following multiple partial excisions at 
different sittings. 

The following description of Wyeth's treatment of the superficial 
capillary angioma is taken from his article referred to above : " I have 
employed this method successfully and without accident in a number 
of cases of capillary angioma, but on account of their superficial char- 
acter, they being within the substance of the integument, some cicatri- 
zation is apt to result unless very great care is taken. The weak tissues 



288 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

of the new growth do not offer the resistance of the normal skin which 
overlies the venous or arterial angiomata, and may break down under 
the hot water. In all of my cases the scarring has been very slight, and 
I think the method is well worthy of thorough trial in these cases. As 
they occur chiefly in children and are situated on the face, it is important 
to have the patient very firmly held while the injections are being made 
without narcosis. The legs, arms, body and head should be kept 
immovable, while the face should be covered by a mat in which an 
aperture is cut sufficient to expose the area to be injected. I take the 
additional precaution to have an assistant hold a sponge saturated 
with cold water immediately over the needle in order to prevent 
scalding the cuticle should the apparatus leak. The small hypodermic 
needle is used, and this should be thrust through the sound skin, 
about one-eighth of an inch from the edge of the angioma, pushed 
beneath the neoplasm, care being taken not to let the point come 
through the surface. From 5 to 15 minims of w^ter may be injected in 
one spot, changing the needle here and there to suit the size of the mass. 
When the injections are made directly into the enlarged capillaries, 
necrosis almost always occurs, but if the water is forced well beneath 
the surface, the deeper parent vessels will be coagulated, causing the 
nevus to disappear by gradual denutrition (granular metamorphosis). 
It is a wise precaution to cover the area injected at once with aseptic 
collodion to prevent infection. This operation may be repeated from 
time to time until a cure is effected." 

The simple angiomas or port-wine stains that are too large for oper- 
ative treatment may be treated with the carbon dioxide snow. W. A. 
Pusey, 1 states that " The most useful field for the agent (Solid Carbon 
Dioxid) is in the treatment of nevi, both pigmentary and vascular. 
Moles, which are small pigmented nevi, you can get rid of early by 
freezing two or three times from half a minute to a minute. With pig- 
mented nevi up to the size of a coin you can usually get practically 
perfect results. With large nevi the results are only relatively good, but 
better than by any other method. 

" In the flat nevi, port-wine marks, where there is simply a red dis- 
coloration of the skin, you cannot get as good results as in cases where 
there is an excess of tissue to work on. In these lesions up to the size 
of a coin in young children I have been able to get excellent results, 
but in the larger lesions the results are not as good as can be gotten with 
radium or x-rays or with these combined with carbon dioxid. In small 
elevated nevi, no matter how cavernous, one can usually get almost 
perfect results, especially when treating young children." 

The snow is collected in chamois skin bags or in some mechanical 
contrivance and formed into sticks or pencils of the desired size. The 
degree of pressure and the duration of the freezing determine the 
amount of reaction. The time of freezing varies from five seconds to a 

iThe Therapeutic Application of Solid Carbon Dioxid. 111. Med. Jour., February, 
1912. 



TUMORS OF THE SCALP 



289 



minute or more. The tissues in children are naturally more sensitive 
and require the minimum amount of exposure. With an application of 
ten seconds' duration in children you get as much reaction as with thirty 
seconds in adults. Pusey advises caution in treating the terminal areas 
of circulation, as the borders of the ear, the bridge of the nose, the 
extremities, particularly the legs. 




FIG. 61. Epithelioma of scalp. Chronic sloughing ulcer, irregular in outline, with 
elevated borders and infiltrated reddened areola. Six months' duration. Second point 
of ulceration beginning at lower periphery of the neoplasm. (Martin.) 



Malignant Growths. Malignant growths of the scalp may be 
primary or secondary. The primary cancers are either chronic super- 
ficial epitheliomas or deep aggressive tumors. 

The superficial cancers, epitheliomas or rodent ulcers are not rare on 
the scalp, and are more frequent than the deep variety. They are 
found almost entirely in advanced or middle life, and develop as a rule 
on some preexisting benign lesion, such as a wart, mole, adenoma, or a 

VOL. I 19 



290 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

sebaceous or sweat gland, old ulcer or senile seborrhea. Chronic irri- 
tation of one of these latter lesions seems to be the cause of the malignant 
degeneration in most cases. Some cases develop in apparently normal 
skin, without a preexisting lesion. The forehead, in the region of the 
eye or temple, is the favorite location. The breaking down of the first 
small nodule in the skin results in an ulcer which is shallow and 
unevenly rounded, and which has a more or less indurated border. 
This border may be slightly elevated, uneven and somewhat under- 
mined. The surface usually bleeds on slight irritation. There is a 




FIG. 62. Superficial epithelioma of the scalp. (Hertzler.) 

tendency at times for the ulcer to become covered temporarily with 
epidermis, and sometimes scar tissue forms to such an extent as to 
draw the surrounding skin into folds. In the early stages, even for 
years, the ulcer may be freely movable with the skin, but later, with 
deeper invasion, it becomes fixed. 

While these cases are chronic from the beginning, and sometime are 
small at the end of five or ten years, with no apparent metastases, they 
may at any time become vicious and rapidly invade the surrounding 
structures, destroying even the underlying bone. 



TUMORS OF THE SCALP 291 

The deep cancer while less frequent on the scalp than the superficial 
is a much more formidable type of tumor, as it quickly invades the 
surrounding tissues in all directions, and early spreads to the neighbor- 
ing lymph nodes and to more distant parts of the body. In this variety 
the tumor element is a prominent feature from the beginning and 
ulceration is often deep. 

Skin cancer sometimes grows as a papillary tumor, originating either 
in a preexisting benign wart, or developing as a malignant papilloma 
from apparently normal skin. Horns may be present in these cases. 

Differential Diagnosis. The differential diagnosis of the skin cancers 
calls for a consideration of syphilitic and tuberculous ulcerations, and 
sometimes the ulcers of blastomycosis. In the latter three conditions 
the lesions are usually multiple, and they lack the induration so char- 
acteristic of most cancers. For further details see special headings. 
The Wassermann and tuberculin tests are helpful here; and the finding 
of the blastomyces in the smears would settle the diagnosis in the case 
of blastomycosis. Too often it is the change in character which a 
preexisting benign lesion has assumed that is misunderstood. It is a 
singular fact that cancers on the surface of the body, where they can be 
seen and felt, are very frequently allowed to progress to an incurable 
stage before the correct diagnosis is made. When a wart begins to grow 
larger or ulcerates, or when nodules develop in a chronic ulcer, malig- 
nancy should always be suspected, and a positive diagnosis made at 
once. 

In all doubtful cases, and these are usually the early cases, the lesion, 
if not too large, should be completely excised, and the diagnosis made 
from the frozen section. If the surface ulceration is quite extensive 
and the diagnosis still in doubt, excision of a suspicious piece will allow 
the diagnosis to be made from the frozen section, the wound in the 
meantime being packed with Harrington's solution No. 9. 

Treatment. The treatment for skin cancer is complete excision of the 
growth and the lymph nodes most likely to be involved. The latter 
should be excised en masse, with the surrounding fat, regardless of 
whether they are palpable or not. It is, however, impossible to deal 
thus radically with the parotid lymph nodes unless one is willing to 
sacrifice the facial nerve. Many cases confined entirely to the skin, 
and without glandular involvement, have been apparently cured by the 
use of the z-rays or radium, but most of these could have been excised 
without resulting deformity. In inoperable cases the z-ray, radium, 
caustic pastes and the cautery will often be of some service in retarding 
the superficial growth and in keeping down hemorrhage and infection. 

Sarcoma of the Scalp. Sarcoma of the scalp may occur at any age 
or in any region. It may be primary in the connective tissue of the 
apparently normal skin or fascia, but it usually arises secondarily in 
warts, moles or vascular nevi. Grossly they are divided into two 
groups : The nodular, aggressive tumor which infiltrates the surround- 
ing tissues, and the warty type, which grows more as a papilloma. The 
nodular type may or may not be markedly elevated above the surround- 



292 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

ing skin surface, having edges in some cases like a mushroom, but it is 
always a more or less formidable tumor invading the surrounding tissue 
and leading to extensive metastases to the nearest lymph glands and 
to the various organs of the body. The overlying skin, especially in the 
deeper varieties, may remain intact for a long time. If ulceration occurs 
it is more superficial and smooth, rather than deep and crater-like as in 
carcinoma. 




FIG. 63. Sarcoma of scalp. Death a few months after photograph was made. 
(Dr. W. L. Rodman's case.) Presbyterian Hospital. (Ashhurst.) 




FIG. 64. Endothelioma of the scalp. (Hertzler.) 

The warty sarcomas present themselves as bleeding fleshy warts, 
whether they develop primarily as such or secondarily in a papilloma. 
They are found chiefly in advanced life and their clinical course is much 
more benign than that of the nodular variety. 



WOUNDS OF THE CRANIAL BONES 293 

Melanosarcoma, arising from a pigmented mole, is in a class by itself 
because of its viciously malignant course. It may develop as a very 
aggressive nodular mass or as multiple pigmented nodules in the 
skin, in any event leading to early metastases through the lymph and 
blood channels to the glands, viscera, bones or skin. The pigment in 
both the original tumor and the metastases is the striking feature. 

Angiosarcoma, which may exist as a relatively hard tumor or as a 
soft pulsating variety, may arise from the endo- or perithelial cells of 
hypertrophied bloodvessels. 

Endothelioma, i. e., lymphangio-endothelioma, is not only rare in the 
scalp, but it is impossible to recognize it clinically. It consists of a slow- 
growing circumscribed nodule with very little tendency to metastasis 
and hence is a relatively benign tumor. 

Diagnosis. Sometimes it is necessary to differentiate sarcoma from a 
rapidly developing gumma. 

Prognosis. The prognosis of the above mentioned forms of sarcoma 
varies according to the type of tumor we are dealing with. The type 
described as nodular offers a very bad prognosis, the warty variety a 
relatively good prognosis, while in melanosarcoma and all very vascular 
sarcomas the outlook is exceedingly bad. Endotheliomas are relatively 
benign. 

Treatment. The treatment in all cases, if not inoperable, is wide 
excision. In the inoperable cases, and in certain postoperative cases, it 
is well to try the oxray, and also Coley's mixture of the toxms of 
erysipelas and bacillus prodigiosus. The o>ray should be intensive 
and should be given daily for a period of six days. This procedure 
should be repeated every few weeks for a period of several months. 



THE CRANIAL BONES. 

WOUNDS OF THE CRANIAL BONES. 

Wounds of the cranial bones are usually classified as incised, punc- 
tured and contused wounds. Naturally the character of the wound will 
depend to a great extent upon the shape and size of the contusing 
surface, as well as upon the force and direction of the blow. 

Incised Wounds. A saber cut, or a blow with the sharp edge of a 
hatchet, if delivered with force squarely on the vault, may result in an 
incised wound of the bone with no surrounding fragmentation or frac- 
ture, except possibly a fissure extending out from either end of the cut. 
The same blow, with less force, may cause an incised wound of the 
outer table with more or less fragmentation of the inner table. A 
powerful blow with the same instrument in a tangential direction may 
slice off a flap of bone. Though these cases are all open to inspection 
it is sometimes difficult to determine accurately the extent of injury 



294 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

to the internal table or the underlying soft parts. The prognosis 
depends not only upon the latter, but upon the presence or absence of 
infection. 

If the history of the injury, the appearance of the wound, and the 
lack of symptoms make it reasonably certain that the wound is non- 
penetrating, disinfection, partial suture and drainage of the wound, 
is probably all that is necessary. If the wound has penetrated the 
cranium, disinfection, trephining, removal of foreign bodies and drain- 
age are always indicated. The drainage should extend through the 
dura if the latter has been opened. 




FIG. 65. Sword cut; fissured fracture. 

Punctured Wounds. Punctured wounds are similar to incised 
wounds in many respects, with these differences, however: that they 
are not so freely open to inspection, and that, if not operated, drainage 
is poor. Consequently they are more liable to serious deep infections. 
Moreover, the penetrating body is liable to be broken off. 

Every case calls for early disinfection, trephining, removal of foreign 
bodies and drainage. The drain should always extend to the cortex if 
the dura is not intact. 

Contusions. A subcutaneous contusion of the skull always carries 
with it the question as to whether one is dealing with a contusion or a 
fracture. 

Diagnosis. In making a probable diagnosis one has to consider the 
force and direction of the blow and the size of the contusing surface, 
as, for instance, a swift blow from a body with a small surface, like a 
hammer, delivered squarely on the head, is very likely to have caused 
a fracture. Under such circumstances one is justified in making an 
accurate diagnosis by inspection and palpation through an exploratory 
incision. On the other hand, with the history of a less severe blow, 
especially if delivered on a tangent, and in the absence of intracranial 
symptoms, expectant treatment may be all that is called for. One 
should always be on his guard lest he be led into the diagnosis of 



WOUNDS OF THE CRANIAL BONES 



295 



depressed fracture by the firm ring of reactionary edema so often 
noticed in contusions with hemorrhage into the soft external coverings. 
Distinct intracranial symptoms, such as those of compression, will 
demand active exploration even though the injury itself has the 
appearance of being a simple contusion. 

Prognosis. The prognosis in all head injuries, especially in those of 
advanced years, and in those with distinctly bad family histories, from 
the standpoint of the central nervous system, should allow for possible 
subsequent mental symptoms, epilepsy, etc. 

Osteomyelitis may possibly develop later on as a result of diminished 
local resistance, but this is not very frequent. 




FIG. 66. Fissured fracture, z-ray findings confirmed at operation. (H. P. Knapp.) 

Skull Fractures. The diagnosis of a fracture of the skull in the 
absence of an open wound, is sometimes exceedingly difficult, or even 
impossible. A fracture may exist without bony deformity and with 
no symptoms referable to the brain or cranial nerves. On the other 
hand cerebral symptoms may follow an injury to the skull without 
fracture; hence they have more to do with prognosis than diagnosis. 
Tumefaction of the scalp may completely obliterate an underlying 
depression, and even palpable depressions may not be of recent origin. 
In the latter case an unconscious patient could not explain that his 



296 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

depression was due to an old injury, disease or deformity. Contusion 
with hemorrhage into the soft coverings and certain infections in the 
scalp may so closely simulate fracture with depression as to deceive 
capable, but somewhat careless, diagnosticians. A contusion at one 
point may lead to a fracture or cerebral involvement at another point. 
The x-ray examinations may be of great assistance, and even the 
careful use of the stethoscope, combined with percussion, is considered 
by some as being helpful in some cases. 

It is no longer permissible to explore every simple contusion merely 
to determine the existence of a fracture. The exploratory incision is to 
be made on the grounds of cerebral injury rather than those of fracture, 
except possibly in those cases where the history of the injury, combined 
with suggestive local findings, render it probable that a bending 
fracture has occurred. 




FIG. 67. Fracture of vault. (Hartung and Huber.) 

Palpation and the #-ray are practically our only means of diagnosing 
simple, or closed, fractures. For this reason the uncomplicated fissured 
fracture will often go unrecognized. A probable diagnosis of this con- 
dition would be made if there existed a persistent tenderness along 
a definite line, especially if the pain were noticeable on both direct 
and indirect pressure. Such a diagnosis, however, would be of little 
consequence. 

If, following an injury, there were found under the scalp a collection 
of fluid that pulsated with the brain, and which also became tense with 
increased intracranial tension, as in coughing, crying, sneezing, etc., 



WOUNDS OF THE CRANIAL BONES 



297 



a fracture with rupture of the dura would be diagnosed. The fluid 
might be blood or cerebrospinal fluid. The latter is most frequently 




FiG._68. Circumscribed depressed fracture, outer surface. 

found in the fractures of the infant cranium, and is spoken as a meningo- 
cele spuria. Likewise a collection of air beneath the pericranium, 
pneumatocele capitis, following injury, means fracture through an air- 
containing sinus. 




FIG. 69. Circumscribed depressed fracture, inner surface. 

The simple depressed and comminuted fractures of the vault can 
usually be easily recognized by palpation alone, especially if seen 



298 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

directly after the injury. As stated in a previous paragraph the history 
of the accident, combined with suggestive local findings, will often 
make the existence of a fracture most probable. Thus when a patient 




FIG. 70. Circumscribed fracture with inclusion of hair. 

receives a powerful blow with a hammer squarely on the vault a bend- 
ing fracture with comminution of the internal table is almost certain 
to be present. 




FIG, 71. Circumscribed depressed fracture. 

Compound fractures of the vault with anything more than a small 
skin wound will usually be both visible and palpable. The only danger 
here would lie in carelessly mistaking a rough suture line, Wormian 
bones, senile atrophy or the irregularities of an old osteomyelitis for 
fracture. 



WOUNDS OF THE CRANIAL BONES 



299 



Having made a diagnosis of fracture of the external table, whether 
simple or compound, it is not always possible to know definitely whether 
the internal table is fractured or not. Most of the fissures involve both 
tables, and all steep depressions, except possibly those over the air- 




FIG. 72. Fracture of internal table. 



containing sinuses, not only involve the inner table, but the latter is 
broken more extensively than the outer table. Punctured fractures 
practically always involve both tables, the inner more than the outer. 
Gunshot injuries will be mentioned later. Fracture of the internal table 




FIG. 73. Teevan's diagram to show that the inner table often is more extensively 
damaged than the external, because it is in the line of extension. (Ashhurst.) 

alone is to be surmised when a sharp local impact over an area where 
diploe exists, though showing no external fracture, results in local 
cortical irritation. A good skiagram might possibly establish a positive 
diagnosis. 



300 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

Fractures of the Base. Basal fractures are in a class by themselves 
because of the mechanism of their production, their serious nature, the 
fact that they nearly always traverse some cavity containing infectious 
germs, and because of the fact that the fracture cannot be palpated. 
The symptoms on which the diagnosis is based are mostly indirect. 

The contusing violence here is of a diffuse character, i. e. y instead 
of the sharp impact over a small surface as we find in bending fractures, 
the force is more of a crushing, compressing violence, covering a broader 
area and tending to press the poles of the skull together. As examples 
of such violence one might mention a blow from a falling timber, a 
fall from a height striking on the head, etc. Any force which presses 
the opposite poles together tends to burst the skull along the lines of 
the meridians. The direction of the meridian or fracture depends upon 




FIG. 74. Diagram showing the usual course taken by fissured fractures of the base 

of the skull. 

the direction of the force or compression. As the base of the skull offers 
the least resistance to this bursting effect, the line of fracture will be 
found more frequently here than over the vault. 

Symptoms. As to the symptoms which lead us to infer that a 
fracture of the base has occurred, one of the most important is hemor- 
rhage, free or into the tissue's, with, however, definite qualifications. 
Bleeding may occur freely into the nose or nasopharynx or through the 
ear. Here it is necessary to exclude local injury to the nose, mouth and 
throat or to the extracranial parts of jthe ear. Very slight injuries may 
cause bleeding from the nose, especially in certain individuals, but if 
the hemorrhage from the parts is associated exclusively with injury to 
some part of the cranium, it takes on a distinct significance. The bleed- 
ing from the nose in cases of fracture of the anterior fossa comes 
usually from a break through the ethmoid, while in middle fossa frac- 



WOUNDS OF THE CRANIAL BONES 301 

tures it generally comes through the sphenoid sinus. In some cases 
it reaches the nasal cavity through the Eustachian tube, having come 
from a fracture through the middle ear without rupture of the drum. 

When considering the local causes of hemorrhage from the nose and 
nasopharynx one must remember the possibility of penetrating wounds 
of the base resulting from falls upon a pointed stick or weapon. 

A free hemorrhage from the ear in case of injury to some other part 
of the skull is probably due to a fracture of the base involving the 
middle ear, usually with rupture of the drum membrane, though the 
latter may remain intact, the blood then escaping through the roof of 
the canal. A very mild hemorrhage following a direct trauma may 
mean merely injury of the extracranial parts of the ear. 

Hemorrhage into the tissues may be due to a contusion without 
fracture, as seen in the ordinary black eye, or it may follow a fracture. 
In the former case it appears as a black and blue swelling promptly 
after the injury, whereas in the case of fracture it makes its appearance 
late, at least hours afterward, but usually one or two days after the 
injury. 

Ecchymosis in or about the orbit, like hemorrhage into the nose, may 
result immediately from slight local injuries, or from straining, as in 
severe fits of coughing, but if due to fracture it comes not only late, but 
is more extensive. If a large vessel, like the cavernous sinus or the 
orbital branch of the middle meningeal, were ruptured, the infiltra- 
tion of the tissues and the appearance of the ecchymosis would be 
more rapid. According to the location of the fracture the ecchymosis 
may appear in the upper lid, beneath the conjunctiva, or in the retro- 
bulbar fat. In the latter case exophthalmus might be a result, the 
degree and the time of appearance depending upon the amount of 
hemorrhage and the size of the vessel involved. Pulsating exophthalmus 
with the eyeball pushed outward as well as forward, would indicate 
injury of both the internal carotid and cavernous sinus with a resulting 
arteriovenous aneurysm. In this event the other signs of arteriovenous 
aneurysm would be present. 

Ecchymosis appearing in the region of the mastoid or temple several 
days after a head injury is usually indicative of a fracture of the middle 
fossa; likewise a late appearing ecchymosis in the occipital region or 
neck may point to fracture of the posterior fossa. 

Unquestionable signs of fracture are the escape of cerebrospinal fluid 
and brain substance. The latter is found only in case of severe frac- 
tures, while the former may occur in either the mild or severe cases. 
The cerebrospinal fluid has been noticed in only about 5 per cent, of 
cases of fracture of the base. It may be small in amount or very free. 
In one of my cases the escape was so free that large sterile pads had to 
be kept over his ear. During coughing or sneezing the fluid was noticed 
on several occasions to spurt a distance of two feet from the patient. 
The peculiar feature of this case was that the young man, who had been 
thrown from a delivery wagon, striking on his head, sustained only a 
moderate concussion, and scarcely felt sick enough to remain in bed. 



302 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

In this particular case the fluid was noticed promptly after the accident, 
though in the ordinary case it is not noticed until hours afterward, at 
any rate not until the free hemorrhage clears up. It may make its 
first appearance days after the injury. The flow may last from a few 
hours to a week or more. Cerebrospinal fluid, like hemorrhage in basal 
fractures, may find its way into the nose through fractures of the 
ethmoid or sphenoid, or it may come down the Eustachian tube from 
the ear. It contains large quantities of chlorides, but no albumin 
unless mixed with blood or exudates. The exudates, on the other 
hand, contain only a small amount of chlorides, while they possess a 
comparatively large amount of albumin. If the quantity of clear fluid 
escaping from either the ear or nose is small its source cannot be deter- 
mined without a chemical examination. If it is large, and especially 
if the rate of flow depends upon the variations of intracranial pressure, 
there can be no question about its being cerebospinal fluid. 

Symptoms due to involvement of the cranial nerves possess only a 
relative diagnostic value because they may represent either a peripheral 
or central lesion with or without fracture. They are often of distinct 
service, however, in locating the seat of fracture, especially if the 
grouping of the symptoms is studied. Thus paralysis of the seventh, 
eighth and sixth nerves determines the course of the fracture through 
the petrous process (von Bergmann). The time of the onset of the 
symptoms, and the extent of the paralysis, will materially aid in estab- 
lishing the nature of the lesion, whether rupture, compression from 
hemorrhage or inflammatory exudate, etc. The nerve most frequently 
involved is the facial because it traverses a long, tortuous canal in 
the petrous process which is so often the seat of fracture. The sixth 
ranks next to the facial in frequency of involvement. In fractures of 
the anterior fossa the nerve most frequently injured is the olfactory 
because of the usual involvement of the fragile cribriform plate of the 
ethmoid. The second and third nerves, and the first division of the 
fifth may be more or less involved. In middle fossa fractures the nerve 
most frequently injured is the seventh. As stated before, the eighth is 
frequently implicated with the seventh. The second and third divisions 
of the fifth nerve are seldom injured. Fractures through the cavernous 
sinus may involve the first division of the fifth, the sixth, third and 
fourth nerves. In fractures of the posterior fossa, involving the 
jugular foramen, the ninth, tenth and eleventh nerves, which pass 
through this foramen, are only occasionally injured. 

Fracture of the base is often associated with fracture of the vault, 
probably in about three-fourths of the latter; and fissure of the vault 
is frequently found hi cases where the basal injury predominates. The 
character of the injury, whether a localized sharp impact or a diffused 
compression, is a decided factor in the determination of the kind of 
fracture, whether bending or bursting. The location of the impact 
and the direction of the force determines to a great extent the general 
direction of the line of fracture. For these reasons a detailed history 
of the accident can often be of distinct assistance in the diagnosis. 



WOUNDS OF THE CRANIAL BONES 303 

After all, the diagnosis of fracture in its various forms and locations 
is of service only insofar as it enables the surgeon to recognize and treat, 
or to prevent, associated lesions of the intracranial structures. The 
important features, therefore, i. e., lesions of the brain, its coverings, 
etc., will be discussed later on under their proper headings. 

Prognosis. The gravity of skull fractures can be appreciated when 
one realizes that approximately one-thjrd of all cases prove fatal, 
largely because of the violence to the intracranial structures. As 
practically all basal fractures and the majority of vault fractures are 
compound, the possibilities of early or late infection, thromboses, etc., 
become manifest. Then, too, there is always the remote possibility of 
degenerations, cortical irritations, etc., leading to epilepsy, insanity 
and the various neuroses. The prognosis then depends to a great 
extent upon the surgeon's ability to cope with the existing conditions 
arid upon his ability to prevent the remote pathology. His unavoidable 
limitations in these respects, especially in basal as compared with vault 
fractures, can be better imagined than described. 

Rawlings in a study of the records of over 300 cases came to the 
conclusion that the temperature chart of the patient is of great value 
in formulating a prognosis in cases of head injuries. He concludes that 
for a variable period of time after the injury the temperature is sub- 
normal, this being the period of shock. Death may occur during this 
period, or reaction, accompanied by a rise of temperature, may set in. 
If the temperature remains normal the prognosis is good. If it rises 
moderately and then "marks time" the prognosis is held in abeyance 
as the case has reached its crisis; a fall to normal now indicates a 
recovery, while a further rise usually points to a fatal termination. A 
rapid and progressive rise of temperature (6 or 8 in a few hours) is 
usually an indication of early fatal termination. Laceration of the 
brain was present in the majority of cases with marked temperature. 

Treatment. The treatment of all of these cases has for its object the 
conservation of the functions of the brain rather than any special 
treatment of the bony lesion itself. 

In simple fractures of the vault interference is warranted (a) on 
definite indications of bony deformity, such as depression regardless of 
symptoms, (6) by the evidence of localized compression whether extra- 
dural or intradural, (c) by the evidence of localized cortical irritation. 
In special cases subdural drainage may be indicated on the grounds of 
general compression in case of edema. Those cases associated with 
contusion and general cerebral irritation do not call for operation. 
In any case operation should not be performed during profound 
shock. 

All compound fractures of the vault are operative, if for no other reason 
than primary wound disinfection. Especially is this the case in punc- 
tured fractures, for evident reasons. In all these cases adequate drain- 
age to the cortex or dural opening is indicated, and free drainage must 
likewise be provided for the blind pockets under the scalp. A torn dura, 
like a torn scalp, may be partially sutured. Dirt ground into the tissues, 



304 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

whether soft tissues or bone, must be cut away with scissors or bone 
instruments. 

Loose fragments of bone, large or small, free or impacted, may be 
retained in simple fractures. In compound fractures, however, they 
had better be removed unless they have pericranial attachments, or 
unless the wound, in the judgment of the surgeon, is reasonably clean. 
In many cases they can be retained and removed later if necessary. 

In fractures of the base operative interference is seldom called for, 
and then it is only on the ground of compression from hemorrhage or 
edema, or because of infection. Middle meningeal or lateral sinus 
hemorrhage may call for trephining in order to arrest the bleeding. 
General oozing or cerebral edema may lead to such a degree of compres- 
sion as to demand relief through subtemporal drainage of the subdural 
space. 

The only justifiable treatment in the average case is the so-called 
expectant treatment, viz., absolute quiet, rest, through sedatives if 
necessary, ice-cap, elevation of the head of the 5ed, elimination through 
cathartics, normal salt solution, etc. Little can be done to avoid infec- 
tion through the open connection between the cranial cavity and the 
air sinuses into which the fracture has extended. One can, however, 
at least avoid the added dangers of meddlesome irrigation, spraying 
and plugging of the ear and nose. In the case of the ear we must be 
content with gentle cleansing of the external ear and canal with a 
swab soaked in a 1 per cent, lysol solution, and the insertion in the canal 
of a slender, very loosely applied strip of gauze for drainage. A sterile 
pad should be applied externally. 

If the case does not die during the first forty-eight hours the prog- 
nosis, so far as recovery is concerned, is fairly good, but one should 
always be on the lookout for symptoms calling for justifiable inter- 
ference. Rest in bed for at least one month, and avoidance of all work 
or mental activity for at least six months, should be insisted upon. 

Gunshot Wounds of the Skull. Gunshot wounds of the skull, like 
fractures of the base, are in a class by themselves, and consequently 
are separately described. Of all the influences governing the effects 
of this class of injury the chief ones are the physical properties of the 
skull contents and the velocity and physical properties of the missile. 
The semi-fluid character of the skull contents allows the active force 
of the bullet of high velocity to be transmitted in all directions, in other 
words to explode. As the velocity diminishes the explosive effect grows 
less until finally the results may become no more nor less than those of 
a punctured wound, or a mild bending fracture from a spent ball. A 
soft bullet, such as is used in the ordinary pistol of civil life, and the 
partially " jacketed" bullet with the soft nose, such as is used in hunting 
for big game, flatten out, become mushroomed, when they strike an 
object, and so tear frightful holes in the tissues. Thus with a low 
velocity their destructive effects on the skull and brain may be just as 
great as those of the full- jacketed bullets of higher velocity. Further- 
more the soft bullet of low velocity is more apt to become fragmented 



WOUNDS OF THE CRANIAL BONES 



305 



and lodge in the skull or brain. The dum-dum bullet with high initial 
velocity combines the action of the deformed missiles with that of the 
explosive or hydrodynamic force. 




FIG. 75. Gunshot fracture of skull, posterior view. 




FIG. 76. Gunshot fracture of skull, anterior view. 



VOL. i 20 



306 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

The injuries of the dura mater correspond somewhat in extent with 
those of the skull. At the wound of entrance the inner table is always 
more extensively shattered than the external, the opposite obtaining 
at the wound of exit. 

These fractures are naturally aH compound with more or less com- 
minution and displacement of fragments or loss of substance. Many 
have bursting fissures extending into the base. According to circum- 
stances the fracture may be a perforating, penetrating, gutter or 
simply an inbending fracture. Because of the violence of the intra- 
cranial injuries leading to increased tension, these cases are very apt 
to present extrusion of the brain substance at the points of fracture. 
Nerves are sometimes implicated without the skull cavity having been 
penetrated. Notable examples of this are the destruction of the optic 
nerves in attempted suicides. 

Diagnosis and Prognosis. The practical points in the diagnosis and 
prognosis concern the immediate and late pathology of the intracranial 
contents and cranial nerves. The immediate symptoms due to the 
destruction of brain tissue, and hemorrhage, and the later symptoms of 
sepsis and brain irritation will be discussed later on. 

Skiagraphs may be of service in defining more or less of the bone 
lesions, and also in locating the bullet or its fragments. 

Though the bullet itself is to be looked upon as free from infection, 
it frequently opens up a track through septic cavities, or it may carry 
with it pieces of hair, cap, etc., that are not sterile. 

Nearly half of the cases die immediately, and a further percentage die 
as a result of unavoidable subsequent complications. 

Treatment. The treatment is unsatisfactory as the destruction of 
the brain tissue in the path of the missile or within the reach of the 
"active force" of the bullet with high velocity cannot be repaired. 
Likewise no amount of skill can regularly eliminate infection from a 
fissured base; nor can foreign bodies, deeply embedded, be extracted 
without further damage. Even an early leptomeningitis at the base 
can rarely be checked. 

Meddlesome interference, such as probing and irrigating and unneces- 
sary operating, should be avoided. Dry shaving and painting the 
site of the scalp wound with tincture of iodin is all that is necessary in 
some cases; in others operative interference is indicated for the removal 
of pieces of bone or foreign bodies imbedded in the surface of the brain. 
If drainage should be indicated, as in cases where foreign bodies, such 
as bits of clothes, hair, etc., have been lodged near the brain surface, 
it should not extend deeper than the subdural space, as brain drainage 
is very unsatisfactory, and may be very harmful. Complications, such 
as hemorrhage, cerebral edema, infections, etc., are to be watched for, 
and met, as described in fracture of the base. A bullet which has lodged 
in the cranial cavity is to be regarded as aseptic, and there should be no 
attempt at its removal unless it is in a readily accessible position, or 
unless it is causing symptoms of brain irritation. 



AFFECTIONS OF THE CRANIAL BONES 307 

Skull Injuries in Infants and Young Children. Vault fractures or 
indentations are occasionally seen in the newborn as a result of difficult 
labor or instrumental delivery. Even fracture of the base has been 
observed. Indentations are also seen in very young children as the 
result of falls. To admit of this the skull bones must necessarily be 
thin and very elastic. 

These cases are to be treated on the same general principles as frac- 
tures in adults, except that the indentation should be allowed a week 
or ten days to undergo spontaneous reduction, the usual occurrence. 
If this latter does not take place, the bone should be forced into its 
proper position through the use of some smooth instrument, like a 
Kocher's director, inserted through a small opening at the margin of the 
depression. 




FIG. 77. Fracture of right frontal bone in a newborn infant, fracture extending into 

orbit. 



AFFECTIONS OF THE CRANIAL BONES. 

Atrophy. Atrophy of the cranial bones is of interest chiefly from the 
standpoint of diagnosis. It is usually a local process, due to local pres- 
sure, to inflammatory changes, or to a combination of local pressure 
and constitutional disease. It may occur as a more or less local process 
in the form of the so-called eccentric atrophy of old people, the cause of 
which has not been determined. 

Intracranial pressure under normal conditions shows its effect in the 
depressions for the Pacchionian granulations, and the grooves for the 
venous sinuses and the middle meningeal arteries. Pathologically, 
pressure atrophy is found over intracranial tumors situated immedi- 
ately beneath the bone. In cases of prolonged increased intracranial 
tension the venous stasis may lead to extensive atrophy through dilata- 
tion of the veins of the diploe, or it may show itself chiefly at the site 



308 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

of the emissary vessels. The pressure in the case of tumor may lead 
to spontaneous decompression by perforation of the skull. 

Extracranial pressure, as from tumors, notably dermoids and 
angiomas, may lead to atrophy of the underlying bone, but this is rare, 
because the soft scalp admits of easy expansion in the direction of 
least resistance. Atrophy has followed pressure from cephalhematoma. 

Senile or excentric atrophy, found chiefly in old men, is a bilateral 
patchy atrophy, occurring in the region of the parietal protuberances. 
Its cause is unknown, but Konig suggests that it is the result of involu- 
tion changes. The atrophic process starts in the diploe and extends 
outward, leading to excavations which are sometimes mistaken for 
fractures. It is a rare affection. 




FIG. 78. -Craniotabes, rachitis. 

Osteomyelitis, especially of the tuberculous type, may lead to a 
rarefaction of the bone. 

The atrophy of rickets is the most frequent variety met with in the 
skull bones. These spots of atrophy are found chiefly in the parieto- 
occipital region and are known as craniotabes. The bone at these 
points may become as thin as paper, or even disappear altogether, so 
that, as Konig says, the occiput may feel like a soft abscess. 

Accompanying the absorption of the bone there are excessive deposits 
of soft osteoid tissue in the frontal and parietal regions, which, with the 
flattening of the occiput from pressure, give to the head the character- 
istic cuboidal appearance. The fontanelles are larger than normal, and 
may remain open until the third year. The edges of the sutures are 
usually very soft. The craniotabes usually disappears before the end 
of the third year unless complications are present. The deposits of 
osteoid tissue in the frontal and parietal regions do not disappear, but 
become very hard as recovery takes place. 



AFFECTIONS OF THE CRANIAL BONES 



309 



The usual constitutional symptoms and other skeletal changes are 
present. 

Diagnosis. The diagnosis is usually easy, but there are other diseases 
presenting as part of their pathology areas of thin bone or deformed 
cranial bones, large fontanelles, soft suture edges, etc. Among these 
we find hydrocephalus , which may coexist with rachitis, congenital 
fragilitas ossium or osteogenesis imperfecta, chondrodystrophia or 




FIG. 79. Achondroplasic skeleton. 

achondroplasia (Jetal rickets), congenital syphilis, cretinism, etc. The 
associated lesions and z-ray findings in the long bones will help to 
differentiate most of these conditions, all of which are rare except 
congenital syphilis and hydrocephalus. 

In achondroplasia and congenital fragilitas ossium there is a lack of 
development rather than an atrophy of bone. In the former case the 
pathology is confined mostly to a premature union of the epiphyses 



310 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

of the long bones, the skull usually being very little affected. The 
infant early has the characteristic appearance of a dwarf. The head 




FIG. 80. Achondroplasia. 





FIG. 81. Osteopsathyrosis. 

changes in congenital f ragilitas ossium are often very marked, especially 
at the back, where the bone may be almost entirely wanting. The 



AFFECTIONS OF THE CRANIAL BONES 311 

fragility of the bones throughout the body leads to frequent fractures, 
even intra-uterine. 

Treatment. The treatment is entirely along general lines. Soft 
areas in the skull should be protected from pressure by ring pads, or 
inflated ring cushions. 

Carl Beck, 1 in an interesting article on Osteopsathyrosis, refers to 
Bossi's clinical and experimental work in connection with adrenalin in 
the treatment of osteomalacia. He says, " To me the theory of Bossi 
seems the most probable that the suprarenal capsules have an influence 
upon the regulation of the salt deposits in bones, and that the absence 
of the particular secretion is responsible for the riot of the cells carrying 
on the absorption of lime salts. It seems to be borne out by experiments 
as well as by the good results obtained by Bossi and others, and also 
by myself, by the use of adrenalin." 

Bossi found in his experiments on sheep that removal of the supra- 
renal capsules was followed by changes almost identical clinically and 
pathologically with osteomalacia, and thus established the connection 
between growth of bones and the suprarenal capsules. 

Beck then cites the case of a young girl who developed a softening of 
most of the bony skeleton, chiefly of the long bones, with a great 
tendency to fractures; and very little disposition to healing. "With 
the injection of adrenalin the pathological condition gradually shows 
clearly an increase of lime salts and gradual healing." He injected ten 
to twelve drops of the 1 to 1000 solution daily for twenty-five days. 
Relief from pain was noticed after the first injection. 

Emil Beck, in an article read before the Chicago Surgical Society, 
cited a case of cystic degeneration of bone cured by the use of adrenalin. 

A number of the cranial hypertrophies, separately described because 
differing in many respects, seem to possess enough fundamental 
similarities to warrant the conclusion that they are etiologically related. 
Moreover, one form may be associated with another in the same 
individual. The chief diseases here referred to are acromegaly, leontiasis 
ossea, gigantism and osteitis deformans. 

Acromegaly. Acromegaly is a systemic disease of a distinctly 
trophic character, involving especially the osseous system, though the 
soft tissues are more or less involved. The most striking feature is 
general hypertrophy of the bony skeleton. The bones of the skull 
take on the form of a diffuse hyperostosis, those of the face, especially 
the lower jaw and the supra-orbital ridges, becoming very heavy and 
prominent, giving the face the appearance so characteristic of the 
disease. 

The onset of this condition occurs usually in late youth or early adult 
life, and tends to a fatal issue in from ten to thirty years. Most cases 
are associated with some pathology of the hypophysis cerebri, though 
cases of acromegaly and allied conditions have been reported in which 
the autopsy showed no lesions of the hypophysis; and, on the other 

., Gynec. and Obstet., 1910. 



312 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 




FIG. 82. Acromegaly. 




FIG. 83. Leontiasis: skull of a Chinese woman. 



AFFECTIONS OF THE CRANIAL BONES 313 

hand, lesions of the hypophysis have been found in cases with no sign 
of trophic changes in the bony skeleton. 

Treatment. Operation may possibly prove of benefit in those 
cases where the symptoms and #-ray findings point to disease of the 
hypophysis. 

Gigantism. Meige 1 states that: "When the disease commences in 
youth we get a case of gigantism; when in adult life acromegaly; if 
commencing in youth and continuing into adult life we get a combin- 
ation of the two. Acromegaly never precedes gigantism. Acromegaly 
sets in during the course of about one-half of the cases of gigantism." 
Woods Hutchinson 2 states that we are " justified at least in the tentative 
conclusion that acromegaly and gigantism are simply different expres- 
sions of one and the same morbid condition." 

The average duration of life is seldom over twenty years. 

Leontiasis Ossea. Leontiasis ossea is a chronic disease of unknown 
origin leading to marked diffuse thickening and sclerosis of the bones of 
the face and cranium. Either or both sets of bones may be involved. 
Bassoe 3 states that "Baumgarten's view that the disorder is trophic 
and developmental is probably the best at present." It usually starts 
in childhood, beginning as a rule in one of the bones of the face. " Of 
the cranial bones the anterior part of the frontal is usually most 
affected." (Bassoe). 

The massive thickening of these bones leads to a gradual diminution 
in size of the cranial chamber and more or less obliteration of the 
foramina and accessory cavities of the skull. These changes eventually 
give rise to the various symptoms of cerebral compression and cranial 
nerve impingement. The orbit being more or less obliterated, exoph- 
thalmos is one of the results. 

Diagnosis. Though some authors consider Osteitis deformans of 
Paget as identical with this disease, still leontiasis ossea is described 
as a diffuse hypertrophy limited to the bones of the face and cranium 
while the osteitis deformans involves the spine and lower extremities as 
well as the cranium, von Bruns states that while osteitis deformans 
fibrosa may involve the skull alone it must be admitted that the skull 
affection may represent the beginning of a general disease of the 
skeleton. Osteitis deformans furthermore does not involve the bones 
of the face. Acromegaly always begins in the epiphyses of the long 
bones of the extremities. Sarcoma of the maxillary bones may be 
mistaken for the early hyperostosis of leontiasis ossea, or it may be 
associated with the latter. 

Treatment. There is no curative treatment of this malady, though 
operations have been performed with the idea of relieving pain due to 
nerve compression. The duration of the disease may vary from ten to 
thirty years. 

1 Arch. gen. de med., October, 1902. 

2 New York Med. Jour., March 12, 1898. 

3 Jour. Nerv. and Ment. Dis. 



314 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 




FIG. 84. Case of pre-adolescent hyperpituitarism, with giant overgrowth. Enlarged 
sella turcica. Weight, 275 pounds; height, 8 feet, 3 inches. Note the narrow chest, 
enlarged joints, hypertrichosis, and large size of hands. (From Cushing's Pituitary 
Body.) 



ACUTE INFECTIONS OF THE CRANIAL BONES 



315 



Osteitis Deformans. Osteitis deformans, also known as Paget's 
disease of bone, is a very rare disease, leading to irregular but sym- 
metrical enlargement and deformity of more or less of the bony skeleton. 
It occurs chiefly in middle life and is found mbst frequently in men. 
The cause of this condition is not known. While the long bones of the 
extremities become thickened and elongated they also become bent in 
various directions. These changes, combined with osteophytic deposits 
here and there and curvature of the spine, lead, at times, to very 
grotesque deformities, and a decided shortening of stature. The skull 
changes usually affect only the cranial bones in the form of an excentric 
hypertrophy. For this reason there are seldom present the symptoms of 
intracranial compression. 




Fid. 85. Osteitis deformans (Paget's disease) in a patient, aged seventy-two years. 
Duration, twelve years. Orthopaedic Hospital. (Ashhurst.) 



ACUTE INFECTIONS OF THE CRANIAL BONES. 

Acute Pyogenic Osteomyelitis or Periostitis. Acute pyogenic osteo- 
myelitis or periostitis of the cranial bones is exceedingly rare as a 
hematogenous infection. While it may take place in this way after 
trauma, or even without the latter, it usually occurs in connection with 



316 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

an open scalp wound, or by direct extension from one of the accessory 
sinuses. 

Acute infection under tension in the diploe, regardless of how it 
reached the area, gives rise to both the constitutional symptoms and 
the local signs of acute osteomyelitis, viz., usually a chill, always fever, 
and always marked pain and local sensitiveness. Infective thrombo- 
phlebitis may spread extensively through the diploetic veins or the 
emissary vessels and reach one of the large venous sinuses, causing 
thrombosis, or the pus may rupture into the subpericranial area, strip- 
ping up the periosteum, or it may perforate the bone internally, leading 
to an extradural abscess with cerebral compression, or it may even lead 
to a meningitis, a local brain abscess, or a diffuse meningo-encephalitis, 
or it may serve as the focus of a pyemia. As in the long bones, so here 
in the skull, the early stages of the infection may be unaccompanied 
by marked swelling of the soft parts. Later, as the tension is relieved 
by perforation of the bone, there may be considerable swelling of the 
scalp. Necrosis may be limited or extensive. The peculiar thing about 
the cranial bone necrosis is that no involucrum is formed as in the long 
bones. Only occasionally is a slight one formed. 

Diagnosis and Prognosis. While the diagnosis is usually easy the 
prognosis is always serious because of the possibilities of intracranial 
infection. 

Treatment. The treatment indicated is drainage of the infected area 
within the first twenty-four or thirty-six hours. As in the case of the 
long bones, release of tension by removing one or more buttons of the 
outer table is all that is usually necessary. It is of the greatest prac- 
tical importance in these cases to make early extensive incisions through 
the periosteum down to the bone because this causes the lymph stream 
to carry the infections away from the body. If there is any question 
about extradural infection the trephine opening should extent through 
the entire thickness of the skull. Later, when necrosis has occurred 
free drainage is still indicated until the necrotic bone is well outlined, 
when it should be removed, as waiting until it is loose would prolong 
the possibilities of intracranial inflammations. 

Syphilis. Syphilis of the cranial bones or their periosteal coverings 
is usually found as tertiary lesions of acquired syphilis, though it some- 
times occurs as a hereditary manifestation in children. It usually 
starts in the pericranium, but may involve the diploe first. Both 
become involved more or less in either case. The brow and the top of 
the head are the favorite seats, the base being rarely affected. The 
spirochetes are abundant in the gummata of infants. Trauma is often 
the cause of the localization. 

Symptoms. The subjective symptoms may be few and mild. 
Though tenderness is present, pain is usually not a prominent feature 
unless the disease involves the dura, primarily, or secondarily as a 
pachymeningitis externa. When pain is present, as in some of the 
cases developing acutely, it is usually worse at night, as in most chronic 
bone inflammations. 



ACUTE INFECTIONS OF THE CRANIAL BONES 



317 



The gummata appear as solitary or multiple lesions, tender, slightly 
elevated and firmly fixed to the bone. Chronic from the beginning, 
they tend to gradually increase in size and coalesce, often forming 
irregular serpiginous patches of bone destruction. The rarefaction 
and absorption of the bone, most marked along the Haversian canals, 
is accompanied by an overproduction and sclerosis of bone at the 
periphery of the lesion, forming at times tophi and nodules. The des- 
truction, however, exceeds the new bone formation. The caseation 
and softening may extend to the dura, which usually acts as an effec- 
tive barrier, or it may extend outward and lead to scalp ulceration and 
sinus formation with their characteristic earmarks. The dura may 
become thickened and contracted. The entire process may be limited 




FIG. 86. Syphilitic caries of cranium. 

to a small area of local caries or it may result in extensive necrosis, 
usually in such form as to give the skull a worm-eaten appearance. 
Pulsation of the swelling may be present after perforation of both 
tables. The gravity of the case is usually altered by the mixed infection 
which often occurs in connection with the marked softening. 

Diagnosis. The diagnosis ordinarily should not be difficult. One 
or more chronic, slightly tender, rather painless swellings on the vault 
of the skull, with a history of syphilis some years before, and with a 
positive Wassermann reaction, would leave practically no question 
about the diagnosis. The vast majority of cases of osteomyelitis of the 
skull, especially on the forehead and the top of the head, not due to 
trauma, are syphilitic. 



318 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

The diagnosis is most difficult in the early stages when there is no 
history of syphilis. In this case the solitary lesion might be mistaken 
for sarcoma, but the multiple lesions never. Tuberculous osteomyelitis 
might have to be differentiated. This, however, is usually found in 
children, and, in almost any event, has usually a primary focus of tuber- 
culosis in the lungs or glands, or some other portion of the body. Not 
only that, but it is more apt to be found associated with a tubercu- 
lous sinusitis, especially of the mastoid. The tuberculin test should 
be positive. Other granulomata, though exceedingly rare, must be 
thought of. 

In syphilis there can usually be found associated lesions, character- 
istic of the disease, in other parts of the body. Furthermore the posi- 
tive Wassermann and the response to rigid antisyphilitic treatment 
clinches the diagnosis. 

Treatment. The treatment consists in energetic antiluetic treatment, 
which is often all that is necessary. Free drainage is indicated in all 
suppurating cases. Gummata resisting treatment should be opened, 
curetted and packed or excised. Dead bone should be removed with a 
chisel or curette, care being used to avoid unnecessary denudation of 
the living bone. Intracranial tension from extradural gummata or 
exudates calls for relief through trephining if there is no prompt 
response to medication. No delay is admissible if the pressure is great. 
In cases of pachymeningitis externa that have resisted treatment care- 
ful curettement is indicated, providing cerebral symptoms are present. 
Defects of soft parts or of the skull may be corrected through plastic 
surgery, though quite a number of cases are on record showing a 
considerable reproduction of the bone in these syphilitic cases, due 
probably to the activity of the dura. 

Tuberculosis. Tuberculosis of the cranial bones, while more com- 
mon than it was formerly thought to be, is nevertheless a rather rare 
condition, limited almost exclusively to childhood. It is usually only 
a part of a more or less generalized tuberculosis. It occurs as circum- 
scribed or diffuse lesions starting generally in the diploe. The circum- 
scribed lesions usually perforate the bone in both directions, though 
occasionally only one or the other of the two tables may be involved. 
A cold abscess is the usual result. The diffuse lesions, the so-called 
infiltrating types, spread along the diploe, perforating here and there 
toward the dura or toward the scalp, resulting in more or less necrosis 
of the bone and tortuous sinuses in the soft parts. The granulomatous 
mass on the inner surface of the skull may push the dura away from the 
bone and set up a pachymeningitis. A leptomeningitis from direct 
invasion is rare, though not uncommon as a hematogenous infection. 
These tuberculous lesions tend to bone destruction exclusively, rather 
than to a combination of overproduction and absorption as occurs in 
syphilis. Tuberculosis of the temporal bone is in a class by itself, 
being usually secondary to tuberculosis of the mastoid. It will be 
described in a subsequent chapter. 



ACUTE INFECTIONS OF THE CRANIAL BONES 319 

Symptoms. The symptoms of tuberculosis of the cranial bones are 
largely objective. Slight pain in the head and local tenderness followed 
by a soft, torpid, fluctuating swelling not due to trauma, with later 
discoloration and perforation of the overlying skin and sinus formation, 
constitute the usual sequence of symptoms. The afternoon tempera- 
ture is always in evidence. The mouths of the sinuses have the char- 
acteristic appearance of tuberculous sinuses. At the bottom of the 
tract one can frequently find, in the circumscribed cases, a small circular 
sequestrum which can usually be easily lifted out, contrary to the case 
in syphilitic necrosis. The soft swelling may pulsate with the brain in 
some cases of perforation of the skull. 




FIG. 87. Perforating tuberculosis of the skull. 

Diagnosis. In the differential diagnosis syphilis can ordinarily be 
excluded by the absence of other lesions characteristic of syphilis, by 
the negative Wassermann test, and by the fact that syphilis of bone is 
usually found in adult life rather than during childhood. In the tuber- 
culous cases one can usually obtain a positive tuberculin reaction. 
Glanders and actinomycosis are exceedingly rare in the cranial bones 
and, when they do occur, it is only as a secondary manifestation of the 
infection in some other part. The specific microorganism can be demon- 
strated in each case. 

Treatment. The treatment of tuberculosis of the skull consists in the 
operative removal of the local lesion if possible, unless contra-indicated 
by the gravity of the associated lesions. Operation is especially 
indicated where meningeal or cerebral symptoms indicate a pachy- 
meningitis with pressure. Bone defects, as in syphilis, are sometimes 
filled in spontaneously. When operation is out of the question, the 
case must be handled as any other case of so-called surgical tuber- 
culosis. The unruptured cold abscess should be aspirated and care- 



320 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

fully injected with formalin and glycerine or iodoform emulsion; but 
if mixed infection has already occurred free drainage is indicated. 

In any event the case always calls for the modern general dietetic 
and hygienic care of tuberculous individuals, including the use of the 
tuberculin. 




FIG. 88. Exostosis of the skull. 



TUMORS OF THE CRANIAL BONES. 

Osteoma. Osteoma is a benign tumor occurring as an exostosis 
chiefly on the outer surface of the cranial bones, though it is also found 
on the inner surface or in one of the accessory sinuses. It generally 
appears at puberty. Enostosis, arising from the diploe, is seldom, if 
ever, seen in the cranial bones. The exostoses are most frequently seen 
on the frontal or parietal bones, usually as a solitary growth and gener- 
ally of the compact type. External and internal exostoses have been 
seen at the same site. As most of the cranial bones are laid down in 
membrane the fibrous osteoma is the prevailing type, though chondral 
osteoma has been met with in the ethmoid and sphenoid. Osteophytes, 
probably of inflammatory origin, are sometimes found on the inner 
surface of the cranial bones, especially in pregnant women and tuber- 
culous cases. 

According to their structure osteomata are spoken of as hard, 
eburnated or spongy. In size they vary greatly. While most of those 
on the cranium are sessile, the pedunculated are sometimes found. 



TUMORS OF THE CRANIAL BONES 



321 



Diagnosis. The diagnosis of the external osteomata of the cranial 
vault is usually easy as they are slow-growing hard tumors firmly 
attached to the bone, with no invasion of the soft parts. They are 
entirely symptomless. Sarcoma, especially ossifying sarcoma and 



^ 




FIG. 89. Osteoma of skull. 




90. Same as Fig. 89, seen from below. 



gumma, sometimes call for exclusion. Konig mentions local atrophy 
of the skull, with bulging due to intracranial pressure, as of some 
differential diagnostic importance. 

The diagnosis of the internal exostoses is a more difficult matter. As 
they are of very slow growth the brain may show no signs of irritation 



VOL. I 21 



322 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

or compression from a moderate-sized tumor, especially over a silent 
area. Where symptoms are present they are usually those of irritation 
or paralysis of the cerebral cortex or cranial nerves. Even then exos- 
tosis will hardly be thought of unless revealed by an x-ray examination, 
or unless an external osteoma is present. 

The signs of osteoma in the accessory sinuses depend upon the special 
sinus involved. As it grows it causes an expansion of the sinus walls in 
the direction of least resistance with a displacement of the adjoining 
soft parts. There is also a tendency to sinus infection due to inter- 
ference with drainage, and sometimes cerebral or meningeal infection, 
leading to the diagnosis of ordinary sinusitis. Thus a bulging over the 
region of the frontal sinus with displacement of the eye downward 
and outward, combined with attacks of sinusitis, is characteristic of a 
frontal sinus osteoma. In the sphenoidal sinus the optic nerves may be 
compressed or the growth may reach into the nasal cavity. 

Treatment. The treatment of exostoses depends upon the location 
and the form of the tumors, and the presence or absence of symptoms 
due to the growth. Thus a pedunculated or a very unsightly tumor 
should be removed; also one causing cerebral or cranial nerve symp- 
toms or displacements of important structures, such as the eye. Those 
leading to sinus infection should also be removed. The internal and 
sinus cases will often call for exploration. If operation is attempted 
thorough removal should be the rule in order to avoid recurrence. The 
sinus cases naturally have a decided mortality rate due to infection. 

Cavernoma. Borchardt 1 cites an interesting case of cavernoma 
communicating with the superior longitudinal sinus, which presented 
itself as a pulsating tumor near the junction of the sagittal and lamb- 
doidal sutures. The entire venous system of the skull was dilated, 
though the arteries were found to be normal at the subsequent post- 
mortem. Intracranial pressure was evidenced by the bilateral choked 
disks. He regarded the case as a progressive phlebectasia pericranii of 
congenital origin. 

Schone has described 8 cases of central cavernoma, and Blecher 5 
cases of cholesteatoma of the cranial bones, (v. Bruns.) 

Echinococcus Cysts. Echinococcus cysts of the cranial bones are 
exceedingly rare. They occur in the diploe, and those reported have 
been of the unilocular type, though most cases in the long bones are of 
the multilocular variety. Atrophy of the adjacent bone occurs. The 
complement-fixation test in the diagnosis of echinococcus lesions is very 
satisfactory. 

Treatment. The treatment of the unilocular cases consists in removal 
of the lining membrane and drainage. 

Sarcoma. Sarcoma of the cranial bones is rare in comparison 
with sarcoma of the extremities. It may be found at any site at any 
age. It is not infrequent in children, and has been found in the newborn. 
It may be primary or metastatic, and, though usually solitary, it may 
be multiple. 

1 Zentralbl. f. Chir., 1913, xxviii, 33. 



TUMORS OF THE CRANIAL BONES 



323 



Histology. The histology of sarcoma of the cranial bones is the same 
as in other regions of the bony skeleton. It may start primarily in the 
pericranium, the dura or the diploe. Any one of the various cell types 
may predominate, the round, the spindle, or the giant cell, though the 
spindle cell seems to be most frequently found. The giant cell belongs 
to the myelogenous sarcoma. Often there are mixed-cell types. Endo- 
thelioma may arise from the vessels in the bone, giving rise to angio- 
sarcoma. 

Symptoms. The symptoms naturally depend upon the location of 
the tumor, whether encroaching upon the cranial cavity or not, upon 
the matter of invasion of the brain or involvement of the cranial nerves 
or accessory sinuses, etc. As a matter of fact the dura seems to act as 




FIG. 91. Osteosarcoma of the temporal region. 

thyroid. 



Metastatic tumor in the arm and 



a barrier against invasion and so the sarcoma tends outward, no matter 
where it starts. In the cases starting on the inner surface the symptoms 
may be the general symptoms of brain tumor, plus, in many cases, the 
focal symptoms due to pressure on or invasion of some special point 
on the cortex of the brain. When perforation of the skull eventually 
occurs the cerebral pressure symptoms are relieved and the tumor 
becomes manifest under the scalp. Before long the scalp is invaded, its 
subcutaneous veins greatly enlarged and ulceration results in the usual 
bleeding fungus of sarcoma. 

In myelogenous sarcoma arising in the diploe the periosteal irritation 
sometimes leads to the formation of a bony capsule on the outer side, 
resembling a separation of the tables, or, in the early stages, an osteoma. 



324 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

In this variety and in those starting on the surface of the skull there are 
usually no brain symptoms, except possibly headache, and the tumor 
presents itself early as an external swelling with sometimes more or less 
pain and tenderness. 

Diagnosis. The diagnosis of sarcoma of the cranial bones, like most 
deep tumors in other portions of the body, is seldom made in the earliest 
stages when operation has the most to offer. Too often it is the visible 
or palpable tumor that is the first recognized sign of sarcoma of the 




FIG. 92. Fungating osteosarcoma of cranium. 



skull. At first this tumor is a flat, rounded swelling attached immov- 
ably to the bone. Though it may be hard at first, it frequently becomes 
softer in the later stages, and, as it grows more rapidly in the softer 
tissues than in the bone, it may be somewhat constricted at the base. 
The galea for a time may act as a barrier to malignant invasion, but 
soon the fixation of the skin, with its enlarged veins, becomes marked. 
Given such a tumor in the early stages, it is necessary to differ- 
entiate sarcoma, primary or secondary, secondary carcinoma, gumma, 
tuberculosis and actinomycosis . The rare myeloma, chloroma and 



TUMORS OF THE CRANIAL BONES 325 

echinococcus cysts, as well as the more common simple osteoma, must 
also be considered. 

A general physical examination will help to determine the presence 
or absence of similar or coincident lesions in other portions of the body, 
and thus aid in the differentiation of syphilis and tuberculosis, metas- 
tatic sarcoma and secondary carcinoma. An accurate, orderly clinical 
history, combined with the usual Wassermann and tuberculin tests, are 
absolutely necessary. A skiagraph may be of distinct service. In case 
syphilis cannot be excluded by these means a vigorous antisyphilitic 
treatment for three weeks should be tried. Tuberculosis is more apt to 
present itself as a soft fluctuating mass, a cold abscess from the begin- 
ning; while actinomycosis is a distinctly inflammatory tumor, and is 
practically always present in some other part of the body primarily. 
After the tumor is once open the finding of the ray fungus settles the 
diagnosis. Myeloma shows itself as multiple myelogenous tumors, 
confined entirely to the bony skeleton, with the Bence-Jones body in 
the urine. Myelogenous sarcoma in the early stages with its outer wall 
of new periosteal bone, and ossifying sarcoma, may be mistaken for a 
time for simple osteoma (exostosis). The rapid growth of sarcoma, 
however, soon rules out osteoma. Sarcoma of the dura must present 
symptoms more like a brain tumor, and hence is not usually considered 
in the above diagnosis until it begins to perforate the skull, or until a 
skiagraph offers the suggestion. 

Treatment. The treatment of sarcoma, here as elsewhere, consists 
in wide excision unless the case is considered inoperable because of 
metastasis or too extensive local invasion. Excision with the actual 
cautery has distinct advantages. From the standpoint of the cell type 
the myelogenous variety should offer the best prognosis, but, as a 
matter of fact, the external or pericranial tumor can be recognized 
earliest of all, and hence should offer a prognosis which is less serious 
than that of the deeper sarcomas. They are all bad. 

Myeloma (Multiple Myelema). Myeloma is a systemic disease 
characterized by the formation of multiple tumors confined entirely to 
the osseous system, the bones of the trunk and skull rather than the 
long bones being chiefly involved. Starting in the marrow it leads to a 
softening and absorption of the bone. Simultaneous development of 
multiple foci, rather than metastasis, is the rule. It has been found 
more often in males over forty years of age. The cause of the disease 
is unknown. The urine in these cases contains a heterogenous albumose 
known as the Bence-Jones body. This body has been found in the urine 
prior to the recognition of the tumors. The prognosis is absolutely 
hopeless. 

Chloroma. Chloroma is a very rare form of tumor which derives 
its name from its green color. It seems to have some connection with 
myelogenous leukemia and spreads by metastasis like a sarcoma. 
Simmonds and Homer 1 conclude that "Chloroma is only a biological 

1 Deutsch. med. Wchnschr., 1914, xl, 260. 



326 INJURIES AND DISEASES OF SKULL AND ITS COVERINGS 

subvariety of leukemia with a special tendency to malignant prolifer- 
ation." Reid 1 states that "they originate in the periosteum, generally 
of the skull bones, and show unbounded proliferation into the soft parts. 
They are generally accompanied by changes in the blood picture." He 
cites a case, however, which did not originate in the periosteum and 
which was not accompanied by blood changes. The blood changes are 
those of myeloblastic leukemia. Dock 2 calls attention to the fact that, 
notwithstanding their usual origin in the periosteum, they show none 
of the elements ordinarily found in periosteal tumors no spindle or 
giant cells, and no tendency to bone formation. They are associated 
with the myeloblastic type of leukocyte. He calls it an aberrant form 
of myelomatosis. Authors disagree as to whether the disease is to be 
classed among the leukemias or the sarcomata. The cause of this 
disease is unknown. It occurs chiefly in the bones of the skull, the spine 
and in the humerus. The tumors on the skull are said to form " flat, 
plate-like masses, often extending over lai^e areas." (Hektoen- 
Riesmann. 3 ) 

1 Beitr. z. klin. Chir., 1915, xcv, 47. 

2 Am. Jour. Med. Sc., 1893, cvi, 152. 

3 An American Text-book of Pathology, p. 205. 



DIAGNOSIS AND TREATMENT OF TUMORS, 

INFLAMMATIONS AND ABSCESSES 

OF THE BRAIN. 

BY ALLEN B. KANAVEL, M.D., 
TUMORS AND ALLIED PROCESSES IN THE BRAIN. 

Diagnosis in Brain Tumors. 

THERE is no more fascinating field in surgery than that of diagnosis 
in brain tumors fascinating because it calls for the highest degree of 
reasoning power based upon an intimate knowledge of intricate 
anatomical structures and for an intensive study of the symptoms and 
signs to be elicited in a given case. Many are the disappointments of 
the most careful observer and yet, on the other hand, brilliant success 
does at times reward the student. Much of the pessimism of the 
profession regarding results in brain tumor cases is justified, but 
unfortunately this pessimism has been unduly magnified by careless 
diagnosis on the part of the internist and by hasty, injudicious oper- 
ations on the part of the surgeon. These cases should all be under the 
care of the trained observer for many days before any operation is 
carried out, except under the most urgent circumstances. The oper- 
ations should be performed with the knowledge that more than familiar- 
ity with surgical cleanliness and technic is required by the surgeon. 
Each operation should be planned with the idea of reaching and remov- 
ing the tumor, not with the idea of opening the skull, and, after a 
hasty examination, doing a decompression. Manifestly this calls for 
the possession of a high degree of neurologic knowledge by the surgeon 
as well as the internist. 

That care should be exercised by the diagnostician is especially 
emphasized when one remembers that while there are known focal 
centers, there is a large "silent" area in the brain. Association fibers 
serve to confuse the picture by reacting to neighborhood stimuli and 
by assuming destroyed functions if the process grows slowly. The 
most important factor is that the known tracts and focal centers are 
so closely associated that involvement of one will produce spurious 
signs on the part of the others. Therefore, it follows that the history 
of the development of the tumor is of the greatest importance. The 
very earliest symptoms should be painstakingly sought for, since in 
the later stages the pictures become almost too complex for under- 
standing; for example, the early deafness may serve to differentiate a 

(327) 



328 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

cerebellopontine from a cerebellar tumor. In general we should always 
bear in mind that the symptoms fall into four groups: 

A. Those produced by irritation or depression of the neurological or 
physiological function of the area involved; e. g., monoplegic motor 
paralysis, or acromegaly associated with hypophyseal disease. 

B. Those produced by irritation or depression of neurological or 
physiological function in adjacent nervous structures and changes in 
other adjacent anatomical structures; e. g., sensory aura in motor 
tumors, adiposity in third ventricle hydrops, changes in the cerebro- 
spinal fluid, and the enlarged sella turcica in hypophyseal tumors. 

C. Those associated with the nature of the growth. Here we 
emphasize the coincident systemic tuberculosis in the tubercles of the 
brain; the leukocytosis, fever, ear and nose findings, etc., associated 
with abscess; the Wassermann and syphilitic findings in gumma; the 
destruction of tissue and rapid growth associated with sarcoma; the 
cystic degeneration and sudden hemorrhage j,vith consequent signs 
found in gliomata; evidences of carcinoma, deciduoma malignum, 
neurofibromatosis, etc. 

D. Those produced by the general increase of intracranial pressure. 
To elicit these facts a most careful examination is necessary, and 

the neurological student will do well to familiarize himself with a defi- 
nite routine in his investigation. The following method is suggested. 
It must be amplified when the general location of the tumor has been 
found, and intensive study must be directed to this location. 

I. History given by the patient orHhe mode of onset and course of 
the disease. After the statement is made by the patient, it must be 
amplified by direct questioning bearing on the points brought out by 
the patient and suggesting new correlative data for the patient to 
accept or refuse as a part of his history. Questions should be asked 
concerning sensory and motor symptoms; e. g., spasms, convulsions, 
anesthesia, burnings, and tinglings. The date of the onset of each new 
symptom is of the greatest importance. 

II. Family history, e. g., syphilis, tuberculosis. 

III. Previous disease, and if a woman, obstetrical history; e. g., 
syphilis, nephritis, ear disease, nasal disease, injuries, infected mis- 
carriages. 

IV. Examination. 

A. General physical examination. 

B. Examination of the nervous system. 

1. Mental functions, e. g., intelligence, memory, drowsi- 

ness, coma, hallucinations. 

2. Local examination bf head, e. g., local tenderness, 

tumors, thin hair, local infection. 

3. Cranial nerves. Examine each in order for irritation 

and paralysis. Gross tests are made of the 
second and eighth and these reserved for full 
study later, 
(a) Smell. 



TUMORS AND ALLIED PROCESSES IN THE BRAIN 329 

(6) Field of vision, form, color. Ophthalmoscopic 
examination, choked disk, atrophy, hemor- 
rhages, choroiditis, etc. 

(c) (d) (e) Ocular movements, con vergences, diplopia, 
nystagmus. Pupils comparative size, shape, 
reaction to light, accommodation. 

(/) Sensation face and mouth. 

(g) Motor: face, forehead, taste, chorda tympani in 
anterior two-thirds of tongue. Mouth: mas- 
se ters, temporals. 

(h) Hearing air and bone. 

(i) Taste posterior third of tongue, anesthesia of 
pharynx, difficulty of swallowing. 

(?) Palate. Heart. Respiration. Vocal cords. 

(k) Motor sternomastoid and trapezius. 

(/) Motor tongue. 

4. Spinal nerves. 

(a) Motor head, neck, arms, intercostal and ab- 

dominal muscles, legs. Investigate paralysis, 
paresis, incoordination in gait, and adiado- 
kokinesia and pointing tests, atrophy. 

(b) Sensory subjective: pain, headache, vertigo, 

tingling, formication. Objective: absent and 
increased reaction, touch, pain, temperature, 
stereognosis. 

5. Reflexes. 

Superficial: conjunctival, palatal, epigastric, ab- 
dominal, cremasteric, plantar, anal. Deep: jaw, 
radial, knee, Achilles tendon, ankle-clonus, knee- 
clonus, Babinski. 

6. Sympathetic : proptosis, exophthalmos, local or general 

vasodilatation or contraction. 

7. Functional tests and examination: speech, bladder, 

rectum, genital, hypophyseal adiposity, growth, 
etc., pineal. 

8. Special laboratory tests: blood, urine, Wassermann 

spinal fluid, Abderhalden, x-rays, brain puncture. 
Cerebral Localization. General. The hope of relief in an individual 
case must rest upon our knowledge of functional localization. The 
difficulties of accurate localization rest, not so much upon our ignorance 
of the centers for special function, as upon the fact that the brain is 
largely made up of association centers and tracts, so that although we 
may know well the center for a special function, we may yet be in 
doubt in a given case as to whether there may be involvement of the 
center itself, of the fibers leading to it, or away from it, whether there 
may be involvement of the association fibers correlating the function, 
or of the motor fibers expressing the function. This is well illustrated 
in cases of aphasia of which there are so many forms. 



330 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

Galen drew attention to the occurrence of contralateral paralysis in 
traumatic lesions of the head, and the small trephine openings over the 
motor areas in the Peruvian skulls suggest a like knowledge by these 
people. Gall, the founder of phrenology, must be given credit for the 
revival of modern study upon this subject, since he recognized more 
clearly than his predecessors that the cerebral hemispheres were the 
seat of intelligent acts and functions, although Flourens disproved the 
assumption Gall made as to their seat. Broca in 1861 confirmed the 
older statements of Dax that aphasia in right-handed people was asso- 
ciated with a lesion of the third frontal convolution of the left side, 
hence known as Broca's convolution, although later Marie proved the 
lack of constancy of this. Hughlings Jackson, in 1864, drew attention 
to localized spasms with lesions of certain parts of the central con- 
volutions. The first direct evidence of motor localization was brought 
forward by Fritsch and Hitzig in 1870, when by experiments on dogs 
they showed that the gray matter of the corte^ was excitable and that 
by irritation at specific points it was possible to produce certain move- 
ments. Ferrier elaborated and confirmed these observations on the 
monkey. Horsley later added much, while Schafer, Beevor, Gushing, 
Frazier, and many others have contributed both experimental and 
clinical observations. To Sherrington particularly, we owe a great 
debt for his careful and painstaking studies, especially that part in 
which he demonstrated that the motor zone lies in the anterior central 
convolutions. 

The relations of the various convolutions and sulci should be clearly 
understood by the neurological surgeon, since at any time it may be 
necessary for him to enter various areas for exploration or the extir- 
pation of tumors. The sulci are most vascular and should be avoided 
where possible. The most superficial layer of the brain is made up 
largely of association fibers; consequently destruction of this layer 
may not lead to permanent impairment of function. A microscopic 
section will show the following cell structure from the cortex inward, 
the following layers with approximate thicknesses as follows: (1) 
molecular, 0.34 mm.; (2) small pyramidal, 0.90 mm.; (3) stellate cells 
or granular layer, 0.22 mm.; (4) large pyramidal in the motor area 
has large solitary cells, cells of Betz, 0.22 mm.; (5) polymorphous cell 
layer, 0.31 mm. 

Roughly, the function of these layers may be classed as follows: 
the pyramidal cells, associative; the granular layer, sensory; the large 
pyramidal cells of Betz, motor; and the polymorphous layer, which 
presides over the lower functions such as sexual desire, the getting of 
food, etc. From the cortex the various fibers pass to the base of the 
brain and to different parts making groups known as projection, 
association, and commissural fibers, a complete discussion of which 
would be too extensive for inclusion here. 

Attention should be drawn to the centers for the cranial nerves, 
since involvement of these is of so much importance in localization. 
The centers and function of the first eight are well known. When the 



PLATE II 



FIO. I 




Cerebral Localization, 



FIG. 2 




Cerebral Localization. 

Note the large number of centers upon the vertex. 



TUMORS AND ALLIED PROCESSES IN THE BRAIN 331 

centers for the others are involved by a tumor lying along the aqueduct 
of Sylvius and the fourth ventricle, certain reflex acts are impaired, 
such as respiratory and vasomotor function, cardiac inhibition, masti- 
cation, deglutition, sucking, vomiting, phonation, articulation, in 
addition to the impairment of the function of other cranial nerves. 
In such cases we speak of these acts as if they had a special center, 
e. g., cardiac center, swallowing center, vasomotor center, etc., rather 
than distinguishing the individual nerve,' since the impaired function 
can seldom be referred to one nerve or separated from others. 

The "silent area" found in the human brain is largely made up of 
association fibers. These "silent areas" increase in amount as we 
ascend the scale of intelligence. They are particularly seen in the loca- 
tions of known sensory tracts and should be described in connection with 
the tract with which they are most closely connected; e, g., the visual- 
sensory and visual-association, the auditory-sensory and the auditory- 
psychical. This also serves to emphasize the difficulty of localization 
since the higher we go in the scale of life the greater must be the 
latitude allowed for the location of a tumor because here it may either 
involve the center or its association tract. Thus we see that in the 
future the knowledge of localization must come from intensive study of 
the physical findings and the chronological history of disease in each 
individual case, the collection of numbers of such observations, and the 
correlation of the findings, rather than from experimental observations 
on lower animals. 

The most satisfactory results of localization study have been secured 
in investigations of the motor area. While it was originally believed 
that the motor areas extended both anteriorly and posteriorly from the 
central fissure, we know now, thanks to the investigations of Sherring- 
ton, that they are located anterior to the fissure. The relation of these 
centers may be seen by reference to the accompanying drawing (Plate 
II), showing the centers as depicted by Sherrington and others. The 
motor cells extend to the floor of the central fissure. 

In operating it should be remembered that these centers lie more on 
the vertex than on the side of the brain. In dogs the ablation of these 
centers produces a paralysis from which the dog later recovers; in 
monkeys, the recovery is slower and less complete; while in man a 
destruction of the centers produces permanent paralysis. At times, 
however, we see recoveries from a paralysis apparently complete, but 
such cases are probably due to an injury of the association tracts. At 
times such a paralysis may be seen clearly to be outside t)f the motor 
centers, since the loss of motion is chiefly in relation to volitional move- 
ments, e. g., the arm may be paralyzed yet may be raised in association 
with a movement involving the other arm. In such cases a small 
degree of recovery may be noted. 

The predominant influence of the motor cortex is inhibitory of^the 
stronger muscles of the body and the tonus which is constantly main- 
tained. Thus when we excite the motor cortex, an inhibition of the 
postural tone and of the antagonistic muscles is brought about as well 



332 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

as a stimulation of the muscles directly involved. This is proved by 
the experimental removal of the cerebrum in dogs, which leads to gen- 
eral muscular rigidity, "decerebrate rigidity" so-called. It follows, 
therefore, that in those cases in which the inhibitory function of 
the cerebrum is removed, as for instance where conduction through 
the pyramidal tracts is interfered with, we will have spasticity of the 
muscles. 

Sherrington and Griinbaum have shown by experimental observation 
that tactile and muscular sensibility is chiefly" related to the central 
convolutions including those anterior to the central fissure, but that 
they are especially dependent upon the postcentral gyrus. Starling, 




FIG. 93. Endothelioma of forebrain. (Northwestern University Medical School 

collection.) 

to whom I am indebted for abstracts freely taken, says that Fleshsig 
has shown that fibers from the thalamus which may probably be 
regarded as continuations of the fillet system, are also distributed to 
other portions of the cortex, i.e., temporal, frontal, and occipital lobes. 
It is therefore not surprising that the hemi-anesthesias produced by 
lesions of the central convolutions are rarely or never complete. 

The senses of pain and temperature probably lie in the intermediate 
postcentral zone of Campbell, i. e., in the posterior part of the post- 
central gyrus, and stereognostic sense in the parietaHobe. 

Special. FRONTAL LOBES. The third left frontal lobe Broca's con- 
volution has long been considered as the center for motor speech 



TUMORS AND ALLIED PROCESSES IN THE BRAIN 333 



and undoubtedly we do at times find an impairment of speech from 
tumors located here; but whether this impairment is due to destruc- 
tion of the tissue at that area or to pressure upon adjacent brain-tissue, 
is open to question. At the present time, for the reasons mentioned 
below, when discussing temporal lobe tumors, considerable doubt must 
be thrown upon this assumption. 

The presence of psychical disorders has also been ascribed to tumors 
of the frontal lobes, but it must be admitted that these phenomena 
may be associated with tumors in any part of the brain, as Miiller has 
shown, and probably they have little localizing value. Franz 'has 
shown by experiments on monkeys that destruction of the frontal lobes 
causes loss of recently formed habits. He concludes that the frontal 
lobes are the means by which we are able to learn and form habits, 
that is, to regulate our behavior in accordance with the needs of our 
position in society. 




FIG. 94. Tuberculomata of cortex monoplegic signs in the early stages. 
(Northwestern University Medical School collection.) 

Bruns first drew attention to rigidity of the neck and cerebellar 
ataxia and thought these symptoms were due to tumors lying in the 
marginal gyrus and the corresponding portion of both frontal lobes. 
Granger and Stewart have drawn attention to the disappearance of the 
abdominal and epigastric reflex on the opposite side and a fine tremor 
on the same side which they have shown in some cases by holding the 
extremities outstretched. This finding is not constant, however, and 
when present is most often seen in the arm. Petit mat may be seen. 
Early and persistent anosmia due to pressure on the olfactory nerve 
may be seen in tumors beginning on the under surface. 

Motor and Sensory Zones. Tumors of the cortical motor zone lying for 
the most part in the anterior central gyrus give contralateral signs, those 



334 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

upon or near the surface being characterized by irritative symptoms; 
e. g., epilepsy followed by paralysis, the latter being primarily monoplegic 
brachial, facial and later more general (Fig. 94). The deeper the 
tumor lies, the less irritative it becomes and the more a paralysis may 
precede convulsions. Moreover, the extent of paralysis is great early 
in its course extending even to a complete hemiplegia at the internal 
capsule or above (Fig. 95). Hemorrhage into a tumor, for instance into 
a glioma, may produce a sudden paralysis. Paracentral lobule tumors 
may give bilateral symptoms. 

Owing to the juxtaposition of the sensory areas in the posterior 
central gyri, the convulsive attacks are frequently preceded by aura, 
such as paresthesia in a part of an extremity burning in the dis- 
tribution of a nerve of the foot. As the growth extends into these 




FIG. 95. Central glioma early hemiplegia. 



areas the evidences become more marked although complete hemi- 
anesthesia is seldom produced. There may be impairment of tactile 
sensibility alone, or all types of cutaneous sensibility may be affected. 
The sense of position may be affected. Complete and persistent 
analgesia and thermo-anesthesia are apparently never caused by cir- 
cumscribed cortical foci. 

Astereognos's, i. e., the loss of ability to recognize objects by palpation, 
may be seen, especially in tumors of the postcentral gyrus. The deeper 
the tumor lies, the more extensive the anesthesia, although it is seldom 
characteristically hemilateral unless the lesion involves the posterior 
zone of the internal capsule or the corresponding ganglion masses in 
the optic thalamus, or the complete bundles in their course. Symptoms 
of sensory irritation, e. g., contralateral pain, are uncommon in cortical 
lesions but may accompany deeper foci. 



TUMORS AND ALLIED PROCESSES IN THE BRAIN 335 

TEMPORAL LOBES. The centers definitely established for the 
temporal lobes are the bilateral ones for taste and smell and the left 
unilateral center in right-handed individuals for sensory appreciation 
of speech. However, owing to the pressure of tumors upon adjacent 
areas, the symptoms in these cases may be most complex. Tumors 
involving the median area of the temporal lobes, the gyrus fornicatus, 
and the uncus, give rise to the so-called uncinate fits, an attack begin- 
ning with a disturbance of taste or smell, generally most unpleasant, 
followed by a dreamy, confused state or semi-unconsciousness lasting 
several seconds. These attacks may be accompanied by motor phe- 
nomena, such as smacking of the lips or even convulsions. 

It should be remembered that direct pressure upon the first nerve 
may produce similar sensations. The exact location and limitations 
of the centers for taste and smell are still undetermined. In animals, 
with these senses highly developed, marked growth is seen in the 
olfactory lobe including the bulb, the dentate convolution with the 
hippocampal gyrus, the part of the gyrus fornicatus encircling the 
corpus callosum and the anterior commissure. To these areas the sense 
of taste and smell are generally ascribed but nothing definite is known. 

Owing to the complexity of the function of speech, the exact location 
of the centers controlling it is somewhat doubtful. It is thought that 
sensory aphasia, word deafness, loss of the power of understanding 
speech, may be produced by a lesion of the posterior part of the first 
left temporal convolution or in the angular or supramarginal gyri; 
while pure alexia, word blindness, occurs with destruction of the 
posterior part of the third left temporal convolution. 

It must be remembered that these are not centers in the strict inter- 
pretation of the word, but are really association tracts, and that inter- 
ruption at various points will give varying types of aphasia. Broca's 
convolution in the frontal lobe has long been considered as the motor 
center, but reports of clinical cases of tumors in this region without 
impairment of speech a condition which has been especially studied 
by Marie combined with the experimental evidences that this center 
can be destroyed without harm, and with microscopic proof that the 
cells do not resemble those of known motor areas, all cast doubt upon 
this assumption. It should not be forgotten, however, that tumors in 
this region have produced loss of speech; whether due to local destruc- 
tion or pressure upon adjacent areas may be open to question. It is 
thought by some that pure motor aphasia is to be associated with a 
lesion of the lenticular nucleus or its neighborhood, in the anterior 
part of the genu of the internal capsule and possibly of the external 
capsule. 

It should be noted that temporal lobe tumors may cause convulsions 
or disturbance of consciousness which are ushered in by auditory 
aura, such as tingling and whistling in the opposite ear. If the tumors 
lie deeply, pressure upon the posterior end of the internal capsule may 
produce contralateral hemianesthesia or even hemiplegia; likewise 
hemianopsia may appear in the contralateral half of both visual fields 



336 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

due to involvement of the underlying optic radiation. Pressure upon 
the optic thalamus, since it is a reflex center for emotional expression, 
may produce marked diminution of emotional expression upon the 
opposite side of the face. 

OCCIPITAL LOBE. Since the occipital lobe is the center of vision, the 
characteristic evidence of tumor here is disturbance of the visual sense 
(Plate III). The center is situated on the mesial aspect for the most 
part, lying partly above and partly below the calcarine fissure. The 
lower quadrant of the half field is represented above the fissure, i. e., 
in the cuneate lobule; the upper quadrant below, i. e., in the lingual 
lobule. It follows that in rare cases, temporonasal hemianopsia may 
be seen and in extremely rare cases, quadrate blindness. Evidences of 
irritation may be seen in hallucinations of vision such as flashes of 
light. These frequently precede hemianopsia, but may be met in the 
blind area later. Bruns says choked disk is rare. Wernike's hemiopic 
pupillary phenomenon of course is absent. 

"Wernike's hemiopic pupillary phenomenon is an absence of pupil- 
lary contraction when a ray of light is thrown on the blind half of the 
retina of an eye having hemianopsia. It signifies a lesion of the visual 
path behind the chiasma and below or at the corpora quadrigemina. In 
retroquadrigeminal hemianopsia, where the lesion is anywhere between 
the corpora quadrigemina and the visual cortex, the pupillary reaction 
is normal." (Stewart.) 

CENTRAL GRAY MATTER. Tumors lying in the central gray matter 
and basal ganglia and in the wall of the third ventricle, produce the 
general symptoms of brain tumor with varying phenomena as the 
different centers may be involved. The picture is often most complex. 
Weisenberg has collected the literature and classified tumors of the 
third ventricle as follows: 

" 1. Those cases in which a tumor of moderate size is situated in the 
floor of the third ventricle and in which there is no extension into the 
foramen of Monro or aqueduct of Sylvius. 

"2. Small tumors so situated as to obstruct the foramen of Monro, 
the position of which can be changed by deviation of the head. 

"3. Those tumors, whether large or small, which either extend into 
the aqueduct of Sylvius affecting the surrounding structures by direct 
extension or pressure, or those in which the posterior portions of the 
cerebral peduncles and pons are compressed, either by direct pressure 
or by dilatation of the .aqueduct of Sylvius. 

"The first class does not offer specific symptoms, but present evi- 
dences of internal hydrocephalus, viz., headache, choked disk, nausea, 
vomiting, and dizziness. In tumors of large size, indirect pressure upon 
the internal capsule causes paresis of the corresponding limbs. These 
symptoms may likewise result from internal hydrocephalus alone. The 
reflexes are nearly always increased. The mental symptoms, generally 
supposed to be present in tumors of the third ventricle, are attributed 
by Mott to impairment of the function of the cortex as a result of the 
pressure of the dilated ventricles. 






TUMORS AND ALLIED PROCESSES IN THE BRAIN 337 

"The second class is unimportant as but one case has been observed. 
This group presents a variation in symptoms of headache, nausea and 
impairment of vision upon tilting the head forward. 

" The third class offers a fairly well-recognizable symptom-complex. 
The symptoms arise from involvement of the third nerve nuclei, red 
nucleus, or superior cerebellar peduncles and from pressure upon, or 
destruction of, the posterior longitudinal bundle or the intercommuni- 
cating fibers between the third nuclei. Among the symptoms noted 
are disturbance of associated o'cular movements, oculomotor palsies, 
large pupils with impaired reaction, protrusion of the eyeballs, cere- 
bellar ataxia, symptoms arising from pressure upon the pineal gland, 
and the general symptoms of tumor cerebri." 

In central tumors the internal capsule is generally affected with 
consequent hemiplegia. In Oppenheim's experience, the facial is fre- 
quently first involved, accompanied by impairment of the reflexes as 
in pyramidal involvement. There may be motor excitability, contra- 
lateral hemichorea, or athetosis, increased on voluntary motion; 
hemianesthesia ; hemianopsia. Many thalamic tumors may have no 
symptoms while in other cases contralateral movements as above, due 
to adjacent rubrospinal tract involvement, may be seen accompanied 
at times by contralateral subjective sensations of heat, cold, pain, etc. 

CORPUS CALLOSUM. There are no definite signs of lesion in the 
corpus callosum. Bristow has given the following symptom-'complex 
as suggestive : slight signs of general pressure with marked impairment 
of intelligence, hebetude, hemiparetic symptoms followed by involve- 
ment of the opposite side and absence of involvement of cranial nerves. 
Large incisions may be made through the corpus callosum without 
serious permanent symptoms. 

CEREBELLUM. The complex functions of the cerebellum have been 
a fruitful source of study. The symptoms of tumor growth are better 
understood if we remember that complete unilateral extirpation in 
animals gives rise to three symptoms; slight loss of power upon the 
same side of the body, asthenia; considerable loss of tone on the same 
side, atonia; tremors or rhythmical movements of muscles on the 
same side accompanying any willed movement, astasia. An animal 
so affected lies upon the same side, being unable to stand, the head and 
neck are curved to the side on which it lies, and upon attempting to 
stand, the animal falls to the same side. After a time although it may 
stand, it has the symptoms mentioned above. Sherrington concludes 
from such investigations that the cerebellum is the head ganglion of the 
proprioceptive system acting as a center to which are sent the afferent 
impulses from the cord, fifth nerve, and especially the labyrinth. "It 
furnishes the subconscious basis for the guidance of the motor functions 
of the cerebrum. Through its connections with the bulb it augments 
the tonic activity of the muscles and consequently when the cerebrum 
is removed, gives rise to rigidity of the body known as '. decerebrate 
rigidity.' " (Sherrington.) 

The symptoms of tumors as emphasized by Stewart, Oppenheim, 

VOL. i 22 



338 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

Hoppe, and others, may be summarized as follows: Stewart and 
Holmes have described a typical picture of lateral lobe tumors in which 
symptoms appear upon the ipsolateral side consisting of paresis, 
diminished muscular tone, asynergia on voluntary movements, espe- 
cially in the arm, weakness of conjugate movements of the eye toward 
lesion, horizontal nystagmus on the ipsolateral side, and subjective 
vertigo in which objects appear to rotate toward the contralate *al 
side. Adiadokokinesia and insecurity in standing on the ipsolateral 
side are therefore important signs. Oppenheim, Spillar, Hoppe, and 
others have found these symptoms at times, but again they may be 
absent. 

Vertigo with loss of equilibrium and nystagmus without a preponder- 
ance of ataxia on either side are seen especially in vermis tumors. 
Cerebellar "fits" have been seen in a few cases. These are character- 
ized by tonic spasms, sudden in onset, especially in the face on ipso- 
lateral side. The ipsolateral leg is adducted, the^contralateral abducted 
and there is a screwlike rotation of the limbs, trunk, and head about 
their own long axis. 

Cerebellar tumors may be latent or atypical. The symptoms also 
vary with the location of the tumor. The extracerebellar tumors 
naturally give rise to extracerebellar symptoms early, and intracere- 
bellar, late; e. g., pressure or irritation of fifth, seventh, eighth, and 
other cranial nervefe, pressure on pons, with alternating hemiplegia 
and paralysis with conjugate deviation toward the side of the tumor, 
pressure upon the medulla with its centers and nerves, pressure upon 
the pyramidal tracts, with hemiparesis and paraparesis spastic in 
nature, pressure obstructing the flow of the cerebrospinal fluid with 
hydrocephalus with pressure upon the optic nerve and blindness, also 
anosmia, occipital lobe symptoms, and increased intraspinal pressure 
possibly destroying knee-jerks. The general symptoms are prominent; 
vomiting is quite constant, bilateral choked disk appears early, head- 
ache is most often in the occipital region accompanied by pain in the 
neck and the upper part of the back, but it may be in the frontal 
region. 

CEREBELLOPONTINE ANGLE. Tumors here if typical in onset are 
easily recognized. In this region as elsewhere, a study of the symptoms 
in their chronologic order is of the greatest importance. Since the 
tumor is frequently a neurofibroma or endothelioma growing from the 
eighth nerve, the patient gives a history of a slowly developing buzzing 
or ringing in the affected ear followed by deafness. The coincident 
or subsequent involvement of the fifth, sixth and seventh nerves gives 
symptoms ordinarily ushered in by burning or tingling over the face 
on the same side and loss of eorneal reflex. This is accompanied or 
followed by evidences of pressure upon the cerebellum, pons, and 
medulla; vertigo, ataxia, nystagmus, paralysis of conjugate deviation, 
and bulbar symptoms. General symptoms of brain pressure develop 
early. The absence of these and a tendency to bilateral involvement 
tend to differentiate the tumors of the pons from the tumors of the 



TUMORS AND ALLIED PROCESSES IN THE BRAIN 339 

cerebellopontine angles, while in cerebellar growths the cerebellar 
symptoms precede the nerve symptoms and are more marked. A 
somewhat similar picture may be produced by basilar syphilis or 
meningitis, by sarcomata growing from the meninges, gliomata growing 
from the ventral surface of the cerebellum, as well as by other tumors 
of the immediate neighborhood. 




FIG. 96. Cerebellopontine tumor. This patient presented but few of the typical 
symptoms of cerebellopontine angle tumors, having no definite paralysis of the seventh 
or other cranial nerve symptoms. The slight weakness in the left arm and leg with a 
history of some slight impairment of auditory function combined with the evidences of 
general brain pressure led us to do suboccipital operation. The tumor was found and a 
considerable area scraped away but owing to cardiac symptoms appearing due probably 
to pressure on the vagus whenever the tumor was touched in its deeper part, the operation 
was discontinued. The patient recovered from the immediate operation but died six 
weeks later of brain pressure. (Wesley Memorial Hospital, No. 56035.) 

PONS AND MEDULLA OBLONGATA. The tumors of the pons are 
most often gliomata or tuberculomata, and the local signs are more 
marked than the general. Choked disk is generally absent. The 
typical picture is that of a hemiplegia alternans, presenting commonly 
a paralysis of the fifth, sixth and seventh nerves, on the ipsolateral, 
and the extremities on the contralateral side. The eighth nerve may 
be involved on one or both sides, and the third on the same side. The 
seventh may be the only nerve involved early, and Oppenheim has 
reported several cases in which long before paralysis of the opposite leg, 
the patient presented ipsolateral facial paralysis, paralysis of conjugate 
deviation, and Babinski's reflex on the contralateral leg. He has also 
drawn attention to conjugate deviation of the eyes and the turning of 
the head toward the contralateral side. In the majority of cases, owing 
to the extension of the tumor, .there soon develops bilateral paralysis 
of the cranial nerves and the extremities, accompanied by dysarthria 



340 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

and dysphagia. Less often owing to extension, pressure, or location 
in the dorsal region of the pons, we may have sensory disturbances, 
hemiataxia, or convulsions. 

The tumors of the medulla have many symptoms in common with 
pure pontine tumors, except that they involve the eighth to twelfth 
nerves more prominently giving rise to deafness, difficulty in swallowing 
and respiration, hiccough, dysarthria accompanied by irregular heart, 
and at times glycosuria, diabetes insipidus, and vasomotor phenomena. 
Pressure on the cerebellum may produce cerebellar symptoms. 

CEREBRAL PEDUNCLES. Tegmental Region. Due in all probability 
to involvement of the red nucleus, we have here the so-called "Bene- 
dikt's syndrome" consisting in an ipsolateral paralysis of the third 
nerve with contralateral paresis accompanied by an intention tremor 
of the type of paralysis agitans or chorea, due to an interruption of the 
rubrospinal tract (Monakow's bundle). This tremor has been found 
in eight out of eighteen peduncular tumors repp/ted. If the growth 
involves the median fillet, we have contralateral anesthesia. 

Ventral Region. Here we have incomplete third nerve palsy of the 
ipsolateral side, and contralateral hemiplegia face, arm and leg 
usually associated with spasticity. Owing to the close relation of the 
nuclei of the third nerve, the growth early produces a bilateral paralysis 
of this nerve (nine out of eighteen cases). 

CORPORA QUADRIGEMINA. These tumors generally involve the 
lateral geniculate body, the subcortical auditory center in the posterior 
corpora quadrigemina, the third and frequently the sixth nerves, and 
in addition in advanced cases press upon the cerebellar peduncles. 
The commonest symptom is a combination of bilateral ptosis with 
weakness of upward and downward movements of the eye and feeble- 
ness of convergence. The pupillary reflex may be sluggish or absent. 
Amblyopia or hemianopsia, due to injury of the external geniculate 
body, is frequently seen, or complete blindness may be present. The 
peduncular pressure gives ataxia on walking or standing with no loss 
of sensation. Deafness is less constant. Intention tremors, athetosis, 
and vasomotor changes may be seen, while nystagmus is common. 

HYPOPHYSIS. Tumors of the hypophysis give rise to symptoms 
first because of perversion of secretion, and second because of pressure 
upon adjacent structures. 

Perversion of Secretion. Our present conception of the functions 
of the hypophysis and consequently the symptoms due to their per- 
version is largely due to the painstaking work of Cushing, Crowe, and 
Goetsch, and their associates. 

The work of Cushing and his monograph detailing his investigations 
"The Pituitary Body and its Disorders" will long stand as a monu- 
ment to American scientific endeavor. He has subdivided and classi- 
fied the functions of the gland although naturally there is still much 
uncertainty and controversy concerning them. Whether the symp- 
toms may be due to a hyposecretion or hypersecretion or a dyspitui- 
tarism in various cases, must still be decided; also whether the anterior 



TUMORS AND ALLIED PROCESSES IN THE BRAIN 341 

or posterior lobe or the pars intermedia may be the source in an indi- 
vidual state. It is manifest that there may be an excessive activity of 
one and a lessened activity of another at the same time. Lewis has 
drawn particular attention, and with justice it seems to me, to the 
function of the pars intermedia and attributes in great measure to this 
the functions assigned to the posterior lobe by Gushing. At the present 
time it seems justifiable to assign growth to the anterior lobe and 
functional changes; e. g., fat deposit, polyuria, etc., to the pars inter- 
media or posterior lobe; a hyperpituitarism before the age of ossifica- 
tion of the epiphyses gives rise to gigantism and acromegaly; after 
ossification to acromegaly, accompanied by excessive growth of hair and 
overactivity of the sebaceous follicles in the skin, while the anterior 
lobe hypopituitarism is accompanied by lack of bony growth, absence 
of hair, and soft skin characteristic of childhood. Posterior lobe insuffi- 
ciency (Gushing) produces adiposity, high sugar tolerance, subnormal 
temperature, slow pulse, asthenia and drowsiness. Polyuria probably 
accompanies changes in the pars intermedia. 




FIG. 97. See Fig. 98. The right eye was completely atrophied. (Wesley Memorial 

Hospital, No. 46392.) 



It is manifest that the clinical picture will vary with the type of 
tumor and as to whether it stimulates an excessive secretion or impairs 
the secretory activity (Figs. 97 and 98). Moreover, this picture may 
change from an excessive to an underactivity at any stage in the pro- 
gress of the disease. We have, however, certain general symptom 
groups that accompany disease of this gland. 

Froelich has classified the group accompanying certain preadolescent 
tumors, consisting essentially in a lack of development beyond the age 
of puberty no growth of body hair, aplasia of the genitalia, with 
lack of function, lack of general bony growth to which is added per- 
version of secretion producing an excessive deposit of fat. This type 
is frequently accompanied by cystic degeneration of the anterior lobe 
or anlage from the primitive pharynx lying in the sella turcica, but may 
accompany other tumors, such as adenomata. The adenoma, however, 



342 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 



is more characteristic of the tumors developing later in life giving rise 
to gigantism and acromegaly characterized especially by excessive 
bony growth, hypertrichosis, excessive thickness of skin, excessive 
gland secretion supposed to be due to anterior lobe hypersecretion, 




P'IG. 98. Hypopituitarism. Girl, aged eighteen years, cyst of hypophysis. No develop- 
ment after age of puberty, but no excessive fat deposit. (Wesley Memorial Hospital, 
No. 46392.) 

followed by posterior lobe insufficiency, deposit of fat, high sugar 
tolerance, mental deterioration, etc. (Fig. 99). 

The etiology of adiposis is still under discussion. It has been found 
accompanying tumors of the pars nervosa and the anterior lobe of the 
hypophysis, tumors in the neighborhood of the hypophysis, destruction 



TUMORS AND ALLIED PROCESSES IN THE BRAIN 343 

of the hypophysis by a bullet, and not to be forgotten, accompanying 
hydrocephalus of the third ventricle produced by pineal, quadrigeminal, 
third ventricle, and cerebellar tumors. Pollock has drawn especial 
attention to the results of this latter type of hvdrocephalus. 




FIG. 99. Acromegaly. Photograph of patient and sella. In spite of the evident 
enlargement of the sella and the marked signs of acromegaly no operation has been 
performed, since there is no impairment of vision and the disease has apparently been 
stationary for fifteen years. (Wesley Memorial Hospital, No. 53277.) 



Certain hypophyseal tumors grow so rapidly as to produce only 
pressure symptoms (Figs. 100, 101 and 102), while on the other hand 
neighborhood tumors and those causing third ventricle hydrocephalus 
may .produce functional changes as noted above, especially those due 
to posterior lobe insufficiency (Fig. 103.) 



344 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

Pressure Symptoms. Pressure upon the surrounding bony structures 
produces either an enlargement of the sella turcica or destruction 





FIG. 100. Sarcoma of hypophysis. Girl, aged fourteen years. Patient died six months 
after palliative partial hypophysectomy. Symptoms developed rapidly. No evidences 
of perversion of secretion. Early blindness and enlarged sella led to diagnosis. (Wesley 
Memorial Hospital, No. 47897.) 

especially of the posterior wall. While tumors may grow out of the 
sella turcica without causing enlargement we are always loath to make 
a positive diagnosis without it. The enlargement of the sella practi- 






TUMORS AND ALLIED PROCESSES IN THE BRAIN 



345 



cally always accompanies the Froelich type, and frequently the acro- 
megalic. Sarcomata are apt to produce destruction of bone. An 
absence of the posterior wall of the sella turcica does not necessarily 
mean a sarcomatous destruction, since an aplasia due to pressure in 
early life may be seen. In sarcomatous destruction a fragmentation is 
often noted, but this also may be present as a result of benign growth. 





FIG. 101. Glioma of hypophysis. Girl, aged fifteen years. Early blindness and 
change in sella, with lack of hair and other evidences of perversion of secretion, led to 
diagnosis. Convulsive seizures and marked brain pressure symptoms are explained by 
the growth of the tumor into the third ventricle (see cut section) and surrounding tissue 
with consequent hydrocephalus. (Wesley Memorial Hospital, No. 52242.) 

The second most important symptom is pressure upon the optic 
nerve. Theoretically the tumor should produce, because of its location, 
a bitemporal hemianopsia, and while this frequently occurs, its absence 
does not contra-indicate the diagnosis. A glance at the accompanying 
chart modified from Stewart, will show how the picture may vary 
according to the pressure exerted (Plate III). There is frequently 
a history of transient attacks of blindness; amaurosis may be seen. 
These patients may first consult the oculist and because of the varying 



346 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

fields a preliminary diagnosis of hysteria is frequently made. Choked 
disk is uncommon, there being rather a primary atrophy of the nerve. 
The involvement of other cranial nerves is fairly common. In 207 
acromegalic cases Uhthoff found exophthalmos in 8 per cent.; muscle 
palsies in 10 per cent. The third nerve was involved in 23 cases, the 
sixth in four cases. In a series of 121 patients with tumor and without 
acromegaly, 25 per cent, showed muscle palsies; third nerve, twenty- 
six times; sixth nerve, seven times. 




FIG. 102. X-ray photograph of sella in case shown in Fig. 62. Note the absence of 
a posterior clinoid process. This observation led to a diagnosis of erosion by malignant 
growth. The autopsy showed that while the growth was malignant there was no 
erosion, the absence of the process being apparently congenital. 



Pressure upon the cerebral peduncles will later cause accentuated 
knee-jerks and finally even more serious symptoms. This may follow 
from direct growth extending downward or, as in one of my cases, the 
tumor may invade the third ventricle and cause similar signs. 

Pressure upon the uncinate process of the hippocampal gyrus may 
produce epileptiform seizures preceded by gustatory and olfactory 
sensations and a dreamy state. 

Pressure upon the frontal lobes may be the possible cause of the 
mental deterioration seen in many cases. 



TUMORS AND ALLIED PROCESSES IN THE BRAIN 347 

Evidences of general brain pressure may supervene at any time, due 
to hemorrhage into cysts, to the growth of the tumor outside of the 
sella, or consequent ventricular hydrops. 




FIG. 103. Brain and sella of patient presenting evidences of hypdpituitarism. Exces- 
sive fat, little hair, etc. Patient died after two years' observation. Temporary relief 
was secured by corpus callosum puncture, subtemporal decompression having been of 
little value. Postmortem showed no tumor mass, but internal hydrocephalus, probably 
of inflammatory origin. (Wesley Memorial Hospital, No. 50909.) 






PINEAL GLAND. Bailey and Jelliffe have collected the reports of 
these rare tumors and classified the symptoms. The general symptoms 
of pressure are commonly present and the focal evidences are found in 
two groups : (a) the neurologic, (6) the metabolic. 

The Neurologic. These cases show not alone the evidences of 
general brain pressure and hydrocephalus, but also those findings 
peculiar especially to third ventricular dilatation, perversion of pos- 
terior lobe hypophyseal secretion, v. s. Pressure upon the corpora 
quadrigemina gives ocular and pupillary signs. Isolated nerve palsies 
are common. Nystagmus is not infrequent. Cerebellar symptoms 
arise from pressure upon the peduncles. 

The Metabolic. We commonly see adiposis, early sexual maturity 
and cachexia. Whether the adiposis is due to pineal perversion or to 
distention of the third ventricle and pressure with non-absorption from 
the posterior lobe of the pituitary gland may be open to discussion, but 
its presence is fairly common. 

Gutzeit first drew attention to the early development of sexual 
characteristics with enlargement of the penis, general hypertrichosis, 
increased libido, and at times change of voice. Here, again, we do not 
know whether this is due to the inherent physiology of the pineal gland, 
to pressure, or to an irritation of the neighboring structures. 



348 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

VISUAL REFLEXES. If we follow the optic nerves back from the 
eyeballs, we find that the nerves meet at the base of the brain and form 
the optic chiasm where a decussation takes place; the fibers from the 
temporal halves of the retina passing backward on the same side, and 
the fibers from the nasal haves crossing to the opposite side uniting 
with the opposite temporal fibers forming the optic tracts. Central 
fibers from the macula lutea pass into both optic tracts. These tracts 
wind around the crus cerebri to the primary optic centers, the external 
geniculate body, the anterior corpora quadrigemina, and the pulvinar 
of the optic thalamus. There arise also commissural fibers which pass 
forward and cross in the optic chiasm connecting the two internal 
geniculate bodies. 

It is believed that the optic thalamus and the external geniculate 
body have to do with the reception of visual impulses and the forward- 
ing of these to the cerebral cortex, while the anterior corpora quadri- 
gemina are mainly concerned with the coorcJination of visual impulses 
and visual movements, and movements especially relating to the laby- 
rinth and cerebellum. This is corroborated by experimental evidence 
in that stimulation of these bodies excites movements of the eyes and 
head and extirpation interferes with coordination but not with sight. 
Fibers arise from the optic thalamus and the external geniculate body 
and possibly also from the anterior corpora quadrigemina and pass 
backward through the hinder end of the posterior limb of the internal 
capsule to form the optic radiation and be distributed to the occipital 
lobes. The center in the occipital lobe is mainly, but not entirely, on 
the mesial aspect of the hemisphere and is divided into an upper and a 
lower part by the calcarine fissure, the cuneate lobe lying above and 
the lingual gyrus below. These two parts represent quadrants of the 
corresponding half of the visual field; e. g., a lesion of the left cuneus 
will cause blindness of the right lower quadrant of both visual fields. 
Besides these centers, there is a higher center on the convex surface of 
the occipital lobe where a superficial lesion will cause not hemianopsia 
but crossed amblyopia, i. e., a concentric contraction of both visual 
fields, more marked in the opposite eye. Also in right-handed people, 
there is in the left angular gyrus a center for the storage of visual 
memories of written and printed words, destruction of which produces 
word blindness (Stewart). The diagrammatic representation after 
Vialet (Plate III) shows the various types of blindness produced by 
lesions of given parts of the nerve and tracts. In addition to the coordi- 
nated movements governed by the anterior corpora quadrigemina, the 
centers for eye movements are found in the centers of the nerves, 
third and others, lying in the floor of the iter and the third ventricle. 
Stimulation of the back part of the third ventricle causes contraction 
of the pupil; of the corpora quadrigemina, dilatation: while stimulation 
along the floor of the iter produces contraction of the various eye 
muscles. Certain movements of the eye may also be produced by 
stimulation of the surface of the occipital lobe in the eye centers, a 
result brought about possibly through association fibers. 



PLATE III 

Cuneus 



Optic Radiations^ 

Corpus Callosum- 
Optic Thalamus^ 

Corp. genie, exl " 

( 

Optic Tract-- 
Optic Nerve'" 




Diagram after Vialet, Showing Various Types of 
Blindness. 

1, Blindness of One Eye; 2, Bitemporal Hemianopia; 3, Binasal 
Hemianopia; 4, Right Hemianopia with Hemiopie Pupil Reaction; 
3 and 6, Right Hemianopia with Normal Pupil Reaction; 7, Crossed 
Amblyopia. 



TUMORS AND ALLIED PROCESSES IN THE BRAIN 349 

Relation of the Ear to Tumors and Abscesses of the Brain. I am 
indebted to Dr. J. Gordon Wilson for the following discussion of the 
relation of the ear to tumors and abscesses of the brain. 

The chief symptoms of lesions of the membranous labyrinth of the 
ear (including the VIII nerve) are deafness, tinnitus, vertigo, nys- 
tagmus and ataxia, with nausea and vomiting. These symptoms also 
may occur in lesions of the brain and so a differential diagnosis fre- 
quently has to be made. When the lesion is confined to the ear the 
diagnosis is as a rule easy. When the VIII nerve is involved directly, 
for instance, by pressure of a tumor in the internal auditory meatus, 
the diagnosis may be more difficult. When the lesion involves the 
labyrinth and a lesion secondary to it in some part of the cranium, 
e. g., an abscess, the location of the abscess may involve considerable 
difficulty. Yet there are certain broad lines which taken together 
offer a basis for an accurate diagnosis. The history of the case and the 
involvement of other cranial nerves should those be present are of 
very material assistance. 

Deafness. Deafness may occur not only from involvement of the 
termination of the auditory nerve in the labyrinth and its central 
connections but also from disease in the conducting mechanism in the 
external meatus and middle ear. This preliminary separation of deaf- 
ness due to disease in the conducting mechanism from nerve deafness 
is made by tests well known to otologists but because of the frequency 
with which both are involved no hard and fast distinction can always 
be made. When we try to locate the defect in hearing in some part of 
the nerve or of its central connections we are met with great obstacles 
unless we are aided by some concomitant symptom such as pressure 
on the seventh nerve, involvement of the vestibular mechanism, etc. 

Nerve deafness may occur from a lesion in the cochlear branch of the 
eighth nerve or in its central connections. A gross lesion of the eighth 
nerve previous to entering the brain will almost certainly involve the 
vestibular branch of the eighth and very often the seventh cranial 
nerve. As the cochlear nerve decussates early and is widely distributed 
a lesion of the brain resulting in total deafness will rarely occur unless 
we have a very considerable lesion. Thus deafness may be due to dis- 
ease in the temporal lobes but can only be considerable if the auditory 
sphere of both sides be involved. In short, deafness is often difficult 
to definitely locate and so it becomes only an important accessory in 
locating a lesion. 

Tinnitus. Tinnitus the sensation of noises in ear or head, is a fre- 
quent symptom of all forms of aural complications. Tinnitus may not 
cease after destruction of the -labyrinth or section of the eighth nerve. 
It is difficult to estimate because its phenomena are purely subjective. 
It has little diagnostic value unless it be directly related in its time of 
appearance and in its intensity to a cranial lesion. 

In disturbances of the vestibular mechanism nystagmus, vertigo 
and ataxia we have symptoms that lend themselves more definitely 
to observation and to estimation. As these three symptoms are fre- 



350 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

quent in cerebellar disease and as it is from lesions of the cerebellum 
that one has most commonly to separate labyrinthine disease, we may 
confine our observations chiefly to the differential significance of these 
symptoms in labyrinthine and in cerebellar lesions. It may here be 
noted that a slowly progressing disease of the vestibular mechanism 
may present no symptoms; and in the diagnosis the otologist may have 
to depend on tests for the physiological activity of the labyrinth, e. g. t 
the caloric and rotation tests. A sudden onset or marked acceleration 
of vestibular disease always is accompanied by the above symp- 
toms. 

Nystagmus. Nystagmus or oscillation of the eyes occurs in various 
diseases of the brain, e. g., in tumors of the posterior corpora quad- 
rigemina and cerebellum; also in peripheral eye lesions and in labyrinth 
diseases. In a considerable number of normal individuals a slight 
spontaneous nystagmus is present in extreme lateral position of the 
eyes and has no pathological significance. ^ Marked spontaneous 
nystagmus on looking to the side and even slight nystagmus on looking 
straight forward is pathological. 

Nystagmus occurring in a labyrinthine lesion consists of two phases: 
a slow lateral deviation, labyrinthine in origin, followed by a quick 
return movement, cerebral in origin, synchronous in both eyes. It is 
decreased or even arrested by looking in the directions of the slow 
phase, it is increased by looking in the direction of the quick phase. 
By the use of suitable lenses which reduce or eliminate fixation, laby- 
rinthine nystagmus is increased or even made to appear. The only 
cranial lesion that gives an identical picture is one involving the central 
connection of the vestibular branch of the eighth nerve, to the eye nuclei, 
for instance, a lesion of Deiter's nucleus and of the posterior longi- 
tudinal bundle. The slow phase in labyrinthine lesions is toward the 
side of the lesion. Exceptions to this rule may arise from irritation 
(not paralysis) of the vestibular nerve somewhere in its central course. 
So far as the otologist is concerned, dealing with the terminal organ, it 
only arises in connection with a well marked inflammatory lesion in 
the ear involving the petrous temporal bone and the vestibular nerve. 
In labyrinthine lesions the nystagmus with the slow phase to the side 
of the lesion varies in intensity during the first few days then gradually 
diminishes. If it persists unaltered for several days it points to involve- 
ment of the vestibular nerve. 

Cerebellar nystagmus consists of movements which are ataxic in 
character. With the eyes at rest it tends to lessen or disappear but is 
increased by fixation. The plane in which the nystagmus moves as 
well as its intensity varies from time to time. It also frequently shows 
a slow and quick phase the slow phase may be away from the side 
of the lesion or toward it, according to whether we are dealing with an 
irritative or a destructive lesion. 

In short, labyrinthine and cerebellar nystagmus differs in uniformity 
of direction and in character. Not all cerebellar lesions produce nys- 
tagmus and, further, it is possible for a cerebellar tumor to produce the 



TUMORS AND ALLIED PROCESSES IN THE BRAIN 351 

labyrinthine type by pressure on the vestibular nerve or the vestibular 
path in the pons. 

Vertigo. Vertigo is one of the most general symptoms of brain dis- 
ease. The little appreciation of its value in diagnosis may be due to a 
failure to appreciate its significance and the wide application of the 
term to symptoms of very different kinds. It is applied to a variety 
of subjective sensations and even from intelligent patients it is very 
difficult to get a clear account of these sensations. The more severe 
symptoms of vertigo are associated with disease of the labyrinth and 
its vestibular nerve; and of the cerebellum with its peduncles. These 
are frequently associated with objective symptoms of vertigo, insta- 
bility, falling, etc. The most distinctive subjective sensation which 
the patient complains of is the apparent rotation of himself or of 
external objects. In labyrinthine disease the apparent rotation is 
directly related to the nystagmus, it is in the direction of the quick 
phase and the direction of falling is in the direction of the slow phase. 
There is not the same uniformity in cerebellar disease and the rules 
suggested by Stewart and Holmes are only to be regarded as valuable 
suggestions. Attacks of vertigo with its objective symptoms caused 
by labyrinthine lesions gradually disappear as the acute attack passes 
off. In neurasthenia they may persist for a long time but gradually 
lose their distinctive labyrinthine character. 

Disorientation and Ataxia. In both cerebellar and labyrinth lesion 
there is a deviation in walking toward one side to the side of the lesion 
if unilateral. This the patient corrects when the eyes are open. But 
with the eyes shut, when the patient recognizes the deviation he may 
deviate to the other side. Especially in cerebellar cases he is very apt 
to overcorrect. Romberg's sign is present in labyrinthine disease. It 
is rare in atrophy and sclerosis of the cerebellum; it is frequent in 
abscesses, tumors or lesions which from their nature are prone to affect 
other structures. In labyrinthine lesions in the Romberg position the 
patient falls in the direction of the slow phase of the nystagmus and 
if the head be turned he will fall backward or forward but still in the 
direction of the slow phase. This relation of falling to position of the 
head does not exist in cerebellar disease. 

Dysmetria. Dysmetria is not present in labyrinth disease. The 
muscular failure in labyrinthine cases is due to a failure of accurate 
perception of changes of the head in space resulting in a maladjustment 
of muscles to maintain equilibrium and direct orientation. The drunken 
gait of the cerebellar patient is not pronounced in labyrinthine disease. 

In addition the otologist has at his disposal direct functional tests 
for labyrinth activity in the rotation test and the caloric reaction which 
afford information in regard to the physiological activity of the laby- 
rinth. A discussion of these is not called for here. The above account 
is necessarily brief. Little has been said of those complex cases which 
involve both the eighth nerve and the cerebellum. Detailed informa- 
tion in regard to such cases and to functional testing must be sought 
for in the numerous articles available. 



352 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

Conjugate deviation of the eyes and head toward the same side is 
found in disease of the cerebrum which commences with paralysis of 
the opposite side of the body, in which case, especially at the onset, 
the head and eyes are often deviated toward the side of the lesion; 
i. e., away from the paralyzed side. In spasmodic conditions the devia- 
tion is toward the same side. The sign is seen especially in lesions of 
the first and second frontal convolutions, but may be seen elsewhere 
(e. g., angular gyrus, occipital lobe, etc.). In pontine disease the eyes 
deviate toward the same side as the paralysis, due probably to involve- 
ment of the crossed posterior longitudinal bundle. 

Another important finding is that of astereognosis, i. e., the loss of 
the power to recognize the form and shape of objects by palpation. 
This condition may be due to tactile anesthesia, but generally represents 
a combined psychophysical act, in which association fibers come into 
play. Astereognosis may be due, therefore, to lesions of the post- 
central convolutions, to lesions behind it (Wernicke), or to lesions in 
the parietal lobe (Oppenheim, Bruns, Mills, etc*.). 

General Symptoms and Signs of Brain Tumor. These are due to 
an increase in intracranial tension, produced both by the growth of the 
tumor and the improper circulation or increase of the cerebrospinal 
fluid. The most important of these are: choked disk, headache, and 
vomiting ; and to these must be added slow pulse, vertigo, stupor, and 
convulsions. It should be remembered that the triad may be produced 
by nephritis, severe anemia, lead poisoning, and less frequently by 
other causes. 

Choked Disk. This is found in 90 per cent, of the brain tumors at 
some time in their course. Early transient dimness of vision is common, 
and a certain degree may be present with perfect vision. Frequently 
the congestion is greater upon the affected side, although both eyes 
are generally involved. In cerebellar tumors, choked disk is especially 
early in onset, due to overfilling of the ventricles with fluid. The 
choked disk is followed in time by atrophy with its persistent blindness 
although one may regain a certain amount of vision in almost hopeless 
cases if some vision is still present. In tumors pressing directly upon 
the nerves, the atrophy may progress without noticeable congestion 
at any time. This is seen particularly in hypophy seal tumors. Gushing 
has laid particular stress upon the interlacing of the color fields, saying 
that it is present in 40 per cent, of the cases. This has not, however, 
been of much diagnostic importance in the experience of the author. 

Headache. This is the most constant symptom, and is often of 
great severity, consisting of a constant dull ache, accompanied by 
exacerbations. This latter is an important observation, since the 
former may be due to many causes. The patient is little relieved by 
treatment. The headache is generally diffuse, but may localize, 
although localization is not diagnostic except where the tumor is near 
the surface and the localized headache is accompanied by localized 
tenderness of the skull, and even in such instances it may lead to error; 
cerebellar tumors may produce frontal headache. Anything that 






TUMORS AND ALLIED PROCESSES IN THE BRAIN 353 

increases cerebral hyperemia, e. g., exertion, excitement, coughing, 
will increase the headache. Von Bruns has noted that tumors of the 
posterior fossa produce morning headache due in his opinion to the 
congestion incident to the recumbent position. If the headache in the 
back of the head is accompanied by stiffness of the neck muscles, it 
speaks somewhat for a tumor there. 

Vomiting. This is not constant, but is present in a majority of cases, 
and is most constant in cerebellar tumors. It follows the headache and 
is often projectile in character, and may or may not be accompanied 
by nausea, occurring independently of the taking of food and without 
relation to gastro-intestinal disorders. 

Slow Pulse. This is a valuable sign when present. It may be 
transient or permanent, and is usually a late sign. It falls to 48 or less 
and may be accompanied by Cheyne-Stokes breathing, yawning, and 
hiccough. 

Stupor. This may be preceded by a progressive mental change. 
The patient is apathetic, answers question slowly, and finally passes 
into a stupor in which he may lose control of the bladder and rectum. 

Vertigo. One finds vertigo most commonly associated with tumors 
involving the cerebellum, cerebellar peduncles and the corpora quad- 
rigemina, but it is associated with certain other basal tumors involving 
these areas secondarily and the vestibular nerve or its ganglia. Bruns 
has noted its presence in cysticercus of the fourth ventricle. The 
vertigo is more often a confusion such as is seen in intoxication; real 
giddiness and falling down is less common. It is seen at times asso- 
ciated with paresis of the eye muscles, due to close association of their 
centers with Deiter's nuclei. A more detailed discussion of its relation 
to cerebellar disease and otitic processes will be found in the sections 
dealing with these diseases. 

Convulsions. We distinguish here the Jacksonian type due to 
primary involvement of the motor area. As a sign of general increase 
of intracranial tension, they appear late, although they may be the 
earliest evidence, and one must wait for choked disk and other evidences 
of tumor before idiopathic epilepsy can be excluded. They are seldom 
of localizing value. 

Diabetes, polyuria, polydipsia, genital changes, adiposity, etc., may 
be seen, but are to be considered rather under local signs. Auscul- 
tatory changes the cracked pot in fractures or in the skull which has 
separated along the fissures, and bruit in aneurysms may be heard; 
indeed, the bruit may be heard in other conditions; e. g., in infants and 
where the vessels are compressed by a tumor. It may be heard only 
by the patient as a subjective sensation. Tympany on percussion may 
be noted where the skull is much thinned. 

The differential diagnosis must take into consideration the many 
diseases that will produce the general sign of tumor, e. g., nephritis, 
lead poisoning, multiple sclero sis, epilepsy, paretic dementia, abscess, 
gummata, and finally the so-called pseudo-tumor, in which little or no 
pathology may be found at postmortem. At times an acute hydro- 

VOL. i 23 



354 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

cephalus may be seen that may be relieved by lumbar puncture or a 
localized ependymitis of the Sylvian aqueduct with resulting distention 
of the ventricles. 

It should be remembered that gummata may resist syphilitic treat- 
ment. Sudden apoplectiform seizures in the course of cranial disease 
may be seen in gliomata. It has happened to the author to operate 
upon one case while the hemorrhage was active and the preoperative 
diagnosis was made because of the Complication. 

Abscesses generally give a history of some possible primary source 
and in the acuter forms we have a leukocytosis. Tubercles frequently 
occur at the cerebellopontine angle and adjacent areas. Gliomata 
originate in the brain and do not involve the meninges or bone while 
the sarcomata originate in the meninges or bone and compress or 
involve the brain-tissue. The gummata and tubercles may resemble 
each other on superficial examination and a microscopic examination 
be necessary to differentiate them. Gliomata, appear especially in 
order of frequency in the hemispheres of the cerebrum, cerebellum, and 
pons; the solitary tubercles in the pons, cerebellum, or cerebral cortex; 
the gummata generally in the cerebrum; sarcoma in the meninges, 
bones of the base, parietal and sphenoid especially. The gliomata 
grow slowly and the sarcomata rapidly. Gummata have rapid growth 
and sudden recession. The gliomata and sarcomata are single and the 
tubercles and gummata may be multiple. 

Cysts may occur as a result of parasitic growth (echinococcus or 
cysticercus) or trauma. The first will have the history of the disease 
in some other part of the body, and the latter a history of injury. At 
times they have origin in a hemorrhage into a glioma. Von Bruns has 
studied particularly the occurrence and signs of cysticercus in the 
fourth ventricle. 

Carcinoma is generally secondary but may occur in connection with 
the choroid plexus. Cholesteatoma, psammoma, fibroma, and lipoma, 
are uncommon. Endotheliomata are fairly common, developing from 
about the vessels of the meninges. 

Lumbar Puncture and the Cerebrospinal Fluid. As a means of 
diagnosis an examination of the cerebrospinal fluid is of considerable 
importance. Unfortunately, the findings are not pathognomic, but 
must be correlated with the clinical data. Therefore, a just apprecia- 
tion of the* value comes only after considerable bedside experience. 
We cannot expect the laboratory to report that this or that patient 
has a gumma, tumor, or meningitis. 

There is some therapeutic value to puncture in certain types of 
brain pressure, unfortunately generally transitory, although in my 
experience certain cases of vertigo and tinnitus have been relieved 
over a considerable period. 

Some danger is to be feared in tumors so located as to impinge on 
the cord or medulla at the foramen magnum, since the latter may be 
compressed and cause sudden death. Where there is cause to fear this, 
and indeed, in all brain tumors, it is advisable to withdraw fluid slowly, 



TUMORS AND ALLIED PROCESSES IN THE BRAIN 355 

and to place the patient with the head lower than the body. The pos- 
sibility of infection is slight if care is taken, and the same may be 
said of injury to nerves. It is advisable to have the patient rest for 
twenty-four hours after the puncture, especially if headache develops. 
Where a small amount of fluid is withdrawn this is not necessary. Ten 
cubic centimeters may be removed without anxiety, and I have often 
taken forty slowly, without injury. The fluid is rapidly replaced. 

Technic. The skin is sterilized and cocainized, and the patient 
placed preferably upon the side with the back bent, the thighs flexed 
up toward the flexed head. If brain tumor is not suspected, a sitting 
posture renders the operation less difficult. The point of choice for 
puncture is between the third and fourth, or better, the fourth and 
fifth lumbar vertebrae, determined by drawing a line between the crests 
of the ilia. A small sharp, unrusted needle, the lumen of which has 
been tested, about 8 cm. long, is chosen. The surgeon places the ball 
of the thumb upon the spine of the fourth lumbar vertebra and at the 
lower and outer angle; i. e., one-half inch outside and below the spine, 
the needle is inserted upward and inward at such an angle as to reach 
the center at a depth of about two and a half inches. Here the needle 
strikes the ligamentum subflavum between the vertebrae. This slight 
resistance is overcome and the needle immediately enters the sub- 
arachnoid space and the spinal fluid begins to drop out. If we strike a 
lamina, the needle is withdrawn slightly and inserted above or below. 
After feeling the sudden penetration through the ligamentum sub- 
flavum, if the fluid does not flow, a stylette is passed to clear the lumen 
of any clot of blood or push away a nerve that may be blocking the 
needle. If no fluid escapes, we may puncture at the next space above. 
The procedure should be carried out with as little trauma as possible, 
since the presence of blood interferes with our tests. If some blood 
does appear, it may be clear after a few drops. If it does not become 
clear, a second puncture should be made higher up, since a delay until 
another day may result in slight local inflammation that will also 
impair the accuracy of our findings. Indeed, some days must elapse 
before we are sure of securing a clear fluid. 

The cerebrospinal fluid is absolutely clear, colorless, and of a 
specific gravity of 1005 to 1008. It is alkaline and contains a trace of 
serumglobulin and albumose and also will reduce Fehling's solution. 
Microscopically a few large endothelial plates will be seen and in the 
centrifuged specimen a few lymphocytes, three to five to the cubic 
centimeter. The presence of blood in the serum impairs the value of 
the microscopic and chemical tests. 

The pressure of the fluid should be noted. This can be approximated 
clinically by always using in our puncture the same size of needle and 
placing the patient in the same position. We may measure it by 
attaching a rubber tube and a manometer to the needle. 

The color and clarity are important findings. If blood be present 
it may come from the local trauma or a skull fracture or subarachnoid 
hemorrhage. If the blood is from a preexisting subarachnoid hemor- 



356 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

rhage, cerebral or spinal, we may determine this at times by centri- 
fuging, since a fluid will remain yellowish and not present the clear 
limpid serum characteristically found when freshly mixed blood and 
serum are treated similarly. It may be turbid or purulent from acute 
meningitis. 

Microscopic examination reveals the presence of lymphocytes, poly- 
morphonuclear leukocytes, blood, and bacteria. The number per 
cubic millimeter and character of the cells should be noted. 

The chemical characteristics have been extensively studied. An 
increased serum albumin content may suggest spinal tumor, meningitis, 
etc. Various tests for the globulin have been devised, such as the 
Noguchi butyric acid or the Nonne ammonium sulphate, Lange's 
colloidal gold reaction, the Ross-Jones ammonium sulphate tests. 

Wassermann reaction for syphilis may show in the fluid when it is 
not evident in the blood. 

The clinical deductions of the tests are, as *oted above, relative 
rather than absolute. In general it may be said that slowly growing, 
chronic meningeal inflammations due to various causes and tuber- 
culosis and syphilis will produce excessive globulin and an increase of 
lymphocytosis, while the more acute inflammations give rise to poly- 
morphonuclear deposits and excessive globulin. Varying with the 
severity and stage in any individual disease, the picture may be different. 

Tuberculous meningitis shows a high lymphocytosis, even running 
into the hundreds per cubic millimeter. The polynuclear element may 
be marked in the acute cases. Fehling's solution may or may not be 
reduced. There is a positive globulin reaction, but the fluid is generally 
not turbid as in acute meningitis. Careful examination of the coagulum 
that settles out after some hours will frequently show tubercle bacilli. 

Acute meningitis shows a turbid fluid with many polynuclear 
leukocytes, some lymphocytes, globulin, lack of Fehling reduction, 
and the typical organisms. 

Syphilis presents a varied picture, corresponding to the stage of the 
disease: the more acute processes presenting the leukocytes and lym- 
phocytes, globular reaction, and a Wassermann reaction. As the 
disease progresses to the stage of tabes and such chronic conditions, 
the leukocytes decrease, the lymphocytes increase and then decrease, 
the globulin ultimately disappears, and the Wassermann cannot be 
obtained. 

Brain tumors may produce no changes in the fluid, but in certain 
cases where the meninges are irritated, e. g., cerebellopontine tumors, 
the cell count may be increased and the globulin tests be positive. 

Radiology in Brain Tumors and Abscesses. In tumors of the 
hypophysis, in abscesses following destruction of the mastoid, and in 
calcified tumors, the surgeon receives great help from the z-ray. The 
changes in the sella turcica in hypophyseal disease probably are of 
greater importance than any other sign. They consist of enlargement 
of the sella or destruction of the walls. The enlargement finds its best 
type in the adipose genital form of the disease when the slow growth 



TUMORS AND ALLIED PROCESSES IN THE BRAIN 357 

in bone not yet fully calcified permits extensive distortion and new 
growth of bone. This is true in a lesser degree of the changes occurring 
in adenomata growing later in life. Here we may have either enlarge- 
ment or destruction, or both. The destruction involves particularly 
the posterior clinoid processes and the wall between the sphenoid cells 
and the sella. In younger individuals there may be an absence of the 
posterior wall giving rise to an erroneous diagnosis of sarcoma, since 
the absence may be due to early pressure with aplasia of the wall. 
The malignant growths cause destruction and here the fragmented 
wall may be seen, although it has been my experience to find this same 
destruction in benign tumors. 

Destructive processes, especially of the mastoid, may be seen and 
direct us to the diagnosis of an abscess. Less often may be seen cal- 
cified tumors and cysts, exostoses pressing upon the brain, sarcomatous 
or carcinomatous destruction of bone, and aneurysms (Fig. 104). 




FIG. 104. Osteoma of skull. These excessive bony deposits may at times conceal 
an endothelioma of the meninges; therefore, the surgeon should always examine the 
underlying structures. 

Where tension is great in young individuals a separation or widening 
of the fissures may be noted with a deepening of the fossae or of the 
venous sinus and emissary vein canals. The dilatation of the venous 
canals may be more apparent than real, since the veins engorged with 
blood magnify the enlargement. These signs are for the most part 
general; exceptionally, they may be of localizing value. 

The manner of taking the pictures is of great importance. Miss 
Brindley at the Wesley Memorial Hospital Laboratory has made a 



358 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

special study of this matter in my cases, and has been enabled to 
secure most excellent pictures by paying great attention to placing the 
skull directly parallel to the plate. Care is taken to see that the 
occipital protuberance, nasion, and the sagittal plane of the head at 
the vertex, are the same distance from the plate. A diaphragm picture 
is then taken. Absolute superposition of the parts is necessary for 
sella turcica pictures. Whenever the picture is not clear, stereoscopic 
plates are made. These are always made where there is a question of 
destruction or of hyperplasia of the skull proper. 

THE TREATMENT OF BRAIN TUMORS. 

Craniocerebral Topography (Plate IV) The surgeon should so 
familiarize himself by cadaver study with the general appearance of 
the fissures and convolutions as to enable him to recognize them at 
sight. He should also be able to visualize the pa/ts of the brain under 
the unopened skull and also the relation of the ventricles to the various 
convolutions he may have in sight. The general relations of the brain 
to the cranial bones are as follows : The frontal bone covers the greater 
part of the frontal lobe and the whole of the lowest convolution. The 
posterior parts of the other convolutions are covered by the parietal 
bone. The frontal eminence marks the second convolution. The 
antero-inferior angle of the parietal indicates the inferior frontal con- 
volution. The parietal bones cover the posterior ends of the upper 
two frontal convolutions, the central convolutions, and a part of the 
occipital lobe. The parietal eminence corresponds to the supramarginal 
gyrus. The central convolutions lie more on the top of the brain than 
the side; hence are under the upper part of the parietal bone. The 
posterior arm of the Sylvian fissure ends just below the parietal 
eminence, and is therefore higher than one would think. The temporal 
bone covers the greater part of the temporal lobes; the highest point 
of the squamous suture lying over the Sylvian fissure. The temporal 
muscle covers the temporal lobes, lower frontal convolutions and the 
Sylvian fissure. The zygoma is on a line with the floor of the middle 
cranial fossa; hence the lower level of the temporal lobe. 

Reid, Thane, Horsley, Kroenlein, Froriep, and many others have 
attempted to establish measurements that would accurately outline 
the various lobes. Owing to the special importance of localization in 
the motor zone, these surgeons have placed especial emphasis upon the 
position of the Sylvian fissure and the central sulcus. The investiga- 
tions of Sherrington which have placed the motor centers in the pre- 
central con volutions have simplified the mensurations necessary since, as 
Kocher has shown, a line drawn from the midpoint on the sagittal line 
from the nasion to the occipital protuberance downward and forward 
at an angle of about 60 degrees to the midpoint of the zygoma roughly 
indicates the direction of the top of the precentral convolution. I use 
this method in ordinary cases. Where more comprehensive knowledge 
is needed, the Kroenlein method is probably as satisfactory as any 



PLATE IV 



FIG. 1 




FIG. 2 




Cranioeerebral Topography. 



PLATE V 



U 




Kroenlein's Method of Cerebral Localization. 



THE TREATMENT OF BRAIN TUMORS 359 

(Plate V). By this a line is drawn through the inferior edge of the 
orbit and the upper edge of the auditory meatus. A second line is 
drawn parallel with this from the upper edge of the orbit. Three per- 
pendiculars are now erected: one from the middle of the zygoma, one 
in front of the tragus, and one at the posterior border of the mastoid. 
The last is projected upward until it meets the sagittal line drawn 
between the nasion and the occipital protuberance. From this point, 
called the superior Rolandic point, a line is drawn forward and down- 
ward to the point where the upper horizontal meets the anterior per- 
pendicular coming from the middle of the zygoma, this point being 
called the Sylvian point. The middle perpendicular from in front of 
the tragus is then projected up to meet this oblique line drawn between 
the superior Rolandic point and the Sylvian point. The point where 
this meeting occurs is called the inferior Rolandic point. The part of 
this oblique line between the superior and inferior Rolandic points 
indicates the central fissure, and hence the motor centers are in front 
and the sensory centers behind. If a second oblique line be drawn from 
the Sylvian point upward and backward, bisecting the triangle made 
by the Rolandic line and the upper base line, we have the line of the 
Sylvian fissure. The superior Rolandic point lies about 2J cm. back 
of the midpoint of the nasio-inionic line. These lines can indicate only 
relatively the position of the convolutions, since skulls vary in their 
configurations. However, they are just as satisfactory as the various 
craniencephalometers for which there is so little use that description 
is unnecessary. 

Treatment of Tumors. The technic of craniotomy is treated else- 
where, but it remains for us here to speak of the technic of removal 
of tumors in cases where it is possible to remove them. With the 
entrance into the field of the trained neurologic surgeon and with the 
introduction of methods comprising gentleness in handling the brain, 
care in preventing hemorrhage, and rapidity of operating, our results 
are growing better. Statistics show that permanent relief may be 
hoped for in from 6 to 8 per cent, of cases; marked relief in fully 30 
per cent.; while in a majority of the remainder some temporary amelio- 
ration may be hoped for. The mortality of the operation itself in the 
hands of the skilled American surgeon has been much lower than in 
European clinics, the fatal cases being attributable in a large part to 
the late stage at which relief is sought, although there is still a con- 
siderable mortality incident to operation especially in cerebellopontine 
and hypophyseal tumors. While rapidity of operation has been men- 
tioned as a desideratum, it is of small importance compared to nicety 
of technic and the prevention of hemorrhage. 

Ether anesthesia is used for the most part although preliminary 
injection of the area with novocain and adrenalin seems to lessen the 
hemorrhage and may lessen the amount of anesthesia used. The field 
of local anesthesia is being widened constantly and it is possible to 
do many of these brain operations by this method. 

The patient should be placed in as comfortable a position as possible 



360 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

not alone for the benefit of the patient, but particularly for the aid it 
gives the surgeon. The head should be higher than the body so as to 
lessen the hemorrhage and then reduce the intracranial tension. This 
can be produced by elevating the head of the table or by tipping the 
whole table, the patient being held in position by straps or supports. 
If the special tables devised for supporting the head and maintaining 
the body are available, so much the better. 

The dura having been exposed, any large vessels that may bleed are 
ligated with the finest of catgut or silk, and the dura opened. Owing 
to the increased intracranial pressure, the brain will tend to bulge 
through the small primary slit in the dura, and great care must be used 
to avoid injury to the engorged pial veins which may give rise to embar- 
rassing hemorrhage. Small pledgets of moist cotton can be laid against 
such an area temporarily, or small pieces of the patient's muscle-tissue 
may be held firmly in place at the site and when once agglutinated may 
be left. ^ 

Ample opening of the skull should be made immediately. The 
beginner is tempted to make a small opening and enlarge it where 
necessary, thus prolonging the operation, incising the dura'disadvan- 
tageously, and adding to the shock. 




FIG. 105. Glioma with cyst formation. 

Shock when it occurs is generally due to loss of blood or excessive 
traumatism, both of which are directly due to the surgeon's technic; 
therefore every possible precaution should be taken to prevent them. 

Where the intracranial pressure is so great as to interfere with opera- 
tive procedures, a puncture of the ventricle should be done. This will 
facilitate not alone the operative procedures upon the brain, but also 
will be of material assistance in closing the wound. . Corpus Callosum 
puncture may be made and exceptionally, lumbar puncture may be 
resorted to, but one should always remember the especial danger that 
accompanies this procedure in the presence of brain tumors. 



THE TREATMENT OF BRAIN TUMORS 361 

When the field is exposed, search should be made for the tumor. If 
it is upon the surface and is highly vascular, if its margins are ill- 
defined and of soft consistency, it is probably a rapidly growing malig- 
nant tumor or a glioma. It is the part of wisdom to let- such tumors 
alone, for while it is justifiable at times to remove a small glioma in a 
"silent" area, we usually find that, added to the danger of bleeding and 
death, there is the probability that the tumor will grow more rapidly 
after attempts at removal. So marked is this tendency that some 
cranial surgeons make it a rule never to attempt to remove gliomata. 
Non-vascular cystic tumors may be gliomata lying somewhat dormant, 
into which hemorrhage has occurred (Fig. 105). Traumatism of these 
tumors also gives rise to rapid growth. If the growth is firm and sharply 
outlined the tumor is probably an endothelioma and operation is indi- 
cated. If the tumor lies below the cortex and can be felt but not seen, 
it speaks for a glioma which should not be operated upon except that, if 
cystic, it may be gently aspirated. If the tumor is well defined, how- 
ever, it may be a cyst or abscess demanding removal. A consideration 
of the aspirated fluid may help us, but here much good judgment is 
called for. 

Before we come to consider the special technic in the various lobes, 
it may be well to investigate the probable site and nature of the tumors. 
Tooth's tabulation of 500 cases reported at the Seventeenth Inter- 
national Congress is as follows: 

TABLE I. 

Sex. 



Region. 


M. 


F. 


Total. 


Per cent. 


1. Frontal 


60 


40 


100 


21.7 


2. Central pre- and postparietal .... 


43 


20 


63 


13.7 


3. Temporosphenoidal 


24 


25 


49 


10.6 


4. Occipital 


8 


6 


14 


3.0 


5. Corona radiata, corpus callosum, etc. 


4 


6 


10 


2.1 


6. Lateral ventricle 


2 


1 


3 


0.6 


7. Pituitary 


10 


4 


14 


3.0 


8. Optic thalamus 


4 


2 


6 


1.3 


9. Mesencephalon 


18 


8 


26 


5.2 


10. Pineal 


4 




4 


0.8 


11. Choroid plexus; III and IV ventricles . 


4 


1 


5 


1.0 


12. Cerebellum . 


44 


33 


77 


16.7 


13. Extracerebellar 


19 


21 


40 


8.7 


14. Pons 


19 


24 


43 


9.3 


15. Medulla 




1 


1 


0.2 


16. Base 


1 


3 


4 


0.8 



Total 264 195 459 

17. Not localized 24 17 41 

Grand total. . . 288 212 500 

Forebrain, 239, or 52 per cent. ; midbrain, 30, or 6.5 per cent.; cerebellum and pons, 
160, or 34.2 per cent. 

Of the group shown as not localized, many are unquestionably 
located in the frontal and temporosphenoidal regions. 

In regard to the age the author sums up as follows : Tumors of the 
forebrain tend to appear more frequently in middle-age, but no age is 



362 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

exempt. Those of the midbrain, on the other hand, are most predomi- 
nant in the early or adolescent period, and the same may be said of 
tumors of the cerebellum and pons. Comparatively few occur here 
after thirty. 

As to the variety of the tumor, gliomata comprised 127, or 49.2 
per cent.; fibrogliomata, 15; fibromata, 13; endotheliomata, 37; sarco- 
mata, 21; carcinomata, 15; tuberculomata, 14; simple cysts, 5; papillo- 
mata, 3 ; cholesteatomata, 2 ; pituitary tumors, 2 ; pineal gland tumors, 4. 
Cancerous heredity was present in 37 cases, or 7.2 per cent. In no 
case was there any history of a brain tumor. Gliomata were well 
distributed throughout the brain, comprising 58 per cent, of all growths 
in the forebrain, 50 per cent, of those in the midbrain, and 38.4 per cent, 
of those in the cerebellum and pons. Fibrogliomata and fibromata were 
peculiar to the cerebellum, pons and medulla; endotheliomata occurred 
only in the anterior fossa of the skull. Sarcoma occurs in any portion 
of the brain. Of the 21 cases, 6 were undoubted round- or spindle- 
celled sarcomata and were secondary; the remainder of the cases were 
primary. 

Of the 15 carcinomata only 1 was unquestionably primary. Primary 
tumors in 7 secondary cases were located; 3 times in the mammary 
gland and 1 each in the ovary, suprarenal, pancreas and rectum. 

Cysts are said to be more common in the cerebellum than in other 
parts of the brain. Of these there are many varieties; parasitic, der- 
moid, serous due to transformation of sanguineous effusion or an area 
of softening or hemorrhage into a glioma; and cysts due to serous 
meningitis. 

Operations upon the frontal lobes must take into consideration the 
extent of the frontal sinuses, since they may be a source of meningitis 
if the operation leads through them. X-ray pictures should be taken 
accurately outlining the sinuses before operation begins. Large tumors 
may be removed without doing serious permanent damage. 

When the tumor lies in the paracentral lobules, great care should be 
taken not to destroy any more of the brain tissue than is absolutely 
necessary. Here especially one should be conservative in the treatmenc 
of the gliomata for fear that the final state of the patient may be worse 
than the present. If the cerebral tension can be lessened by a Cushing 
subtemporal decompression it is the operation of choice. Endothelio- 
mata, tuberculomata and cysts should, however, be removed. One 
cyst that was removed by my colleague, Dr. H. M. Richter, had grown 
to such a size as to cause almost complete paralysis on the contralateral 
side, yet by gentle manipulation, the fluid was aspirated, and by grasp- 
ing the wall of the cyst and twisting slowly the entire cyst sac was 
removed without hemorrhage and with an ultimate complete restora- 
tion of function. The adjacent brain tissue should be gently separated 
from the tumor mass by a spatula covered with moist cotton or wiping 
it off with the cotton-covered finger as the tumor is extracted. Violent 
tearing or cutting should be avoided. The tumor should never be 
"gouged" out. Care should be taken not to injure the blood supply 



THE TREATMENT OF BRAIN TUMORS 



363 



along the central fissure. It should be remembered that the cortical 
0.5 cm. is made up largely of association fibers and can therefore be 
cut with much more impunity than the lower lying pyramidal cell- 
bearing tissue. 

The temperosphenoidal lobes are frequently the seat of tumors, and 
especially upon the right side may be removed extensively. 

Tumors of the interior of the forebrain or midbrain and those involv- 
ing the ventricles are inoperable, and are frequently best treated by 
puncture of the corpus callosum or this associated with a decompression 




FIG. 106. Central glioma producing marked hydrocephalus. 

Medical School collection.) 



(Northwestern University 



(Fig. 106). When a tumor of the cortex is removed and the resulting 
defect connects with the ventricle, no alarm need be felt, but one may 
here interpose a pad of fat to fill the defect, being careful not to use 
too large a piece. 

Tumors arising from the dura can be removed without difficulty 
either by peeling them off or removing the dura involved and trans- 
planting a flap of fascia lata to take its place. 

As mentioned above where a cyst sac can be removed, it should be 
done. If thin walled it may be removed by grasping the edges of the 



364 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

opening and twisting slowly and gently. If this is not feasible, the 
walls may be cut away; or if the wall is too thick for this, it should be 
curetted so as to thin it and favor collapse. The interior should be 
painted with iodine to further irritate the connective tissue and destroy 
any epithelial cells, so that union of the collapsed walls may take place. 
In exceptional cases drainage either into the subdural space or into the 
subaponeurotic space may be indicated. Elsberg suggests a strip of 
Cargile membrane for drainage material. The possibility of a cystic 
degeneration of a glioma should not be forgotten. 




FIG. 107. Chloroma of dura. The color cannot be shown in the photograph. (North- 
western University Medical School collection.) 

Cerebellar and Cerebellopontine Tumors. Operations upon the cere- 
bellar region have two special dangers : hemorrhage and the possibility 
of involving medullar function producing sudden death. For these 
reasons such operations are looked upon with concern by the surgeon. 
The operations per se upon the cerebellum are not dangerous. Frazier 
says that the whole of a lateral lobe may be removed or destroyed with- 
out serious permanent injury to the patient, but after any operation 
edema and added pressure upon the medulla or the accumulation of 
large clots or the changed relations of the structures pressing upon the 
medulla or the forcing of it down into the foramen magnum, are sources 
of real danger. To obviate these it is wise to have the patient in such a 
position that the surgeon is master of the situation at all times. The 
lateral, head-up position of Frazier is very satisfactory, the patient 
being held in position by arm supports. 



THE TREATMENT OF BRAIN TUMORS 365 

Gushing and others have advocated bilateral removal of bone below 
the transverse sinuses and in most cases the bone is not replaced. In 
most cases it may be advisable to remove the posterior portion of the 
bone about the foramen magnum. Manipulation should be made with 
care so as not to traumatize the pial vessels which will be engorged 
and bleed profusely if extra tension is present. Frazier has considered 
these operations in a masterful manner and has emphasized these 
points repeatedly, insisting that, if the tumors are malignant or ad- 
herent, no attempt at removal should be made, a decompression being 
the wiser procedure. Special warning against lumbar puncture should 
be given owing to the danger of driving the medulla down into the 
foramen magnum. He also does not believe that a bilateral operation 
is generally needed. Persistent drainage of cerebrospinal fluid may 
continue for some days from these wounds without serious conse- 
quences. If a cyst is found in the cerebellum it may be removed with 
especially good prognosis. The endotheliomata, fibromata, and neuro- 
fibromata that appear are most commonly found at the cerebello- 
pontine angle. Owing to their frequent origin from the eighth nerve, 
they are called acoustic tumors. They may be removed and at times 
permanent cure results. The mortality incident to the procedure has, 
however, been exceptionally high. Von Eiselsberg lost 13 out of 17 
cases and as a result speaks against removal when the tumors are larger 
than a walnut, advising rather morcellation and partial removal. 
Other surgeons have had similar experiences. Marx collected 50 cases 
operated upon by the Krause technic showing a mortality of 7t) per 
cent. The Borchardt (5 cases) and Panse (4 cases) operations have not 
been used often enough to give a correct idea of their value. 

Krause does a unilateral suboccipital removal of the bone going 
down to the foramen magnum (Fig. 108) . The dura is cut in flap form 
and the lateral cerebellar lobe gently retracted toward the middle and 
upward exposing the petrous portion of the temporal bone, this is 
followed inward until the tumor is exposed attached to the eighth 
nerve. The facial nerve generally lies upon the tumor and should be 
retracted to avoid injury. The tumor is gently enucleated by a thin 
blunt spatula, working the tumor upward and outward away from the 
medulla. Elsberg warns especially against the use of the finger. The 
gush of cerebrospinal fluid that appears on first exposing the tumor 
need give no alarm. The tumor having been removed, the area is 
dried, the lateral lobe allowed to fall back into position and the dura 
and muscles or muscles alone sutured. Frazier says that he has seen 
no bad consequences follow resection of a cerebellar lobe if this is 
necessary to give good exposure. Rather than do this, it may be wiser 
to make a two- or three-stage operation. This should be done in any 
instance where hemorrhage threatens serious consequences. 

Panse suggested reaching the tumor directly through the mastoid 
and labyrinth (Fig. 109). With the labyrinth a large part of the petrous 
bone is removed and the dilated internal meatus exposed. Through 
this opening the tumor is curetted away. Schmiegelow has operated 



366 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

twice by this method and has had a recovery in both cases, and Kum- 
mell and Quix in two previously reported cases were also successful. 




FIG. 108. Krause operation for cerebellopontine tumor. Note the distance from the 

tumor. 




FIG. 109. Panse operation for cerebellopontine tumor. 



THE TREATMENT OF BRAIN TUMORS 



367 



There is great probability of destroying the seventh nerve by this pro- 
cedure, but in view of the gravity of the operation and the frequency 
of paralysis of this nerve previous to the time of the operation, the 
saving of this should not be a desideratum if further experience demon- 
strates its safety. 

Borchardt combines the advantages of both of these procedures 
(Fig. 110). He removes the outer third of the occipital bone and the 
labyrinth and mastoid as well, thus securing a larger opening for work. 
This procedure necessitates ligating the sinus and cutting it with the 
dura. While the author has never attempted the Borchardt method, he 
feels that it has much to recommend it. The unilateral removal of the 
occipital bone has, however, in his hands been fairly satisfactory since 







FIG. 110. Borchardt operation for cerebellopontine tumor. 

it permits of extensive dislocation of structures and provides ample 
room for subsequent edematous swelling. 

Hypophyseal Tumors. The reasonable certainty of accurate localiza- 
tion in hypophyseal tumors gives fair encouragement for operative 
relief in most and cure in some cases. Judged by the criterion of return 
to society as a self-supporting member, the results of treatment may be 
said to be better than in most other brain tumors. The work of Gushing, 
Frazier, Lewis, Elsberg, von Eiselsberg, Hirsch, McArthur, and earlier 
by Horsley and others, has been a bright page in the study of the treat- 
ment of these tumors. In spite of this, however, we are not able to 
count a large number of complete cures. The author has two patients 
who suffered from cystic disease who have been well now a number of 
years; one for over eight and one for five. Both are self-supporting 



368 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

members of society, neither has suffered mental deterioration, but 
neither has secured complete physiological restoration as to growth 
and sexual function. Von Eiselsberg, Hochenegg, and others report 
similar experiences. 

The author has elsewhere discussed the various operative procedures 
and the following is modified from these various contributions. Many 
routes have been advocated for approach to the gland. The advan- 
tages and disadvantages will be discussed after considering the technical 
points as to the various routes. 

The Intracranial Routes. Through the Middle Fossa. At the present 
time this route is not used by many. It was originally suggested by 
Caton and Paul and was used by Horsley in all of his cases. Dalgren, 
Gushing and others have attempted to follow the same route. The 
author has had no experience with it, but believes it is inferior to others 
because of its inherent difficulties and the fact that it does not expose 
the region as satisfactorily as does the frontal *f>proach. 

Through the Anterior Fossa. To McArthur and Bogojowlensky 
should be given the credit of bringing again to the attention of the pro- 
fession this route which had previously been suggested by Killini and 
Krause. The former proposed making a dural and bone flap and ele- 
vating the frontal lobe while Krause proposed an extradural route under 
the frontal lobe to the chiasm. The suggestion of McArthur to remove 
the orbital ridge in addition to the frontal bone is a landmark in this 
procedure. The operation was still extradural down to the optic 
chiasm. The ridge was removed separately from the frontal bone flap 
but was replaced after operation. Frazier modified this by leaving 
the orbital ridge attached to the frontal bone, and Elsberg, by adding 
that the flap should be made with its base inward, has made the 
approach nearly ideal for those cases in which the intracranial operation 
is chosen. Adson's technic of intracranial approach described later is 
also highly recommended. Elsberg's technic is described by himself as 
follows : 

" ^T-rays having been taken to determine the size and extent of the 
frontal sinuses, the side of the frontal bone is selected in which the sinus 
is the smallest. If the patient has lost the sight of one eye, it is best to 
do the operation on that side. 

"An incision is made from the inner angle of the eyebrow outward 
to the external angular process of the frontal bone, then upward and 
backward to within the hair line and then inward to near the median 
line. With an ordinary trephine, openings are made at the beginning 
of the incision, just above the external angular process and at the 
upper outer and upper inner angles of the incision in the soft parts. 
The bone is cut in the usual manner with Hudson forceps. The soft 
parts are slightly dissected down from the supraorbital ridge, the roof 
of the orbit about 1 cm. behind the supraorbital ridge divided by slight 
blows with a small chisel, the supraorbital ridge cut at each trephine 
opening with a Gigli saw or sharp Liston forceps, and the bone fractured 
toward the median line. On account of the thickness of the bone in 



THE TREATMENT OF BRAIN TUMORS 



369 



the median line, it is usually necessary to partly divide the base of the 
bone flap with the cranial forceps (Fig. 111). 

"With various rongeurs, the thin roof of the orbit is removed down 
to the optic foramen, care being taken that the direction of the rongeur- 
ing is correct so as not to open into the ethmoid sinuses, and that the 
periosteum of the orbit is not injured. As the operator approaches 
the optic foramen, a long-bladed rongeur must be used, the orbital 
contents depressed, and the frontal lobe in its dura slightly elevated. 
As soon as the optic foramen is reached, and after all oozing of blood 
has been controlled by gauze pressure, an incision about 3 cm. long is 
made from the exposed anterior clinoid process toward the median 




FIG. Ill, Technic of Elsberg approach. Drawing furnished by the kindness of 

Dr. Elsberg. 

line, a small brain retractor introduced into the opening and the frontal 
lobe elevated. The optic chiasm, hypophysis, and sella turcica are 
now in good view. 

"When the treatment of the hypophyseal lesion has been finished, 
the bone flap is returned into place and the soft parts sutured in the 
usual manner. 

"The operation is not at all difficult in the hands of the surgeon 
experienced in cranial surgery, and an excellent exposure of the region 
of the hypophysis is obtained. It is possible to extirpate or partially 
remove a growth from around the pituitary body in full view, and the 
operation is surgically very satisfactory. The amount of elevation of 

VOL. i 24 



370 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 



the frontal bone that is necessary is not very great, so that no injury 
to the brain should occur. The orbital roof should be removed over an 
area about 2 cm. in width, and if an ethmoid sinus be opened it should 
be closed with a little Horsley wax. The supraorbital ridge forms 
part of the osteoplastic flap which is better than if the bone is removed 
in one piece and later replaced as in Frazier's operation. The amount 
of visible scar is very small, only a small line between the external 
angular process of the frontal bone and the hair line." (Fig. 112.) 

In the author's hands this operation has been satisfactory in certain 
cases in which solid growth can be prognosticated. If there is much 
evidence of brain pressure, a corpus callosum puncture should be made 
previous to operation since excessive brain pressure adds materially to 
the difficulty. He .has also used a much larger bone flap extending well 




FIGS. 112 and 113. The patient was operated upon by the author after Elsberg's 
method. Note the manner in which the scar can be covered by the hair. (Wesley 
Memorial Hospital, No. 50909.) 

back toward the motor area, combining with this a dural flap in some 
cases. If there is much brain pressure exceptional care should be taken 
to remove the orbital ridge with the skull flap; otherwise it will be 
difficult to hold the orbital section in place. 

Adson has developed a more lateral approach under the frontal lobe. 
It is to be highly commended not alone because of the directness of the 
approach but also because of the adequateness of the primary bone 
flap. Frazier has lately advocated an intradural approach through the 
incision recommended by him, while Heuer and others have also sug- 
gested a return to this earlier method; but Adson has developed the 
operative technic and introduced many new features that highly 
recommend his procedure. I quote the following from his discription 
of the technic : 

"The patient is placed on the operating table at an angle of 80 
degrees with the horizontal plane. The head is held back in a position 
to permit the natural gravitation of the frontal lobe from the anterior 



THE TREATMENT OF BRAIN TUMORS 371 

cranial fossa. The anterior limb of the osteoplastic flap corresponds 
to the margin of the hairline, and this affords three-fourths inch of 
space posterior to the external angular process of the orbit, thus pre- 
venting injury to the motor branch supplying the frontal division of 
the occipitofrontalis and guarding against any paralysis of the muscle. 
The incision is carried upward to the median line three-fourths inch 
from the longitudinal sinus; it is then extended backward for a distance 
of three and a half inches and downward over the parietal eminence 
to a position above the middle of the ear. 

"After the dura has been exposed a flap is made to permit the 
exposure of the frontal lobe, but it is made at right angles to the 
osteoplastic flap, which has been broken in the region of the temporal 
bone and turned downward. The dural flap is permitted to remain in 
position and to cover the cortex of the brain, and the frontal margin 
is raised by tension sutures of silk. The brain substance, as well as the 
exposed dural surface, is covered with warm, moist cotton, which, in 
turn, is covered by rubber tissue. 

" In the elevation of the frontal lobe, rubber tissue strips are placed 
gently over the convolutions in a shingle effect in order to give a 
uniform pressure over the cortex as it is elevated by the retractor. 
There is very little difficulty with bleeding during this process; occasion- 
ally there is a small venous communication between the cortex and 
the dura. With gentle manipulation the optic commissure and the 
hypophyseal body are readily exposed. Important landmarks during 
the elevation of the frontal lobe are the anterior cranial fossa, the 
margin of the lesser wing of the sphenoid to the anterior clinoid process, 
the right optic nerve and the internal carotid artery. The procedure 
is then carried on mesially until the commissure as well as the left 
optic nerve and the hypophyseal body are brought into view. A 
gentle dissection of the tumor is then begun with blunt hooks to free 
it from the commissure, nerves, and surrounding tissue. Usually the 
tumor is definitely encapsulated, and if freed from the constricting 
bands it is readily elevated. In case there is slight bleeding it is 
controlled by very small pledgets of cotton guarded by long strings of 
silk to prevent their loss. As the tumor is free from the surrounding 
structures a septile snare is applied to its pedicle, which is gradually 
constructed to control the bleeding and to remove the tumor mass. 
The further removal of the pituitary tumor from the sella turcica may 
then be continued." 

TRANSSPHENOIDAL METHODS. Supranasal Route. Schloffer first 
used this method. He turned the nose to the right, excised the turbin- 
ate, the ethmoid cells, and the septum, removed the inner wall of the left 
orbit down to the optic foramen and the inner wall of the antrum of 
Highmore with a portion of the nasal projection of the left superior 
maxilla, and then reached the tumor through the sphenoid sinus. 
Hochenegg, Moskowicz and Tandler, Chiari, Michel, Giordano, and 
others, have modified the procedure. Of all these modifications that 
of von Eiselsberg is most popular. His technic 1 is as follows: 

1 Described in Surgery, Gynecology and Obstetrics (International Abstracts, 1913, 
xvi, p. 245). 



372 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

Three days before the operation the patient receives 2 gm. urotropin 
daily. The coagulability of the blood is determined and calcium lactate 
given if it is delayed. The nose and throat are carefully examined. 
Anesthesia with morphin and ether or Billroth's mixture. The oper- 
ative field is sprayed with J per cent, novocain (H. Braun), to stop 
hemorrhage. Tamponade is accomplished by Bellocque's method. The 
incision is made along the left nasolabial groove up to the glabella, 
over the bridge of the nose to the right palpebral fissure. The nasal 
bone is cut through with hammer and chisel. The philtrum nasi is 
cut at its juncture with the upper lip. A large portion of the septum 
and vomer is detached with the nasal flap. The remains of the 
septum, vomer, rostrum, and the turbinates are next removed. 

Hemorrhage is stopped with adrenalin and compression. The 
sphenoid sinus is now opened, its anterior and inferior walls removed 
and the cavity scraped out. The hypophyseal tumor is usually exposed 
at this stage, the dura is incised, and as much of t]je tumor as is thought 
advisable is removed with a sharp spoon (excochleation) . After stop- 
ping the hemorrhage a cigarette drain is placed in the defect and 
fastened by a stitch around the left nostril. No tamponade is necessary. 
Finally the nasal cavity is cleaned out, Bellocque's tampon is removed 
and the nasal flap sutured in its place. 

Infranasal Route. Owing to the danger of meningitis from exposing 
the cribriform plate and for the purpose of simplifying the procedure 
it was suggested by the author that the sphenoid should be approached 
through the inferior portion of the nose, thus avoiding the removal of 
the ethmoid. In his hands the operation has been most satisfactory. 
He has now modified the procedure as originally proposed in that a 
submucous resection of the septum is done, following the suggestion of 
Hirsch which is certainly a distinct advantage. Halstead and Gushing 
have since followed the same route with some modifications in technic. 
Instead of incising in the nasolateral fold, Halstead raises the lip and 
makes his incision in the labiobuccal fold. He has operated with bril- 
liant success by this method. The author has used both the method 
to be described and the Elsberg method and believes that certain cases 
should be operated upon by the infranasal method and others by the 
transfrontal. 

The infranasal technic has been described in the author's various 
contributions, from which this description is taken. Its steps are as 
follows 4 . 

The nose is packed with strips of adrenalin gauze to lessen the 
bleeding. The patient is placed in a semisitting position so that the 
blood will not accumulate in the sphenoid sinus and over the field of 
operation. A tight posterior nasal gauze plug is inserted. This is not 
necessary so much to prevent blood entering the pharynx since if the 
operation is done properly there should be no tear in the mucous 
membrane, but it does prevent air escaping through the nares during 
the operation. An incision of the skin down to the bone is now made in 
the crease close under the nares and the alee of the nose. The nasal 



THE TREATMENT OF BRAIN TUMORS 



373 



spine is cut and with the greatest of care the mucous membrane is 
raised from the floor of the nose and off of the septum, back to the 
sphenoid bone and off from the front of this bone. The septum and 
the anterior wall of the sphenoid sinus is now removed, followed by 




FIG. 114. Position of patient for hypophysis operation. (Author's method.) 

removal of the posterior wall, i. e., the anterior wall of the sella turcica. 
This is best entered by a chisel and the bone removed by a punch for- 
ceps. The dural covering now being cut the soft tumor mass appears 
and may be curetted away. If a cyst is found, its walls should be gently 
curetted and in my experience should be lightly packed with gauze 



374 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

saturated with a weak iodine solution to favor obliteration of the sac or 
to preserve an opening into the sphenoid. If a solid tumor is removed, 




FKJ. 115. Line of incision for author's operation of hypophysectomy. A string is 
attached to posterior nasal plug. 

no drainage is necessary if the bleeding is well controlled. The mucous 
walls of the removed septum are allowed to fall together, a subdermal 




FIG. 116. Hypophysectomy author's operation. The mucous membrane is raised from 
the floor of the nose and the septum. The bony spine is being cut. 

stitch closes the skin wound, the nares are packed lightly for twenty- 
four hours with bismuth subnitrate saturated gauze to stop the oozing 



THE TREATMENT OF BRAIN TUMORS 



375 



of blood from the nose, the posterior nasal plug removed, and the 
patient returned to bed. 

The anesthetic is best given through intratracheal insufflation, or 
pharyngeal tube, although the author has used rectal anesthesia with 
satisfaction. The operator should be familiar with the anatomy of 
the anterior of the nose, especially the sphenoid sinus, and the relations 
of the sella turcica. He should provide himself with proper instruments 
and an excellent headlight. No matter what method of approach is 
used, the operation is difficult and should be undertaken only after 
thorough preparation. 




FIG. 117. Hypo physectomy author's operation. The mucous membrane has been 
pushed to the side by the speculum and the septum removed. The speculum is long and 
has a set-screw attached which holds it in position. 

Hirsch has operated under local anesthesia with remarkable results. 
He has described his technic as follows: 

In his earlier cases he removed the inferior and middle turbinates 
at the first sitting; at the second, the anterior and posterior ethmoids; 
at the third, the anterior wall of the sphenoid with the impinging 



376 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

septum; and at the fourth, the anterior wall of the sella turcica. The 
tumor was then removed by a curette. Later he suggested the sub- 
mucous route, and urged it as a means of lessening the dangers of 
infection. He has described his technic as follows: 

The mucous membrane of both sides of the nasal septum is desensi- 
tized with a 20 per cent, cocain solution. An incision is now made 
along the anterior edge of the quadrangular cartilage, through the 
mucous membrane on one side, down to the cartilage, and the mucous 




Hypophysectomy author's operation. 



membrane is raised by means of a raspatorium, together with peri- 
chondrium and periosteum, from the cartilage and bone. The cartilage 
is now incised J cm. from the original incision and a raspatorium slipped 
between the perichondrium and the cartilage and carried to the pos- 
terior border of the septum ; the mucous membrane, together with the 
perichondrium and periosteum, are now raised from cartilage and bone 
on this side. The membranes are now held apart by a nasal speculum 
and in this way a medial nasal cavity formed in which one sees the bare 



THE TREATMENT OF BRAIN TUMORS 



377 



cartilage. This is removed with one sweep of the cartilage knife, and 
the vomer and the perpendicular plate of the ethmoid are resected with 
the aid of a bone forceps. Up to this point this operation is identical 
with Killian's submucous septum resection. 




FIG. 119. Hypophysectomy author's operation. The mucous membrane which has 
been removed by the artist to show the line of removal of the septum, is preserved at 
the operation. 

To bare the wall of the sphenoidal cavity it is necessary that the 
mucous membrane of the vomer where it joins the sphenoid be sepa- 
rated from the bone. This is very easily done, after which the mucous 




FIG. 120. Shows the wound closed with subcutaneous stitch, no scar is visible. 

membrane is separated from the anterior surface of the sphenoid on 
both sides as far as the ostium sphenoidale, so that the raspatorium 
falls into the sphenoidal cavity. Now through this sack of mucous 



378 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

membrane one removes the posterior part of the vomer and the rostrum 
sphenoidale, with the bone forceps, and with several strokes of a chisel 
one breaks through the anterior wall of the sphenoid cavity, and after 
removing the sphenoidal septum one sees the hypophyseal prominence 
in its entirety. 

After opening the sella turcica and the dura of the hypophysis res- 
pectively, the hypophyseal tumor lies free in the sphenoidal cavity. 

Approach Through the Mouth. Many authors have suggested 
approach through the antrum of Highmore, or behind the soft palate, 
but they are not to be recommended. 

Choice of Operation. It is natural that in any procedure in which 
there are so many inherent difficulties and in which the outcome is not 
always satisfactory from the technical standpoint, there should be 




FIGS. 121 and 122. Cyst of hypophysis. Note the enlargement of the sella and the 
eye-grounds shown in Fig. 123. This patient was operated upon three times by the 
author. The repeated operations were necessitated by the refilling of the cyst and 
each operation was done by the infranasal approach. Since the last operation, three 
years ago, he has remained well. The author has a second case with similar pathology, 
well after five years. (Wesley Memorial Hospital, 45762.) 



considerable difference of opinion as to the advisability of various 
procedures, and also it is easily understood why the same surgeon may 
at different times be in favor of different types of operation. As our 
knowledge grows, it is certain that various modifications of procedures 
now suggested will be made. For the most part, however, adherence 
will be given, it would seem, either to an approach through the frontal 
area or infranasally. It would seem to the author that the various lines 
of procedure will be indicated ultimately by the type of pathology 
found in the various cases, and as our diagnostic acumen becomes 
developed we will be able to say that for one type of disease one method 
is better suited and for another type of disease another method of 
approach is better. It would seem that it is not advisable for any 
surgeon to become an adherent of any one method of procedure, but 



THE TREATMENT OF BRAIN TUMORS 



379 



rather that he so equip himself that he is competent to approach hypo- 
physeal tumors either through the nose or intracranially. 

At the present time there is much to be said in favor of approaching 
all hypophyseal cysts by the infranasal route as described by the 
author. This type of disease we know to be most common in adipose 
types; Froelich's syndrome. The difficulty of removing all of the 
lining of the cyst and the probability of recurrence if the lining is not 
destroyed would speak in favor of an approach by which secondary 



LEFT 




FIG. 123. Before operation, see Fig. 122 (Case No. 45,762). 




270 



FIG. 124. Eye-grounds in No. 45,762 (see Fig. 122) after the first operation. 

operation could be done easily if desired. It is manifest that repeated 
intracranial operations w r ould not be looked upon with favor since the 
difficulties would increase with each operation. Not only is approach 
through the nose in secondary operations feasible, but it is really much 
simpler in the primary procedure. The author has in one case operated 
three times upon such a cyst with complete primary recovery, judged 
by five years of freedom from recurrence. On the other hand, the field 
of vision is not so good through the infranasal approach as it is through 



380 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

widely executed frontal approach. Therefore, there is some justi- 
fication for the belief that in many cases of adenoma the frontal 
approach is to be advised. Against this, however, is the fact that if the 
tumor is confined to the sella turcica it can be completely removed 
through the nose, probably with less trauma to the cranial tissues than 
if removed through the frontal route. This is especially true in those 
patients with an increased intracranial tension at the time of operation. 
The intracranial route is preferred, however, in a majority of solid 
tumors. In favor of the intracranial route, is the fact that neighbor- 
hood tumors may be reached at the same time when one has operated 
for an intracranial sellar tumor and it has not been found. The ability 
to remove such tumors with permanent recovery is yet to be proved. 




FIG. 125. X-ray picture of patient shown in Fig. 122, taken forty-eight hours after 
operation. The dark shadow is the outline of the cyst shown by the bismuth gauze 
which was packed in the cyst after opening. The packing was not done tightly ; therefore, 
the cyst was probably much larger. 

The transsphenoidal route gives a decompression opening in case of 
future growth. Thus it is possible to prolong life by it in those cases 
in which complete removal of growing tumors is not possible. 

In general then it may be said that in those patients suffering from 
cystic disease, operation through the nose has many advantages and 
would seem to be the method of choice. In solid tumors an approach 
by the intracranial method, either that practised by Frazier and 
Elsberg or that advocated by Adson, would seem to be the method of 
choice. Future experience may modify these generalizations. 



THE TREATMENT OF BRAIN TUMORS 381 

Indications for Operation. It may be said that all cases of hypo- 
physeal tumefaction should be operated upon, since even patients in 
extreme condition have been relieved temporarily. Operation is indi- 
cated absolutely in those patients in whom the tumor jeopardizes 
the life of the individual or is causing progressive blindness. It is 
relatively demanded for the well-being, when ultimately the life of the 
individual is threatened. Therefore pressure symptoms either local or 
general will demand immediate intervention. The pressure symptoms 
may be due to a rapidly growing tumor or to a cyst which may be 
enlarging rapidly or which has become suddenly filled with hemorrhagic 
extravasation. As our knowledge increases the field of relative demand 
for operation will be broadened. How far simple perversion of physio- 
logical action as evidenced by a lack of growth or overgrowth (acro- 
megaly) should influence us in operation must at the present time be 
detei mined. As the safety of the procedure is increased and our knowl- 
edge of diagnosis progresses, it is to be hoped that the disease may be 
attacked before the destruction or perversion of these physiological 
actions may have occurred. Specifically we might say that the adipose- 
genital type of disease where an enlarged sella can be shown is by far 
the most favorable subject for operation. Acromegaly evidenced by 
increased secretion apparently must at the present time be treated 
conservatively, particularly since many of the cases at the time they 
are seen have passed through into the stage of hypopituitarism. 

The mortality which in the past has been approximately 35 per cent, 
will probably so continue in the hands of those doing little cranial 
surgery. Gushing and Hirsch now report an average of 10 per cent, 
mortality, while the author has operated upon 15 cases with four deaths, 
all but one of these in the earlier cases. The patient has a right to an 
expression of opinion not alone as to the immediate result but also as 
to the ultimate result of any operative procedure. Our knowledge is 
yet so incomplete that we cannot give an absolute prognosis as to either. 
However, it would seem that we may assure the patient that good 
results as to local pressure can be assured in case of cysts. Horsley 
and others have shown evidence as to recurrence after operation and as 
stated above in one of the author's cases there were two recurrences 
after operation. But it would seem that repeated operations if neces- 
sary will ultimately end in a destruction of the cyst and that such cases 
may remain well is shown by the experience of various surgeons. The 
brain pressure is relieved, there is no further progress in the atrophy 
in the eye grounds, and the eye signs become uniformly improved 
unless complete nerve atrophy is present. The excessive adiposity 
has been lessened or removed, although this would seem to be aided 
by whole gland feeding. There has been little change in the sexual 
development, although von Eiselsberg reports some improvement in 
one of his cases. No marked change in growth has as yet been produced 
by operation or by gland feeding. The growth of hair seems to be 
improved, especially when gland feeding is instituted. The surgeon 
should bear in mind that hemorrhages may occur into the cyst giving 



382 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

rise to acute pressure symptoms, these pressure symptoms subsiding 
after the absorption of the blood. Therefore, an absolutely bad prog- 
nosis cannot be given even when operation is refused. It should also 
be borne in mind that many of the perversions of physiology are due not 
alone to the immediate pressure but to the previous destruction of 
gland tissue ; therefore gland feeding should be instituted even though 
operation is not performed. 

While some surgeons have reported an improvement following 
operation upon acromegaly, these results are so indefinite that one is 
inclined to be conservative regarding any physiological result which 
can be obtained by operation. There has been reduction in swelling 
of the soft parts with no effect upon bones. Hochenegg, von Eisels- 
berg, Gushing and others report the return of sexual function one year 
after operation which was supplemented by gland feeding. The sight 
when involved has been favorably affected. Gushing has stated that 
acromegalics who have gone over into a state qj hypopituitarism have 
been markedly benefited by feeding the whole gland without operation. 
It is evident, however, that we are dealing with the ultimate stage of the 
disease, and it is to be hoped that the time may come when diagnosis 
may be made early and the operation be sufficiently safe to justify 
procedures in the early stage of the disease when it is probable more 
definite results may be obtained. Those intracellar adenomata can 
probably be removed with a possibility of no recurrence. Where they 
have grown beyond the sella, however, into surrounding area, it is 
problematical as to how much result will be obtained; although 
improvement of symptoms produced by local pressure and the 
amelioration of some general symptoms may be expected at least 
temporarily. 

Pineal Gland Tumors. Tumors of the pineal gland have been con- 
sidered inoperable although attempts at removal have been made. 
While the operation should be considered a desperate undertaking, 
experience has shown that it may be feasible. Pussep made a horse- 
shoe-shaped incision, the center of which was four fingers above the 
occipital protuberance, the ends curving down to the level of the 
mastoid processes and one and one-half fingers inside. The underlying 
bone was removed, and the wound closed. The second stage of the 
operation, six days later, consisted in ligating the occipital sinus and 
cutting the dura under the transverse sinuses. The right transverse 
sinus was ligated and cut. The dura along the longitudinal sinus 
upward and the tentorium inward, were cut. The occipital lobe being 
retracted, showed a cyst of the pineal gland. This was aspirated, 
some of the wall cut away, and the remainder packed and the wound 
closed. So much cerebrospinal fluid escaped on the first day that the 
packing was removed and the wound closed. The patient died on 
the third day, but lived long enough to demonstrate the feasibility 
of the procedure. 

Rorschach has gone down beside the falx and cut the posterior 
portion of the corpus callosum. No tumor was found, but the only 



THE TREATMENT OF BRAIN TUMORS 



383 



untoward result was a transitory paralysis of a leg and slight inter- 
ference with sensation. 

Nasetti has operated similarly except that he ligated the longi- 
tudinal sinus and cut the falx, then incising the corpus callosum. 

Removal of Tumors of the Gasserian Ganglion is not exceptionally 
difficult. The method of attack is the same as for removal of the 
ganglion for trifacial neuralgia. The tumors are not common and are 
endotheliomata, arising from the dural sheath. 

Puncture of the Brain and Ventricles. Punctures of the Corpus 
Callosum. This procedure carried out for diagnostic and therapeutic 
purposes is a measure of considerable value in some cases. It has been 
used most often in hydrocephalus, hypophyseal, cerebellar, and other 




FIG. 126. Schematic drawing representing a few of the areas in which tumors may 
especially produce hydrocephalus. 



tumors which have caused large accumulations of fluid in the ventricles 
(Fig. 126). The principles upon which it is supposed to act is that if 
in cases where the pressure is high, an opening be made through the 
corpus callosum connecting the subarachnoid and ventricular spaces 
between the hemispheres, the intraventricular pressure will tend to keep 
the opening patent and thus provide a permanent drainage into a space 
where absorption of the secreted fluid is freer than in the ventricle. 
While the beneficial results in my hands have not been so brilliant as 
those reported by Anton and others, a moderate use of the procedure 
has convinced me that in certain cases we may expect great relief from 
pressure symptoms through puncture, and in a few cases a symptomatic 
cure. There is very little danger attached to the procedure. Veins 



384 TUMORS., INFLAMMATIONS AND ABSCESSES OF BRAIN 

may be injured leading to troublesome hemorrhages, or too deep 
puncture may injure the optic thalamus with temporary impairment. 
This is especially to be feared in basal tumors distorting the ventricle. 
No bad result has occurred in my experience except that in one patient 
there was a temporary paralysis of the arm ; whether due to making the 
puncture too far back or to a change in pressure of the unlocalized 
tumor, was not known (Fig. 127). 




FIG. 127. Technic of corpus callosum puncture. 

Technic. If the patient is not nervous the operation may be per- 
formed under local anesthesia. In such cases it is my custom to give, 
unless contra-indicated, a preliminary dose of scopolamine ^$ gr. 
and morphin | gr. two hours and one hour before operation. The area 
being infiltrated, a longitudinal incision is made running backward 
from the coronal suture and parallel to the longitudinal suture. The 
skin and the aponeurosis of the occipitofrontalis are retracted by the 
ordinary mastoid retractor. A trephine now removes a button of bone 
the center of which is about 2 cm. from the coronal suture and the same 
distance from the longitudinal. A slit is made in a non-vascular part 
of the dura which is retracted with fine retractors. A puncture needle 
is chosen that has a blunt end. Elsberg uses a needle devised by him- 



THE TREATMENT OF BRAIN TUMORS 385 

self in which the end is slightly bulbous with holes at the end and side. 
Before learning of this the author had devised a needle somewhat 
similar having, however, a more olive-pointed tip and the upper end 
flattened so the more perfect orientation at the concealed point is 
possible. The olive point enters the corpus easily but offers some 
resistance to withdrawal, thus indicating its position (see Fig. 128). 
The needle should be flexible, with a stylette, and should be at least 
10 cm. long. The needle is bent at an angle of about 90, approxi- 
mately 6 cm. from the end, since this is the average distance from the 
surface of the brain to the ventricle. A few small veins pass from the 
cortex veins to the longitudinal sinus and in most cases there is a slight 
adhesion of the cortex to the longitudinal sinus. The needle is gently 
passed through this area and rotated downward along the falx cerebri. 
A slight resistance is felt when the corpus callosum is reached. The end 
of the needle is gently moved back and forth to avoid penetrating the 
pial vessels and then is thrust through the corpus and the stylette 
removed. If tension is present, the fluid flows out freely. The needle 
end is rotated back and forward for about a centimeter to tear the 
corpus callosum and then is withdrawn. Care should be taken not to 



V. MUELLER S CO. 



FIG. 128. Modif^i needle used in corpus callosum puncture. 

go too far forward and miss the ventricle and too far backward and do 
injury to important structures. The dura is closed, the bone plug 
replaced or not as desired, and the wound closed. 

Puncture of the Ventricles. If the third ventricle be dilated it may be 
reached through the corpus callosum puncture just described; if not, 
the puncture will reach a lateral ventricle. Other sites for puncture 
of the lateral ventricles may be chosen and in ordinary cases where 
we wish to aspirate them for diagnosis or for therapeutic purposes, 
these locations are preferable. The relation of the ventricles may 
be seen from examining Plate IV. It should be remembered that the 
ventricle lies nearer the median line than the beginner would believe. 
The known centers should be avoided and care used not to injure pial 
vessels or to direct the needle toward the choroid plexus or the island 
of Reil where hemorrhage is very likely to occur. Again, the needle 
should be thrust directly into the ventricle and not moved about after 
the puncture is started. In the hands of the expert operator, puncture 
may be made from almost any site. Kocher, Keen, Neisser and Pol- 
lock, and others have drawn attention to points of election. Kocher's 
point is 2| cm. from the median line and 3 cm. anterior to the central 
fissure. The ventricle lies at a depth of 4 to 5 cm. and the widest part, 
2 cm. in width, is somewhat backward. . Keen's point is about 3 cm. 

VOL. i 25 




386 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

behind and 3 cm. above the external auditory meatus. The needle is 
carried in about 5 cm. in the direction of the opposite pinna. This 
strikes the ventricle where the lateral and posterior cornua are given 
off from the body of the ventricle at the posterior end of the thalamus. 

The puncture can be made under morphin \ and scopolamine 
-j-J-u- in divided doses, with local anesthesia for the scalp and even 
without the latter if a rapidly moving hand power small drill 2 to 4 mm. 
in diameter is used to go through the scalp and skull. If a craniotomy 
has been done one remembers that Keen's point corresponds to the 
posterior part of the first temporal convolution. If the frontal lobes 
are exposed, the anterior cornu is reached best through the second 
frontal gyrus about 1J cm. from the median line. In children the 
ventricle may be reached by puncture through the lateral angle of the 
anterior fontanelle, the needle being directed slightly backward and 
downward. 

Puncture of the Brain Substances. The firSt systematic description 
of brain puncture was given by Schmidt, but Neisser and Pollock have 
given us the most comprehensive clinical article upon the subject. 
They have located the points of predilection for diagnostic puncture 
and demonstrated that it can be done without great danger to the 
patient. On the other hand, there is a real possibility of injury to the 
pial vessels and sinuses; therefore, blind puncture should be resorted 
to only in exceptional cases. It is far better to remove a button of 
bone and thus avoid any possibility of injuring the vessels or sinuses. 
The procedure is carried out by means of a medium- sized needle with 
a stylette. Neisser uses a graduated platinum-iridium needle, 7 cm. 
long and 1.06 mm. thick, with an oblique point. The needle is inserted 
3 to 4 cm. The stylette is withdrawn and, if fluid or pus is present, it 
can be determined readily. If search is being made for a solid tumor, 
aspiration is now done and the small particles drawn into the needle 
examined microscopically. It is evident that in the latter instance the 
results obtained are far from satisfactory. The educated finger may, 
however, obtain data of value as to density of the tissue penetrated and 
in case of cyst, abscess, or hydrocephalus, real knowledge may be 
secured. Neisser and Pollock's article 1 illustrates the points of election. 

CEPHALOCELE. 

Diagnosis. The diagnosis of cephalocele rests upon the congenital 
nature of the condition, the location of the tumor in the lines of fetal 
closure of the skull, and the physical characteristics. While cephalocele 
may grow large after birth they are always congenital, and are to be 
found especially in the median line in the occipital or lower frontal 
region, the latter being most common. They may appear at the base 
between the ethmoid and sphenoid projecting into the nasal cavity, 
where they may be mistaken for polyps. Such a case is reported by 

1 Die Hirnpunktion, Mitt. a. d. Grenzgeb. a. d. Med. u. Chir., xiii, 807. 



CEPHALOCELE 387 

Christian Fenger, in which an error in diagnosis led to operation and 
death. Cephalocele occurring in the occipital region may emerge 
above or below the occipital protuberance, communicating in the 
former instance with the posterior fontanelle and in the latter with 
the foramen magnum. Those which appear in front emerge through the 
horizontal plate of the ethmoid and appear above or below the nasal 
bones, the former being most common. 

On examination cephalocele may be translucent or opaque, varying 
with the contents of the sac which may be made up almost entirely of 
cerebrospinal fluid or, in rare instances, brain tissue alone. The char- 
acter of the sac and the contents gives the name to the various types: 
meningocele, or better hydrencephalocele ; myelocystocele ; kenen- 
cephalocele (Heinecke); myelocystomeningocele; encephalocysto- 
meningocele. Histological examination of the sac wall shows skin, sub- 
cutaneous tissue, arachnoid membrane, either cystic or non- cystic, and 
a layer of tissue which may be either the ependymal lining alone of the 
ventricle or a thin or thick layer of brain tissue lined with this ependyma. 
In other words, the interior of the tumor is continuous with a ventricle ; 
the pericranium, skull, and dura being absent. The pericranium 
and dura generally merge into each other at the base of the tumor. If 
the tumor contains only the ependymal lining it is called a hydren- 
cephalocele; if some brain tissue be present with considerable fluid, 
it is a myelocystocele; if the arachnoid be the seat of cystic degener- 
ation, it may be either a myelocystomeningocele or an encephab- 
cystomeningocele. It will be seen, therefore, that pure meningocele is 
extremely uncommon as first shown by Muscatello. The opening into 
the ventricle proper may be very small. 

The tumors may be of any shape from flat to pedunculated ; the 
skin may be loose or tense ; they may or may not be translucent, solid, 
or fluctuating; they may or may not pulsate. Attempts to expel the 
contents of the sac into the brain cavity should not be made since the 
increase of brain pressure may give rise to alarming symptoms; but 
lumbar or tumor puncture to study the content or, in the former 
instance, the decrease of tension, is justifiable. Dermoids may occur 
at these sites and are differentiated by the physical characteristics and 
the result of puncture. 

Treatment. Cases of encephalocele with exencephalus live only a 
short time and hence are inoperable. The same may be said foi* those 
cases complicated with hydrocephalus or severe congenital lesions 
destroying the brain, or those arising from deep portions of the brain 
involving vital structures such as the medulla or the basal ganglia. 
Where there is a fairly well developed head, however, with the cephalo- 
cele engrafted upon it, operation is fiequently followed by good results, 
the results being in inverse ratio to the amount of brain tissue in the 
sac. The presence of some brain tissue does not necessarily preclude 
operation since the function of the portion of the frontal lobes destroyed 
may be taken over by that remaining. The cases with small pedicles 
and little brain tissue give especially good results. 



388 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

The tumor should be removed at the base, making no attempt to 
replace any brain tissue. A considerable amount of cerebrospinal fluid 
may be lost without endangering the We of the patient, but provision 
should be made to prevent such loss by placing the patient in such a 
position during the operation as to prevent the escape of the fluid. 
The lining membrane should be sutured together, the neck of the sac 
isolated from the surrounding bone, and the edges brought together if 
possible. If this is not possible or if the union is seen to be weak, a 
layer of fascia lata should be transplanted to cover the defect and 
carefully sutured to the outer surface of the surrounding dura allowing 
the edges to lie under the bone. If possible a flap of bone from the 
adjacent region should be transplanted to cover the defect. This 
latter is often not feasible and frequently not necessary. Because of 
the age and general condition of these patients, osteoplastic and compli- 
cated operations are not generally indicated. 

^ 

HYDROCEPHALUS. 

Diagnosis. The diagnosis of the presence of hydrocephalus is made 
easy by the well-known characteristics presented by the condition. 
The skull is large with a flaring vertex, overhanging the facial bones; 
if young, the fontanelles are not closed and the sutures may not be 
united, and through the thinned skin the veins engorged by the 




FIG. 129. Hydrocephalus. 

increased intracranial tension show plainly (Fig. 129). As the disease 
progresses, destruction of brain tissue and pressure upon the tracts 
leads to mental deterioration, rigidities of the muscles, with spasms, 
etc. If the condition comes on later in life the hardening of the bones 
may preclude the marked changes to be seen externally, but within the 
process may be more intense. External hydrocephalus is uncommon, 



HYDROCEPHALUS 389 

although we may have a spurious external hydrocephalus due to serous 
meningitis, cystic change hi the arachnoid, and the local degeneration 
of brain tissue with fluid formation and perforation into the subdural 
space, such as may occur in cerebral hemorrhage in the newborn. 

Internal hydrocephalus is the more common. For the purposes of 
treatment a diagnosis should be made as to the location of the obstruc- 
tion if one is present, since it is very important to know whether the 
serum passes freely into the fourth ventricle and the spinal subarach- 
noid space. Obstruction is most often seen at the foramina of Monro 
or Majendie or along the iter. In the true form this closure is probably 
due to inflammation but it may be seen as a result of tumor formation 
pressing upon the walls and thus obstructing the exit of the serum 
(Fig. 130) . In many cases on examination no obstruction can be found. 




FIG. 130. Internal hydrocephalus, probably inflammatory, but possibly due to hypo- 
physeal cyst. Following subtemporal decompression during the acute stage papillitis 
disappeared and the patient has had no symptoms for six years. Note the decompression 
tumefaction upon the right side. 

Treatment. For the purpose of treatment, the surgeon should 
determine if possible if obstruction is present. In those cases in which 
lumbar puncture fails to relieve the excessive cranial pressure, we 
assume such obstruction to be present and direct our surgical pro- 
cedures to the cranium. If no obstruction is found, either lumbar 
,6r cranial drainage may be instituted. 

Unfortunately no procedure has been found to be of great avail in 
this condition. Failure has been due chiefly to two causes: (1) the 
altered condition of the brain at the time the patient is presented for 
treatment (Fig. 131), and (2) the inability of the surgeon to produce 
continuous drainage owing to connective-tissue growth about the size 
of the drainage tube. To correct the first, all physicians should be 
urged ;to present the cases for as early operation as possible. Various 



390 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

procedures have been suggested to overcome the second difficulty. 
Unfortunately, none are particularly satisfactory. Direct puncture of 
the ventricles through either Keen's or Kocher's point (vide supra), 
followed by the insertion of tubes of various material such as glass, 
silver, etc., has often been tried with isolated successes. These tubes 
may reach to the subdural space or into the subcutaneous tissue. In 
either case, scar-tissue is likely to interfere soon. To obviate this, 
Payr suggested transplanting living veins, either in continuity with the 
vascular system or into the subdural space. The author has had some 
experience with this procedure. Temporarily the cases were relieved, 
but ultimately they ceased to drain. Others have made living tubes 




FIG. 131. Moderate degree of hydrocephalus showing brain change. 

of dura, with probably no better success. Murphy suggested drain- 
age of the fourth ventricle by opening through the roof, and lately 
Haynes has tried to insert a silver tube from the fourth ventricle to the 
lateral sinus. Haynes makes an incision from the occipital protuber- 
ance to the foramen magnum, somewhat to one side. The bone is 
removed up to and over the sinus. A purse-string suture holds one 
end of a specially prepared angular tube in the roof of the ventricle 
and the opposite end in the sinus. Owing to especially favorable con- 
ditions any of these procedures may at times be successful, but for the 
most part they are doomed to failure. Anton has reported several 
cases treated by corpus callosum puncture (vide supra) with marked 
relief, and to this the author can add his experience. While it is often 



TURMSCHADEL AND OXYCEPHALIA 391 

not satisfactory, in several cases, both of acquired hydrocephalus due 
to tumor and other conditions, and in the infantile type, the results 
have been all that could be expected. 

In those cases in which communication is free into the subarachnoid. 
spinal space, drainage may be instituted in the lumbar region, either 
anteriorly or posteriorly. The technic here also has the same dis- 
advantage as that instituted on the cranium. Metal tubes, silk, 
veins, arteries, etc., have all been used. Gushing suggests doing a 
laparotomy, splitting the peritoneum to the left of the rectum, trephin- 
ing the fifth lumbar vertebra, and inserting the female half of a silver 
cannula down to the spinal dura. The child is now turned over and a 
laminectomy done, the subarachnoid space opened, strands of cauda 
separated, and the male portion of the cannula locked in the female. 
The wounds are closed and the fluid escapes into the retroperitoneal 
tissue, unless connective tissue obliterates the opening. The same 
procedure may be carried out by using the patient's saphenous vein. 
The vein is sutured in place, fat being left on the vein to prevent 
collapse. In a majority of cases any of these procedures end in failure. 
At times in acute hydrocephalus, repeated lumbar puncture may appar- 
ently produce a cure. 

HERNIA CEREBRI. 

Treatment. This lamentable condition generally presupposes one 
or both of two conditions; increased intracranial pressure, and infec- 
tion. The treatment is based upon the removal or lessening of the 
protrusion and procedures designed to retain the structure. As a 
preliminary the intracranial tension should be lowered and this is best 
done by lumbar puncture, frequently repeated. If the tension is 
intracranial, ventricular puncture may be indicated. If this is not 
sufficient, the protruding mass may be removed, especially if it com- 
prises a "silent" area. The pericranial tissue may now be sutured 
over the area with tension sutures, and in favorable cases a flap of 
fascia lata may be inserted although infection which is commonly 
present may preclude this procedure or vitiate the result. Osteoplastic 
flaps after the Koenig method may be used. Where the tension is not 
too great, or where the opening is small or the protruding brain tissue 
sloughs off, granulation-tissue will spring up and the wound heal by 
cicatrization or be covered by Thiersch grafts. 

TURMSCHADEL AND OXYCEPHALIA. 

This condition has been supposed to be due to a congenital or 
premature closure of the fissures in the skull (Fig. 132) . If the fissures 
at the base and the sides are closed thus early, there is a tendency for 
the skull to grow upward presenting the appearance shown in the 
photograph. This naturally leads to an increase of intracranial 
pressure as evidenced by intense headache, the early development of 
optic atrophy and proptosis of the eyeball. The condition is one not 



392 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

readily amenable to surgical intervention. Discovered early, however, 
an extensive decompression operation may be done. To prevent the 
secondary changes in the eye due to turmschadel, Schloffer has advo- 
cated in certain cases removing the roof of the orbit and that section 
of the bone through which the optic nerve escapes from the skull. 




FIG. 132. Turmschadel. 

INFLAMMATIONS OF THE BRAIN AND THE MENINGES. 

Pachymeningitis Externa. This condition associated with coinci- 
dent osteomyelitis, syphilis of the bone, erysipelas, tumors, etc., should 
not be considered as a special disease. Since the process is localized, 
the signs are those of the causative disease with some evidences of 
subjacent brain irritation or pressure. These latter are slight as a 
rule. Prompt removal of the cause with adequate drainage will gener- 
ally relieve the condition. In the acute inflammatory disease, e. g., 
otitis media, unless prompt treatment is instituted it may lead to an 
acute leptomeningitis. 

Pachymeningitis Interna Hemorrhagica. Whether this condition is 
due to an inflammation as maintained by Virchow, Hesche, and Barrat, 
or to a hemorrhage followed by organization (Spiller, McCarthy) is 
open to question. Pathologically early we see a delicate pink or grayish 
deposit on the inner surface of the dura. This deposit is detachable 
and is usually studded with punctiform hemorrhages. The dura may 
be slightly distended. Successive layers are at times deposited, making 
a thick membrane. Oppenheim says that the milder grades of the 
disease may accompany any chronic inflammation and that it is 
common in senile dementia, chorea, any general infection, hemorrhagic 
disease, alcoholism or injuries. 



INFLAMMATIONS OF THE BRAIN AND THE MENINGES 393 

Diagnosis. A probable diagnosis may be made in the presence of one 
of these etiological factors accompanied by the evidences of cortical 
irritation and followed by the evidences of pressure, but lacking the 
signs of acute meningitis with its cranial nerve involvement and spinal 
fluid changes. At times the diagnosis may be confirmed by finding 
blood mixed with the fluid. The picture may be atypical and acute 
or subacute. 

Treatment. In a majority of cases the treatment will consist in 
sedatives, and the local use of an ice cap, combined with elimination by 
cathartics. Neisser and Pollock have reported cures by their method 
of brain puncture, but the operation surely should be done only in 
exceptional cases or not at all since the danger of injury to the pial 
vessels is too great to be overlooked. In severe states of pressure or 
prolonged convulsions, a decompression operation is indicated. 
Repeated lumbar puncture gives a slight measure of temporary relief, 
and in mild cases may be of benefit. 

The treatment of post-traumatic extravasations and allied condi- 
tions leading to mental changes as well as the acuter more extensive 
meningeal hemorrhages, will be discussed in the section devoted to 
traumatisms. 

Acute Inflammation of the Meninges. We shall limit our discussion 
to those types of meningitis of especial interest to the surgeon and 
speak here of the generalized form, reserving for the section upon 
abscess and localized inflammations the discussion of pachymeningitis 
and serous meningitis. 

The acute inflammation may arise in the course of any of the acute 
systemic diseases, such as pneumonia, influenza, etc., or may be due to 
the introduction of bacteria through traumatic sources or by extension 
from a local suppurative process in the bones,, sinuses, or bloodvessels, 
adjacent to the brain. It is manifest, therefore, that the onset may be 
fulminating, or more or less chronic if the organism be avirulent, or 
the local condition present the possibility of plastic exudate, hindering 
the rapid spread as in chronic otitis media. In the more explosive form 
there may be no prodromal symptoms. In the chronic type the pro- 
dromal symptoms may precede the typical signs of meningitis by many 
days, consisting of malaise, slight headache, etc., characterized by the 
patient as bilious symptoms. The typical symptoms of extending 
leptomeningitis may be characterized as toxic, irritative, and para- 
lytic, and. the diagnosis is made upon these added to the history of an 
etiological factor, the findings upon lumbar puncture and physical 
examination. Unfortunately for the standpoint of surgical relief, we 
have no pathognomonic early symptoms. Haines has emphasized the 
rapid increase of blood-pressure and edema of the fundus. 

The patient complains of an intractable headache incompletely 
relieved by morphin. Exacerbations are noted even during delirium; 
some optic neuritis is present but not the typical choked disk; vomiting 
is frequent but not constant. The patient rapidly passes into delirium, 
convulsions, and finally coma. Meanwhile, the fever may be most 



394 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

variable, being high or even subnormal later. The pulse may be fast 
or slow. The urine is febrile and may contain sugar. In addition to 
the signs of cerebral tension and irritation, the signs of nerve irritation 
become marked. The vision may become dim and photophobia appear. 
The eye muscles may become spastic or paralyzed, the pupils con- 
tracted early and later dilated; the seventh nerve may produce mus- 
cular twitchings in the face. Irritation of the sensory nerves produces 
hyperesthesia of the skin and irritability of the muscles; of the motor 
nerves, stiffness of the neck, abdominal rigidity, inability to extend the 
leg (Kernig) or flex the thigh (Lasegue), or convulsive seizures, etc.; 
of the trophic nerves, herpes, urticaria, and other skin eruptions of the 
vasomotor nerves, secretory and vasomotor phenomena. 

Early lumbar puncture will show little, but later turbidity produced 
by polymorphonuclear leukocytes and few or many bacteria will be 
present a finding which should not be awaited if we expect to benefit 
the patient by surgical treatment. ^ 

The symptoms of acute meningitis may be produced in a modified 
form by local infective processes in the cranial cavity and also by the 
toxemias of acute infections; e. g., pneumonia, typhoid, septicemia, 
uremia, delirium tremens, hysteria, etc. In children even gastro- 
intestinal disorders may present a typical picture, except for the phys- 
ical findings, the cerebrospinal fluid changes, and the rapid recovery 
following catharsis. It should be noted that acute otitis media espe- 
cially in children may give headache, convulsions, delirium, stupor, and 
even a paralysis of the sixth nerve from accompanying edema. 

Treatment. Owing to the fact that little can be expected from 
treatment, especial care should be used in prophylaxis. This consists 
in asepsis in cranial injuries and treating otitis media and various 
chronic sinus infections. Some clinicians believe, in spite of experi- 
mental evidence to the contrary, that the administration of large doses 
of hexamethylamin (gr. xxx to xxxv) every few hours may retard infec- 
tion, and the author has used, with apparent success, antistreptococcus 
sera in 50 c.c. doses as a prophylactic in certain operative procedures 
where there was great danger of such infection. 

When the infection has once started, the primary focus should be 
treated and free local drainage instituted. Beyond this many pro- 
cedures have been suggested without as yet demonstrating any positive 
benefit in severe cases. Many milder types have apparently been 
cured by repeated lumbar puncture. 

Various operative procedures having for their purpose drainage or 
the introduction of medicaments have been suggested. The condition 
of the patient is not impaired by these and a certain few cases have 
apparently been benefited. The repeated intraspinal injection of 
hexamethylamin (McKernon) gr. 100 in sterile solution in such concen- 
tration as that its bulk equals one-half of the amount of cerebrospinal 
fluid removed has been followed by a few recoveries. Others (Barr) 
have introduced a needle into the ventricles and injected sterile normal 
salt or antiseptic solutions, meanwhile removing fluid by lumbar 



INFLAMMATIONS OF THE BRAIN AND THE MENINGES 395 

puncture; this has not as yet given satisfactory results but is worthy 
of further study. Haynes has suggested drainage by way of the cis- 
terna magna. An incision is made downward from the occipital pro- 
tuberance, and the tissues retracted, a trephine opening is made one 
inch below the protuberance and enlarged by the rongeur down to the 
foramen magnum. The dura and arachnoid are opened and a gutta- 
percha drain inserted. Day and others, however, have not had success 
with this procedure. 

Barth has reported the recovery of three cases in which lumbar 
drainage by laminectomy was performed and Leighton has since 
reported two recoveries by the same procedure. An incision is made 
over the third lumbar vertebra and the spines and laminae of the third 
and fourth removed. The dura is opened and a drain inserted down to 
the dura and the muscles sutured. During its operation the head is 
placed at a lower level than the wound. 

Early diagnosis and treatment is undoubtedly a strong factor in the 
cure and at the present time a thorough eradication of the focus of 
infection with free local drainage added to lumbar drainage would 
seem to offer the best results, and it is possible that to this may be 
added intraspinal urotropin injections. 

Brain Abscess. Diagnosis. Abscess of the brain appears in one of 
three forms: (a) acute fulminating; (6) latent; (c) stage of exacerba- 
tion. 

(a) The acute fulminating type is an immediate sequela of a primary 
focus still present, and besides the focal and general evidences of brain 
lesion presents to a marked degree the signs of the primary focus and 
the evidences of inflammation, e. g., fever, leukocytosis, etc. Here the 
question is not the diagnosis between an abscess and a tumor, but 
rather the diagnosis from an extradural or intradural abscess, menin- 
gitis, both purulent and serous, and the primary focus itself. This is 
often most difficult and frequently can be told only upon operation. 

The extradural abscess does not present the marked focal evidences 
frequently present in the abscess. If it develops from an otitis media, 
there is often pain on pressure back of the mastoid, swelling in this 
region, and a tendency to hold the head in a fixed position, and upon 
operation such an amount of pus is evacuated before reaching the 
brain that the operator concludes that the pressure may have come 
from this. 

In purulent meningitis we have the presence of bacteria and leuko- 
cytes in the spinal fluid. The evidences of a more diffuse involvement 
of the entire system is described above. 

Sinus thrombosis is considered below. 

Subdural abscess, purulent meningo-encephalitis, is to all intents 
and purposes, a brain abscess. 

Serous meningitis frequently accompanies an otitis media. Here 
we have a diffuse involvement with an early optic neuritis. The 
symptoms are relatively mild, as regards temperature. The focal 
symptoms are generally less positive and persistent than in abscess and 



396 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

less extensive and severe than in purulent meningitis. It should be 
remembered that any of these processes may accompany an abscess. 

(b) Latent Stage. An abscess may remain for many years and pro- 
duce no signs whatever, or there may be a history of vague symptoms, 
particularly slight headache, some impairment of vision especially upon 
careful tests, and mental deterioration, noted especially as hebetude 
(Fig. 133). 




FIG. 133. Old abscess of the brain. 

(c) Stage of Exacerbation. This may appear in various forms from 
indefinite evidences to positive signs of brain involvement as noted 
below. Here the question of diagnosis from brain tumor immediately 
arises and we search for a history of a primary focus and the evidences 
of inflammation, either of which will be of great aid in the diagnosis. 
Unfortunately the primary focus may have healed years before, while 
the encapsulation and a toxicity of the old abscess may prevent the 
development of the evidences of inflammation. 

The stage of exacerbation is prone to be ushered in brusquely in one 
of the following ways: The patient may begin suddenly to complain 
of headache and vomiting. The patient seems to be somewhat apathet- 
ic, and an examination of the eye grounds often shows a retinitis, 
whether due to pressure or to toxemia as Lewandowsky suggests, may 
be open to question, but the frequent absence of choked disk seems 
to speak for the latter. Slow pulse is frequently present. In addition 
we may have focal symptoms from the sites of predilection of abscess. 

The occurrence at any time of life of a hemiplegia which starts as 
a monoplegia and requires several days for development, if accom- 
panied by the above symptoms and particularly if signs of inflammation 
are present, is very suggestive. 



INFLAMMATIONS OF THE BRAIN AND THE MEN I NOES 397 

The sudden onset of convulsions, otherwise unexplainable and 
accompanied by fever, very strongly suggests abscess. The more or 
less sudden development of aphasia or monoplegia in a patient with a 
history of otitis warrants in a majority of cases the diagnosis of an 
abscess. 

Given any one of the groups of symptoms, the diagnostician imme- 
diately searches for confirmatory evidences as found in (a) sign of 
inflammation, (6) primary focus, (c) focal signs. 

As has been said fever and leukocytosis may be absent in fully a 
third of the cases, and when present they are generally moderate in 
degree. A high fever generally indicates either acuteness, impingement 
of the abscess upon the meninges or ventricles, or rupture into them. 
Chills may be present. 

The most common source of abscess is the middle ear, but the abscess 
may arise from a nasal sinus or from orbit disease, from any other 
focus about the skull, or from a metastatic source. The nasal sinus or 
orbit naturally give rise to frontal abscesses, the roof of the tympanic 
cavity or of the mastoid to temporal, and the mastoid process and 
labyrinth to cerebellar abscesses. Metastatic abscesses locate along 
the Sylvian fissure. 

Focal symptoms may be entirely lacking, especially in the frontal 
and right temporal lobes. The left temporal may give rise to partial 
or complete word deafness, amnesia, or paraphasia. If the abscesses 
are large or deep, they press on the motor and sensory zones with 
corresponding signs. When arising from the ear, they frequently lie 
near the base and may give rise to basal nerve signs, especially the 
third and sixth. 

For a complete discussion of focal signs in the various regions, the 
reader is referred to that section in the early portion of the chapter, 
since they differ in nowise from those found in tumors. 

Treatment. Since about a third of the abscesses of the brain follow 
infected injuries and a considerable proportion of the remainder have 
their origin in otitis media especially of the chronic type, especial 
prophylactic care should be directed to these conditions. 

When there is no evidence of a primary focus and no localizing signs 
can be elicited, we should remember that by far the largest number of 
abscesses are found in either the temporosphenoidal lobes or the cere- 
bellum. They may, however, be found in the frontal lobe from nasal 
or orbital disease, along the Sylvian fissure, from metastatic foci, the 
occipital lobe, or, indeed, any part of the brain. Statistics would seem 
to show that 60 per cent, of the abscesses are in the temporosphenoidal 
lobe, 25 per cent, in the cerebellum, and 15 per cent, in the frontal lobe 
and other parts of the cerebrum. Ballance has suggested that in sus- 
pected abscesses with nothing to suggest a location, we should make 
a good-sized decompression, open the dura by the flap method, and 
pack the area under the edges of the dura for one or two days for the 
purpose of producing limiting adhesions and favoring the advance of 
the abscess toward the surface a procedure that has much^to recom- 



398 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

mend it in certain cases. In whatever portion of the brain we attack 
we should remember that the abscesses tend to lie in the white matter, 
owing to the fact that it is more easily liquified than the neuroglia- 
bound cortex upon which the abscess is prone to impinge, however, 
and hence seldom lies deeper than an inch. Again, the abscesses tend 
to lie in juxtaposition to the site of origin. Thus frontal abscesses most 
frequently lie in the inferior frontal convolution ; the temporosphenoidal 
in the inferior convolution near the petrous portion of the temporal 
bone; the cerebellar in the lateral lobe near the same bone; while the 
metastatic lie near the Sylvian fissure. Ballance has drawn attention 
to the so-called " stalk," a connective tissue sinus-like connection 
between the abscess and the site of entry. When this is found it is a 
valuable guide in locating the abscess. Owing to the fact, however, 
that most unlocalized abscesses are approached from the external 
surface and these " stalks" come off from the petrous portion of the bone 
on the basal portion, they are not frequently found at operation, 
except by the otologist who searches for the abscess by way of the ear. 
Much controversy is found as to the proper technic to be used in search- 
ing for the abscess. Lately Sharpe has advised large osteoplastic flaps 
over the temporal or cerebellar regions, not alone for more adequate 
investigation, but also to guard against the ill effects of consequent 
brain edema. If Sharpe's method is followed a muscle-splitting opera- 
tion should be done to prevent hernia, since if the abscess is found, 
drainage must be instituted. It probably is true, at least, that the small 
trephine openings advocated by some are frequently inadequate. 
Again, there is much debate as to wiiether the dura should be cut in 
flap form, the subdural space walled-off, and the abscess sought for at 
the time or after a day or two, or whether multiple small cuts should 
be made through the dura and the punctures made through these. 
The latter has much to recommend it in cases where there is consider- 
able doubt as to the diagnosis. Puncture through the unopened dura 
should never be done owing to the possibility of injury to the pial 
vessels. 

The pus is generally thick; therefore, if a needle is used it should have 
a 2 mm. aperture at least. Ballance and others recommend a knife, 
but most surgeons prefer a large needle, groove director, or preferably a 
searcher of small size that has two blades which may be separated, 
allowing the pus to escape between the blades. Page and others have 
devised and described such forceps (Fig. 134). Having found the 
abscess, the pus should be allowed to escape freely. Krause inserts his 
finger and breaks up the loculi, a procedure that in most cases is not 
advisable, but if it were done would probably lead to detection of 
secondary abscess if they were present. It goes without saying that 
the subdural space should be well walled-off by gauze if limiting 
adhesions are not present. Gutta percha or cigarette drains should 
be inserted, and in the chronic cases should be left in for a considerable 
period. One case coming under the author's observation was drained 
three times with ultimate recovery, a multiplicity of operations which 



INFLAMMATIONS OF THE BRAIN AND THE MENINGES 399 

would have been avoided if the drain had been left in place longer a 
procedure which necessitates suturing the drain to the skin or dura. 

With these general principles considered, let us ask ourselves what 
should be our method of attack in a given case. While considerable 
difference of opinion exists as to the proper procedure, it has seemed 
to the author that the following may be considered as a working basis. 

1. In chronic cases with no localizing signs or evidences of primary 
focus, a large subtemporal muscle-splitting decompression with cutting 
of the dura may be done, and the undersurface of the dural edge 
traumatized or packed lightly with gauze to produce adhesions after 
the Ballance method. The opening should be adequate and go well 
down on the temporal bone so as to expose the first temporal convolu- 
tion. Its greatest diameter should be anteroposterior to give ample 
field for puncture in various directions. The frontal or cerebellar 
regions may be similarly exposed when desired. 




FIG. 134. Page pus searcher. 

2. Acute Processes with Suspected Abscess. Let us suppose the 
process to be an acute otitis media. As stated above the diagnosis is 
difficult and we may be in doubt as to whether we are dealing with an 
otitis alone or otitis complicated with an extradural abscess, a sinus 
thrombosis, serous meningitis, subdural abscess, or an intracerebral 
or intracerebellar abscess. The condition of the patient in any case 
will be such as to demand expeditious operation. Therefore, our 
operation should be so planned as to meet these possibilities. We have 
three courses open: (1) we may begin with the ear, open the mastoid, 
antrum, and ear, and then proceed directly to the cerebrum or cere- 
bellum as the diseased bone may suggest; (2) after opening the mastoid 
we may make a second trephine opening over either the temporo- 
sphenoidal lobe or the cerebellum; (3) after opening the mastoid we 
may make the opening over the sigmoid sinus and enlarge the opening 
both upward to expose the temporosphenoidal lobe and downward and 
backward to expose the cerebellum. In a majority of the acute cases, 
it is wiser to proceed directly from the ear, in which case the technic 
is as follows: The mastoid and ear having been cleaned out rapidly 
without attention to minor details, the wall is examined for caries. If 



400 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

the wall of the tegmen or the anterior surface of the petrous bone are 
destroyed, it suggests extradural abscess here or temporosphenoidal 
abscess; if over the vestibule or the internal auditory meatus the cere- 
bellum is suspected or both, they may be examined if desired. If the 
posterior fossa is suspected the bone is removed over the sinus; if 
extradural, pus is evacuated. This may be all that is necessary. The 
sinus is palpated and inspected. If still unsatisfied, two routes are 
available; viz., to the inner or outer side of the sinus. Infection from 
the antrum may produce a lateral sinus thrombosis, or pass internal 
through the dura mater. Infection from the labyrinth may pass 
between the semicircular canals and destroy the posterior wall of the 
petrous portion or may pass into the internal auditory meatus and 
along the seventh or eighth nerves to the deeper part of the cerebellum. 
By going to the anterior side of the sinus we have a more direct path in* 
case the abscess lies deep. Special care should be used not to injure 
the facial nerve. The outer or posterior route gives more dependent 
drainage and is in a less infected field but the abscess is more likely to 
be missed. In the inner or anterior route, the posterior bony wall of 
the ear operation field is removed, laying bare the inner margin of the 
lateral sinus. The dura is raised and the field a very small triangle 
exposed, bounded by the facial nerve and the sinus, a dangerous area 
for one not intimately acquainted with aural surgery. The dura is 
cut horizontally keeping the edge of the sinus in view. The exploring 
needle is passed backward, inward, and slightly upward. By the 
outer route which is somewhat easier, an incision is made transversely 
backward from the original skin incision . The scalp tissues are elevated 
and the bone removed, exposing the sinus and going backward until 
the dura below is exposed for at least an inch in each direction. The 
incision of the dura is parallel with the sinus and below it. The cere- 
bellum is now explored by passing the exploring needle inward and 
slightly upward, since the abscess lies near the anterior surface of the 
lateral lobe. If found, drainage is instituted as described above. 

If the destruction of bone suggests the temporosphenoidal lobe, or 
if for any other reason it is desired to explore the lobe from the ear, one 
proceeds as follows: The roof of the operation cavity is removed, 
going inward, upward and forward. If no extradural abscess is found, 
the dura is incised. The presence of serous meningitis may explain all 
of the symptoms, but on the other hand such a meningitis often accom- 
panies an abscess. The exploring needle is pushed upward for three- 
fourths of an inch; if no pus is found it is inserted forward and upward, 
and then backward and upward. Do not go too deeply since the abscess 
is generally near the surface in the inferior lobe. 

Whenever the dura is to be opened, the field should be cleaned as 
well as possible, painted with tincture of iodine, and if space permits, 
the subdural space around the edges packed with gauze. If only a 
small incision is made in the dura, the brain bulges into the cut so as 
to practically obliterate the spaces. 

In the second method, after cleaning out the ear and mastoid, search 



INFLAMMATIONS OF THE BRAIN AND THE MENINGES 401 

of the temporosphenoidal lobe from a separate opening is carried out 
by one of two ways : either the skin incision already made may be con- 
tinued upward and forward to expose an area one inch in diameter, 
the central point of which is one inch above the posterior margin of the 
external auditory meatus, or,we may use a small subtemporal muscle- 
splitting operation over the Inferior temporosphenoidal lobe. 

If we wish to enter the cerebellum by a separate opening, a line is 
drawn from the occipital protuberance to the external auditory meatus 
and a trephine opening is made 1 cm. below this line and 3J cm. 
behind the auditory meatus. The bone opening is enlarged as necessary. 
The dura is opened and the brain explored as described above. 

If the third method is chosen, after the ear and mastoid have been 
cleaned out, the bone may be cleared off and a trephine entered one 
inch behind and one-quarter inch above the external auditory meatus. 
This will expose the sinus. By removing bone above and anteriorly 
the temporosphenoidal lobe may be reached, and by removing it down- 
ward and backward the cerebellum may be reached. 

3. In chronic cases with a primary focus present, the same three 
courses of treatment are open as above. There is some slight advantage 
in opening the two fields separately since if no abscess is found there is 
less danger of infection; on the other hand, by operating through the 
ear there is greater probability of identifying the " stalk" mentioned 
and thus following it to its source. 

4. In chronic cases with localising signs without a primary focus being 
present, either a one- or two-stage operation may be done. The latter 
is certainly safer and where delay is not dangerous is worthy of con- 
sideration. In either case the area is reached by one of the extradural 
routes mentioned above for the individual lobes. 

In Korner's series of 212 temporosphenoidal abscesses, the best 
results were obtained when the abscess was opened by the mastoid 
route, and by direct trephining of the skull; the next best by opening 
through the mastoid route; while the poorest results came from direct 
trephining without operation on the mastoid. 

If good results are to be obtained in the treatment of brain abscesses 
the surgeon must be prepared to operate on evidence which amounts 
to much less than certainty and expect to fail in finding the abscess in 
a certain number of cases. 

Thrombosis of Intracranial Blood Sinuses. Diagnosis. These pre- 
sent the evidences of obstruction to the return of blood through the 
afferent veins, and if the process is an infectious one, the symptoms of 
local inflammation and general septic phenomena. From a surgical 
standpoint thrombosis of the lateral and cavernous sinuses is most 
important particularly the former, although the longitudinal and other 
sinuses may be involved. 

When the cavernous sinus is the seat of thrombo-sinusitis, we have 
cyanosis of the orbital and the frontal regions with protrusion of the 
eyeball. Pain along the first branch of the fifth nerve may be present 
with possible paralysis of the third, fourth, and sixth. To these signs 

VOL. i 26 



402 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

are added the fever, leukocytosis, chills, etc., associated with sepsis. 
When the lateral sinus is involved, the origin is frequently from an 
otitis media. We will therefore commonly have the evidences of this 
disease and superimposed upon it the signs of occlusion of its afferent 
vessels, producing headache, edema posterior to the ear, dilatation 
of the cutaneous veins; secondly the signs of local infection, as tender- 
ness; thirdly, the local and general evidences of extension of the clot 
down the jugular vein, with tenderness in the neck, torticollis, and the 
cordlike feeling of the vessel due to the clot therein; fourthly, the evi- 
dences of sepsis, with chills, fever, and the signs of extension of the 
septic process into the lungs ; fifthly, the effect upon the nerves, since 
at times the ninth, tenth, eleventh and twelfth may be involved and 
paralysis ensue. It is seen, therefore, that early the signs may simulate 
an extradural abscess, or brain abscess, since the impaired circulation 
may produce a choked disk, vertigo, vomiting, slow pulse, stupor, excita- 
bility, etc., with the signs of infection. If thisigns of pyemia develop 
with involvement of the jugular, the diagnosis is clear. Operation, 
however, should be performed early before these complications develop. 

Treatment. If we hope to aid these cases, the operation should 
be done before the stage of sepsis. Therefore, in the lateral sinus cases 
we should give prompt attention to any evidence of extension from an 
otitis media, the operation being planned to care for any complication 
that may be piesent, whether an abscess or a sinus thrombosis, and we 
should be guided by the findings as the operation progresses. If the 
extension to the jugular is evident or pyemia develops, the attack 
may then be made directly upon the sinus or the jugular vein as the 
case seems to demand. In connection with the consideration of the 
technic in these cases, the section upon brain abscess should be noted. 
Jones recently collected from English surgeons the various opinions as 
to the procedure in these cases, and correlated them as follows: 

In every case of temporal bone disease with symptoms suggesting 
the presence of a perisinus abscess or the onset of pyemia, expose the 
sigmoid sinus with the least possible disturbance to its walls until 
healthy wall is seen and the blood in the part is judged to be fluid and 
the lumen controllable. This may involve removing bone up to, or 
even including, the covering of the torcular herophili, and down to 
within reach of the jugular foramen. If no disease is apparent except 
the extradural abscess and the so-called " healthy" granulations spring- 
ing from the sinus wall, and if only one rigor has been observed 
wait. If the pyemia is established but not severe and there is a limited 
occluding clot in the sigmoid, compress above and below clot, remove 
clot, excise outer wall between the compresses, and pack with gauze. 
If the sinus is obviously diseased, but contents are partly fluid and 
systemic symptoms marked, expose the internal jugular vein in the 
neck. Even if the sinus is not obviously diseased, and the blood is 
fluid, and there is severe pyemia or symptoms of bulb-thrombosis, 
expose the internal jugular vein, occlude both sinus and vein, drain, 
and plug the intervening part. If the sinus is clotted and the lower 
limit of diseased wall or clot cannot be reached, expose the vein in the 



INFLAMMATIONS OF THE BRAIN AND THE ME NI NOES 403 

neck this is merely applying the principle of exposing healthy wall 
beyond each end of the clot without undertaking the much longer and 
generally unnecessary operation of exposing the bulb. Having laid 
bare the internal jugular vein at the entry of the common facial vein, 
we have several courses to consider. If the vein is of normal size and 
looks healthy, and if blood is flowing freely through it, compress tem- 
porarily and remove the clot from the sinus down to the jugular 
foramen; if there is a free flow of blood into the sinus, plug the sinus 
after draining and either close the neck wound or put in Voss' pro- 
visional ligatures, according to the severity and duration of the systemic 
symptoms. If the vein is collapsed above the facial, but healthy and 
full of fluid blood below, tie in two places and divide above the facial, 
bring the upper end into the wound, and endeavor to clear out the clot 
from the bulb by gentle irrigation. The same procedure can be adopted 
if the upper vein is clotted but the clot does not reach to the facial vein 
and the lower vein is healthy. It is easier to clear the bulb under these 
circumstances than to do so when the vein is collapsed. 

When the clot extends beyond the facial junction it is better to tie 
and divide the internal jugular as low down as possible in the neck. 
Having dissected up the vein and tied off the tributaries including the 
facial, excise the greater part and bring the upper end into the wound. 
There is always a temptation to leave the vein unopened the first day, 
for fear of severe hemorrhage, but the risk of extension of sepsis from 
the upper vein is too great, and drainage from sinus to vein should be 
established at once. The wound in the neck may be closed, except 
the upper inch without packing, unless the walls of the vein are dis- 
eased, though the danger of suppuration along the trachea is a real 
one. Associated cerebral and cerebellar abscess, meningitis, metastatic 
abscesses must, of course, be dealt with as occasion demand. 

The approach to the cavernous sinus may be laterally by way of the 
middle fossa, through the orbit, or through the nose. The former 
would be used in exceptional cases only. Mosher has described a 
method of draining the sinus through the orbit as follows: 

The eye and the orbital contents are removed, the ophthalmic artery 
tied, the periosteum cleaned from the posterior half of the floor of the 
orbit, and the groove recognized in which the superior maxillary nerve 
runs. The periosteum is now separated from the orbital surface of the 
great wing of the sphenoid, and the outer end of the sphenoidal fissure 
recognized. Now place the chisel vertically and make a cut through 
the great wing of the sphenoid from the notch for the superior maxillary 
nerve to the outer end of the sphenoid fissure above. Enlarge the 
opening, making the lower level of the bone window on a level with the 
floor of the orbit. Elevate the dura from the floor of the middle fossa, 
the outer wall of the sinus being exposed, place a blunt-pointed knife 
against the sinus on a level with the floor of the orbit and carry the 
knife toward the body of the sphenoid, thus opening the sinus. 

To those familiar with intranasal surgery, the following route will 
probably be found more satisfactory. 

Langworthy has proposed an operation as follows : Light ether vapor 



404 TUMORS, INFLAMMATIONS AND ABSCESSES OF BRAIN 

anesthesia. Plugging of posterior nares on one side and free injection 
of adrenalin chloride solution about the operative region. Quick 
removal of obstructing ethmoid labyrinth, middle turbinate, and ante- 
rior sphenoidal wall, by the use of ethmoid curette, turbinate forceps, 
sphenoidal curette, punch, and long narrow-handle gouge and hammer. 
Once in the sphenoid cavity the author's straight and angular blunt 
curettes with overhanging edge can be pushed through the roof of the 
sphenoidal sinus close to the junction of its roof and external wall. 
The blunt ends of these curettes will push the carotid artery aside 
without damage and by rotating the spoon in a forward direction away 
from the carotid artery the overhanging edge of the curette catches 
bone and a hole of some size can be made leading directly into the sinus. 
This can be further enlarged by use of curettes assisted as mentioned 
by a long narrow chisel and hammer. The chief danger of the opera- 
tion here I would say is not quite so much the thick-walled large 
carotid artery but rather some unexpected small branches given off 
frequently in this region which when accidentally torn by instrumenta- 
tion might prove troublesome much of this, however, is at present 
pure speculation. 

Tuberculous Meningitis. Diagnosis. The diagnosis must be made 
on the evidences of a meningitis developing more slowly than the acute 
meningitis, the presence of a possible source, the age of the patient, 
and the findings in the cerebrospinal fluid. The disease is found most 
often in children who are poorly nourished. There is frequently a 
prodromal stage of restlessness and sleeplessness followed by headache. 
In a week to a month the evidences of meningitis appear, with muscular 
twitchings, cranial nerve involvement, and finally delirium, coma, 
paralysis, etc. Variable temperature is present and the spinal fluid 
is clear with a lymphocyte increase; in exceptional cases the spinal 
fluid may be purulent or bloody; deceptive remissions occur. 

Treatment. Operative treatment such as decompression, repeated 
lumbar puncture, etc. have been tried, but without influencing the 
course of the disease. It hydrocephalus follows it may be treated by 
corpus callosum puncture. 

Syphilis of the Brain. The protean picture presented by syphilis 
of the brain is the cause of failure in diagnosis by the novice and the 
most suggestive factor in diagnosis to the expert. This is due particu- 
larly to the many forms the disease may take, from a simple meningitis 
to arterial changes and their consequences, or even to solitary or 
multiple intracerebral manifestations. They may occur as early as 
three or four weeks or as late as many years after infection, while 
isolated gummata may appear indistinguishable in symptomatology 
from brain tumor except for the serological findings. There is most 
often an atypical picture involving both brain and spinal cord. In 
almost all cases where present the disease may be suspected and must 
be confirmed by the Wassermann reaction, before absolute diagnosis 
is possible. Among the suggestive symptoms are headache, motor 
disturbances, cranial nerve involvements, spinal complications, dis- 
orders of sleep, alterations of character, and sensory phenomena. It is 



INFLAMMATIONS OF THE BRAIN AND THE MENINGES 405 

evident that these are not peculiar to brain syphilis, and yet a careful 
study of them may be suggestive. The headache is often most severe, 
being described as throbbing, boring, etc., it is recurring and fairly 
constant, and may be the only symptom or may be associated with 
vomiting, dizziness, and choked disk, especially in gummata, and in 
cases where no assignable cause can be found for such a headache, 
serological tests should be made of both the blood and spinal fluid. 
Motor disturbances are fairly common, varying from a Jacksonian 
epilepsy seen with gumma, to twitching, spasms, localized and atypical 
paralysis. Hemiplegia is not uncommon and when it does occur before 
the natural age and without high blood-pressure is suggestive. The 
cranial nerve most often involved is the third, but any others may be 
so affected, especially the fourth and sixth. Alterations of character 
may be marked : the active may become sluggish; the thrifty, profligate; 
the moral, immoral; or less prominent characteristics changed. 

Insomnia is a very common complaint and when found should lead 
to investigation. 

The sensory changes are most variable but a rather constant symp- 
tom of brain syphilis. 

Treatment. The treatment of brain syphilis calls for most persistent 
attention. The common belief that potassium iodide has any curative 
value in the condition should be discounted. It does give relief to* 
symptoms, and may cause a recession of the gummatous and syphilitic 
deposit, but does not act to destroy the spirochetse. For this purpose 
either arsenic or mercury are necessary and at times the administration 
of both will be of advantage. The mercury should be given in large 
doses and persistently. There is nothing superior to the rubbings with 
blue ointment, but the deep muscular injections in various forms are 
also efficacious. Salvarsan either intravenously or intraspinally may 
be given. It is thought by Hall and others that dissolving the drug in 
the aspirated cerebrospinal fluid and reinjecting it into the subdural 
space may produce better results. This should be repeated frequently 
and is best supplemented by mercury treatment. The treatment should 
be continued until the Wassermann remains negative for at least a 
year, and it is wise to make subsequent tests and keep the patient 
under observation for a number of years. Hamill who has had con- 
siderable experience in the treatment of cerebrospinal syphilis sum- 
marizes his views as follows: Syphilis of the nervous system is to be 
treated as syphilis whether early or late. If early intravenous methods 
probably suffice, but they must be controlled by Wassermann on the 
blood and spinal fluid. The method producing the most favorable 
results is an intermittent one : three or four injections at four- to seven- 
day intervals, two or three months of rest with intramuscular injections 
of mercury and then another and even a third series. Late nervous 
syphilis should receive both intravenous a ad local treatment, if we 
may so term subdural injections. 

In those cases presenting persistent brain pressure symptoms, 
threatening loss of sight, a subtemporal decompression or puncture of 
the corpus callosum may be indicated. 



THE PURPOSE AND TECHNICAL STEPS OF A 
STJBTEMPORAL DECOMPRESSION. 1 

BY HARVEY GUSHING, M.D. 

THE view, long held by some neurologists, that intracranial tumors 
are of far more frequent occurrence than the usual morbidity figures 
would indicate, has, during the past decade, come to be generally 
accepted. That the profession has been slow to appreciate this is not 
to be wondered at, for few have been trained along neurological lines, 
and even those who were, have hesitated to make a diagnosis of tumor 
unless the so-called classical features of an advanced process were 
present. 

When, however, under the caption of "brain tumors," we include 
growths not only of the encephalon but also of its meningeal coverings 
and of its appendages, choroid plexus, pituitary and pineal bodies, the 
symptoms which may be evoked are diverse in the extreme, and, indeed, 
there may be no appreciable symptoms whatsoever until late in the 
course of the disorder and even then unclassical ones. For, regarded 
broadly, intracranial tumors are of most varied sorts, in most varied 
situations, and, as they differ greatly in their rapidity of growth, the 
resultant symptoms vary widely in character and degree. 

Surgery has had much to do with this change of opinion, for the 
promise of operative relief in what is otherwise a hopeless condition has 
led to more precocious and more exact methods of diagnosis. It is but 
a repetition of our experience with the disorders of the appendix, of 
the gall-bladder, of the stomach and duodenum: for a few years ago 
an ulcer of the duodenum was a rare malady, with certain classical 
symptoms, for which we do not now sit and wait. 2 

Most tumors, first or last, lead to the classical symptoms of headache 
and choked disk the chief subjective as well as the most reliable 
objective indication of intracranial pressure. Though pressure dis- 

1 Received tor publication May 6, 1916. 

2 Seven years ago (Boston Med. and Surg. Jour., 1909, clxi, 71-80) the writer had 
occasion to examine the incidence of brain tumor cases in the Johns Hopkins Hospital 
records and found that in approximately 25,000 admissions in the medical wards over 
a period of twenty years there had been about 100 cases diagnosed as tumor or presump- 
tive tumor. As there were about 20 cases in each successive 5000 admissions, 0.4 per 
cent, may be taken to represent the average incidence of tumor in a general medical 
clinic which receives neurological cases. In the surgical service during the same period, 
due to the growing interest taken in these disorders, the percentage had risen from 0.06 
per cent, in the first 5000 admissions to over 3 per cent, in the last 1000. In the first 
5000 admissions to the surgical service at the Brigham Hospital there have been, includ- 
ing pituitary tumors, approximately 400 tumor cases, 8 per cent., or one in every twelve 
admissions, and something over 100 cases a year. This shows how attention paid to a 
special subject may modify the character of a clinic. 

(407) 



408 PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 

comforts may sometimes undergo spontaneous retrogression, as in a 
child with a distensible skull or in the case of a pituitary tumor which 
succeeds in distending the sella turcica, still in the general run of cases 
a persistent increase in intracranial tension if unrelieved by surgical 
measures leads to great physical suffering and ultimately to loss of 
vision. For the purposes of our present topic we may turn our atten- 
tion for a moment to these two most characteristic evidences of 
tension. 




FIG. 135. Example of an improperly placed and improperly executed so-called 
"decompression" for presumed cerebral tumor (actually a cerebellar endothelioma 
with secondary hydrocephalus) . Note curvilinear incision and position of defect too 
high to be protected by muscle. Insecure closure of wound led to a cerebrospinal fluid 
leak; the extreme protrusion to contralateral hemiplegia. (Compare Figs. 177-180.) 

The swelling of the nerve head commonly called a choked disk 
or more appropriately a papilledema is properly regarded today as 
largely a mechanical process due to the stasis of cerebrospinal fluid 
under tension within the subarachnoid space of the optic nerve sheaths. 
The fluid finally backs up in the optic nerves themselves, entering, 
according to Schieck, 1 at the points where the vessels penetrate the 

>Die Genese der Staungspapille, Wiesbaden, 1910, p. 91. 



PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 409 

nerves, thus producing a chronic edema which ultimately leads to 
destructive scar formation. The cerebrospinal fluid element, therefore, 
is the important one and a choked disk depends more upon the situation 
than on the size of a tumor. Thus a slowly growing tumor of a cerebral 
hemisphere may reach large dimensions before a choked disk appears, 
whereas a small growth accompanied by a widespread cerebral edema 
or one which is in the Kind brain and interferes with the cerebrospinal 
fluid outflow through the iter may lead to a high grade of the process as 




FIG. 136. Showing intranasal ether administration; area of shaving; primary 
epidermal incision. 



an early symptom. On the other hand, tumors such as pituitary tumors 
which press upon the optic nerves and thus prevent fluid being forced 
down the optic sheath are rarely accompanied by a choked disk, even 
though they ultimately may reach such a size as to cause an internal 
hydrocephalus from obstruction of the foramina of Munro. 

Headaches, too, are attributed to tension and they vary considerably 
in their situation and intensity. Occasionally the discomforts are of 
localizing value, as is true of suboccipital headaches accompanying 
cerebellar tumors and the bitemporal headaches characterizing pitui- 
tary growths, but as a rule they are described as a general unlocalized 



410 PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 

pressure discomfort which may be so intense as to stupify and to give a 
sensation as though the head would burst. It is not entirely clear just 
what produces the sensation of headache, for the brain is insensitive. 
The dura, however, is a sensitized structure, its nerve supply being 
wholly trigeminal except for a small area around the foramen magnum 
which is innervated by the vagus, and in all likelihood the discomforts 
may be ascribed to stretching of this membrane, or its expansions into 
falx or tentorium. Certain observations lend support to this view. 
Thus, after a total trigeminal neurectomy for neuralgia such headaches 




FIG. 137. Layer of wet bichloride gauze. 

as may follow the operation, whether from the anesthetic or loss of 
cerebrospinal fluid, are usually referred by the patient to the sound 
side on w r hich the dura retains its sensation. Then again, certain forms 
of headache associated with an enlargement of the pituitary gland are 
evidently due to distention of the dural capsule of the gland, for they 
are apt to cease when the growth finally breaks through the capsule 
just as they may cease abruptly after a transsphenoidal operation in 
which the floor of the sella turcica has been removed and the" dura 
incised (sellar decompression). These things make it probable that 



PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 411 . 



distention of the sensitized dura is at least an important element, if 
not the primary element in those forms of cephalalgia which are asso- 
ciated with a local or general increase of tension. 

Extirpation of a lesion, wherever it may happen to be and par- 
ticularly if it be a new growth, is the ideal surgical procedure, but a 
valuable alternative and the only alternative in the case of an intra- 
cranial tumor which cannot be definitely localized, or if localizable 
proves inaccessible, is to relieve the factors of tension which are produc- 
ing these symptoms. The idea of a purposeful operation which has as 







FIG. 138. Primary circular toweling pinned in scalp. 

its objective the mere relief of pressure in these conditions was slow in 
its development. This may doubtless be attributed in part to the con- 
fusion which long existed regarding the causative factor in the production 
of a choked disk for, as the long-used term "optic neuritis" signifies, the 
process, in the minds of many, was due to an inflammation or to some 
sort of neurotoxic effect on the optic nerves produced by the growth. 
From this viewpoint, an operation which did not serve to remove the 
tumor could hardly have been expected to check the optic neuritis. 
Some ten years ago, however, the early view that the process was 



412 PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 



largely mechanical, rather than toxic or inflammatory, was revived 
and came to prevail; and not the least important argument in its 
favor was the fact that exploratory operations which had failed in their 
object of tumor removal sometimes served unexpectedly to relieve 
headaches and, what was more, to preserve vision. 

It is remarkable that this was not appreciated earlier, for neurologists 
and surgeons must often have seen examples of spontaneous palliation 
of symptoms, such as may follow the pressure absorption, by a sub- 
jacent tumor, of the overlying skull, or the diastasis of the sutures in 




FIG. 139. Secondary toweling pinned in tragus. 

pre-adolescent individuals, with consequent relief of headaches. How- 
ever, a discouraging opinion regarding the futility of all operations for 
tumor, except those involving the motor cortex, had been pronounced 
in Germany by von Bergmann and in this country by Agnew. Cases, 
if operated upon at all, were apt to be operated upon late in the disease, 
when a choked disk was so far advanced that blindness might ensue 
even though a tumor was removed and tension completely relieved. 
Moreover, the methods of entering the cranial chamber, and particularly 
of closing the wound afterward, were so imperfect that when great 



PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 413 



tension was encountered, a fungus cerebri and its distressing conse- 
quences often followed. But despite all discouragements, some sur- 
geons, notably Sir Victor Horsley, persisted in their efforts to relieve 
these cases and urged that more precocious explorations be made on the 
basis that they might serve to pa'liate the major pressure symptoms 
even though no tumor be found and removed. This possibility that an 
exploratory operation which fails to disclose an expected tumor may 
nevertheless afford unexpected relief was first clearly expressed, so far 
as I am aware, by Robert F. Weir 1 in 1888 on the basis of a single 




FIG. 140. White operative sheet with indented opening and tapes. 

experience. Similar experiences were soon recorded by others (Horsley 
in 1889, Sahli in 1891, Jaboulay in 1893, Annandale, Keen, Sanger and 
Bramwell in 1894, etc.), as Spiller and Frazier 2 in an article on the 
subject have pointed out. 

A cranial exploration which is unsuccessful in its purpose of tumor 
exposure and removal can, however, hardly be placed in the same 
category as the present day purposeful decompressive craniectomy, and 

1 Weir and Sequin cit., cf. H. Gushing: Jour. Am. Med. Assn., 1909, Hi, 184-192. 

2 Jour. Am. Med. Assn., 1906, xlvii, 679, 744, 849, 923. 



414 PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 

though these operations doubtless grew out of them, it was many years 
before the idea got a footing among the profession in general. Among 
the earliest to clearly advocate a craniectomy for the relief of pressure 
symptoms was Victor Horsley, 1 first at the Berlin Congress of 1895 
and three years later at a meeting of the British Medical Association. 
At that tune he favored a large bone defect over the accessible portion 
of the hemisphere thought to be involved but without opening the dura. 
The term trepanation decompressive was adopted in France by Jabouley 2 




FIG. 141. Final gray covering. 

in 1896 and in the same year employed by Broca and Maubrac 3 in the 
sense in which we now use it. At the outset it was supposed that an 
opening made anywhere in the skull would serve the purpose, but great 
hesistancy was expressed by all in regard to the propriety of opening 
the dura, as a substitute for which Sanger advocated a ventricular, and 
Broca and Maubrac a lumbar puncture. 

British Med. Jour., 1890, ii, 1286; Ibid., 1893, ii, 1365. 

2 Lyon med., 1896, Ixxxiii, -73. 

3 Arch. gen. de med., 1898, i, 129. 



PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 415 

Most of the early operations for tumor have been undertaken in cases 
in which the paracentral (sensorimotor) convolutions were presumably 
involved, for the very evident reasons that here a localizing diagnosis 
is comparatively simple and the area is the most favorable for surgical 
access. Unhappily, however, if a tumor were not found and tension 
proved to be great, a formidable protrusion often occurred with marked 




FIG. 142. Fingers as tourniquet preliminary to incision. 



accentuation of the preexisting local symptoms, even though the sub- 
jective headache and the choked disk might have been relieved. Then 
if the exploration happened to be made over the leading hemisphere 
and aphasia was superadded to the hemiplegia, the patient's helpless- 
ness was so accentuated as to entirely outweight the subjective relief. 
Though Byron Bramwell and Bruns had somewhat hesitatingly 
advocated purposeful trephining for palliative purposes, Sanger was 



416 PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 

one of the first neurologists to speak emphatically on the subject 1 and 
in 1902 2 he advocated the establishment of a cranial and dural defect 
over a relatively silent area of the brain, his favored site being the pos- 
terior portion of the right hemisphere. This procedure, however, may 
lead to an unsightly and unnecessarily large protrusion, particularly 
when, as is often the case, distention of the ventricles is a compli- 
cating factor (Fig. 135), and ten years ago, for the first time I believe, 




FIG. 143. Clamps placed on galea, liberating fingers of one assistant. 

a description was given of operative methods which had for their 
object the purposeful herniation of a silent area of the brain under a 
muscular protection. 3 

1 He then wrote: "Palliative trepanation in case of cerebral tumor is an operation 
which even if not absolutely free from danger is of extraordinary blessedness, and, in 
the hands of a practiced surgeon, one that I would like to recommend in every case, in 
consideration of the impotency of internal medicine, in view of the distressing suffering, 
and, above all, of the menacing blindness." 

2 Sanger: Deutsch. Gesell. f. Chir., 1902. 

Gushing, H.: Surg., Gynec. and Obst., 1905, i, 295-314. 



PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 417 

Considering the fact that these matters are all of such comparatively 
recent date, it is no occasion for surprise that those who have not fol- 
lowed them closely still have somewhat hazy ideas concerning the 
principles involved in a cerebral decompression, which, to recapitulate, 
arose from the finding (1) that a craniectomy with a sufficient opening 
of the dura may relieve headache and choked disk even without tumor 
removal, (2) that a craniotomy over an important cortical area may 
le&d to functional injury of that area in consequence of the ensuing 
protrusion, (3) that, therefore, the defect in the bone and dura should 




FIG. 144. Showing proper placement of clamps. (Natural size.) 

be made over a relatively silent area of the brain, (4) that this area if 
protected only by scalp often leads to a most unsightly and unneces- 
sarily large protrusion and hence, (5) that if possible it is wise to 
decompress for supratentorial lesions over an area which can be pro- 
tected by the careful closure of moderately resistant tissues, such as 
are afforded by the temporal muscle and its fascia. 

In 1905 when the palliative operation which embodied these prin- 
ciples was first described, experiences with it had been few and its 
actual value was somewhat problematical. The operation was unwisely 

VOL. i 27 



418 PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 

called an " intermusculotemporal" procedure from the desire to 
emphasize that the temporal muscle and fascia were split as in the inter- 
muscular laparotomies which avoid the transsection of muscle fibers. 
For this cumbersome name the better term "subtemporal" craniec- 
tomy or decompression was later substituted. 




FIG. 145. Incision through fascia. 

The operation, furthermore, must have been badly described, for 
many seem to have gained the impression, possibly from the illus- 
trations of an incomplete stage of the procedure, that the dura was not 
to be opened; unfortunately, too, a curvilinear skin incision was advo- 
cated and pictured, the object being to still further accentuate the 
" gridiron" approach through the cranial coverings. It was soon found 
that this curved incision interfered with a possible subsequent osteo- 
plastic exploration on the same side and was objectionable also since 
through it the base of the temporal fossa was difficult of access. More- 
over it was found to be unnecessary, for with the separate closure of the 



PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 419 

galea by buried sutures, the scalp wound was found to be sufficiently 
secure even though it directly overlay the incisions through muscle 
and fascia. 




FIG. 146. Elevation of temporal muscle after incision. 




FIG. 147. Form of elevator for temporal muscle. (Natural size.) 



420 PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 

With the gradual adaptation of the operation to cases of basal 
fracture 1 in which a rubber tissue drain for cerebrospinal fluid is advan- 
tageously left emerging from the lower angle of the incision, a linear 
incision through all the layers came to be the approved method. This 
modification was described in 1908 but has apparently not been gener- 
ally followed, judging from the examples of so-called subtemporal 
decompressions which frequently come under observation. Many of 
them have curvilinear scalp incisions with a cranial defect which is 




FIG. 148. Primary opening with burr. 

either too small to be effective even if the dura has been opened, which 
it often is not, or so high that contralateral paralyses may be expected; 
and in not a few a bone flap has been turned back and replaced. From 
these ineffective procedures it is clear why objections to the operation 
have arisen on the score of too small an opening or of distressing con- 
sequences when the opening is sufficiently large (c/. Fig. 135). 

1 Gushing, H.: Ann. Surg., 1908, pp. 641-644. 



PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 421 

Though the simplest and safest of all the operations which are called 
for in the various surgical problems presented by intracranial tumors, 
there nevertheless are technical difficulties connected with it which 
demand practice and properly constructed instruments, but this is 
true enough of all craniocerebral procedures. In the course of some 
three or four hundred decompressions we have learned how to avoid 
operative complications and accidents, and it is the purpose of this 
article to describe in detail the various steps of the procedure. Some of 




FIG. 149. Further enlargement with Montenovesi forceps. 

the technical improvements adopted since the early description of the 
operation fourteen years ago lie in the use of gray operating sheets, in 
the control of hemorrhage from the scalp by digital compression, in the 
use of silver clips for the meningeal branches divided with the dura, of 
proper retractors to elevate the muscle, of the spoon spatula to control 
marked cerebral protrusion during closure, of ventricular puncture to 
lower tension and to aid in diagnosis, and finally in the method of 



422 PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 

closure in three or four layers of buried sutures including the fascia 
and galea. 

The accompanying photographs were taken during the course of the 
usual decompression for an unlocalized tumor and the comparative 
freedom from blood staining can be taken as an evidence of the effec- 
tive hemostasis, though admittedly all of these operations are not 




FIG. 150. Introduction of flat rongeurs well under muscle for further enlargement. 



equally dry. For convenience of description we may divide the pro- 
cedure into the following steps: 

A. Anesthesia and preparation of the field (Figs. 136 to 141). 

B. The incision to completion of the subtemporal bone defect (Figs. 
142 to 152). 

C. The dural opening and cerebral exploration, this being the essen- 
tial part of the operation (Figs. 153 to 160). 

D. The closure and dressings (Figs. 161 to 173.) 



ANESTHESIA AND FIELD PREPARATION 



423 



A. Anesthesia and Field Preparation. The importance of excep- 
tionally skilful anesthesia cannot be emphasized too greatly. Patients 
suffering from the effects of intracranial tension are notoriously bad 




FIG. 151. Flat-nosed rongeur for insertion under muscle edges. (Natural size.) 




FIG. 152. Same as preceding, rongeurs reaching well toward base of skull. 



424 PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 

subjects for narcosis and different operators favor different methods 
and different drugs. Some advocate local anesthesia, which has its 
many objections. The inhalation narcotics are apt to increase tension 
owing to the increased secretion of cerebrospinal fluid which they 
apparently induce, and this is accentuated if the patient is permitted 
to become at all cyanosed, as is more or less inevitable with nitrous 
oxide. Chloroform or mixtures which contain chloroform have their 




FIG. 153. Primary incision in dura. 



especial dangers and, taken all in all, straight ether anesthesia may 
be regarded as the safest and best method. 1 This was formerly given 
by the drop method throughout, but during the last four years, when 

1 The comparative freedom from ether accidents and operative difficulties owing to 
ether during many cranial operations in a long series of cases in the past ten years is 
due entirely to the exceptional skill of Dr. S. G. Davis, of Baltimore, and Dr. Walter 
Boothby, of Boston, who have anesthetized practically all of them. (Cf. This paper 
was written in 1914.) 



ANESTHESIA AND FIELD PREPARATION 



425 



secondary narcosis is once induced by the drop method and mask it is 
supplanted by ether vapor under a measured tension given by the 
Connell apparatus through a tube introduced through the nares into 
the pharynx. By this method the anesthetist is removed from the 
operative field and the induced sleep is usually so quiet and regular 
that the distracting anxiety concerning the anesthetic is eliminated. 

The operative field is shaved the morning of operation. That shown 
in Fig. 136 is larger than necessary. All antecedent preparations of 
the scalp are to be avoided, for they accomplish little more than to give 




FIG. 154. Same as preceding (natural size) to show dural hook. 



the patient a restless night. These operations are palliative, it is to be 
remembered, and many of the patients may soon return to their 
occupations. Particularly in women it is desirable to avoid shaving 
more than the necessary small strip bordering the line of proposed 
incision. The hair should be brushed away and tightly braided in a 
single braid centering in the opposite parietal region. Cotton is placed 
in the auditory canal and the scalp is cleaned merely by sponging with 



426 PURPOSE AND STEPS OF A SUBTEMPORAL DECOMPRESSION 

some green soap followed by alcohol and bichloride. Personally, I 
detest iodin preparations. 1 

In all cranial operations the towels should be securely disposed 
closely about the wound and, to prevent slipping during the course of 
a possible prolonged operation, they should be pinned into the scalp, 
leaving nothing exposed but the actual line of incision. This means, 
therefore, the complete covering of all landmarks, so that it is custom- 




FIG. 155. Furthe